Cancer Res Treat.  2015 Jul;47(3):399-405. 10.4143/crt.2013.229.

Frequency and Outcome of Neuroleptic Rotation in the Management of Delirium in Patients with Advanced Cancer

• Shin SH
• Hui D
• Chisholm G
• Kang JH
• Allo J
• Williams J
• Bruera E

• KMID: 2148488
• DOI: http://doi.org/10.4143/crt.2013.229

Abstract

PURPOSE
The response to haloperidol as a first-line neuroleptic and the pattern of neuroleptic rotation after haloperidol failure have not been well defined in palliative care. The purpose of this study was to determine the efficacy of haloperidol as a first-line neuroleptic and the predictors associated with the need to rotate to a second neuroleptic.
MATERIALS AND METHODS
We conducted a retrospective review of the charts of advanced cancer patients admitted to our acute palliative care unit between January 2012 and March 2013. Inclusion criteria were a diagnosis of delirium and first-line treatment with haloperidol.
RESULTS
Among 167 patients with delirium, 128 (77%) received only haloperidol and 39 (23%) received a second neuroleptic. Ninety-one patients (71%) who received haloperidol alone improved and were discharged alive. The median initial haloperidol dose was 5 mg (interquartile ranges [IQR], 3 to 7 mg) and the median duration was 5 days (IQR, 3 to 7 days). The median final haloperidol dose was 6 mg (IQR, 5 to 7 mg). A lack of treatment efficacy was the most common reason for neuroleptic rotation (87%). Significant factors associated with neuroleptic rotation were inpatient mortality (59% vs. 29%, p=0.001), and being Caucasian (87% vs. 62%, p=0.014). Chlorpromazine was administered to 37 patients (95%) who were not treated successfully by haloperidol. The median initial chlorpromazine dose was 150 mg (IQR, 100 to 150 mg) and the median duration was 3 days (IQR, 2 to 6 days). Thirteen patients (33%) showed reduced symptoms after the second neuroleptic.
CONCLUSION
Neuroleptic rotation from haloperidol was only required in 23% of patients with delirium and was associated with inpatient mortality and white race.

Keyword

Delirium; Haloperidol; Neuroleptic rotation; Acute palliative care unit

MeSH Terms

Chlorpromazine
Continental Population Groups
Delirium*
Diagnosis
Haloperidol
Humans
Inpatients
Mortality
Palliative Care
Retrospective Studies
Treatment Outcome
Chlorpromazine
Haloperidol

Figure

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  Fig. 1. Screening and enrollment. APCU, acute palliative care unit.

Reference

References

1. Fang CK, Chen HW, Liu SI, Lin CJ, Tsai LY, Lai YL. Prevalence, detection and treatment of delirium in terminal cancer inpatients: a prospective survey. Jpn J Clin Oncol. 2008; 38:56–63.

2. Centeno C, Sanz A, Bruera E. Delirium in advanced cancer patients. Palliat Med. 2004; 18:184–94.

3. Zaal IJ, Slooter AJ. Delirium in critically ill patients: epidemiology, pathophysiology, diagnosis and management. Drugs. 2012; 72:1457–71.

4. Moyer DD. Review article: terminal delirium in geriatric patients with cancer at end of life. Am J Hosp Palliat Care. 2011; 28:44–51.

5. Breitbart W, Alici Y. Evidence-based treatment of delirium in patients with cancer. J Clin Oncol. 2012; 30:1206–14.

6. Zhang Z, Pan L, Ni H. Impact of delirium on clinical outcome in critically ill patients: a meta-analysis. Gen Hosp Psychiatry. 2013; 35:105–11.

7. Kang JH, Shin SH, Bruera E. Comprehensive approaches to managing delirium in patients with advanced cancer. Cancer Treat Rev. 2013; 39:105–12.

8. Breitbart W, Strout D. Delirium in the terminally ill. Clin Geriatr Med. 2000; 16:357–72.

9. Tatematsu N, Hayashi A, Narita K, Tamaki A, Tsuboyama T. The effects of exercise therapy on delirium in cancer patients: a retrospective study. Support Care Cancer. 2011; 19:765–70.

10. Prommer E. Role of haloperidol in palliative medicine: an update. Am J Hosp Palliat Care. 2012; 29:295–301.

11. Zimmerman K, Rudolph J, Salow M, Skarf LM. Delirium in palliative care patients: focus on pharmacotherapy. Am J Hosp Palliat Care. 2011; 28:501–10.

12. Boettger S, Friedlander M, Breitbart W, Passik S. Aripiprazole and haloperidol in the treatment of delirium. Aust N Z J Psychiatry. 2011; 45:477–82.

13. Boettger S, Breitbart W. An open trial of aripiprazole for the treatment of delirium in hospitalized cancer patients. Palliat Support Care. 2011; 9:351–7.

14. Candy B, Jackson KC, Jones L, Leurent B, Tookman A, King M. Drug therapy for delirium in terminally ill adult patients. Cochrane Database Syst Rev. 2012; 11:CD004770.

15. Hui D, Reddy A, Palla S, Bruera E. Neuroleptic prescription pattern for delirium in patients with advanced cancer. J Palliat Care. 2011; 27:141–7.

16. Hui D, Bush SH, Gallo LE, Palmer JL, Yennurajalingam S, Bruera E. Neuroleptic dose in the management of delirium in patients with advanced cancer. J Pain Symptom Manage. 2010; 39:186–96.

17. Rijcken CA, Monster TB, Brouwers JR, de Jong-van den Berg LT. Chlorpromazine equivalents versus defined daily doses: how to compare antipsychotic drug doses? J Clin Psychopharmacol. 2003; 23:657–9.

18. Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care. 1991; 7:6–9.

19. Elsayem A, Mori M, Parsons HA, Munsell MF, Hui D, Delgado-Guay MO, et al. Predictors of inpatient mortality in an acute palliative care unit at a comprehensive cancer center. Support Care Cancer. 2010; 18:67–76.

20. Wang EH, Mabasa VH, Loh GW, Ensom MH. Haloperidol dosing strategies in the treatment of delirium in the critically ill. Neurocrit Care. 2012; 16:170–83.

21. Skrobik YK, Bergeron N, Dumont M, Gottfried SB. Olanzapine vs haloperidol: treating delirium in a critical care setting. Intensive Care Med. 2004; 30:444–9.

22. Wang HR, Woo YS, Bahk WM. Atypical antipsychotics in the treatment of delirium. Psychiatry Clin Neurosci. 2013; 67:323–31.

23. Hui D, Kilgore K, Fellman B, Urbauer D, Hall S, Fajardo J, et al. Development and cross-validation of the in-hospital mortality prediction in advanced cancer patients score: a preliminary study. J Palliat Med. 2012; 15:902–9.

24. Lawlor PG, Bruera ED. Delirium in patients with advanced cancer. Hematol Oncol Clin North Am. 2002; 16:701–14.

25. Kwon JH, Hui D, Chisholm G, Hong WT, Nguyen L, Bruera E. Experience of barriers to pain management in patients receiving outpatient palliative care. J Palliat Med. 2013; 16:908–14.