EPEC-G Handout: Delirium. Delirium is a very common and distressing symptom of older persons during the last

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1 EPEC-G Handout: Delirium 1. Abstract Delirium is a very common and distressing symptom of older persons during the last stages of life. Most research on delirium has dealt with hospitalized older persons with key principles generalizable to older dying persons during palliative care. In general, delirium is a preventable syndrome that is due to multiple interacting factors, and specifically medications used to treat other symptoms at the end of life. Delirium is managed through identification and reduction of reversible risk factors as well as pharmacological therapy to reduce agitation, confusion or anxiety. In the dying person, goals of care should be established early to help direct the evaluation and management of delirium. 2. Keywords Delirium, terminal delirium, acute confusion. 3. Objectives At the conclusion of this presentation, clinicians should be able to: Identify delirium as a distressing symptom requiring prompt recognition and treatment. Recognize delirium in older terminal patients, particularly in persons with dementia. Identify potential contributing and reversible causes of delirium and determine whether a search for underlying causes is indicated. Manage delirium in the context of the dying person with pharmacological and non-pharmacological strategies.

2 Determine whether to treat or not. 4. Introduction The development of worsening cognition and altered sensorium at the end of life, that is delirium, is very common in persons suffering from a terminal illness, but remains one of the most undiagnosed syndromes. (1) Delirium results in significant distress for both patients and families and should be addressed as any other symptom in end of life care.(2) Most terminally ill older persons wish to be awake and alert to share their final moments with their loved ones and delirium robs them of this opportunity. Persons with agitated delirium are more likely to be placed in physical restraints, which is distressing for families.(2) Many fears are associated with delirium including the fear of losing one s mind, fear of not being able to report symptoms reliably, or fear of not being able to participate in decisions.(3) Delirium should be viewed as a symptom that may be affecting the quality of life of the dying person. It is a distressing symptom that can often be alleviated with a few simple measures. Delirium may be a marker for worsening organ function, metabolic derangements, or medication toxicity. Compared to younger persons, the frail, dying older person is more likely to have concurrent comorbidities and decreased physiologic reserve, thus making them more prone to develop delirium, often with a more severe presentation. Health care providers can help to reduce the anxiety about delirium by educating patients, families and healthcare workers. Also, physicians should be able to prevent delirium and to manage delirium appropriately. This

3 module will prepare the clinician to address the challenge of identifying those persons who would benefit from evaluation and treatment of delirium. 5. Defining Delirium and Terminal Delirium The DSM-IV defines delirium as an acute confusional state.(4) Specifically, delirium is an acute and global change (over hours to days) in cognitive abilities (usually disorientation, memory problems, language disturbance), attention (easily distractible, unable to focus, sustain or shift attention), and level of consciousness (either agitation, lethargy or alternating between both extremes). In addition, older persons with delirium also tend to develop perceptual disturbances, such as hallucinations, that are not accounted for by other psychiatric or dementing illnesses. The syndrome is characterized by a fluctuating nature often punctuated by periods of lucidity. It occurs in the context of a medical illness, metabolic derangement, or medication use or withdrawal. In the hospitalized person, delirium is generally reversible or short-lived although some older persons with severe delirium may have prolonged cognitive effects. In the older person, the presence of preexisting cognitive impairment or dementia will make the recognition and identification of delirium more challenging. Some have defined the obtundation that occurs in the last days or hours of life as terminal delirium or terminal restlessness.(3) It is often difficult to distinguish whether an episode of delirium is a marker of imminent death (within a few hours) or simply the result of a potentially reversible medical problem, metabolic derangements, or the effect of medications used to treat symptoms related to the terminal illness. A review of the illness trajectory should help to differentiate an

4 acute delirium from a reversible medical cause from terminal delirium. For example, the dying person who has remained relatively functional and cognitively intact who develops lethargy over the course of a few days likely has a reversible medical condition that warrants evaluation and treatment. Whereas, the dying person who has had a gradual and progressive decline in cognition and function over weeks who develops lethargy and eventually coma likely has a terminal delirium. The astute clinician should be able to identify each episode of delirium and proceed with an evaluation as described below. 6. Epidemiology In the hospitalized older persons, the prevalence of delirium is between 10 and 40%, whereas the rate of incident delirium is from 25 to 60%. Delirium is associated with a hospital mortality ranging from 10 to 65%. (5) The wide variability is explained by the different patient populations studied or by the various definitions and tools used. Older persons undergoing surgery or admitted to the intensive care units are much more likely to have delirium.(6) Few data are available in the medical literature concerning the rate of delirium in dying persons. However, the rate of delirium at end of life ranges from 28 to 88% depending on the population and criteria used. For example, among those admitted early in a palliative care unit, only 28% were found to have delirium, whereas 88% of those with imminent deaths became delirious.(7) Even less data is available concerning prognosis. However, among 87 patients with cancer-related cognitive impairment admitted to a palliative care unit, 30% experienced a complete cognitive recovery.(8) In addition, among advanced

