Annals of Internal MedicineComparative Safety Analysis of Oral Antipsychotics for In-Hospital Adverse Clinical Events in Older Adults After Major Surgery

Navigating Antipsychotic Choices in Postoperative Delirium: A Comparative Risk Analysis

In the management of postoperative delirium in older patients, the choice of antipsychotic medication has been a subject of debate. A recent retrospective cohort study delves into the comparative risks of in-hospital adverse events among four commonly used antipsychotics—haloperidol, olanzapine, quetiapine, and risperidone.

HCN Medical Memo
For those treating patients in a hospital, this study suggests that the choice between haloperidol and atypical antipsychotics like olanzapine, quetiapine, and risperidone may have little impact on the risk of in-hospital adverse events. Therefore, treatment decisions can be more flexibly tailored to individual patient needs without a significant compromise on safety.

Study Design:

• Design: Retrospective cohort study
• Setting: US hospitals in the Premier Healthcare Database
• Participants: 17,115 patients aged 65 and older without psychiatric disorders, prescribed an oral antipsychotic after major surgery between 2009 and 2018
• Mean Age & Gender: The weighted population had a mean age of 79.6 years and was 60.5% female
• Interventions: Haloperidol (≤4 mg), olanzapine (≤10 mg), quetiapine (≤150 mg), and risperidone (≤4 mg)
• Measurements: Risk ratios (RRs) for in-hospital death, cardiac arrhythmia, pneumonia, and stroke or TIA were estimated

Up to 50% of patients aged 65 and older may experience postoperative delirium following major surgery, significantly impacting their recovery and long-term cognitive function.

Key Findings:

• In-Hospital Death: 3.1% overall, with no statistically significant difference among the four antipsychotics
• Most Prescribed: Quetiapine was the most prescribed antipsychotic, accounting for 53.0% of total exposure
• Nonfatal Clinical Events: Ranged from 2.0% to 2.6% for cardiac arrhythmia, 4.2% to 4.6% for pneumonia, and 0.6% to 1.2% for stroke or TIA, with no significant differences by treatment group

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