Clinical Assessment and Management of Delirium in the Palliative Care Setting

Abstract

Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.Electronic supplementary materialThe online version of this article (doi:10.1007/s40265-017-0804-3) contains supplementary material, which is available to authorized users.

Validity and Reliability of the Memorial Delirium Assessment Scale-Thai Version (MDAS-T) for Assessment of Delirium in Palliative Care Patients

“…In addition, the Kaiser-Meyer-Olkin statistical measure of sampling adequacy was 0.93, which exceeded the recommended value of 0.6. Moreover, Bartlett's test of sphericity achieved statistical significance (χ 2 [45] = 1957.2; p < .001), which supported the factorability of the correlation matrix. Furthermore, all of the diagonals of the anti-image correlation matrix exceeded 0.9, which supported the inclusion of each item in the factor analysis.…”

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

“…21 The detection of delirium is vital because its presence indicates acute systemic or central nervous system illness, physiological disturbance and drug intoxication or withdrawal; indeed, failure to detect delirium in the acute setting is associated with worse outcomes. 22 The specific management of delirium is of obvious and immediate benefit to patients in many clinical situations, for example in reversing opioid toxicity, enabling the treatment of peripheral infections that have presented with delirium, alleviating distress caused by anxiety and disorientation as well as directly by frightening delusions and hallucinations, 13,[23][24][25] and prompting more thorough assessment and treatment of symptoms. 26 For example, some studies 27 have found that surgical patients with delirium receive less analgesia than those with normal cognition; this matters not only because pain treatment is an end in itself but also because pain is itself a cause of delirium.…”

Drugs used in palliative medicine

“…Of course, you may additionally add drugs that increase sedation, but in the case of psychotic disorders, essential treatment always takes place using neuroleptics. 13 There is basically no rule about the most recommended means, this is done in relation to the current clinical situation of the patient. Rather, a strong neuroleptic should be used (eg, a Rossperidone 0.5-5 mg/d, olanzapine 5-20mg/ d), therefore the administered doses will be lower than in the case of weak neuroleptics (quetiapine 50-250mg/d).…”