CNA803 Literature Review: Antipsychotics for Elderly Delirium Patients

This literature review, conducted by a student, examines the use of antipsychotic drugs to reduce delirium in elderly postoperative patients. The review explores the prevalence of delirium, particularly in this demographic, and the rationale behind using antipsychotics as a treatment option. The methodology involves a search of various databases, including ProQuest, CINAHL, and the Cochrane database, using keywords such as 'delirium,' 'antipsychotic drug,' and 'post-operative delirium.' The review synthesizes findings from peer-reviewed articles published after 2014, focusing on the effectiveness and efficacy of antipsychotics in managing delirium. It discusses the risk factors associated with delirium, such as age and surgical procedures, and evaluates the outcomes of its treatment. The paper also considers the limitations of current research and the need for further studies to determine the optimal use of antipsychotics in this context, including the use of specific drugs like haloperidol and ketamine. The review concludes with an assessment of the effectiveness of antipsychotics and the need for more evidence-based practices.

Running head: LITERATURE REVIEW
LITERATURE REVIEW
Name of the Student:
Name of the University:
Author’s Note:

Is it necessary to give antipsychotics drugs to reduce delirium in the elderly
postoperative?
Introduction
Delirium is one of the common medical condition that is encountered in the world
because of which people consult psychiatrists. Liu et al. (2019) opined that delirium is a
disturbance of consciousness that leads to a reduction in concentration, change in cognitive
ability and perceptual disturbance. It can be predicted that 10 to 15% of mentally ill patients
are delirious and 30 to 50% of the acutely ill geriatric patient have this disorder at some point
in their lives (Wan and Chase 2017).
The phenomenon of postoperative delirium is mostly observed in elderly individuals
who have been a part of a surgical procedure recently (Sarpal et al. 2016). The prevalence of
experiencing delirium in elderly patients is high because of the decreasing capacity of the
individuals to comprehend the reason for delirium. Hence, for the appropriate treatment,
antipsychotic drugs are used which act as antidepressant drugs allowing the nervous system
to calm down as a result of which, the patient can be managed and controlled in an effective
manner (Sarpal et al. 2016). Therefore, the administration of antipsychotic drugs is important
for delirious patient is effective in nature.
The use of the medication among delirious patients is relatively a new aspect in my
mental health facility. It involves considering the impact of antipsychotic drugs on delirium
patients, especially among elderly post-operative patients, undergoing an operation. Hence, a
literature review has been conducted for gaining in-depth information in understanding its
effectiveness and efficacy level in managing the issues.

Method
For conducting the literature review, an electronic search was undertaken in various
databases such as ProQuest Health and Medical Complete, Cumulative Index to Nursing and
Allied Health Literature (CINAHL) and Cochrane database were used. The search items that
have been used were ‘delirium’ ‘antipsychotic drug’, ‘post-operative delirium’, ‘haloperidol’,
‘model of care’, ‘pharmacologic management’ and ‘drug therapy’. For ensuring that the
literature was significant to the current practice, inclusion criteria were not included that
involve journal articles were peer-reviewed, were published after 2014, need to be in English
and the full text was available. The reference list of the articles was reviewed to seek for
addition and relevant information related to the subject topic. In addition to this, the selection
of the articles used for the review was based on the level of evidence hierarchy, includes
systematic studies, meta-analysis, and cohort studies, and randomised control trials.
Each of the literature was individually evaluated to understand the efficacy of the
antipsychotic drugs on the patients suffering from delirium and the population was adults.
This helps in understanding management strategies used among the patient population to
address the issues exhibited by the disorder upon the brain functioning as well as the
cognitive behaviour of patients.
Background
Older surgical patients often experience postoperative delirium (POD) and
postoperative cognitive dysfunction (POCD) growth afterwards. Medical characteristics
include impairment of memory, concentration disturbance and decreased environmental
awareness, resulting in increased morbidity, mortality and increased use of social, financial
support (Androsova et al. 2015). The ageing Western societies could expect the incidence of
POD and POCD to increase. Due to their societal burden, the underlying pathophysiological

mechanisms were studied at the molecular level though with unsatisfactory little research
efforts. The multifactorial cause of delirium and its complex pathophysiology have made
prevention and treatment difficult. Pain, its opioid treatment and the inflammatory response
to injury in surgical patients are all possible risk factors for delirium. A significant
development for perioperative treatment would be a drug that both offers analgesia and
avoids delirium.
As per the 2013 Pain, Agitation and Delirium (PAD) Guidelines of the American
College of Critical Care Medicines, there is no symptomatic target management of the
disorder as there is a lack of compelling data. However, the guidelines state that atypical
antipsychotics can be used for reducing the time of delirium to a low level. Antipsychotic
drugs are found to block the dopamine D2 receptors that are present in the dopaminergic
pathways in the brain, thus, reducing the effect of dopamine. Rivière et al. (2019) opined that
the release of excess dopamine in the mesolimbic pathway is associated with psychotic
episodes. In the case of bipolar disorder and schizophrenia, there is decreased production of
dopamine in the prefrontal cortex and more production in other pathways in postoperative
patients.
Furthermore, antipsychotic has an antagonising effect on 5-HT2A receptors. The
different alleles of the receptors are observed to have associated with different mental
conditions such as psychosis, schizophrenia and depression. Fontaine et al. (2018) opined
that a higher concentration of the receptors particular in the cortical and subcortical areas in
the right caudate nucleus that was previously recorded.
Discussion
Identification of Delirium

