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Regarding “Atypical antipsychotics for delirium: A reasonable alternative to haloperidol?” (Current Psychiatry, January 2011, p. 37-46): Delirium usually is an acute encephalopathy with cerebral dysfunction caused by varying pathologies, most of which are extracranial. Examples include mental confusion induced by hypoxia or hypoglycemia. Primary treatment of delirium must be aimed at the specific cause.
Antipsychotic drugs are only a symptomatic intervention for delirium. They can and do provide behavioral control; however, these medications may worsen cases of alcohol or sedative withdrawal, ictal-related problems, neuroleptic malignant syndrome, etc. An antipsychotic may complicate other conditions, thus creating additional clinical difficulties for some patients. Recommending antipsychotics as a treatment focuses on symptomatic aspects; however, the critical mandate is to diagnose and specifically manage the etiology. Once the cause is corrected, the delirium usually resolves.
While treating the primary pathology, if behavioral issues still urgently require immediate control, a benzodiazepine is safer than an antipsychotic. Both medications provide symptomatic control, but a benzodiazepine is less likely to add new clinical problems. The only major precaution with a benzodiazepine is to avoid overprescribing. It is simply safer to rely on benzodiazepines for short-term behavioral management.
Steven Lippmann, MD
Professor of Psychiatry
University of Louisville School of Medicine
Louisville, KY