AGS Guideline for Postoperative Delirium in Older Adults

Pharmacologic Treatments/Interventions Used to Treat Postoperative Delirium in Older Surgical Patients

XII. Antipsychotics in the Setting of Severe Agitation

Recommendation. The prescribing practitioner may use antipsychotics at the lowest effective dose for the shortest possible duration to treat patients who are severely agitated or distressed, and are threatening substantial harm to self and/or others. In all cases, treatment with antipsychotics should be employed only if behavioral interventions have failed or are not possible, and ongoing use should be evaluated daily with in-person examination of patients (strength of recommendation: weak; quality of evidence: low).

1. 
   Evidence for Recommendation. The evidence from relevant studies is difficult to interpret because of the heterogeneity in the drugs studied, dosages administered, patient populations, outcomes examined, and scarcity of placebo-controlled, randomized clinical trials. All placebo-controlled trials testing the use of antipsychotic agents in treating delirium report using additional open-label haloperidol or other additional antipsychotic medications for agitation in both treatment and placebo groups. Randomized controlled studies comparing antipsychotics in the absence of a placebo comparison arm do not demonstrate a difference in treatment benefit or adverse events between various antipsychotic agents. Patients of older age (>75 years) were less likely to respond to antipsychotics, particularly olanzapine, than younger patients.
   
2. 
   Potential Harms of Recommendation. See harms statement "X. B." (above).
   

XIII. Benzodiazepines

Recommendation. The prescribing practitioner should not use benzodiazepines as a first-line treatment of the agitated postoperative delirious patient who is threatening substantial harm to self and/or others to treat postoperative delirium except when benzodiazepines are specifically indicated (including, but not limited to, treatment of alcohol or benzodiazepine withdrawal). Treatment with benzodiazepines should be at the lowest effective dose for the shortest possible duration, and should be employed only if behavioral measures have failed or are not possible and ongoing use should be evaluated daily with in-person examination of the patient (strength of recommendation: strong; quality of evidence: low).

1. 
   Evidence for Recommendation. There is no evidence supporting the routine use of benzodiazepines in the treatment of delirium in hospitalized patients. A study comparing haloperidol, chlorpromazine, or lorazepam terminated the lorazepam arm early because of significant adverse effects. Substantial evidence points to increased delirium with benzodiazepines, longer delirium duration, and possible transition to delirium in ICU patients.
   
2. 
   Potential Harms of Recommendation. The potential harms of this recommendation include withholding treatment for conditions in which benzodiazepines are indicated, such as alcohol and benzodiazepine withdrawal.
   

XIV. Pharmacologic Treatment of Hypoactive Delirium

Recommendation. The prescribing practitioner should not prescribe antipsychotic or benzodiazepine medications for the treatment of older adults with postoperative delirium who are not agitated and threatening substantial harm to self or others (strength of recommendation: strong; quality of evidence: low).

1. 
   Evidence for Recommendation. Pharmacologic treatment has not been consistently shown to modify the duration or severity of postoperative delirium. In addition, the harms of both antipsychotics and benzodiazepines are substantial and well documented, with the potential for increased morbidity and mortality. Healthcare providers should not prescribe these classes of drugs for treatment of delirium in patients without significant agitation that threatens the patient's safety or the safety of others. The use of antipsychotics at the lowest effective dose should be reserved for short-term management of acute agitation in the setting of possible substantial harm.
   
2. 
   Potential Harms of Recommendation. Patients with hypoactive delirium who may be experiencing hallucinations and delusions might get symptomatic relief from their experiences, even if these medications do not resolve the delirious episode. Hallucinatory and delusional experiences might be difficult to elicit from a hypoactive patient during the delirious episode, and withholding antipsychotic medications in this situation might be associated with increased suffering.