Delirium is one of the primary cause of mortality and morbidity in hospitalised
elderly patients, those who have dementia. Marcantonio (2017) opined that this is a
vulnerable group because due to low immune system, they acquire various conditions such as
hospital-acquired infection, nutritional issue, pressure, immobility, increase cost of healthcare
services, more extended stay in hospital and long term care after discharge. According to the
study conducted by Oh et al. (2017), 10014 admissions in the acute medical unit indicated
that the prevalence of delirium was 24.6% among patients above the age of 65 years and
7.9% on dementia patients. The concern of the disorder needs to be treated in an effective
manner. From the discussion of Oberai et al. (2018), the advance in diagnosis includes brief
screening tools such as 3-Minute Diagnostic Assessment, 4A’s test and proxy-based
measurement. These supported in monitoring the response to treatment, risk stratification and
prevention of symptoms. This indicates that advances in the diagnosis process help in early
recognition and risk identification of delirium. In another study by Mulkey, Olson and Hardin
(2019), nurse prevention and intervention strategies were stated that have evidence of
practice and its effectiveness. The four intervention includes day and night routine, early
mobility, reducing sensory impairment and reorientation. The use of evidence-informed
management requires an individualised and multi-component approach for restoring the
physiological functions of patients. According to a specific study by Lam and Gandell
(2018), it was found that the nurse-led the care process in Britain and pre-operative
assessment was not the structure of Canadian pre-operative clinics among the high-risk
vascular patients. The evidence for reduced length of stay using assessment of the
preoperative comprehensive geriatric patient in the vascular surgical setting.
Risk factors and outcome
The use of systematic review that involves 26442 old patients with the help of semi-
quantitative analysis was conducted for evaluating the risk factors and outcomes of deliriums

subtype (Krewulak et al. 2020). The risk factors that are taken into consideration include age,
sex and APACHE-II score and outcome include mechanical ventilation, mortality, and length
of hospital stay, tube removal and delirium duration. However, due to different aspects of
both reporting and limitation in methodical quality has restricted the generalisation of the
result and the evidence for various subtype-specific risk factors or the outcomes thus, making
it inconsistent among the studies. Kim et al. (2018) noted the persistent episodes of delirium
is found to have a negative impact on the patients because of it. The differences in an
underlying chronic condition that accounts for the difference in the discharge duration and
condition between medical ill patients and patients undergoing surgical suffering from
delirium. However, the disorders are commonly superimposed on dementia as a result which,
the identification process is delayed resulting in no or delayed treatment (Mulkey et al. 2018).
This has a profound impact on the patient’s recovery process and do not validates the care
setting. Thus, the limitations of the study are it was unable to identify the reason because of
which, the training provided was not appropriately addressed even though the assessment
tools were found to be promising in nature.
Use of Antipsychotic Drugs for treating Delirium
Teipel et al. (2018) noted that people that are at a high risk of dementia and
undergone surgery have a long-term risk. This may be involved in increasing the risk factor.
The finding of the paper had stated that perioperative management could be used for reducing
the risk factors and can have benefits in joint replacement surgery that led to long-term
mobility and cognition among older populations. Scholtens et al. (2016) conducted a
preliminary study for evaluating the occurrence of delirium in older patients undergoing hip
replacement surgery and the impact of preoperative Cerebrospinal Fluid (CSF) Melatonin
concentration on the specified group of people. Melatonin is used for regulating the circadian
rhythm, and since delirium has a feature of disturbed rhythmic action of circadian thus, it was

