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Antipsychotics often are used to manage delirium in palliative care patients, despite the lack of clinical evidence to support this practice. This Australian study included 247 hospitalized patients (mean age, 75) who were receiving hospice or palliative care for terminal conditions (cancer in nearly all cases), and who met standardized criteria for delirium. Patients were randomized to receive risperidone, haloperidol, or placebo, with medications dosed according to symptom-driven protocols every 12 hours for 72 hours. All patients received individualized supportive care, management of delirium precipitants, and subcutaneous midazolam as needed; delirium was assessed every 8 hours.
At 3 days, mean validated delirium symptom scores were significantly worse in patients receiving risperidone and haloperidol than in those receiving placebo. Rescue midazolam use was significantly lower in placebo patients on each of the study days; for example, on day 1, 17% of placebo patients received midazolam compared with 35% of medicated patients.
Agar MR et al. Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: A randomized clinical trial. JAMA Intern Med 2016 Dec 5; [e-pub]. (http://dx.doi.org/10.1001/jamainternmed.2016.7491)
Comment
These results strongly suggest that antipsychotic drug use in palliative care patients with delirium should be limited — or eliminated entirely. Supportive care and the causes of delirium, such as social isolation and sensory deprivation, should receive more attention.