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Three Part Question

In [adults presenting with acute confusion]is [Haloperidol] better than [Risperidone] in [managing acute confusion and reducing mortality]

Clinical Scenario

A 46 year old male patient presents at the emergency department with signs of acute confusion. He is being disruptive in the waiting room and you worry he will hurt himself or others. You wonder which out of Haloperidol and Risperidone would be better to sedate him effectively and safely.

Search Strategy

MEDLINE 1950 to June week 4 2010, EMBASE 1980 to 2010 week 26 and the COCHRANE LIBRARY.
(exp confusion/ OR exp delirium/) AND (exp risperidone/) AND ( exp haloperidol/) limit to human and English language.

Search Outcome

Medline found 9 papers, 4 relevant. Embase found 512 papers, none of which were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Chanh-SU Han and Yong-Ku Kim. July-August 2004 Korea	24 patients presenting with altered mental status. randomly assigned half to receive Risperidone and half to receive Haloperidol.	Double-blind randomised control trial.	Memorial Delirium Assessment scale.	both groups improved and no significant difference between the two groups.	Uncertainty about drug dosing strategy's for risperidone as less experienced data available. Very small number of patients. No formal rating for side effects of drugs.
			Side effects	One patient in the haloperidol group showed mild symptoms of akathisia
Shingo Miyaji, Kenji Yamamoto, Syunya Hoshino et al. February 2007 Japan	266 inpatients, consecutively referred as having delirium between July 01 and May 05.	Retrospective	Length of stay in hospital	no significant differences between the groups.	Not all patient received just one drug alone for the treatment. Did not determine the severity of the delirium. Patients did not all have similar levels of underlying disease. Not all patients were followed up and those not found were assumed to still be alive.
			Adverse incidences	Significantly lower for risperidone than haloperidol
			Death rate one year on.	Significantly higher for IV haloperidol than than oral haloperidol and risperidone.
Ozbolt LB. Paniagua MA. Kaiser RM. Jan 2008 America	Various different trials	Review	Effectiveness of antipsychotics	risperidone and haloperidol of similar efficacy.	Only abstract available. Only studying data on elderly.
			Rate of side effects	higher rate of side effects with haloperidol
Lonergan E, Britton AM, Luxenberg J. 2009	3 randomised trials of patients with delirium. One study was comparing haloperidol with olanzapine so not relevant for this question. One study was looking at the effect of haloperidol on preventing delirium, so again not relevant for this study. The third study, (Han 2004) has been mentioned above, comparing haloperidol with risperidone.	systematic review	Control of delirium	no difference between haloperidol and risperidone.	Based on small trials and limited evidence.
			Adverse effects	Higher doses of haloperidol lead to increased risk of adverse effects.

Comment(s)

There is no evidence from these papers that risperidone leads to a worse prognosis than haloperidol. In fact haloperidol has a higher rate of adverse incidences that increases as the dose increases. The papers all show haloperidol has an increased risk of extrapyramidal side effects.

Clinical Bottom Line

Risperidone should be considered as a first-line drug in those with delirium, especially with those requiring high doses or at increased risk of developing extrapyramidal side effects.

References

1. Chanh-SU Han and Yong-Ku Kim A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics July-August 2004; 297-301
2. Shingo Miyaji, Kenji Yamamoto, Syunya Hoshino et al. Comparison of the risk of adverse events between risperidone and haloperidol in delirium patients. Psychiatry and Clinical Neurosciences 2007, 275-282
3. Ozbolt LB. Paniagua MA. Kaiser RM. Atypical antipsychotics for the treatment of delirious elders. Journal of the American Medical Directors Association jan 2008; 18-28
4. Lonergan E, Britton AM, Luxenberg J. Antipsychotics for delirium The Cochrane Collaboration 2009; Issue 1