Boston—Delirium is a very common disturbance in attention and awareness among hospitalized older adults. Past studies have cited the frequency to be as much as 64% in regular hospital units, 50% after high-risk surgery, and as much as 75% in those on mechanical ventilation.

Dealing with the condition and its adverse outcomes is estimated to cost from $38 billion to $152 billion annually in the United States.

A recent study in the Annals of Internal Medicine pointed out that antipsychotics are commonly used to manage postoperative delirium, with a recent decline in haloperidol use and an upswing in the use of atypical antipsychotics.

The study team from Brigham and Women’s Hospital and other Harvard Medical School–related facilities in Boston sought to compare the risk for in-hospital adverse events associated with oral haloperidol, olanzapine, quetiapine, and risperidone in older patients after major surgery. Funding came from the National Institute on Aging.

The retrospective cohort study used data from U.S. hospitals in the Premier Healthcare Database. The study included 17,115 patients aged 65 years and older without psychiatric disorders who were prescribed an oral antipsychotic drug after major surgery from 2009 to 2018. Participants had a mean age of 79.6 years, was 60.5% female, and had in-hospital death of 3.1%.

Those interventions were haloperidol (≤4 mg on the day of initiation), olanzapine (≤10 mg), quetiapine (≤150 mg), and risperidone (≤4 mg). The researchers estimated risk ratios (RRs) for in-hospital death, cardiac arrhythmia events, pneumonia, and stroke or transient ischemic attack (TIA) with those medications.

Among the four antipsychotics, researchers reported that quetiapine was the most prescribed (53.0% of total exposure). Overall, the study team found no statistically significant difference in the risk for in-hospital death among patients treated with haloperidol (3.7%, reference group); olanzapine (2.8%; RR, 0.74; 95% CI, 0.42-1.27); quetiapine (2.6%; RR, 0.70; 95% CI, 0.47-1.04); and risperidone (3.3%; RR, 0.90; 95% CI, 0.53-1.41).

“The risk for nonfatal clinical events ranged from 2.0% to 2.6% for a cardiac arrhythmia event, 4.2% to 4.6% for pneumonia, and 0.6% to 1.2% for stroke or TIA, with no statistically significant differences by treatment group,” the authors wrote.

The researchers advised that their results “suggest that atypical antipsychotics and haloperidol have similar rates of in-hospital adverse clinical events in older patients with postoperative delirium who receive an oral low-to-moderate dose antipsychotic drug.”

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