• Dae Hyun Kim, Su Been Lee, Chan Mi Park, Raisa Levin, Eran Metzger, Brian T Bateman, E Wesley Ely, Pratik P Pandharipande, Margaret A Pisani, Richard N Jones, Edward R Marcantonio, and Sharon K Inouye.
• Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston; Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston; and Harvard Medical School, Boston, Massachusetts (D.H.K.).
• Ann. Intern. Med. 2023 Sep 1; 176 (9): 115311621153-1162.

BackgroundAntipsychotics are commonly used to manage postoperative delirium. Recent studies reported that haloperidol use has declined, and atypical antipsychotic use has increased over time.ObjectiveTo compare the risk for in-hospital adverse events associated with oral haloperidol, olanzapine, quetiapine, and risperidone in older patients after major surgery.DesignRetrospective cohort study.SettingU.S. hospitals in the Premier Healthcare Database.Patients17 115 patients aged 65 years and older without psychiatric disorders who were prescribed an oral antipsychotic drug after major surgery from 2009 to 2018.InterventionsHaloperidol (≤4 mg on the day of initiation), olanzapine (≤10 mg), quetiapine (≤150 mg), and risperidone (≤4 mg).MeasurementsThe risk ratios (RRs) for in-hospital death, cardiac arrhythmia events, pneumonia, and stroke or transient ischemic attack (TIA) were estimated after propensity score overlap weighting.ResultsThe weighted population had a mean age of 79.6 years, was 60.5% female, and had in-hospital death of 3.1%. Among the 4 antipsychotics, quetiapine was the most prescribed (53.0% of total exposure). There was no statistically significant difference in the risk for in-hospital death among patients treated with haloperidol (3.7%, reference group), olanzapine (2.8%; RR, 0.74 [95% CI, 0.42 to 1.27]), quetiapine (2.6%; RR, 0.70 [CI, 0.47 to 1.04]), and risperidone (3.3%; RR, 0.90 [CI, 0.53 to 1.41]). The risk for nonfatal clinical events ranged from 2.0% to 2.6% for a cardiac arrhythmia event, 4.2% to 4.6% for pneumonia, and 0.6% to 1.2% for stroke or TIA, with no statistically significant differences by treatment group.LimitationResidual confounding by delirium severity; lack of untreated group; restriction to oral low-to-moderate dose treatment.ConclusionThese results suggest that atypical antipsychotics and haloperidol have similar rates of in-hospital adverse clinical events in older patients with postoperative delirium who receive an oral low-to-moderate dose antipsychotic drug.Primary Funding SourceNational Institute on Aging.

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