In this episode, I’ll discuss the unwarranted continuation of antipsychotics after ICU and hospital discharge.
Although the use of antipsychotics to treat ICU delirium does not have robust patient-focused outcomes data, they are frequently used. Usually antipsychotics are started when a patient with ICU delirium becomes agitated to the point they are a danger to themselves or ICU staff.
The SCCM PADIS Guidelines explain this in the details of their conditional recommendation against the use of antipsychotics to treat ICU delirium:
Although this recommendation discourages the “routine” use of antipsychotic agents in the treatment of delirium, patients who experience significant distress secondary to symptoms of a delirium such as anxiety, fearfulness, hallucinations, or delusions, or who are agitated and may be physically harmful to themselves or others, may benefit from short-term use of haloperidol or an atypical antipsychotic until these distressing symptoms resolve based on the panel’s clinical experience. Patients who start with an antipsychotic for delirium in the ICU often remain on these medications unnecessarily after discharge. Continued exposure to antipsychotic medication can result in significant morbidity and financial cost. Panel members judged that the undesirable consequences of using either haloperidol or an atypical antipsychotic far outweighed the potential benefits for most critically adults with delirium and thus issued a conditional recommendation against their routine use.
Researchers recently published in AJHP a retrospective, multicenter, descriptive analysis of the unwarranted continuation of antipsychotics for the management of ICU delirium during transitions of care.
The inclusion/exclusion criteria were as follows:
patients were included in the study if they received at least 3 doses of antipsychotics while in the ICU with presence of either a clinical diagnosis of delirium or a positive Confusion Assessment Method score. Patients were excluded if they were on an antipsychotic before ICU admission.
The authors found that:
Of the 300 patients included and initiated on antipsychotics for ICU delirium, 157 (52.3%) were continued on therapy upon transfer from the ICU to another level of inpatient care. The number of patients continued on newly initiated antipsychotics further increased to 183 (61%) upon discharge from the hospital.
These are very high rates of unwarranted continuation of antipsychotics, and the study underscores the importance of discontinuing this treatment before the patient leaves the ICU.
The authors went on to apply multivariable logistic regression analysis to identify risk factors for antipsychotic continuation both at ICU and hospital discharge.
Patients transferring out of a mixed ICU vs a medical ICU had a 4.5-fold higher odds of antipsychotic continuation, and a 2.1-fold higher odds if they were transferring out of a surgical vs a medical ICU.
For continuing an antipsychotic at hospital discharge, the odds ratio was 1.12 for patients that had longer ICU lengths of stay.
If ICU delirium is an acute and reversible condition, these high rates of antipsychotic continuation are unwarranted. The ICU pharmacist can be the clinician that highlights and eliminates antipsychotic continuation after ICU discharge. Strategies to accomplish this include reconciliation, hand-off tools, and protocolized discontinuation.
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