Antipsychotic use and diagnosis of delirium in the intensive care unit

Abstract

IntroductionDelirium is an independent risk factor for prolonged hospital length of stay (LOS) and increased mortality. Several antipsychotics have been studied for the treatment of intensive care unit (ICU) delirium that has led to a high variability in prescribing patterns for these medications. We hypothesize that in clinical practice the documentation of delirium is lower than the incidence of delirium reported in prospective clinical trials. The objective of this study was to document the incidence of delirium diagnosed in ICU patients and to describe the utilization of antipsychotics in the ICU.MethodsThis was a retrospective, observational, cohort study conducted at 71 United States academic medical centers that reported data to the University Health System Consortium Clinical Database/Resource Manager. It included all patients 18 years of age and older admitted to the hospital between 1 January 2010 and 30 June 2010 with at least one day in the ICU.ResultsDelirium was diagnosed in 6% (10,034 of 164,996) of hospitalizations with an ICU admission. Antipsychotics were administered to 11% (17,764 of 164,996) of patients. Of the antipsychotics studied, the most frequently used were haloperidol (62%; n = 10,958) and quetiapine (31%; n = 5,448). Delirium was associated with increased ICU LOS (5 vs. 3 days, P < 0.001) and hospital LOS (11 vs. 6 days, P < 0.001), but not in-hospital mortality (8% vs. 9%, P = 0.419). Antipsychotic exposure was associated with increased ICU LOS (8 vs. 3 days, P < 0.001), hospital LOS (14 vs. 5 days, P < 0.001) and mortality (12% vs. 8%, P < 0.001). Of patients with antipsychotic exposure in the ICU, absence of a documented mental disorder (32%, n = 5,760) was associated with increased ICU LOS (9 vs. 7 days, P < 0.001), hospital LOS (16 vs. 13 days, P < 0.001) and in-hospital mortality (19% vs. 9%, P < 0.001) compared to patients with a documented mental disorder (68%, n = 12,004).ConclusionsThe incidence of documented delirium in ICU patients is lower than that documented in previous prospective studies with active screening. Antipsychotics are administered to 1 in every 10 ICU patients. When administration occurs in the absence of a documented mental disorder, antipsychotic use is associated with an even higher ICU and hospital LOS, as well as in-hospital mortality.

Antipsychotic Drug Use and Screening for Delirium in Mechanically Ventilated Patients in Canadian Intensive Care Units: An Observational Study

“…The results reported here are similar to those obtained in a retrospective cohort study conducted at 71 US academic hospitals in 2010. 13 In that study, delirium was diagnosed in only 6% of hospitalizations with an ICU admission, and antipsychotics were administered to 11% of patients. Haloperidol was most commonly prescribed (62% of patients), followed by quetiapine (31%).…”

“…Haloperidol was most commonly prescribed (62% of patients), followed by quetiapine (31%). 13 In a survey investigating sedation and delirium management practices in 23 ICUs in Australia and New Zealand, 28 only 2 sites (9%) reported routine use of a delirium scale. Of the 234 patients, only 56 were assessed for delirium, with 12 (21%) of these screening positive.…”

“…However, international surveys and observational studies indicate that antipsychotic drugs are commonly used in the context of critical care, [12][13][14][15][16] including in the management of delirium (e.g., psychomotor agitation), 12,13 despite the absence of evidence showing improved clinical outcomes with their use.…”

“…[1][2][3][4][5][6] Professional society guidelines 7,8 recommend the routine use of screening tools specifically designed for detecting delirium in critically ill patients (e.g., the Confusion Assessment Method for the Intensive Care Unit [CAM-ICU] 9 and the Intensive Care Delirium Screening Checklist [ICDSC] 10 ). However, international surveys and observational studies have indicated that delirium screening tools are not widely incorporated into critical care practice, [11][12][13][14][15][16] which represents a missed opportunity to detect the syndrome. As such, delirium may go unrecognized.…”

Reflective Writing to Teach Interdisciplinary Management of Delirium to Internal Medicine Residents

“…2 There is evidence of poor recognition, documentation, and management of delirium in hospitals. 3,4 Additionally, geriatric medicine competencies for internal and family medicine residency programs emphasize residents' ability to diagnose and effectively manage delirium. 5 This small group didactic activity employs casebased discussions followed by reflective writing to evaluate learners' conceptual understanding of an evidence-based screening, with an interdisciplinary management approach to delirium.…”