Delirium is a disorder characterized by impairments in attention, concentration, and cognition resulting from insults such as medical illnesses and medications.¹ Many terms have been used to refer to this syndrome, including acute brain syndrome, acute confusional state, and intensive care unit psychosis. In the terminally ill, delirium is sometimes referred to as terminal restlessness or terminal agitation. Contemporary experts, however, are advocating for the use of the term delirium exclusively.
In people receiving palliative care or people who are terminally ill, the incidence of reported delirium is high. For patients receiving palliative care, the incidence of delirium is estimated to be 33%–85%. For people terminally ill or approaching death, the incidence increases to 80%–90%.²
Causes of delirium are multiple but are typically precipitated by underlying physiologic disorders caused by acute events (infections, dehydration, metabolic diseases) or worsening of a chronic illness (atherosclerosis, diabetes). Additionally, many medications may cause delirium (e.g., cold remedies, sleep medications, opioids), especially in older adults. People with pre-existing dementias (e.g., Alzheimer's disease, vascular dementia) are at increased risk for delirium and have higher incidences of delirium.
The onset of delirium is rapid, occurring over hours to days. Persons suffering from delirium display symptoms such as overactivity (restlessness, agitation) or underactivity (sleepiness), confused thinking, and inappropriate behaviors (e.g., disrobing, removing medical equipment). Delirium sufferers are more likely to experience adverse medication reactions, fall, develop pressure ulcers, or develop infections.³
Pharmacotherapy
Haloperidol (Haldol®), chlorpromazine (Thorazine®), and lorazepam (Ativan®) are medications commonly used to treat delirium in terminally ill patients. Haloperidol and chlorpromazine are classified as neuroleptics (or anti-psychotics). Haloperidol is inexpensive and easily administered. In people with dementia, however, it may cause parkinsonian-like side effects. Risperidone (Risperdal®) and olanzapine (Zyprexa®) are newer anti-psychotics, comparable to haloperidol and chlorpromazine, but they are expensive and have limited routes of administration.4 Recent research has found that risperidone may have adverse cardiovascular consequences in some older adults. The prescribing of risperidone, as with all medications, requires a careful evaluation of risk versus the benefit for the person.
Chlorpromazine tends to cause more adverse cognitive side effects. However, chlorpromazine is more sedating than haloperidol and can therefore be used for persons with agitated delirium. Lorazepam is classified as a benzodiazepine, a different class from the anti-psychotic drugs. It is short-acting and generally well tolerated, however it can be very sedating. Although there have been many studies exploring the use of these drugs in delirium, there is a lack of sufficient scientific evidence to determine the best medications, or combinations of medications to use in the terminally ill.5
Conclusions
What then are best treatment options for delirium in palliative or terminally ill patients? As Finucane6 points out, drug treatment needs to be based on the goals of treatment. Early recognition and treatment of delirium is critical in minimizing its adverse consequences. Attention to the underlying cause(s) of delirium is most important. Each individual is unique and requires a treatment plan based on his or her condition. All drugs should be given at the lowest effective dose. However, undermedicating for pain will increase delirium, so careful pain evaluation and treatment for the cognitively impaired individual is also vitally important.
Nursing staff are typically the first to observe the subtle changes in early delirium. The assistance of families and friends provides opportunities for nonpharmacologic support (e.g., physical presence, reassurance) during delirium. In this way, the entire care team, working together, is able to increase quality of care by decreasing the adverse symptoms of delirium.
This month's Tip is provided by Mary Shelkey, PhD, ARNP, Geriatric Specialist, and Director, RN Clinical Research Unit of Benaroya Research Institute, Virginia Mason Medical Center, Seattle, WA. Ms. Shelkey also is Assistant Professor, School of Nursing, Seattle University.
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References
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, (4th ed.). Washington, D.C.: American Psychiatric Press.
Goy, E. & Ganzini, L. (2003). Delirium, anxiety, and depression. In R.S. Morrison, D.E. Meier, & C. Capello (Eds.). Geriatric Palliative Care (pp. 286–303). New York: Oxford University Press.
Foreman, M.D., Mion, L.C., Trystad, L., & Fletcher, K. (2003). Delirium: Strategies for assessing and treating. In M.D. Mezey, T. Fulmer, I. Abraham, & D. Zwicker (Eds.) Geriatric Nursing Protocols for Best Practice (2nd ed., pp. 116–140). New York: Springer Publishing Company.
Olsen, E. (2003). Dementia and neurodegenerative diseases. In R.S. Morrison, D.E. Meier, & C. Capello (Eds.) Geriatric Palliative Care (pp. 160–172). New York: Oxford University Press.
Jackson, K.C. & Lipman, A.G. (2004). Drug therapy for delirium in terminally ill patients [Review]. The Cochrane Database of Systematic Reviews, 3, pp. 1–21.
Finucane, T.E. (2002). Delirium at the end of life. Annals of Internal Medicine, 137(4), p. 295