Haloperidol Prophylaxis in Older Emergency Department Patients (HARPOON)

• The number of days there is a significant change from baseline in the mean Delirium Observation Screening (DOS) score. [ Time Frame: Assessed from date of first documented delirium, up to 30 days from admission. ] [ Designated as safety issue: No ]
  Reflecting the duration of in-hospital delirium, which is the number of days in-hospital delirium is present in each participant who developed documented in-hospital delirium. Delirium is diagnosed according to a mean Delirium Observation Screening (DOS) score >3 out of three DOS scale scores/24 hours (indicating significant change), and meeting DSM-IV criteria.
• Significant change from baseline in the mean Delirium Observation Screening (DOS) score. [ Time Frame: Assessed up to 30 days from admission. ] [ Designated as safety issue: No ]
  Reflecting the incidence of in-hospital delirium, which is the number of participants (percentage) that newly develop documented in-hospital delirium. Delirium is diagnosed according to a mean Delirium Observation Screening (DOS) score >3 out of three DOS scale scores/24 hours (indicating significant change), and meeting DSM-IV criteria.
• Change in the Delirium Rating Scale-Revised-98 (DRS-R-98) score in subjects with documented delirium. [ Time Frame: Assessed from date of first documented delirium, up to 30 days from admission. ] [ Designated as safety issue: No ]
  Reflecting the severity of in-hospital delirium in each participant who developed documented in-hospital delirium. Delirium severity is assessed according to a gliding score between ≥ 16 - 39 on the 13 severity items of the DRS-R-98 (higher scores indicate more severe delirium) in subjects with documented delirium (according to a mean Delirium Observation Screening (DOS) score >3 out of three DOS scale scores/24 hours, and meeting DSM-IV criteria).

• The number of days before there is a significant change from baseline in the mean Delirium Observation Screening (DOS) score. [ Time Frame: From date of admission until the date of first documented delirium, assessed up to 30 days from admission. ] [ Designated as safety issue: No ]
  Reflecting the time-to-develop delirium, which are the number of days from admission day until the first day delirium is diagnosed, assessed up to 30 days from admission. Delirium is diagnosed according to a mean Delirium Observation Screening (DOS) score >3 out of three DOS scale scores/24 hours (indicating significant change), and meeting DSM-IV criteria.
• The (mean) number of days subjects are admitted to the hospital. [ Time Frame: Assessed up to 30 days from admission. ] [ Designated as safety issue: No ]
  The number of admission days per subject will be used to evaluate the mean hospital length of stay (LOS) in both study arms. The mean LOS is defined by the mean number of days each participant is admitted to hospital, assessed from admission day up to discharge date.
• Functionality at baseline according to the Index of Independence in Activities of Daily Living (ADL) [ Time Frame: 30 days prior, to the date of hospital admission. ] [ Designated as safety issue: No ]
  Functionality at baseline will be assessed according to the 6-item Index of Independence in Activities of Daily Living (ADL), administered on admission. Scores rang from 0-6 for both women and men, with higher scores indicating high function/independent.
• Change from baseline functionality at 3 months according to the Index of Independence in Activities of Daily Living (ADL) [ Time Frame: From baseline to assessment at time point 90 days after discharge date. ] [ Designated as safety issue: No ]
  Change from baseline functionality at 3 months after discharge date will be assessed at time point 90 days from hospital discharge date, according to the 6-item Index of Independence in Activities of Daily Living (ADL).
• Change from baseline functionality at 6 months according to the Index of Independence in Activities of Daily Living (ADL). [ Time Frame: From baseline to assessment at 180 days after discharge date. ] [ Designated as safety issue: No ]
  Change in functionality from baseline at 6 months after discharge date will be assessed at time point 180 days from hospital discharge date, according to the 6-item Index of Independence in Activities of Daily Living (ADL).
• Functionality at baseline according to the Instrumental Activities of Daily Living Scale (IADL). [ Time Frame: 30 days prior, to the date of hospital admission. ] [ Designated as safety issue: No ]
  Functionality at baseline will be assessed according to the 8-item Instrumental Activities of Daily Living Scale (IADL), administered on admission. Scores range from 0-8 for women, and 0-5 for men with higher scores indicating high function/independent.
• Change from baseline functionality at 3 months according to the Instrumental Activities of Daily Living Scale (IADL). [ Time Frame: From baseline to assessment at time point 90 days after discharge date. ] [ Designated as safety issue: No ]
  Change from baseline functionality at 3 months after discharge date will be assessed at time point 90 days from hospital discharge date, according to the 8-item Instrumental Activities of Daily Living Scale (IADL).
• Change from baseline functionality at 6 months according to the Instrumental Activities of Daily Living Scale (IADL). [ Time Frame: From baseline to assessment at time point 180 days after discharge date. ] [ Designated as safety issue: No ]
  Change in functionality from baseline at 6 months after discharge date will be assessed at time point 180 days from hospital discharge date, according to the 8-item Instrumental Activities of Daily Living Scale (IADL).
• Mortality during hospital admission. [ Time Frame: From admission date to the date death from any cause is documented during hospital admission, assessed up to 30 days from admission. ] [ Designated as safety issue: No ]
  In-hospital mortality is reflected by the number of deaths (percentage of the total number of subjects included in the study) during hospital admission, assessed up to 30 days from admission date.
• Overall mortality [ Time Frame: From date of randomization until the date death from any cause is documented, assessed up to 180 days from hospital discharge date. ] [ Designated as safety issue: No ]
  Overall mortality is reflected by the number of deaths (percentage of the total number of subjects included in the study) from the date of randomization until the assessment time point at 180 days from admission date.

