Avoiding use of antipsychotic medicines

If you have delirium and you are distressed, your healthcare team will investigate what is causing your distress and reassure you, and address anything that is disturbing you, such as pain, discomfort or noise. Your family or carers will be encouraged to be involved in your care.

Antipsychotic medicines (such as the active ingredients quetiapine, olanzapine and risperidone*) are not usually recommended, because they do not help to treat the underlying cause of delirium and their side effects can result in serious harm. They may be considered if you are likely to harm yourself or others, and if it is not possible to reduce your distress in other ways. In this case, a clinician may discuss using an antipsychotic medicine at a low dose for a short time. A single dose may be enough. When an antipsychotic medicine is being considered for this reason, your clinician will discuss with you and your family or carer the choice of antipsychotic medicine, its side effects and benefits, dose, and how long you need to take it for.

Use of devices that restrict movement is avoided whenever possible.

If a patient with delirium has severe behavioural or emotional disturbance:

• Investigate possible causes by conducting a comprehensive assessment that includes a medication review. Identify medicines that are known to contribute to delirium and adjust if appropriate, such as medicines with anticholinergic or sedative properties. Ensure that any medical causes for distress and agitation, such as pain, constipation, urinary retention and hypoxia, are treated
• Reassure the patient and offer non-drug strategies – involving family or carers, if possible, or one-on-one nursing – to calm the patient and de-escalate the situation
• Obtain information about the patient, their needs and preferences, and ways to reduce distress. If the patient cannot provide the information themselves, engage with family or carers, and use a structured tool such as the TOP 5 model
• Ensure that the environment is safe for the patient and that noise is minimised, and the patient is observed without the staff invading their personal space
• Use verbal and non-verbal techniques to de-escalate the situation, such as:
  • being respectful
  • introducing yourself and using their title rather than their given name if the patient does not know you
  • talking slowly and calmly
  • not disagreeing with the patient
  • asking questions and listening to the answers
  • expressing empathy and concern to show that you have understood
  • inclining your head slightly, to show you are listening and to give you a non-threatening posture
  • acknowledging their feelings and that the situation they find themselves in is frightening or distressing
  • providing a distraction
• Avoid using physical or mechanical restraints, as they can increase agitation, prolong delirium and increase the risk of injury.

Evidence does not support the routine use of antipsychotics for treating delirium. However short-term antipsychotic use may be considered in limited circumstances – for instance, when non-drug strategies are unsuccessful and there is an imminent risk of the patient harming themselves or others. In such cases, assess the potential harms and benefits of prescribing an antipsychotic and, whenever possible, discuss the use of the medicine with the patient and family and obtain informed consent. Use the lowest appropriate dose for the shortest possible duration, as described in Therapeutic Guidelines: Psychotropic. A single dose is usually enough. When an antipsychotic medicine has been used in an emergency situation, discuss the use with the patient and their family or carer, so they understand why it was used.

If an antipsychotic is prescribed for a longer duration (more than a single dose), document the plan for the duration of therapy and the criteria for cessation – that is, the change in behaviour to be achieved. Advise the patient and their family or carer that longer-term use of antipsychotics has a greater risk of harm than of benefit, except in limited circumstances. Provide information on the process for review and monitoring the use of the medicine.

Arrange psychiatry or geriatric review for a patient with delirium who has other indications for antipsychotic use, or who has an existing prescription for antipsychotics.

Over-sedation can have serious consequences, such as dehydration, falls, respiratory depression, pneumonia and death. People with Parkinson’s disease or with Lewy body dementia are at an increased risk of severe adverse reactions from antipsychotics. Avoid benzodiazepines when managing delirium, as complications are common and long-acting benzodiazepines increase delirium.

Ensure that policies and systems are in place to treat delirium and to support using non-drug strategies as first-line therapy. The policies should include guidance about the non-drug strategies to be tried, evaluated and documented. These may include patient specialling (cohort care or one-on-one nursing), using specialist delirium/dementia care nurses with expertise in behaviour interventions, and involving family or carers. Provide regular training for clinicians on de-escalation techniques and other non-drug strategies.

Ensure that clinicians have access to guidance about:

• The potential harms of antipsychotic medicines and current recommendations for their use in delirium
• Appropriate prescribing when there is an imminent risk of self-harm or harm to others, including the appropriate choice of antipsychotic, and dose and duration (such as described in Therapeutic Guidelines: Psychotropic).

Policies should describe the process followed for when an antipsychotic is being considered for a patient at risk of harming themselves or others. The process should include documenting:

• The non-drug strategies tried
• How the patient and family will be advised and provide informed consent
• The process for review, monitoring and cessation of the medicine, including review before discharge.

If antipsychotic use occurs in an emergency context, the policy should ensure that the patient and family or carer are advised.

Ensure that discharge communication to primary care clinicians and care providers, the patient and their family or carer is accurate, to prevent inadvertent continuation of antipsychotics used acutely.

Ensure that systems are in place to minimise the use of physical restraints, and that clinicians are educated in the appropriate use of restraints.