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Delirium among terminal patients

Are antipsychotics ineffective?


Delirium is a frequent problem among terminal patients. If non-medicinal measures are insufficiently effective, an obvious choice would appear to be the administration of antipsychotics like haloperidol and risperidone. Recent research, however, has shown that there is no rationale to support this. In fact, there is evidence that this might be counterproductive, in that the terminal patients do not benefit from the drug, but do suffer the side-effects. The current guidelines need to be tightened, taking into account the marginal benefit of antipsychotics for terminal patients with a delirium.

  • The use of haloperidol or risperidone in combination with basic treatment for terminal patients with a delirium who reside in a hospice appears to be less effective than the basic treatment alone.
  • Although the findings presented in the study discussed here relate to patients residing in a hospice, it seems safe to assume that the palliative use of antipsychotics for terminal patients residing at home also lacks beneficial effects.
  • The primary treatment option for terminal patients with a delirium is an individualised comforting and relational approach, and the prevention of delirium-inducing factors.
  • The only drug registered in the Netherlands for the treatment in the terminal stages is haloperidol. Prescribing risperidone, clozapine, olanzapine, quetiapine or rivastigmine for this indication is off-label.
  • The indication for the use of antipsychotics in the Dutch guidelines for the treatment of delirium in the palliative phase should be further tightened up. 

  1. Richtlijn delier Volwassen en ouderen. Nederlandse Vereniging voor Klinische Geriatrie 2013. Via: https://www.nvvp.net/stream/richtlijn-delier-volwassen-en-ouderen-2014.pdf.
  2. Eizenga WH, Dautzenberg PLJ, Eekhof JAH, Scholtes ABJ, Van Venrooij MH, Verduijn MM, et al. NHG-Standaard Delier(eerste herziening). Huisarts Wet 2014;57(4):184-93. Via: https://www.nhg.org/?tmp-no-mobile=1&q=node/1741.
  3. Richtlijn Delier. Integraal Kankercentrum Nederland 2018. Via: https://www.pallialine.nl/delier.
  4. Agar MR, Lawlor PG, Quinn S, Draper B, Caplan GA, Rowett D, et al. Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care. JAMA Intern Med 2017;177(1):34-42.

The literature refers to the Dutch text

Authors

  • dr A.J.F.A. Kerst