PDF(Pubmed)
Abstract：
BACKGROUND: International guidelines discourage antipsychotic use for delirium; however, concerns persist about their continued use in clinical practice.
OBJECTIVE: We aimed to describe the prevalence and patterns of antipsychotic use in delirium management with regard to best-practice recommendations. Primary outcomes investigated were prevalence of use, antipsychotic type, dosage and clinical indication.
METHODS: Eligibility criteria: studies of any design that examined antipsychotic use to manage delirium in adults in critical care, acute care, palliative care, rehabilitation, and aged care were included. Studies of patients in acute psychiatric care, with psychiatric illness or pre-existing antipsychotic use were excluded.
METHODS: we searched five health databases on 16 August, 2023 (PubMed, CINAHL, Embase, APA PsycInfo, ProQuest Health and Medical Collection) using MeSH terms and relevant keywords, including \'delirium\' and \'antipsychotic\'. Risk of bias: as no included studies were randomised controlled trials, all studies were assessed for methodological quality using the Mixed Methods Appraisal Tool.
RESULTS: descriptive data were extracted in Covidence and synthesised in Microsoft Excel.
RESULTS: Included studies: 39 studies published between March 2004 and August 2023 from 13 countries (n = 1,359,519 patients). Most study designs were retrospective medical record audits (n = 16).
RESULTS: in 18 studies, participants\' mean age was ≥65 years (77.79, ±5.20). Palliative care had the highest average proportion of patients with delirium managed with antipsychotics (70.87%, ±33.81%); it was lower and varied little between intensive care unit (53.53%, ±19.73%) and non-intensive care unit settings [medical, surgical and any acute care wards] (56.93%, ±26.44%) and was lowest in in-patient rehabilitation (17.8%). Seventeen different antipsychotics were reported on. In patients aged ≥65 years, haloperidol was the most frequently used and at higher than recommended mean daily doses (2.75 mg, ±2.21 mg). Other antipsychotics commonly administered were olanzapine (mean 11 mg, ±8.54 mg), quetiapine (mean 64.23 mg, ±43.20 mg) and risperidone (mean 0.97 mg, ±0.64 mg).
CONCLUSIONS: The use of antipsychotics to manage delirium is strongly discouraged in international guidelines. Antipsychotic use in delirium care is a risk for adverse health outcomes and a longer duration of delirium, especially in older people. However, this study has provided evidence that clinicians continue to use antipsychotics for delirium management, the dose, frequency and duration of which are often outside evidence-based guideline recommendations. Clinicians continue to choose antipsychotics to manage delirium symptoms to settle agitation and maintain patient and staff safety, particularly in situations where workload pressures are high. Sustained efforts are needed at the individual, team and organisational levels to educate, train and support clinicians to prioritise non-pharmacological interventions early before deciding to use antipsychotics. This could prevent delirium and avert escalation in behavioural symptoms that often lead to antipsychotic use.
OBJECTIVE: We aimed to describe the prevalence and patterns of antipsychotic use in delirium management with regard to best-practice recommendations. Primary outcomes investigated were prevalence of use, antipsychotic type, dosage and clinical indication.
METHODS: Eligibility criteria: studies of any design that examined antipsychotic use to manage delirium in adults in critical care, acute care, palliative care, rehabilitation, and aged care were included. Studies of patients in acute psychiatric care, with psychiatric illness or pre-existing antipsychotic use were excluded.
METHODS: we searched five health databases on 16 August, 2023 (PubMed, CINAHL, Embase, APA PsycInfo, ProQuest Health and Medical Collection) using MeSH terms and relevant keywords, including \'delirium\' and \'antipsychotic\'. Risk of bias: as no included studies were randomised controlled trials, all studies were assessed for methodological quality using the Mixed Methods Appraisal Tool.
RESULTS: descriptive data were extracted in Covidence and synthesised in Microsoft Excel.
RESULTS: Included studies: 39 studies published between March 2004 and August 2023 from 13 countries (n = 1,359,519 patients). Most study designs were retrospective medical record audits (n = 16).
RESULTS: in 18 studies, participants\' mean age was ≥65 years (77.79, ±5.20). Palliative care had the highest average proportion of patients with delirium managed with antipsychotics (70.87%, ±33.81%); it was lower and varied little between intensive care unit (53.53%, ±19.73%) and non-intensive care unit settings [medical, surgical and any acute care wards] (56.93%, ±26.44%) and was lowest in in-patient rehabilitation (17.8%). Seventeen different antipsychotics were reported on. In patients aged ≥65 years, haloperidol was the most frequently used and at higher than recommended mean daily doses (2.75 mg, ±2.21 mg). Other antipsychotics commonly administered were olanzapine (mean 11 mg, ±8.54 mg), quetiapine (mean 64.23 mg, ±43.20 mg) and risperidone (mean 0.97 mg, ±0.64 mg).
CONCLUSIONS: The use of antipsychotics to manage delirium is strongly discouraged in international guidelines. Antipsychotic use in delirium care is a risk for adverse health outcomes and a longer duration of delirium, especially in older people. However, this study has provided evidence that clinicians continue to use antipsychotics for delirium management, the dose, frequency and duration of which are often outside evidence-based guideline recommendations. Clinicians continue to choose antipsychotics to manage delirium symptoms to settle agitation and maintain patient and staff safety, particularly in situations where workload pressures are high. Sustained efforts are needed at the individual, team and organisational levels to educate, train and support clinicians to prioritise non-pharmacological interventions early before deciding to use antipsychotics. This could prevent delirium and avert escalation in behavioural symptoms that often lead to antipsychotic use.
