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Editorials |3 September 2019

Old Habits Die Hard: Antipsychotics for Treatment of Delirium

Edward R. Marcantonio, MD, SM

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
This article was published at Annals.org on 3 September 2019.
  • Beth Israel Deaconess Medical Center, Boston, Massachusetts (E.R.M.)

    Disclosures: The author has disclosed no conflicts of interest. His form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-2624.

    Corresponding Author: Edward R. Marcantonio, MD, SM, Division of General Medicine, Beth Israel Deaconess Medical Center, CO-216, 330 Brookline Avenue, Boston, MA 02215.

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Thirty years ago, during my internal medicine residency, I was taught that it was “normal” for hospitalized patients, particularly older adults, to get confused. This confusion had little significance and no impact on outcomes but could be a nuisance. If so, 10 mg of haloperidol (“vitamin H”) would take care of the problem.
Where have we come in the past 30 years? We now know acute confusion is delirium and that it is never “normal” (1). We have standardized methods to identify delirium (1, 2), though over one half of cases still go unrecognized. We also know that delirium is common, affecting one third of hospitalized elders and three quarters of all adults in the intensive care unit (ICU) and in palliative care (1). Far from being of little consequence, delirium is a powerful predictor of short- and long-term adverse outcomes, including in-hospital complications, such as falls, functional decline, cognitive decline, and death (1). And delirium is costly, prolonging length of stay, leading to institutional care after discharge, and costing the U.S. health care system billions of dollars annually (3). Of note, we also know that delirium is preventable—particularly with multifactorial, nonpharmacologic approaches (2, 4).
Despite these advances, when delirium occurs, we still often turn to the same treatment used 30 years ago: antipsychotics. There have been some advances in this domain. First, in addition to haloperidol, we now have several second-generation antipsychotics, which arguably have...
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Marcantonio ER. Old Habits Die Hard: Antipsychotics for Treatment of Delirium. Ann Intern Med. [Epub ahead of print 3 September 2019]:. doi: 10.7326/M19-2624

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Published: Ann Intern Med. 2019.

DOI: 10.7326/M19-2624

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2019 American College of Physicians
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