What’s New in the Patient Safety World

January 2018

What Happens After Delirium?



A much needed study on delirium has recently been published. We and others have done multiple columns on preventing and managing delirium but one question has largely been ignored: “What happens to patients who have been started on antipsychotics for delirium?”.


The new study addresses that question. Johnson and colleagues (Johnson 2017) wanted to know how many inpatients begun on antipsychotic medications for delirium had a clear discontinuation plan after discharge. They conducted a retrospective chart review identifying geriatric inpatients in their health system started on a new antipsychotic during admission and in those discharged from the hospital on a new antipsychotic, they examined the discharge summary for a discontinuation treatment plan. Of patients started on a new antipsychotic (82% of whom had a diagnosis of delirium), 30.2% were discharged on the antipsychotic. Only 12.4% of those patients discharged on an antipsychotic with a diagnosis of delirium had included in their discharge summaries instructions for discontinuation of the antipsychotic. Of those patients who were discharged with instructions for discontinuation, 80% had received a psychiatric or geriatric medicine consult.


Antipsychotic drugs have significant potential adverse consequences. Anticholinergic effects, sedation, sexual dysfunction, movement disorders, postural hypotension, cardiac arrhythmia, and sudden cardiac death are well-known consequences. Metabolic syndrome has also been associated with many of the newer antipsychotics. Increased mortality rates are seen in nursing home patients treated with antipsychotic drugs, and falls are frequent in the nursing home patient on antipsychotics. So it’s really important that we don’t continue antipsychotic drugs any longer than necessary in this population.


Good medication reconciliation at discharge (and, for that matter, at all transitions of care) is essential. Even when an antipsychotic is intended to be continued temporarily following discharge, there should be a clear plan and instructions for how long it should be continued, whether it should be tapered or abruptly discontinued, and for what symptoms it should be restarted. Consultation by a geriatrician or geropsychiatrist may be very beneficial in this regard.



Some of our prior columns on delirium assessment and management:

·       October 21, 2008 “Preventing Delirium”

·       October 14, 2008 “Managing Delirium”

·       February 10, 2009 “Sedation in the ICU: The Dexmedetomidine Study”

·       March 31, 2009 “Screening Patients for Risk of Delirium”

·       June 23, 2009  “More on Delirium in the ICU”

·       January 26, 2010 “Preventing Postoperative Delirium”

·       August 31, 2010 “Postoperative Delirium”

·       September 2011 “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”

·       December 2010 “The ABCDE Bundle”

·       February 28, 2012 “AACN Practice Alert on Delirium in Critical Care”

·       April 3, 2012 “New Risk for Postoperative Delirium: Obstructive Sleep Apnea”

·       August 7, 2012 “Cognition, Post-Op Delirium, and Post-Op Outcomes”

·       February 2013 “The ABCDE Bundle in Action”

·       September 2013 “Disappointing Results in Delirium”

·       October 29, 2013 “PAD: The Pain, Agitation, and Delirium Care Bundle”

·       February 2014 “New Studies on Delirium”

·       March 25, 2014 “Melatonin and Delirium”

·       May 2014 “New Delirium Severity Score”

·       August 2014 “A New Rapid Screen for Delirium in the Elderly”

·       August 2014 “Delirium in Pediatrics”

·       November 2014 “The 3D-CAM for Delirium”

·       December 2014 “American Geriatrics Society Guideline on Postoperative Delirium in Older Adults”

·       June 16, 2015 “Updates on Delirium”

·       October 2015 “Predicting Delirium”

·       April 2016 “Dexmedetomidine and Delirium”

·       April 2016 “Can Antibiotics Lead to Delirium?”

·       July 2016 “New Simple Test for Delirium”

·       September 20, 2016 “Downloadable ABCDEF Bundle Toolkits for Delirium”

·       January 24, 2017 “Dexmedetomidine to Prevent Postoperative Delirium”

·       March 21, 2017 “Success at Preventing Delirium”

·       July 2017 “HELP Program Reduces Delirium Rate and LOS”






Johnson KG, Fashoyin A, Madden-Fuentes R, et al. Discharge Plans for Geriatric Inpatients With Delirium: A Plan to Stop Antipsychotics? J Am Geriatr Soc 2017; 65(10): 2278-2281







Print “PDF version”













Tip of the Week Archive


What’s New in the Patient Safety World Archive