Antipsychotic Drugs Don't Ease ICU Delirium Or Dementia

To be fair i'm not the least bit surprised. Having been in a Pediatric ICU or CCT for 20+ years Ive never seen these drugs work with any sort of reliability at least in the short term we use them.

Powerful drugs that have been used for decades to treat delirium are ineffective for that purpose, according to a study published online Monday in the New England Journal of Medicine.

Antipsychotic medications, such as haloperidol (brand name, Haldol), are widely used in intensive care units, emergency rooms, hospital wards and nursing homes.

"In some surveys up to 70 percent of patients [in the ICU] get these antipsychotics," says Dr. E. Wesley "Wes" Ely, an intensive care specialist at Vanderbilt University Medical Center. They're prescribed by "very good doctors at extremely good medical centers," he says. "Millions of people worldwide are getting these drugs to treat their delirium." www.npr.org...

They do seem to work short term in that they allow the ICU's to sedate agitated patients for the short term but do not seem to help get at the root cause of the ICU Psychosis we see.

Typically we use a variety of non medical methods (this is pediatrics mind you) and use Haldol as a last resort.

Quiet hospital concept (minimal noise etc)
Day / night: rather than have the harsh room lights on 24/7 they will drop them down during the night shift using only the minimum
Clustering care to minimize disruptions.
Try not to work on full moon nights (more for me than the patients)

Beyond that I'm at a loss as what else we can do.

Some of the meds I was prescribed for my epilepsy are not tollerated by the majority of northern Europeans cultures. They can be used temporarily but not long term. After a month I started to get side effects on all five classes of the meds I was given. The longer I was on them the worse they got. Initially they worked but in a month or two, some of them gave me more seizure activity than without them. I cannot take any of the five classes, I am totally dependent on diet and special supplements, and even those foods I need to rotate to treat my condition. I do not have grand Mal seizures, just TLE seizures, I do not know if diet would effectively treat all epileptics.

Thorazine is a terrible med, my cousin had a real bad reaction to that. I have similar intolerance to that according to my genetics, lots of people have bad side effects with that if they do not metabolize it correctly, it poisons them. Same with many anti-psychotics, sometimes they make people worse. At first they seem to work, but the body needs to be able to break them down and excrete them properly, fat cells can buffer the med initially, the people gain weight as the fat cells absorb the med so they do not die. But eventually they get saturated and cannot help.

I work in critical care.

It doesn't work all the time but honestly I have seen patients lives saved because this drug let us do what he had to do when they have become delirious so I think for this to really change practice we need more evidence.

Its interesting that the study seems to be talking more about long-term use in treatment of delirium but it does specifically mention that the drugs can be used to clam people down when this is required. I personally have only ever really seen it used for this or as a anti-psychotic not for long-term post-icu delirium. Treatment for that is usually as the OP says much more about environment and time.

My reading of this does not say that Haliperidol should not be used for treatment of acute delirium.

It works, I used it daily, and when you have some poor old boy whose a ex-boxer who is trying to use you as a punch bag anytime you try to get that IV-line in him, I am still going to be thinking about Haliperidol as a option.

Still really interesting article, think I will have to go see if I can get a full copy of it.

What is paediatric delirium like though? I only work with adults so av never seen it.

I had a severe psychotic reactions to demerol in the hospital once. Seeing things that were not there such as critiquing Scarlet O'hara's choice of wardrobe etc. I was given Haldol which honestly made it worse before getting better. Same hallucinations, just couldnt really move.

It was terrifying.

originally posted by: FredT
To be fair i'm not the least bit surprised. Having been in a Pediatric ICU or CCT for 20+ years Ive never seen these drugs work with any sort of reliability at least in the short term we use them.

Powerful drugs that have been used for decades to treat delirium are ineffective for that purpose, according to a study published online Monday in the New England Journal of Medicine.

Antipsychotic medications, such as haloperidol (brand name, Haldol), are widely used in intensive care units, emergency rooms, hospital wards and nursing homes.

"In some surveys up to 70 percent of patients [in the ICU] get these antipsychotics," says Dr. E. Wesley "Wes" Ely, an intensive care specialist at Vanderbilt University Medical Center. They're prescribed by "very good doctors at extremely good medical centers," he says. "Millions of people worldwide are getting these drugs to treat their delirium." www.npr.org...

They do seem to work short term in that they allow the ICU's to sedate agitated patients for the short term but do not seem to help get at the root cause of the ICU Psychosis we see.

Typically we use a variety of non medical methods (this is pediatrics mind you) and use Haldol as a last resort.

Quiet hospital concept (minimal noise etc)
Day / night: rather than have the harsh room lights on 24/7 they will drop them down during the night shift using only the minimum
Clustering care to minimize disruptions.
Try not to work on full moon nights (more for me than the patients)

Beyond that I'm at a loss as what else we can do.

