What are the recommended antipsychotics for treating Intensive Care Unit (ICU)-acquired delirium?

Antipsychotics in ICU-Acquired Delirium

Antipsychotics should NOT be routinely used to treat ICU-acquired delirium, as they do not reduce delirium duration, mechanical ventilation time, ICU length of stay, or mortality. 1

Primary Treatment Approach: Non-Pharmacological First

The cornerstone of ICU delirium management is multicomponent non-pharmacological intervention, not antipsychotics. 1, 2

First-Line Non-Pharmacological Interventions:

• Early mobilization reduces both incidence and duration of delirium and should be implemented whenever feasible 1, 2
• Reorientation strategies including cognitive stimulation, use of clocks and calendars 1, 2
• Sleep optimization through controlling light/noise, clustering care activities, and minimizing nighttime stimulation 1, 2
• Sensory optimization ensuring patients have access to hearing aids and eyeglasses 1, 2
• Light sedation targets with daily sedation interruption rather than deep sedation 1, 2

When Antipsychotics May Be Considered (Limited Role)

Short-term antipsychotic use may be warranted ONLY for patients experiencing significant distress from hallucinations/delusions or dangerous agitation that poses physical harm to themselves or others. 1, 3

Key Evidence Against Routine Use:

• Haloperidol: No published evidence that it reduces delirium duration in ICU patients 1
• Atypical antipsychotics (quetiapine, ziprasidone, olanzapine): May reduce delirium duration but evidence is low quality and does not demonstrate improvement in mortality, ICU length of stay, or mechanical ventilation duration 1, 4
• Statins: Not effective for delirium treatment 1

If Antipsychotics Are Used:

• Discontinue immediately following resolution of distressing symptoms 1, 3
• Avoid in high-risk cardiac patients: Do not use in patients with baseline QTc prolongation, history of torsades de pointes, or concurrent QT-prolonging medications 1, 2
• Atypical antipsychotics (risperidone, olanzapine, quetiapine) have fewer extrapyramidal side effects than haloperidol if pharmacological intervention is deemed necessary 5, 4

Preferred Pharmacological Strategy: Sedation Management

For mechanically ventilated patients with agitation precluding weaning/extubation, use dexmedetomidine rather than benzodiazepines. 1

Sedation Principles:

• Dexmedetomidine over benzodiazepines for sedation in delirious patients (except alcohol/benzodiazepine withdrawal) reduces delirium duration 1, 2
• Avoid benzodiazepines as they are a risk factor for developing delirium 1, 2
• Analgesia-first approach: Manage pain before using sedatives 1, 2

Critical Pitfalls to Avoid

• Do NOT use antipsychotics prophylactically to prevent delirium—this is explicitly not recommended 1, 2
• Do NOT use rivastigmine (cholinesterase inhibitor) as it does not reduce delirium duration 1
• Do NOT rely on pharmacological interventions without addressing modifiable environmental factors and underlying causes 2
• Do NOT forget to screen regularly using validated tools (CAM-ICU or ICDSC) for early detection 2

Algorithm for Decision-Making

1. Implement multicomponent non-pharmacological bundle (mobilization, reorientation, sleep optimization, sensory aids) 1, 2
2. Optimize sedation strategy: Use dexmedetomidine over benzodiazepines if sedation needed 1, 2
3. Reserve antipsychotics ONLY for: Severe distress from hallucinations/delusions OR dangerous agitation threatening patient/staff safety 1, 3
4. If antipsychotic used: Choose atypical agent (quetiapine, olanzapine, risperidone), check QTc, use shortest duration possible, discontinue when symptoms resolve 1, 2, 5

The 2018 Society of Critical Care Medicine guidelines represent a significant shift from earlier 2013 recommendations, now explicitly advising against routine antipsychotic use based on higher-quality randomized trials showing no benefit on meaningful clinical outcomes. 1