Clarifying Delirium Management: Practical, Evidenced-Based, Expert Recommendations for Clinical Practice

Abstract

Delirium is highly prevalent in those with serious or advanced medical illnesses. It is associated with many adverse consequences, including significant patient, family, and health care provider distress. This article suggests a novel approach to delirium assessment and management and provides useful, practical guidance for clinicians based on a complete review of the existing literature and the expert clinical opinion of the authors and their colleagues, derived from over a decade of collective bedside experience. Comprehensive assessment includes careful description of observed symptoms, signs, and behaviors; and an understanding of the patient's situation, including primary diagnosis, associated comorbidities, functional status, and prognosis. The importance of incorporating goals of care for the patient and family is discussed. The concepts of potential reversibility versus irreversible delirium and delirium subtype are proffered, with a description of how diagnostic and management strategies follow from these concepts. Pharmacological interventions that provide rapid, effective, and safe relief are presented. Employing both pharmacological and nonpharmacological interventions, including patient and family education, improves symptoms and relieves patient and family distress, whether the delirium is reversible or irreversible, hyperactive or hypoactive. All interventions can be provided in any setting of care, including patients' homes.

Comprehensive care in gynecologic oncology: The importance of palliative care

“…Delirium is characterized by an acute onset of disturbances in arousal, attention, and cognition that can wax and wane over time. These changes occur due to underlying medical problems associated with many adverse consequences including increased admissions or prolonged hospitalization, unnecessary medical interventions, increased mortality, and increased cost as well as significant distress for the patient, family and caregivers [66,67].…”

“…It is important to note than even in the context of serious illness, physiologic disturbances that lead to delirium may be reversible, so diagnostic evaluation should include an assessment of potentially reversible causes. Common causes for patients with terminal gynecologic malignancies include: medications (benzodiazepines, opioids, steroids, anticholinergics), infections, fluid and electrolyte derangements, hypoxia, renal failure, liver failure, constipation and urinary retention [67]. However, in terminally ill patients, delirium is a reliable predictor of impending death [65].…”

“…Nonpharmacologic approaches include: providing familiar materials to help keep patient oriented, minimizing quantity of stimulation the patient receives, use of family or volunteers as constant companions to reassure and reorient, minimizing use of restraints, and encouraging the use of glasses/hearing aids to promote communication [67]. For first-line treatment of potentially reversible, hyperactive delirium, evidence supports the use of antipsychotics such as haloperidol 0.5-2 mg every 2-12 h (PO, IV, IM, SC) or chlorpromazine 12.5-50 mg every 4-6 h (PO, IV, IM, SC, PR) to reduce agitation [66].…”

“…Atypical antipsychotics such as olanzapine and risperidone should also be considered as effective alternatives for patients that are intolerant of haloperidol. It is important to note that these agents are more expensive, have limited routes for administration (PO, IM) and have not been shown to have improved efficacy [67]. When irreversible, hyperactive delirium has been diagnosed, benzodiazepines such as lorazepam 1 mg SC or IM every 30 min may be most appropriate in place of, or in addition to haloperidol.…”

Les troubles psychiatriques en soins palliatifs et en fin de vie

“…Ce syndrome est une cause de souffrance psychologique importante : chez les patients qui lors des phases de lucidité restent perplexes, angoissés voir traumatisés lorsqu'on les confronte à une réalité qui diffère de celle qu'ils sont en train de vivre ; chez l'entourage familial déjà épuisé par l'accompagnement et traumatisé par cet épisode aigu et la crainte que le proche malade ne termine sa vie dans la folie ; chez les équipes soignantes mises en tension voir en conflits lors de désaccords sur certaines modalités de prise en charge comme la contention physique, notamment en cas de passage hétéro agressif du patient sur un membre du personnel soignant. Sa fréquence en soins palliatifs est importante avec une incidence estimée entre 3 à 45 % [18], une prévalence estimée entre 40 à 62 % lors des admissions en unités de soins palliatifs et de 60 à 88 % dans les dernières semaines ou heures de vie [18][19][20]. Cette entité est un facteur de gravité sur le plan pronostique et reste donc associée à des taux de mortalité élevés pouvant varier entre 10 à 65 % chez des patients déjà fragilisés et menacés par l'évolutivité de leur pathologie somatique [21].…”