Retired 20 years University of Michigan Med Center, Trauma, ER, Burn, Survival Flight, Med Proc.Units....now EMT/ERT 1st Responder-ADLS. I agree with comments so far.

The days of Thorazine, Lithium, etc...as far as a quick fix in/out/? It doesn't seem to be effective short term. Any immediate reaction may or may not be the instant stabilzer, go home, prescibed same, and it's a crap shoot if it works at all. For some it does.

Anti- psychotics, and all alike don't seem to be as effective as they once were. Many of these die-hards once worked on a majority of issues...now, not so much. With the manic depressives, bi-polars, antisocials, delusionals...it used to be the Benzo's, barbituates, even hypnotics like qualudes were...I think now...over-prescribed as an end-all...and we're often mixed in with the same patients once discharged taking these w amphetamines to reverse their side effects unknown in the 50's thru 90's.

We just didnt know now of the contra-indications and side effects. I can remember family members going to the ER...getting Lithum...Thorazine...Elavil-Diazapam...going home and being put on those among others, then getting Nembutol, Tuintol, Seconal for sleep...then amphet.s to get them moving the next day. It just confounded and didn't cure the underlying psychosis.

We have a huge problem these days with more and more men, women, children with issues then ever before. But without staying on meds a bit, then going off to determine their abilities to curb the psychosis...some doctors proceed with the "So how are you doing?" q + a sessions...keep patients on them...(sure for some it's a necessary direction)...but what worked before short-term, and being continually prescribed without counseling and good after-care...patients stay in psychosis the minute they go off them.

I have family now with bi-polar and mania issues...and with the "cocktails" I see them prescribed now? It's no wonder....*

ADLS
Advanced Life Support
EMT/911
Emergency Response Team
Michigan

*Full moon nights on our rigs are something else....!

a reply to: FredT

Beyond that I'm at a loss as what else we can do.

Might I suggest a low dose of THC...

I have a couple residents that have been put on Marinol which is synthetic THC, and the results are fantastic...

One of them use to literally chase me down the hall, I mean she HATED me... I assume I reminded her of someone in her past... In any case she was violent and belligerent when she arrived, and didn't eat or drink anything for at least a week.

Now she loves mostly everyone... shes happy, and has a good appetite

Now she does have dementia, but I also have many other residents that are perfectly fine... just old, and there are almost always benefits when they're put on a form of THC

a reply to: OtherSideOfTheCoin

ICU psychosis in the pediatric ICU does mirror the experience in the adult world. That is agitation, violence, etc. Its not always that way however, I spent a 12 hour shift in a Denver Bed (its on the floor with walls so people cannot fall) with a 300 pound kid with downs syndrome. He was the record holder in his class for weight lifting at the Special Olympics and had psychosis bad. He was seeing spiders everywhere so him and I spent those 12 hours with flyswatters swatting away at imaginary spiders and he was happy as a clam.

We try non pharm stuff before we go the drug route unless its severe agitation and the patient is at risk of harming themselves or others

@ Rickymouse and Akragon

I’m no doctor and have no medical training whatsoever, so run this by a real doctor...

I have heard that CBD oil (one of the non-psychoactive components of marijuana) is an effective treatment for seizures in some people.... in a few people it’s like a shocking miracle cure, causing people to move where it’s legal (often taking a huge pay cit to do so), and parents to go to jail for giving it to their kids.

Obviously, talk to a dr and check local laws, and use common sense

I've been taking antipsychotic medication for 22 years for schizophrenia. When I first got the illness at age 21 my mom had me involuntarily committed. They gave me an injection of haldol. I was drugged to the max. It worked it brought me out of the psychosis. I then switched to a newer medication that I've been on all these years. It works and I can't imagine life without it. I know it works because I quit taking it once and ended up in a psychosis again. I had to be hospitalized a second time.

Both my grandmothers have alzheimers. One of my grandmothers just passed 2 months ago. My great grandfather had it also. I've seen first hand what the illness does to people. They can be extremely difficult to deal with. I know they use antipsychotic medication for the illenss. The only reason I can think of that they use it is make them more docile. People with alzheimers have delusional type behavior. My grandmother kept looking for her dogs. She was climbing under my uncles bed while he was sleeping looking for the dogs when the dogs were right there. She never took medication. My aunts and uncles took care of her. She was a nightmare to deal with so I understand why they might use haldol in that trype of situation.

When I was in the hospital the doctors told my mom there was little chance I would recover and that I might have to be institutionalized the rest of my life. I was having severe hallucinations and delusions. The drugs brought me out of it. It was a long recovery process. Unlike schizophrenia there's no recovery from alzheimers. Their brain and cognitive function just deteriorates until they die.