Comparative efficacy study of haloperidol, olanzapine and risperidone in delirium☆
Introduction
Delirium is a common neuropsychiatric disorder among medically compromised patients. It is characterized by disturbance of consciousness, attention, cognition and perception and can also affect emotions, sleep and psychomotor activity [1]. The treatment of patients with delirium involves identifying and treating the etiology of the delirium, ensuring safety and improving the patient's functioning. In terms of pharmacological treatment, antipsychotic medications and benzodiazepines are the commonly used agents. Among the antipsychotics, haloperidol continues to be the most commonly used [2]. However, haloperidol can also lead to extrapyramidal symptoms which are more likely to occur in delirious patients because delirium is more common in elderly and severely medically ill patients. In the last decade or so, many researchers have evaluated the usefulness of second-generation antipsychotics in delirium; however, most of the data are in the form of case reports/case series and open-label trials [3], [4]. Although some randomized controlled trials are available evaluating the role of various atypical antipsychotics in delirium [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], the data are still limited. These trials have compared an antipsychotic agent with haloperidol [5], [6], [7], [8], [10] or two atypical agents [11], [14], and only few trials had placebo-controlled design [8], [12] for treatment of delirium. One trial compared haloperidol with chlorpromazine and lorazepam [9]. In general, these trials have shown that there is no significant difference between the efficacy of haloperidol and atypical antipsychotics in the treatment of delirium. However some of these trials have included only subjects admitted to intensive care units who were mechanically ventilated [13], whereas others have been focused on geriatric population. However, delirium is a heterogeneous disorder, arising due to multiple etiologies, and in our setting is seen more frequently in nonelderly population [15]. Hence, the findings of some of the above studies cannot be generalized to this population. Hence, there is a need to evaluate the effectiveness of atypical antipsychotics in delirium inpatients who are relatively young. This prompted the present randomized controlled trial, which assessed the efficacy and safety of second-generation antipsychotics olanzapine and risperidone vs. haloperidol in patients of delirium admitted to medical and surgical wards.
Section snippets
Approval/consent
The plan of the study was approved by the research and ethics committees of the institute (Post Graduate Institute of Medical Education and Research, Chandigarh, India) where it was conducted. Written informed consent was taken from the patients' primary caregivers prior to randomization. Prior to randomization, the purpose of the study and the pharmacological interventions which are currently available were explained to them. If their patient participates in the trial, they were also told
Results
The mean age of all the three groups was in the mid-40s, and only three subjects in the haloperidol group, two subjects in the risperidone group and 6 subjects in the olanzapine group were 65 years or older. The mean number of years of education varied from 9 to 9.35 years, with slightly higher mean for the risperidone group. Majority of the subjects in all the groups were males. However, no statistically significant difference was noted between the three groups on the above variables (Table 1).
Discussion
Management of delirium involves ensuring safety, improving functioning, identifying and treating the etiology of the delirium and using antipsychotics to control symptoms. Haloperidol continues to be the most commonly used antipsychotic in delirium. However, in recent times, some data have emerged which suggest that atypical antipsychotics may be as efficacious as haloperidol in the treatment of delirium.
The present study was a single-blind randomized controlled trial which evaluated the
Acknowledgments
The study was funded by Institute Research Fund.
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Conflict of interest: none.