Discharge Plans for Geriatric Inpatients With Delirium: A Plan to Stop Antipsychotics?

Kim G. Johnson, MD; Adedayo Fashoyin, MD; Ramiro Madden-Fuentes, MD; Andrew J. Muzyk, PharmD; Jane P. Gagliardi, MD, MHS; Mamata Yanamadala, MBBS, MS

Disclosures

J Am Geriatr Soc. 2017;65(10):2278-2281. 

In This Article

Abstract and Introduction

Abstract

Background Studies show inpatient geriatric patients with reversible conditions like delirium may continue on antipsychotic medications without clear indications after hospital discharge. We conducted this study to determine how often geriatric patients were discharged on a newly started antipsychotic during admission with a plan for discontinuation of the antipsychotic documented in the discharge summary.

Design We conducted retrospective chart review identifying geriatric inpatients in our health system started on a new antipsychotic during admission. In patients discharged from the hospital on a new antipsychotic, we examined the discharge summary for a discontinuation treatment plan.

Results Of 487 patients started on a new antipsychotic, 147 (30.2%) were discharged on the antipsychotic. Of those, 121 (82.3%) had a diagnosis of delirium. Discharge summaries of 15 (12.4%) patients discharged on an antipsychotic with a diagnosis of delirium included instructions for discontinuation of the antipsychotic. Of those patients discharged with instructions for discontinuation, 12 (80%) received a psychiatric or geriatric medicine consult.

Conclusion In our health system, the majority of geriatric patients with delirium, discharged on a new antipsychotic had no instructions outlined to outpatient providers for discontinuation management. Further interventions could target increasing antipsychotic guidance at transitions of care.

Introduction

Delirium, or acute and fluctuating disturbance in cognition, is a mental and physical condition occurring in up to 50% of hospitalized patients ages 65 and older.[1] Patients may develop symptoms including agitation, behavioral disturbances, hallucinations, and delusions. The first and foremost step of delirium treatment is to identify and treat the underlying medical cause. Removal of sedating and anticholinergic drugs and non-pharmacologic interventions are important next steps for prevention and management of behavioral disturbances.[2]

Some behavioral disturbances associated with delirium are often treated using antipsychotics although there is a lack of evidence to support this cause.[3,4] Some experts recommend that if antipsychotics are necessary to treat behavioral disturbances, the lowest effective dose for the shortest duration of time possible should be used.[1]

Due to potential long-term adverse consequences and increased health care costs, the continued use of antipsychotics should often be reevaluated, particularly at any transition of care. Long term consequences of antipsychotic use in patients over age 65 include metabolic syndrome, orthostasis, increased mortality from QT-prolongation, ventricular arrhythmias, increased risk for falls, urinary infections, pneumonia, stroke, seizures, and venous thromboembolism.[5–8] Also, patients with dementia are vulnerable to delirium, and antipsychotic use in this population carries a "black box warning" for all-cause sudden death.[9] Prolonged antipsychotic use not only increases the risk of adverse events but also increases health care costs. One study of ICU delirium estimated the annual cost of antipsychotic medication for 20 patients as outpatient therapy at approximately $45,107.[10] Therefore, use of antipsychotic medication should be reviewed often and considered judiciously in the geriatric population.

Although long-term antipsychotic treatment is not recommended for treatment of delirium-associated behavioral changes, many studies demonstrate a significant number of patients started on antipsychotics, for this reason, are given high doses of antipsychotics or continued on antipsychotics after hospital discharge.[10–15] Patients with ongoing behavioral symptoms of delirium that interfere with treatment or safety may benefit from continued antipsychotic treatment at discharge; however, there is a growing concern for inappropriate continuation at the same time. In a retrospective review of 59 medical ICU patients who were started on an antipsychotic during an ICU stay for delirium, 33% were discharged from the hospital on the antipsychotic without an indication for continuing the medication.[11] In another study, geriatricians, hospitalists, and pharmacists were surveyed and reported that as many as 80% of discharge prescriptions for antipsychotic medications were inappropriate.[14]

We undertook the current study to identify opportunities for improving the safety of antipsychotic prescriptions at the time of discharge for older hospitalized patients. The objective was to determine the frequency that patients over the age of 65 with a diagnosis of delirium were discharged on a new antipsychotic that included a treatment plan for discontinuation.

From clinical observations and experience we hypothesized that a notable proportion of these patients would be discharged on a newly started antipsychotic without instructions for discontinuation.

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