thought upon that this drug would be useful in treating the patients. A cohort study was
undertaken upon 67 patients with hip fracture than are above the age of 65 years and were
administered with spinal anaesthesia. From the study, it was concluded that there was no
significant impact of the drug on the patients in term of cognitive impairment or age. Thus, it
clearly indicated that this antipsychotic drug was not useful in case of treating delirium.
Delirium is considered to be one of the common and severe postoperative complications
among people who are older than 60 years and have a high risk of mortality and morbidity. In
another study, the use of subanaesthia ketamine is stated to be administered in case of
intraoperative surgery as a postoperative analgesic and there were some evidence that
suggested that this drug help in preventing the signs of deliriums. A Prevention of Delirium
and Complications Associated with Surgical Treatment (PODCAST) study conducted by
Avidan et al. (2017) was done that involve randomised trials among the adults with 60 years
who had undergone cardiac and non-cardiac surgery which was undertaken general
anaesthesia. From the result, it was interpreted that a single sub anaesthetic dose of ketamine
was not effective in decreasing the disorder among the target population after the surgery and
in severe case, it can be seen that it might cause harm to the patients by inducing negative
experience thus, causing traumatic effect on the patients' population. Therefore, the use of
antipsychotic drugs, specifically ketamine, was not found to be effective in treating delirium
in case of postoperative patients that are above the age of 60 years.
Pahwa, Qureshi and Cumbler (2019) have undertaken case study analysis that
particularly addresses the reason because of which people use antipsychotic drugs and why it
is not useful among delirium patients. With respect to the case, it was observed that the use of
haloperidol was used for reducing the severity and duration of the disorder as well as shorten
the duration of hospitalisation due to hip surgery. There is evidence that states that 10-30% of
the patients had received antipsychotic drugs during the hospital stay due to delirium.

However, the aspect of variability among the patterns of drugs was not understood that
resulted in conflicting results. A piece of evidence indicated that the fact that efficacy of these
drugs was not appropriate and there is an absence of persuasive evidence that indicated any
change in stay length in the hospital or the benefits of antipsychotic drugs in treating
postoperative delirium. A study that was conducted by Kassie et al. (2018) stated that
medicines have the potential of risk factor in case of postoperative delirium. However, due to
inadequate evidence, the extent of the effectiveness of these drugs and the efficacy of the risk
prediction model (RPM) was not known. The use of systematic study was conducted that
supported in understanding the inclusion of preoperative medication in RPM for
postoperative delirium. It was found that even though the medications are commonly used,
however, these are not sufficiently considered in RPM; thus, there is a requirement of
developing an RPM in case of postoperative delirium for understanding the modifiable nature
as well as its impact on factors such as cognition. Tremblay and Gold (2016) had undertaken
a literature review for assessing the postoperative delirium (POD), which is found to be a
serious complication and caused a significant number of mortality and morbidity. In addition
to this, it also leads to various issues such as increases the cost of healthcare services, the
extension of the length of hospital stays; thus, there is a secondary complication after
postoperative delirium. The patient type and timing of the postoperative delirium are
observed to be associated with differential delirium outcome that suggested that fact that
targeted screening and use of interventional approaches are useful in handling the disorder.
From the extensive literature study, it was found that in 14 articles, evidence related to
reducing the incidence of postoperative delirium using pharmacological agent was found
where eight indicated the use of antipsychotic drugs, two with statins one with melatonin,
dexamethasone, gabapentin and diazepam respectively. As per the result, the issue of study
design, methods used and interpretation were found that has a negative impact on the

conclusion. This indicated that use of double-blinded randomised clinical trial needs to be
conducted for understanding the effectiveness of using pharmacological agents in reducing
POD. Oh et al. (2019) had initiated a study to understand the benefits and harms of the use
of psychotic drugs for reducing delirium where a systematic review was done. RCTs were
used for comparing the antipsychotic with placebo or other antipsychotic drugs, and it was
found that there was no difference in any of the variables in using antipsychotic drugs as
compared to placebo. The presence of different clinical characteristics pattern among the
older population of delirium were observed. This finding was relevant into the clinical care
with respect to acutely ill patients and proposed that there is the implication of different
pathways in the pathophysiology in delirium that need to be assessed for the development of
effective management of care. Haque, Naqvi and Dasgupta (2019) stated that due to POD,
there is a high rate of functional deaths. Thus, the use of Ondansetron, which is a serotonin
antagonist, could be used as a therapeutic option for the disorder. A systematic review using
valid and reliable database was used that included three RCTs that were selected in this case.
From the result, it was inferred that Ondansetron might be effective in case of treating or
preventing POD; however, the studies were not valid or reliable as it involves the poor
quality of studies which is responsible for making the conclusion more unsubstantiated in
nature. Therefore, the requirement of large RCTs will be required for understanding the
efficacy level of the drug in treating the disorder among adults’ especially old people that had
undergone cardiac or post-traumatic surgery in the ICU.
Management strategies for delirium
As per the study of Johnson et al. (2017), impatient geriatric patients that have
reversible conditions of delirium may continue to have antipsychotic medications after
hospital discharge. Thus, a retrospective chart review was conducted. It was observed that in
the healthcare system, most of the old population of patients with delirium are discharged

