title: Antipsychotic prescribing patterns during and after critical illness: a prospective cohort study.
abstract: Antipsychotics are used to treat delirium in the intensive care unit (ICU) despite unproven efficacy. We hypothesized that atypical antipsychotic treatment in the ICU is a risk factor for antipsychotic prescription at discharge, a practice that might increase risk since long-term use is associated with increased mortality.
  
  
  
  After excluding patients on antipsychotics prior to admission, we examined antipsychotic use in a prospective cohort of ICU patients with acute respiratory failure and/or shock. We collected data on medication use from medical records and assessed patients for delirium using the Confusion Assessment Method for the ICU. Using multivariable logistic regression, we analyzed whether age, delirium duration, atypical antipsychotic use, and discharge disposition (each selected a priori) were independent risk factors for discharge on an antipsychotic. We also examined admission Acute Physiology and Chronic Health Evaluation (APACHE) II score, haloperidol use, and days of benzodiazepine use in post hoc analyses.
  
  
  
  After excluding 18 patients due to prior antipsychotic use and three who withdrew, we included 500 patients. Among 208 (42%) treated with an antipsychotic, median (interquartile range) age was 59 (49-69) years and APACHE II score was 26 (22-32), characteristics that were similar among antipsychotic nonusers. Antipsychotic users were more likely than nonusers to have had delirium (93% vs. 61%, p < 0.001). Of the 208 antipsychotic users, 172 survived to hospital discharge, and 42 (24%) of these were prescribed an antipsychotic at discharge. Treatment with an atypical antipsychotic was the only independent risk factor for antipsychotic prescription at discharge (odds ratio 17.6, 95% confidence interval 4.9 to 63.3; p < 0.001). Neither age, delirium duration, nor discharge disposition were risk factors (p = 0.11, 0.38, and 0.12, respectively) in the primary regression model, and post hoc analyses found APACHE II (p = 0.07), haloperidol use (p = 0.16), and days of benzodiazepine use (p = 0.31) were also not risk factors for discharge on an antipsychotic.
  
  
  
  In this study, antipsychotics were used to treat nearly half of all antipsychotic-naïve ICU patients and were prescribed at discharge to 24% of antipsychotic-treated patients. Treatment with an atypical antipsychotic greatly increased the odds of discharge with an antipsychotic prescription, a practice that should be examined carefully during medication reconciliation since these drugs carry "black box warnings" regarding long-term use.
authors.affiliation: Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232-7610, USA.
authors.forename: Jason E
authors.initials: JE
authors.lastname: Tomichek
authors.affiliation: Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232-7610, USA.
authors.forename: Joanna L
authors.initials: JL
authors.lastname: Stollings
authors.affiliation: Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, 1211 21st Ave S, Nashville, TN, 37212, USA.|Anesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, 1310 24th Ave S, Nashville, TN, 37212, USA.
authors.forename: Pratik P
authors.initials: PP
authors.lastname: Pandharipande
authors.affiliation: Department of Biostatistics, Vanderbilt University School of Medicine, 2525 West End Avenue, Nashville, TN, 37203, USA.
authors.forename: Rameela
authors.initials: R
authors.lastname: Chandrasekhar
authors.affiliation: Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, 1161 21st Ave S, Nashville, TN, 37232-2650, USA.|Center for Health Services Research, Vanderbilt University School of Medicine, 1215 21st Ave S, Nashville, TN, 37232-8300, USA.|Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, 1310 24th Ave S, Nashville, TN, 37212, USA.
authors.forename: E Wesley
authors.initials: EW
authors.lastname: Ely
authors.affiliation: Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA, 15261, USA. timothy.girard@upmc.edu.
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Girard
mesh_terms: D000368:Aged; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D003422:Critical Care / Q000379:methods* / Q000592:standards; D016638:Critical Illness / Q000523:psychology* / Q000628:therapy*; D011307:Drug Prescriptions / Q000592:standards; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000592:standards / Q000639:trends; D008297:Male; D059065:Medication Reconciliation / Q000379:methods; D008875:Middle Aged; D010351:Patient Discharge / Q000592:standards / Q000639:trends*; D011446:Prospective Studies
chemical_list: D014150:Antipsychotic Agents
keywords: Antipsychotic agents; Critical care; Delirium