Antipsychotic Continuation after ICU and Hospital Discharge

Fall 2021 Newsletter

By Abigail Dunn, Doctor of Pharmacy Candidate, and Lisa C Hutchison, PharmD, MPH
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Delirium occurs in 7-80% of patients who are admitted into intensive care units (ICUs) and is associated with worse outcomes including a 2-4 fold increased risk of death.¹  When non-pharmacological measures are not effective for hyperactive delirium, patients are typically treated with antipsychotics to prevent them from doing harm to themselves or to others.²  Unfortunately, recent studies indicate that more than 50% of patients with ICU-initiated antipsychotics are discharged with the antipsychotic that was newly prescribed during their inpatient stay ^3-7. Older adults, particularly those with dementia, are at increased risk of delirium, and therefore, may be prescribed an antipsychotic for short-term management of delirium.  Antipsychotics carry a boxed warning for older adults with dementia as they are at increased risk of morbidity and mortality due to exposure to antipsychotics.  So, discontinuation of these medications  should be attempted as soon as the patient’s delirium has resolved.

 As noted, discontinuation of newly started antipsychotics at ICU discharge does not always occur as soon as appropriate.  Frequency of discontinuation with ICU discharge occurs in only 50-77% of patients, and 25-39% of patients continue on antipsychotics at hospital discharge.^3-7  Studies of patients discharged from an ICU with an antipsychotic identify some risk factors.  In one study, patients who were white, male, or admitted for sepsis had increased risk of continuing antipsychotic medications after discharge.⁵  Happily, older adults are not significantly more likely to be discharged on an antipsychotic than younger adults in these studies (mean age of subjects ranging from 57-68 years).^4,5,7  However, of significance for older adults, discharge location of long-term care or advanced care facilities is an associated risk factor. ⁴

While benefits for short-term use of antipsychotics for delirium may outweigh the harms in ICU patients, discontinuation should occur as soon as possible after delirium resolves.  Adverse effects associated with antipsychotics include QTc prolongation, increased mortality, weight gain, hyperlipidemia, and newly diagnosed diabetes mellitus ^4,5.  If discontinuation at ICU or hospital discharge cannot safely occur, information regarding the plan for discontinuation should be communicated at transition of care.  In one study evaluating this process, only 12% of patients discharged had instructions for discontinuation of the antipsychotic.⁹  Often, patients being sent home with this unnecessary medication do not have a medication review prior to discharge.⁵  

Methods should be adopted to address discontinuation of unnecessary medications.  One study described how a clinical pharmacist was responsible for intercepting an average of four medication issues per patient at discharge which included discontinuing the use of certain medications in approximately 39% of patient visits ⁵.  An additional option would be a checklist that is formatted and encouraged upon discharge to remind providers to evaluate a patient to determine if they need to continue the prescribed antipsychotic or other high risk medication.⁴  Finally, use of an antipsychotic discontinuation algorithm with multidisciplinary education at ICU discharge showed a 10% increase in discontinuation rate of antipsychotics at ICU discharge and significantly increased rates of discontinuation within 72 hours of ICU discharge and overall lower rates of antipsychotic continuation at hospital discharge .⁶

While sometimes necessary, antipsychotic initiation in hospital ICUs to treat older adults with delirium comes with increased risk.  Discontinuation before discharge from the ICU is preferred, but if continuation is required, plans for discontinuation should be communicated to the receiving medical team or primary care physician.^4.9  It is critical that ongoing evaluation of patients who are discharged with antipsychotics take place to determine if patients continue to require treatment. ^6,8

References

1. Inouye SK, Westendorp RGJ, Saczynski JS.  Delirium in elderly people.  Lancet, 2014; 383:911-22.
2. Kalish, V. B., Gillham, J. E., & Unwin, B. K. (2014, August 1). Delirium in older persons: Evaluation and management. American Family Physician. https://www.aafp.org/afp/2014/0801/p150.html.
3. Flurrie RW, Gonzales JP, Tata AL, et al.  Hospital delirium treatment: continuation of antipsychotic therapy from the intensive care unit to discharge.  Am J Health-syst Pharm, 2015; 72(suppl 3):S133-9.
4. Karamchandani, K., Schoaps, R. S., Bonavia, A., Prasad, A., Quintili, A., Lehman, E. B., & Carr, Z. J. (2019). Continuation of atypical antipsychotic medications in critically ill patients discharged from the hospital: a single-center retrospective analysis. Therapeutic Advances in Drug Safety. https://doi.org/10.1177/2042098618809933
5. Coe, A. B., Vincent, B. M., & Iwashyna, T. J. (2020). Statin discontinuation and new antipsychotic use after an acute hospital stay vary by hospital. PLOS ONE, 15(5). https://doi.org/10.1371/journal.pone.0232707
6. D’Angelo RG, Rincavage MS, Tata AL, et al.  Impact of an antipsychotic discontinuation bundle during transitions of care in critically ill patients.  J Intensive Care Med, 2019; 34:40-7.
7. Lambert J, Vermassen J, Fierens J, et al.  Discharge from hospital with newly administered antipsychotics after intensive care delirium –incidence and contributing factors.  J Crit Care, 2021; 61:162-7. 
8. Johnson KG, Fashoyin A, Madden-Fuentes R, et al.  Discharge plans for geriatric inpatients with delirium: a plan to stop antipsychotics? JAGS, 2017; 65:2278-81.