with a new antipsychotic drug where no instruction was outlined to the providers about
discontinuation management. As known, prolonged use of the drug have several negative
impacts and thus, require interventions that would help in offering more guidance related to
the antipsychotic medication at the transition of care. Finucane et al. (2020) stated that drug
therapy is one of the management for delirium. The use of RCTs for drug therapies in term of
dose by any route, which is a non-pharmacological approach. The studies had reported the
outcome that stated essential elements such as the symptoms of delirium such as agitation and
adverse events of the disorders. The drugs such as haloperidol, risperidone, olanzapine,
placebo, lorazepam and chlorpromazine. As per the study, it was not possible to combine the
data because of lack of similarity in them; as a result, low-quality evidence was observed that
stated drugs such as risperidone and haloperidol had worsened the symptoms of the disease
among terminally ill older patients that have mild to moderate delirium. Thus, further
research needs to be conducted for the determination of the negative impact of drug therapy
on the vulnerable population.
van den Boogaard et al. (2020) conducted a multinational cohort study that was
initiated in understanding the impact of sedation on delirium among critically illness people
where 1660 patients were assessed using Richmond Agitation-Sedation Scale along with
sedating medications. Logistic regression was used that aided in the analysis of the factors
that may potentially affect the level of sedation on the above-stated population. It was found
that the influence was dependent on the usage of the Intensive Care Delirium Screening
Checklist (ICDSU) or Confusion Assessment Method for the Intensive Care Unit (CAM-
ICU). In addition to this, ICU nurses were considered while assessing the level of sedation
among patients suffering from delirium. Thus, it was stated that future studies need to be
conducted that will help in comparing the CAM-ICU and the ICDSC in a simultaneous
manner to understand its effectiveness using a sample population and control group. Eeles et

al. (2020) opined that delirium is one of the major healthcare problems on a global scale and
have severe consequences where the use of sub-optimal management is a universal strategy.
The interval or gap found in the care process of the patients were observed to have
distinctiveness of the disorder as it affects oneself. The corruptive and violent behaviour of
the patient render harm to both selves as well as the external surrounding; thus, require
control over the symptoms, which place the individual at risk of mechanical dehumanisation
behaviour.
Conclusion
From the literature review, it was found that antipsychotic drugs are commonly used
among delirious patients. The most significant aspect of using this class of drug is because
there is less evidence that state the underlying factors and risks with respect to aetiology and
pathophysiology of the disease. Various other management plans have been developed with
respect to delirium among the older population and people suffering from critical illness;
however, the effectiveness of those care processes was not sufficient enough that would help
in limiting the use of antipsychotic drugs. The antipsychotic drugs do not have any evidence
related to its efficacy and effectiveness among the patient population. The focus was given on
postoperative delirium and the impact of antipsychotic drug in disorder, which was not
sufficiently addressed because of lack of evidence. The nursing practices were found to be in
conjunction with the identification and treatment of the disease among patient undergoing
surgeries. Due to lack of proper training related to the use of various assessment tools
available for early detection, the treatment process is hampered to a large extent. One of the
aspects that affect the care plan of postoperative delirium is due to lack of training and
shortage of skilled professional nurses; the condition is often mistaken with dementia. It is
responsible for delaying the process of care mainly that affect the use of antipsychotic drugs
among the specified target population in effectively treating the disorder.

References
Androsova, G., Krause, R., Winterer, G. and Schneider, R., 2015. Biomarkers of
postoperative delirium and cognitive dysfunction. Frontiers in aging neuroscience, 7, p.112.
Avidan, M.S., Maybrier, H.R., Abdallah, A.B., Jacobsohn, E., Vlisides, P.E., Pryor, K.O.,
Veselis, R.A., Grocott, H.P., Emmert, D.A., Rogers, E.M. and Downey, R.J., 2017.
Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery
in older adults: an international, multicentre, double-blind, randomised clinical trial. The
Lancet, 390(10091), pp.267-275.
Eeles, E., England, R., Teodorczuk, A., Pandy, S., Pinsker, D. and Armstrong, A., 2020.
Delirium Management: Anything’s Possible. Canadian Journal on Aging/La Revue
canadienne du vieillissement, 39(1), pp.89-97.
Finucane, A.M., Jones, L., Leurent, B., Sampson, E.L., Stone, P., Tookman, A. and Candy,
B., 2020. Drug therapy for delirium in terminally ill adults. Cochrane Database of Systematic
Reviews, (1).
Fontaine, G.V., Mortensen, W., Guinto, K.M., Scott, D.M. and Miller III, R.R., 2018. Newly
initiated in-hospital antipsychotics continued at discharge in non-psychiatric
patients. Hospital pharmacy, 53(5), pp.308-315.
Haque, N., Naqvi, R.M. and Dasgupta, M., 2019. Efficacy of Ondansetron in the Prevention
or Treatment of Post-operative Delirium—a Systematic Review. Canadian Geriatrics
Journal, 22(1), p.1.
in diagnosis and treatment. Jama, 318(12), pp.1161-1174.