Neuroleptic prescription pattern for delirium in patients with advanced cancer

Background: Neuroleptics are frequently used by palliative care specialists to treat delirium. In this study, we determined the median daily neuroleptic dose and prescription pattern in a cohort of unselected advanced cancer in-patients with delirium. Methods: We retrospectively reviewed the charts of 100 consecutive patients admitted to our acute palliative care unit with delirium for demographics, delirium characteristics, and neuroleptic use during the first five days of delirium. The dose of neuroleptics was expressed using the concept of haloperidol equivalent daily dose (HEDD). Results: The median delirium duration was six days, and the median Memorial Delirium Assessment Scale on day 1 was 13/30. Subtypes of delirium included hypoactive (31 percent), mixed (59 percent), and hyperactive (10 percent). Haloperidol, olanzapine, and chlorpromazine were given to 94 (94 percent), 8 (8 percent), and 5 (5 percent) of patients, respectively. The median five-day average HEDD was 3.2 mg (interquartile range 1.5-6.0 mg). HEDD was not associated with any clinical characteristics except delirium subtype. Among the 31 occasions in which ≥3 breakthrough doses were given in a day, only 9 (29 percent) resulted In an increase in the scheduled neuroleptic dose, and 1 (3 percent) resulted in the addition of a new neuroleptic the next day. Among the 73 patients with ≥4 days of delirium, only 49 (67 percent) had an increase in the neuroleptic dose, and 2 (3 percent) had a new neuroleptic added. Conclusion: HEDD was lower than doses reported in previous studies involving cancer patients and was adjusted sparingly. Prospective clinical trials are necessary to identify the optimal neuroleptic dose for delirium.