Volume 64, Issue 2 p. 299-305
Clinical Investigations

Antipsychotic Use in Hospitalized Adults: Rates, Indications, and Predictors

Shoshana J. Herzig MD, MPH

Corresponding Author

Shoshana J. Herzig MD, MPH

Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Harvard Medical School, Boston, Massachusetts

Address correspondence to Shoshana J. Herzig, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA 02446. E-mail: [email protected]Search for more papers by this author
Michael B. Rothberg MD, MPH

Michael B. Rothberg MD, MPH

Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio

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Jamey R. Guess MS

Jamey R. Guess MS

Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts

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Jennifer P. Stevens MD

Jennifer P. Stevens MD

Harvard Medical School, Boston, Massachusetts

Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts

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John Marshall PharmD

John Marshall PharmD

Harvard Medical School, Boston, Massachusetts

Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts

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Jerry H. Gurwitz MD

Jerry H. Gurwitz MD

Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Community Health Plan, Worcester, Massachusetts

University of Massachusetts Medical School, Worcester, Massachusetts

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Edward R. Marcantonio MD, SM

Edward R. Marcantonio MD, SM

Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Harvard Medical School, Boston, Massachusetts

Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts

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First published: 18 February 2016
Citations: 50

Abstract

Objectives

To investigate patterns and predictors of use of antipsychotics in hospitalized adults.

Design

Retrospective cohort study.

Setting

Academic medical center.

Participants

Individuals aged 18 and older hospitalized from August 2012 to August 2013, excluding those admitted to obstetrics and gynecology or psychiatry or with a psychotic disorder.

Measurements

Use was ascertained from pharmacy charges. Potentially excessive dosing was defined using guidelines for long-term care facilities. A review of 100 records was performed to determine reasons for use.

Results

The cohort included 17,775 admissions with a median age 64; individuals could have been admitted more than once during the study period. Antipsychotics were used in 9%, 55% of which were initiations. The most common reasons for initiation were delirium (53%) and probable delirium (12%). Potentially excessive dosing occurred in 16% of admissions exposed to an antipsychotic. Of admissions with antipsychotic initiation, 26% were discharged on these medications. Characteristics associated with initiation included age 75 and older (relative risk (RR) = 1.4, 95% confidence interval (CI) = 1.2–1.7), male sex (RR = 1.2, 95% CI = 1.1–1.4), black race (RR = 0.8, 95% CI = 0.6–0.96), delirium (RR = 4.8, 95% CI = 4.2–5.7), dementia (RR = 2.1, 95% CI = 1.7–2.6), admission to a medical service (RR = 1.2, 95% CI = 1.1–1.4), intensive care unit stay (RR = 2.1, 95% CI = 1.8–2.4), and mechanical ventilation (RR = 2.0, 95% CI = 1.7–2.4). In individuals who were initiated on an antipsychotic, characteristics associated with discharge on antipsychotics were age 75 and older (RR = 0.6, 95% CI = 0.4–0.7), discharge to any location other than home (RR = 2.5, 95% CI = 1.8–3.3), and class of in-hospital antipsychotic exposure (RR = 1.6, 95% CI = 1.1–2.3 for atypical vs typical; RR = 2.7, 95% CI = 1.9–3.8 for both vs typical).

Conclusion

Antipsychotic initiation and use were common during hospitalization, most often for delirium, and individuals were frequently discharged on these medications. Several predictors of use on discharge were identified, suggesting potential targets for decision support tools that would be used to prompt consideration of ongoing necessity.