How do you select between antipsychotics in the treatment of delirium refractory to nonpharmacological management in hospitalized older adults with dementia?

Five rules for choosing an antipsychotic in delirium for internal medicine residents called overnight for agitation/delirium in an older adult:

1. Treat the cause first. The first-line treatment of delirium is to identify and address precipitating factors such as infection, hypoxia, urinary retention, constipation, pain, medication effects, sleep deprivation, or metabolic disturbances.
2. Do not use antipsychotics unless safety is a concern. Reserve them for severe agitation causing risk to the patie...

I have learned that antipsychotic selection is very institution-based/variable.

Traditionally, at the Brigham, we have preferred Seroquel because it is titratable and avoids issues if the patient has underlying Parkinson's. However, now that Zyprexa is available in IV form, house staff often prefer to use that instead.

There have been two reviews on the literature regarding antipsychotics, and the data is still a bit vague.

Burry et al., PMID 29920656

Neufeld et al., PMID 27004732

For many years, I have had great success with Seroquel IR tablets because they are titratable. Because of the many potential side effects, I start low dose, usually 6.25 mg-12.5 mg in the morning and 12.5 mg-25 mg in the evenings, and titrate to effect, watching for drowsiness and orthostasis as well as for contraindications. This is why I split the doses with lower in the am. Most patients are very restless at night, and the sedative effects are helpful at nighttime with lower doses in am achie...

SNFs in particular face strict CMS/Medicare requirements for PRN antipsychotics, including indication/documentation, monitoring, and a 14-day limit with prescriber reevaluation, so facilities often avoid accepting patients who may still require PRN behavioral medications. We try to avoid any IV/IM or PO PRN antipsychotics if possible. Antipsychotics are not effective in hypoactive delirium.

In terms of selection of antipsychotics for a dementia patient with behavioral issues or hyperactive delir...