2026 Eastern States Conference

Title: Use of antipsychotics compared to polypharmacy de-escalation in resolution of intensive care unit delirium 
Authors: Kaylee Simon, PharmD; Keri Denchfield, PharmD, BCCCP, CNSC; Lisa Pickmans, PharmD, BCCCP, BCPS; Ayah Arafat
Learning Objective: Audience members will be able to describe limitations in current guideline recommendations for treatment of ICU delirium  
Background/Objective: Evaluate whether de-escalation of sedating and/or anticholinergic medications is as effective as antipsychotic initiation for resolving ICU delirium  
Methods: This retrospective single center cohort study utilized chart review to identify patients admitted to the surgical ICU from January 1-October 31, 2025 who are over 18 years of age, have a Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) positive assessment after 24 hours of admission, and are receiving at least one anticholinergic or sedating medication based on the Drug Burden Index. Patients with alternative etiologies of altered mental status or baseline psychiatric disorders requiring antipsychotics were excluded. Patients were grouped into three treatment strategies: antipsychotic initiation, de-escalation of sedative or anticholinergic medications, or no changes. Outcomes included time to resolution of delirium, ICU length of stay, and intensity of medication changes before and after delirium onset. Continuous data was measured using means with standard deviations and medians with interquartile ranges and groups will be compared using the Kruskal-Wallis test.
Results: 170 patients were screened with 14 patients being included. Patients were most frequently excluded due to mechanical ventilation on continuous sedatives within 48 hours of CAM-ICU + score. No statistical analysis was performed on the primary or secondary outcomes and no subgroup analysis was conducted due to the small sample size. The observed median time to delirium resolution in the antipsychotic group was 5 days, 1 day for the de-escalation group, and 2 days for the no change group. The most commonly identified anticholinergic and sedative medications were fentanyl, oxycodone, hydromorphone, methocarbamol, metoclopramide, gabapentin, and buprenorphine. The most common medications de-escalated were opioids.
Conclusions: No firm conclusions can be drawn about the effectiveness of de-escalation of anticholinergic and sedative medications compared to antipsychotics for time to resolution of delirium. De-escalation was observed only in the hypoactive delirium subgroup, suggesting potential utility in this population, though further research is needed.   

Self Assessment Question: What is the current recommendation for antipsychotics for delirium treatment?