Delirium and agitation at the end of life

Abstract

Delirium is common in the last weeks or days of life.1 It can be distressing for patients and those around them. Successful management involves excluding reversible causes of delirium and balancing drugs that may provoke or maintain delirium while appreciating that most patients want to retain clear cognition at the end of life. What is delirium?Delirium is the abrupt onset of fluctuating confusion, inattention, and reduced awareness of the environment. Symptoms can affect different areas of cognition (memory, orientation, language, visuospatial ability, or perception) and may include hallucinations and disturbances in the sleep-wake cycle (box 1).2 Delirium can therefore be distressing to people who experience it and those around them.3 Delirium is classified into hyperactive (restlessness and agitated behaviour predominate), hypoactive (drowsiness and inactivity predominate), and mixed subtypes. The more subtle changes associated with the hypoactive form are often missed. What are the causes of delirium?Delirium occurs when physical factors, often occurring simultaneously (box 2), act on a physiologically vulnerable brain, leading to confusion, changes in perceptions, and altered behaviours. 6 In the last days of life, delirium has been described as the visible culmination of end stage multiorgan failure compounded by other non-reversible factors. 7In an observational study of 213 terminally ill delirious patients with cancer, 8 the main causes identified were hepatic failure, drugs, pre-renal azotemia, hyperosmolality, hypoxia, disseminated intravascular coagulation, organic damage to the central nervous system, infection, and hypercalcaemia. In the same study, the occurrence of hyperactive delirium and the requirement for sedation correlated with hepatic failure, opioids, and steroids, while dehydration related conditions were statistically significantly associated with hypoactive delirium.

Delirium og kognitiv svikt blant eldre i norske akuttmottak

“…I medisinske avdelinger har en av tre eldre pasienter delirium (2), og naer halvparten av pasienter med hoftebrudd utvikler delirium i forløpet (12). Også blant intensivpasienter og hos pasienter i livets sluttfase er tilstanden svaert vanlig (13,14). Da delirium er både vanlig og alvorlig, er det uheldig at tilstanden overses i over 60 % av tilfellene (15,16).…”

Predisposing and precipitating risk factors for delirium in palliative care patients

“…infections/sepsis, impaired functional status, poor nutritional status, adverse effects of radiation/chemotherapy, and treatment with certain medications (e.g., opioids, corticosteroids, and benzodiazepines) (Kang et al, 2013;Hosker and Bennett, 2016;Bush et al, 2017Bush et al, , 2018). In the current palliative care literature, there is limited evidence about socio-demographic or disease-related predictive factors for delirium in palliative care patients (Bush et al, 2018).…”

Air filled, including “air‐charged,” catheters in urodynamic studies: does the evidence justify their use?

“…The use of AFCs in Exeter has been discussed above. Further experience comes from another center which has used the T‐Doc AFC system for 7 years, since 2008, having previously used both Gaeltec micro‐tip catheter for intravesical (and intra‐urethral) pressure measurements and a homemade air‐filled balloon (about 6 cm long and 1.5 cm diameter when inflated with 20 ml air) to measure abdominal pressure rectally . However, although the intravesical T‐Doc AFC is used to measure bladder pressure, it is also used to measure abdominal pressure rectally rather than use the rectal T‐Doc AFC with its stiff, integral guide wire.…”