The investigators propose a multicentre, randomised, double-blinded, placebo-controlled trial to study the effect of additive low-dose haloperidol prophylaxis on top of exciting care in a general population of older patients (age 70 years and over) acutely admitted to the hospital trough the emergency department (ED) for internal medicine or surgical specialism, and who are at-risk for developing in-hospital delirium on admission according to the VMS delirium risk questions (one or more positive answers out of three questions).

The investigators hypothesize that this intervention will reduce the incidence of in-hospital delirium as well as duration and severity of delirium.

To address the aforementioned objectives, we propose a multicentre, randomized, double-blind, placebo-controlled intervention trial.

Eligible patients or their proxies will be verbally informed by the executive investigator on the content of the study, benefits and risks, and will receive a patient information folder on the nature of the study (version number, see appendix). The time to consider participation to the trial will be 2 hours maximum. Subsequently the patient or their proxy is asked for informed consent. After obtaining written informed consent, subjects are screened for delirium-risk by the executive investigator administrating three delirium-risk questions to the patients or their care-givers, as recommended by the Dutch Safety Management (VMS) program:

1. Do you have memory complaints?
2. Did you need any help with activities of daily living in the past 24 hours?
3. During previous illness or hospital admission(s), did you have periods of confusion?

One or more positive answers will identify an at-risk patient, who will be assigned a daily intervention with either low-dose haloperidol (an oral dosage of 1mg, twice-daily) or placebo by stratified randomization. The maximum intervention duration is 7 days. Hospital admission course of non at-risk patients according to the three VMS delirium-risk questions will be retrospectively assessed by medical chart review. Different study measurements will be collected on admission. A baseline ECG and standard ED laboratory will be done. Two additional blood samples of 10ml each will be drawn and stored for future research. The investigator will assess baseline cognitive- and physical functioning on admission with different questionnaires and observational measures: the 6-item cognitive impairment test (CIT), the 6-item Index of Independence in Activities of Daily Living (ADL), the 8-item Instrumental Activities of Daily Living scale (IADL) and Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE-N). The presence of delirium in the ED will be established according to the CAM-ICU and DSM-IV criterial. During admission, all subjects will receive the same 'high standard delirium care' based on effective non-pharmacological delirium intervention methods. Additionally to the standard ward rounds, the investigator will visit the patient at least on day 2, 4, 6 en 8 for (extended) physical examination and to evaluate any possible side-effects related to the intervention. According to protocol, an ECG is performed 6 hours after the first intervention dose by nursing staff on request of the investigator. An ECG will be repeated at a 6-hour time-interval after every dose until a steady state is reached, when QTc > 420ms and ≤ 500ms on baseline ECG, or QTc prolongation > 25% from baseline. If QTc ≥ 500ms, the study medication will be discontinued. A list of QTC prolonging drugs contraindicated when using haloperidol (1st degree drug interactions, reason for action) is available and an a warning system is implemented in the medication prescription system.

Development of delirium symptoms during the study will be evaluated by the Delirium Observation Screening (DOS) scale, administered 3 times per day. When delirium is suspected based on a mean DOS scale score >3/24 hours, the diagnosis is established according to the DSM-IV criteria by either the geriatrician or psychiatrist.

