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.

Fig. 1

Model of palliative care throughout trajectory of life-limiting illness (adapted from Canadian Hospice Palliative Care Association [159]). EOLC end-of-life care, QOL quality of life

Fig. 2

Algorithm for the assessment and management of delirium in palliative care patients. AP antipsychotic, BDZ benzodiazepine, CAM Confusion Assessment Method, DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, EOL end of life, EPS extrapyramidal side effects, ICD-10 International Classification of Diseases, 10th revision

Fig. 3

Factors contributing to delirium in cancer patients (adapted from Bush and Bruera [160], with permission from the publisher)

Fig. 4

Metabolism of haloperidol [–102] (note large interindividual variations in haloperidol pharmacokinetics). CPHP 4-(4-chlorophenyl)-4-hydroxypiperidine, CYP cytochrome P450, EPS extrapyramidal side effects