Background: Delirium is a reversible condition that is common in hospitalized patients. Antipsychotics are often used to manage acute behavioral disturbances associated with hyperactive delirium. During transitions of care, plans to taper or discontinue these newly initiated antipsychotics can be unclear. As a result, these medications may be continued long-term, even as the acute episode of delirium has resolved. This poses a risk to patients as antipsychotics are linked to increased mortality, particularly in the elderly, and have a myriad of side effects including extrapyramidal symptoms, cardiac arrhythmias, metabolic syndrome, and orthostasis. We sought to characterize antipsychotic use at the time of discharge for patients with delirium being managed by the Consult-Liaison Psychiatry team.
Methods: This retrospective quality improvement study examined consults for delirium received by the Consult-Liaison Psychiatry team at our large academic institution from June to August 2024. The electronic medical record was reviewed including review of patient characteristics, medication ordering, the discharge summary from the primary service, and Consult-Liaison Psychiatry notes during hospitalization. We noted whether scheduled antipsychotics were initiated at any point during hospitalization to manage delirium and whether these antipsychotics were discontinued prior to discharge, continued at discharge with a plan to taper or discontinue in the future, or continued without a plan.
Results: A total of 97 consults were reviewed. 60% of patients were male and 40% were female with an age range of 20-89 years and median age of 65 years. Half (50%) of patients were started on a new scheduled antipsychotic, 36% were not on scheduled antipsychotics at any point during hospitalization, and 14% had scheduled antipsychotics that were prescribed prior to admission and continued during admission. Of the newly initiated scheduled antipsychotics, the most common were quetiapine (44%), olanzapine (23%), and haloperidol (21%). Based on discharge summaries, nearly half (48%) of these newly initiated scheduled antipsychotics were stopped before discharge, 10% were continued at discharge with mention of taper or recommended end date, and 42% were continued without a plan. For antipsychotics that were continued without a plan, the most recent psychiatry consult note before discharge did not give recommendations for how to discontinue or taper the medication in 85% of cases.
Conclusions: Despite potential harms of long-term antipsychotic use, half of hospitalized patients with delirium for whom psychiatry was consulted were managed with newly scheduled antipsychotics and nearly half of these patients were discharged on antipsychotics without a clear discontinuation plan. This represents an important opportunity to enhance patient safety. Psychiatry consultation recommendations did not provide this guidance in a majority of these cases, which highlights a key area for collaboration between the primary team and consulting service to facilitate safer transitions of care for patients with delirium. Next steps include interventions to standardize psychiatry consultation documentation to address anticipated medication plans at the time of discharge.