Choice of Drug:

Neuroleptics

Question 7.1

If a new neuroleptic agent is to be tested as a treatment for delirium what agent should the control group have?

Placebo

Haloperidol

Psychostimulants

Psychostimulants have a number of uses in the palliative care setting, including potential benefits in the management of hypoactive delirium. They have been shown to be of benefit in the management of opioid related cognitive impairment and sedation (Bruera et al., 1992).

Psychostimulants can produce adverse effects such as hallucinations, delirium or psychosis (which can be treated with haloperidol or discontinuation of the drug). Amphetamine derivatives have other adverse effects such as decreased appetite, and tolerance can develop to their effects. Before prescribing psychostimulants, careful medical history must be taken to exclude any psychiatric disorder. This is important as psychostimulants are contraindicated in patients with a history of hallucinations, delirium or paranoid disorders. They are also relatively contraindicated with a history of substance abuse or hypertension.

Question 7.2

A study to look at treatment of hypoactive delirium with psychostimulants should:

Compare methylphenidate with placebo

Compare haloperidol with methylphenidate

Compare methylphenidate with a new neuroleptic (e.g. olanzapine)

New neuroleptics

There is insufficient evidence regarding the new neuroleptics (such as olanzapine, risperidone and pimozide) in the management of hypoactive delirium to justify a trial where their effect is compared to psychostimulants, which at present do not have an established role in its management.

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