In case of established delirium within the 7-day intervention period, administration of the assigned intervention is stopped since one of the primary endpoints (i.e. incidence) is reached. Unblinding will be performed immediately and the treating physician will further decide on the treatment of the patients' delirium. Nursing staff will perform the DOS score 3-times daily to assess the duration of delirium, according to protocol. In addition, the investigator will assess delirium duration and severity with the DRS-R-98 once-daily. Both the DOS scale and DRS-R-98 are performed until delirium symptoms resolve or if participation in the study is no longer possible due to for example transfer to an other facility, ICU/CCU admission or death.

If no delirium symptoms develop within the 7-day intervention period, administration of the assigned intervention treatment is stopped after 7 days. If the subject is still admitted, evaluation of delirium symptoms will be done according to protocol with a DOS score 3-times daily . If delirium symptoms develop, and is diagnosed according to the DSM-IV criteria, the DRS-R-98 is administered once daily to until delirium symptoms diminish. Further admission course will be evaluated by retrospective analysis of patients' charts.

In patients discharged home within the 7-day intervention period, the intervention is stopped one day before discharge since it takes approximately 12 - 38 hours to eliminate half of the originally administered oral haloperidol dose. These patients will be subjected to en extended physical examination on the day of discharge to evaluate any possible side-effects related to the intervention. If this is not possible, and the patient is discharged after the first intervention dose of that day, the patient will be phoned 24 hours after discharge by the investigator to check for possible side-effects. In addition, the independent physician and researchers can be contacted for questions any time.

At the end of the study, all subjects' charts will be reviewed by one of the investigators.

In case of established delirium within the 7-day intervention period or when clinically relevant side-effects (possibly) related to the intervention have occured, unblinding will be done. Unblinding is possible 24 hours per day, 7 days a week through the contact number on the study medication packing. Procedures and argumentation will be documented and signed by the person performing the unblinding.

During the follow-up period, an executive investigator will contact the subject and/or proxy by telephone, respectively at 3- and 6-months after hospital discharge, to evaluate physical function at that time with the ADL and IADL scale. Also information on hospital re-admission(s), the need for additional (health)care or (permanent) institutionalization after hospital discharge and death are reported. Each telephone conversation will take an estimated 20 minutes.

• Drug: Haloperidol
  An oral dosage of 1mg twice daily at 12am and 8pm.
  Other Names:

  • Haldol
  • Antipsychotic agent
  • Dopamine antagonist
  • Butyrophenone
• Drug: Placebo
  An oral dosage of 1mg twice-daily at 12am and 8 pm.
  Other Name: Placebo

• Active Comparator: Investigational medicinal product
  Intervention: Drug: Haloperidol
• Placebo Comparator: Placebo group
  Intervention: Drug: Placebo

Inclusion Criteria:

• Patients aged 70 years or over;
• The patient is at increased risk for developing in-hospital delirium on admission according to one or more positive answers on the VMS delirium-risk questions;
• The patient or proxy is able to provide written informed consent;
• The patient or proxy speaks either Dutch or English;
• The patient is admitted to the hospital for an internal or surgical specialty.

Exclusion Criteria:

• Patients presenting in the ED with delirium according to the DSM-IV criteria;
• Patients with clinically significant cardiac disorders: QTc interval prolongation (QTc ≥ 500ms), recent acute myocardial infarction, uncompensated heart failure, acute coronary syndrome (ACS), arrhythmias treated with class IA and III antiarrhythmic medicinal products, history of ventricular arrhythmia, history of torsades, clinically significant bradycardia, second or third degree heart block, uncorrected hypokalaemia;
• Patients with vascular dementia;
• Patients with Lewy Body dementia;
• Patients with Parkinson dementia;
• Patients with (a history of) hypokinetic movement disorders;
• Patients with (a history of) malignant neuroleptic syndrome;
• Patients with (a history of) serotonergic syndrome;
• Patients with (a history of) central anticholinergic syndrome;
• Patients who will be admitted to the oncology ward;
• Patients who are enrolled in other medical- or drug studies;
• Patients using QT prolonging drugs and/or medications of which concomitant use with haloperidol is contraindicated (clinically relevant drug interactions, 1st degree, listed in the appendix of the study protocol);
• Patients using antipsychotics other than benzodiazepines;
• Patients using intramuscular neuroleptic depot injections.