摘要：
背景：国际指南不鼓励使用抗精神病药物治疗谵妄；然而，人们仍然担心它们在临床实践中的持续使用。
目的：我们旨在根据最佳实践建议描述谵妄治疗中抗精神病药物使用的患病率和模式。调查的主要结果是使用率，抗精神病药物类型，剂量和临床指征。
方法：资格标准：对任何设计的研究，这些设计检查了在重症监护中使用抗精神病药物来管理成人的谵妄，急性护理，姑息治疗,康复,老年护理包括在内。急性精神病患者的研究，患有精神疾病或既往使用抗精神病药物的患者被排除.
方法：我们在8月16日搜索了五个健康数据库，2023年（PubMed，CINAHL,Embase,APAPsycInfo，ProQuestHealthandMedicalCollection)使用MeSH术语和相关关键字，包括“谵妄”和“抗精神病药”。偏倚的风险：因为没有纳入随机对照试验的研究，使用混合方法评价工具对所有研究的方法学质量进行评价.
结果：描述性数据在Covidence中提取并在MicrosoftExcel中合成。
结果：纳入研究：2004年3月至2023年8月间发表的39项研究来自13个国家（n=1,359,519名患者）。大多数研究设计是回顾性病历审核（n=16）。
结果：在18项研究中，参与者平均年龄≥65岁(77.79,±5.20).姑息治疗的谵妄患者平均比例最高(70.87%,±33.81%)；重症监护病房之间较低，差异不大(53.53%，±19.73%)和非重症监护病房设置[医疗，外科和任何急性护理病房](56.93%，±26.44％），在住院康复中最低（17.8％）。报告了17种不同的抗精神病药物。在年龄≥65岁的患者中，氟哌啶醇是最常用的，高于推荐的平均日剂量(2.75毫克，±2.21毫克）。其他常用的抗精神病药物是奥氮平(平均11毫克，±8.54毫克），喹硫平（平均64.23毫克，±43.20毫克)和利培酮(平均0.97毫克，±0.64毫克）。
结论：国际指南强烈反对使用抗精神病药物治疗谵妄。在谵妄护理中使用抗精神病药物会导致不良健康结局和谵妄持续时间较长的风险。尤其是老年人。然而,这项研究提供了临床医生继续使用抗精神病药物治疗谵妄的证据，剂量,其频率和持续时间通常不在循证指南建议范围内。临床医生继续选择抗精神病药来控制谵妄症状，以解决躁动并维护患者和工作人员的安全，特别是在工作量压力很大的情况下。个人需要持续的努力，团队和组织层面的教育，在决定使用抗精神病药物之前，培训和支持临床医生优先考虑非药物干预措施。这可以防止谵妄并避免通常导致抗精神病药物使用的行为症状升级。
目的：我们旨在根据最佳实践建议描述谵妄治疗中抗精神病药物使用的患病率和模式。调查的主要结果是使用率，抗精神病药物类型，剂量和临床指征。
方法：资格标准：对任何设计的研究，这些设计检查了在重症监护中使用抗精神病药物来管理成人的谵妄，急性护理，姑息治疗,康复,老年护理包括在内。急性精神病患者的研究，患有精神疾病或既往使用抗精神病药物的患者被排除.
方法：我们在8月16日搜索了五个健康数据库，2023年（PubMed，CINAHL,Embase,APAPsycInfo，ProQuestHealthandMedicalCollection)使用MeSH术语和相关关键字，包括“谵妄”和“抗精神病药”。偏倚的风险：因为没有纳入随机对照试验的研究，使用混合方法评价工具对所有研究的方法学质量进行评价.
结果：描述性数据在Covidence中提取并在MicrosoftExcel中合成。
结果：纳入研究：2004年3月至2023年8月间发表的39项研究来自13个国家（n=1,359,519名患者）。大多数研究设计是回顾性病历审核（n=16）。
结果：在18项研究中，参与者平均年龄≥65岁(77.79,±5.20).姑息治疗的谵妄患者平均比例最高(70.87%,±33.81%)；重症监护病房之间较低，差异不大(53.53%，±19.73%)和非重症监护病房设置[医疗，外科和任何急性护理病房](56.93%，±26.44％），在住院康复中最低（17.8％）。报告了17种不同的抗精神病药物。在年龄≥65岁的患者中，氟哌啶醇是最常用的，高于推荐的平均日剂量(2.75毫克，±2.21毫克）。其他常用的抗精神病药物是奥氮平(平均11毫克，±8.54毫克），喹硫平（平均64.23毫克，±43.20毫克)和利培酮(平均0.97毫克，±0.64毫克）。
结论：国际指南强烈反对使用抗精神病药物治疗谵妄。在谵妄护理中使用抗精神病药物会导致不良健康结局和谵妄持续时间较长的风险。尤其是老年人。然而,这项研究提供了临床医生继续使用抗精神病药物治疗谵妄的证据，剂量,其频率和持续时间通常不在循证指南建议范围内。临床医生继续选择抗精神病药来控制谵妄症状，以解决躁动并维护患者和工作人员的安全，特别是在工作量压力很大的情况下。个人需要持续的努力，团队和组织层面的教育，在决定使用抗精神病药物之前，培训和支持临床医生优先考虑非药物干预措施。这可以防止谵妄并避免通常导致抗精神病药物使用的行为症状升级。
