Fast Fact and Concept #001; Treating Terminal Delirium

2nd Edition

Author(s): Weissman, D.

Some degree of cognitive function loss occurs in most patients in the week or two before death. The typical scenario presented to housestaff is a late-night call from a ward nurse saying, “Mr. Jones is confused, what should we do”. This Fast Fact reviews assessment and management issues in terminal delirium.

Key teaching points:

• The term “confusion” is not an accurate descriptive term—it can mean anything from delirium, dementia, psychosis, obtunded, etc. Patients need a focused assessment, including a brief mini-mental examination. Clinicians should use one of several validated delirium assessment tools to help quantify and document cognitive function.
• Delirium can be either a hyperactive /agitated delirium or a hypoactive delirium; the hallmark of delirium is an acute change in the level of arousal; supporting features include altered sleep/wake cycle, mumbling speech, disturbance of memory and attention and perceptual disturbances with delusions and hallucinations.
• The most common identifiable cause of delirium in the hospital setting is drugs: anti-cholinergics (anti-secretion drugs, anti-emetics, anti-histamines, tricyclic anti-depressants, etc.), sedative-hypnotics (e.g. benzodiazepines) and opioids. Other common causes include metabolic derangements (elevated sodium or calcium, low glucose or oxygen); infections; CNS pathology; or drug/alcohol withdrawal.
• The degree of work-up to seek the cause of delirium is determined by understanding the disease trajectory and overall Goals of Care, see Fast Fact #65.
• The drug of choice for most patients is a major tranquilizer. There is one controlled clinical trial of haloperidol versus lorazepam in HIV patients; haloperidol was the superior agent. Haloperidol is administered in a dose escalation process similar to treating pain. Start haloperidol 0.5-2 mg po or IV q1 prn. Benzodiazepines can be used, but may cause paradoxical worsening of symptoms.
• Non-pharmacological treatments should always be used in delirium management: reduce or increase the sensory stimulation in the environment as needed; ask relatives/friends to stay by the patient; frequent reminders of time/place.

See Fast Fact # 60 for a discussion of newer pharmacological treatments

References:

1. Yennaurjalingam S et al. Pain and terminal delirium research in the elderly. Clin Geriatr Med. 2005 Feb;21(1):93-119.
2. Lawlor PG, et al. Occurrence, causes and outcome of delirium in patients with advanced cancer. Arch Int Med 2000; 160:786-794.
3. Brietbart W, Marotta R, Platt M, et al. A double blind trial of Haloperidol, Chlorpromazine and Lorazepam in the treatment of delirium. Am J Psych 1996; 153: 231-237.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman DE . Diagnosis and Management of terminal delirium. Fast Fact and Concept #1; 2nd Edition, July 2005. End-of-Life Palliative Education Resource Center www.eperc.mcw.edu.

Purpose: Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care