Whats 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 its really important that we dont 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
References:
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
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