Clinical question: Does discontinuation after discharge of antipsychotic medications (APMs) started for hospital delirium result in reduced adverse clinical outcomes compared to APM continuation in geriatric patients?
Background: APMs are frequently used off-label to manage behavioral disturbances due to hyperactive delirium in hospitalized geriatric patients. Clinical consensus has recommended using APMs for the shortest duration possible in delirious patients, and about one-third of older patients are continued on APMs upon discharge. APMs have been linked to multiple adverse clinical outcomes, including death, falls, urinary tract infection (UTI), pneumonia, and stroke.
Study design: Population-based cohort study
Setting: Two nationwide databases: U.S. Medicare claims data from July 1, 2013, through December 31, 2018, and a large de-identified U.S. commercial healthcare claims database (Optum CDM) from July 1, 2004, through May 31, 2024
Synopsis: This study compared discontinuation versus continuation of APMs initiated within 30 days of hospitalization in geriatric patients in two databases. Oral forms of atypical APMs and haloperidol were considered. Exclusion criteria included: diagnosed psychiatric disorders, prior exposure to APM, end-stage kidney or liver disease, metastatic solid tumors, and palliative or hospice care. Incidence density sampling was used to match APM discontinuers (gap of more than 45 days) and continuers based on the type of APM prescribed, time since their first APM prescription, and whether they had been admitted to intensive care prior. A total of 13,712 propensity–score-matched pairs were included. APM discontinuation was associated with lower risks of rehospitalization (hazard ratio [HR], 0.89; 95% CI, 0.85-0.96), recurrent inpatient delirium (HR, 0.87; 95% CI, 0.79-0.96), fall-related visits (HR, 0.77; 95% CI, 0.67-0.90), hospitalization with UTI (HR, 0.79; CI, 0.66-0.94), and all-cause mortality (HR, 0.77; 95% CI, 0.69-0.86). No significant difference was seen in the risk of pneumonia or stroke. Subgroup analysis by dementia status, type and dose of APM, and duration of APM exposure yielded consistent results. Limitations included a lack of specific information on the type of delirium, potential other indications for APM use, and reliance on the gaps between APM for timing of treatment discontinuation.
Bottom line: Discontinuation of APMs after hospitalization is associated with decreased risk of rehospitalization, all-cause mortality, recurrent inpatient delirium, fall-related visits, and hospitalization with UTIs regardless of age, sex, or dementia status. This highlights the importance of minimizing use after acute hospitalization.
Citation: Yang C, et al. Health outcomes of discontinuing antipsychotics after hospitalization in older adults. JAMA Psychiatry. 2025;82(7):671–680. doi:10.1001/jamapsychiatry.2025.0702.
Dr. Garcia
Dr. Garcia is a hospitalist and assistant professor of internal medicine at the University of North Carolina in Chapel Hill, NC.