Background: Delirium is a neuropsychiatric syndrome that can occur in hospitalized patients. The negative impact that delirium has on the patient and the health system are well described and include increased mortality, risk of falls, length of stay and overall healthcare utilization. Delirium can have a heterogenous presentation including hyperactivity with agitation, restlessness and psychosis or hypoactivity with more somnolent confusion. Hyperactive delirium frequently requires some form of pharmaceutical intervention, with antipsychotics being a common tool. There has been mixed review of the impact on antipsychotic medications on delirium. Further, guidelines consistently do not recommend their use given insufficient high-quality studies. This gap in the literature highlights the need to better understand the potentially negative impact of using antipsychotics on patients with delirium.
Methods: A cross-sectional study of all adult inpatient hospitalizations with a positive delirium screen from August 1, 2018 to February 1, 2020 at a large, tertiary care hospital were included in this study. The independent variable was the use of antipsychotics. Clinical outcomes of in-hospital fall and length of stay were analyzed using univariate and multivariate logistic regression.
Results: The study included 3,707 admissions with at least one positive delirium screening. Of these patients 1717 (46.3%) received at least one administration of an antipsychotic during the admission. There were 105 in-hospital falls included in the study and 72 (68.6%) occurred during admissions in which a delirious patient received an antipsychotic. Patients who received an antipsychotic had a mean length of stay of 16.7 days compared to 10.4 days of those who did not based on univariate analysis. Delirious patients who received an antipsychotic had 2.2 (CI 95% 1.44-3.40) times the odds of falling during their admission compared to those who did not. After controlling for demographic and patient comorbidity variables. the odds ration remained stable at 2.2. When controlling for demographic and patient comorbidities that could lead to potential confounding, the receipt of an antipsychotic was positively contributed (increased duration) to LOS with a p-value of 0.0003.
Conclusions: Delirium presents many challenges to hospitalists trying to provide the highest level of care while reducing adverse events like falls and optimizing patient throughput. Often the symptoms of delirium require a pharmaceutical intervention such as an antipsychotics. In our study, delirious patients who received an antipsychotic were more likely to fall and were hospitalized longer compared to those who did not, even when controlling for potential patient and clinical confounders. It is possible that we are describing a group of patients, those so agitated and outwardly symptomatic from their delirium that they require medication, who are overall more ill and have higher risk of falls or increased LOS. However, it is also possible that these medications are contributing to these poor outcomes through sedation, transition to hypoactive delirium or hypotension and orthostasis.