Clinical questions: Are antipsychotics for the treatment of delirium safe and effective? Does efficacy differ between ICU and non-ICU settings? Does efficacy differ between first- and second-generation antipsychotics (SGA)?
Background: Delirium is common in hospitalized patients. Data are mixed about the use of antipsychotics for treatment of delirium, and safety concerns are well founded. A 2007 Cochrane review failed to show compelling evidence for their efficacy, yet they remain widely used for this purpose.
Study design: Systematic review and meta-analysis.
Setting: Fifteen RCTs of adults with delirium.
Synopsis: The primary outcome measure was response rate at the study endpoint, defined using severity of delirium and global scales.
In a comparison of pooled or individual antipsychotics vs. placebo or usual care (UC), antipsychotics were found to be superior, with a response rate of 0.22 (95% CI, 0.15-0.34, P<.00001), NNT=2. Subgroup analysis revealed this superiority to be greater in non-ICU settings, with ICU antipsychotic use only marginally better than UC. Antipsychotics were superior in time to response (TTR). Mortality rates were no different.
There were no differences between chlorpromazine and haloperidol in any outcomes. Among head-to-head comparisons of SGAs, no differences were found. Pooled or individual SGAs, however, had the same overall efficacy as haloperidol but shorter TTR and fewer extrapyramidal side effects. Subgroup analysis showed a small but significant advantage in the use of SGAs over haloperidol in the ICU.
Bottom line: Antipsychotics are more effective than placebo or usual care in the treatment of delirium. There appears to be a benefit to using second-generation antipsychotics over haloperidol.
Citation: Kishi T, Hirota T, Matsunaga S, Iwata N. Antipsychotic medications for the treatment of delirium: a systematic review and meta-analysis of randomised controlled trials. J Neurol Neurosurg Psychiatry. 2015;0:1-8.