5 cancer sufferers who develop delirium, 50% of delirium episodes resolved. (7) This indicates that delirium in terminal patients who are not imminently dying is treatable and reversible. 7. Assessment and Recognition In all settings, delirium is often unrecognized or mistaken for dementia, depression, or acute psychosis.(1) Healthcare professionals and family members often dismiss the signs of delirium as part of normal aging or as an expected part of the terminal illness. Risk factors for underrecognition of delirium in older persons also include baseline cognitive impairment, visual or hearing impairment, and lethargy. (9) a. Cognitive Assessment The first step in diagnosing delirium in older persons is to determine the baseline cognitive status. This may require questioning the family about the temporal pattern of cognitive changes, in order to determine the presence of preexisting dementia or mild cognitive impairment. Instruments have been developed and validated to assist clinicians in assessing baseline function and cognition from family or surrogate history. Most commonly used are the Blessed Dementia Rating Scale (10) and the Informant Questionnaire on Cognitive Decline in the Elderly (11). Second, the clinician performs a cognitive assessment of the patient. Based on the results of this testing and on observations of the patient during testing, the clinician will then be able to determine the presence of delirium using one the tools described in the next section. Among the vast number of cognitive tests available, the Mini- Mental State Examination (MMSE) is widely accepted and familiar to most

6 clinicians.(12) It is usually well tolerated even in very ill patients and can help determine the presence of inattention by errors in registration of three words, spelling world backwards, and the three-step command. The Digit Span test is also used to confirm the presence of inattention.(13) b. Delirium Tools In the past few decades, many tools have been developed and validated for the recognition of delirium, including the Confusion Assessment Method (CAM)(14), the Delirium Rating Scale (15), the Delirium Symptom Interview (16), and the Memorial Delirium Assessment Scale (17). Among these, the CAM was developed as a simple and practical tool to identify delirium in older persons. It has a high sensitivity and specificity and has been used widely in clinical and research areas. The CAM can be performed by trained researchers or clinicians. The CAM asks the clinician to rate the patient on 4 key features based on observations during the cognitive assessment. The 4 features are as follows: 1) Acute change from baseline and fluctuation in the symptoms during the day, either by tending to come and go or by increasing and decreasing in severity. 2) Inattention demonstrated by having difficulty focusing, being easily distracted, or having difficulty keeping track of what was being said. 3) Disorganized thinking or incoherence, such as rambling, irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject.

7 4) Altered level of consciousness referring to any state other than alert and calm, that is, either hyperalert and vigilant or lethargic and drowsy. The diagnosis of delirium requires the presence of features 1 and 2 as well as one the latter two features. c. Patients with Dementia Distinguishing delirium from dementia is one of the most difficult tasks in older dying patients because many of the symptoms are similar. Older persons with baseline cognitive impairment, such as dementia, are up to three times more likely to develop delirium. Therefore, compared to younger persons, the clinician should always rule-out preexisting cognitive impairment or the presence of both delirium superimposed on dementia.(18, 19) When a baseline dementia is suspected or known to exist, it is extremely important to obtain an understanding of the baseline cognitive status in order to determine if a change has indeed occurred. In general, persons with dementia will have normal levels of attention and alertness. If significant inattention is observed or altered levels of consciousness are noted, then delirium is likely to be present in conjunction with a preexisting dementia. 8. Delirium Risk Factors a. A Multifactorial Geriatric Syndrome As with many geriatric syndromes, delirium is often caused by multiple interacting factors contributing to the outcome. This is particularly true in the older terminal patient. Delirium has to occur in the context of a medical illness, however, patient and external factors often predispose older people to the development of

8 delirium. These have been studied in detail among hospitalized older persons and have been divided into predisposing and precipitating risk factors.(20-23) Some extrapolations to the dying older person are valid. Predisposing risk factors are present prior to the illness and include cognitive or sensory impairments, polypharmacy, and malnutrition. Precipitating risk factors include events that occur during the illness such as restraints, surgery, and administration of psychoactive medications. It is often the interplay between predisposing and precipitating risk factors that results in delirium. For example, an older person with several predisposing risk factors (such as advanced dementia, advanced age, and malnutrition) may only require a minor insult such as a urinary tract infection to develop delirium. Compared to younger dying patients, older persons tend to have high baseline vulnerability with risk factors that are less amenable to change such as high comorbidity, compromised renal and liver function, and impaired physical and cognitive function. The precipitant risk factors may be more amenable to reversibility, such as medications, immobility, restraints, dehydration, or electrolyte abnormalities. Among persons with advanced cancer, a prospective study determined that psychoactive medications, particularly opioids, dehydration, and non-respiratory infections were associated with reversibility of delirium. (7) The clinician s task is to identify predisposing and precipitating risk factors which are easily correctable or reduced. b. Common causes Some common causes for delirium are outline in a mnemonic for delirium that includes the following: dementia, electrolytes, lung or other organ disease, infection,

9 rx (medications), injury or pain, unfamiliar environment, and metabolic derangements. c. Medications associated with delirium In general, older persons even with a normal serum creatinine may have a reduced capacity to metabolize even routine doses of hypnotics and sedatives. Thus, careful attention to dosages and types of agents could help reduce the risk of delirium. Creatinine clearance should always be calculated in the elderly even with a normal serum creatinine. Three classes of drugs are most often associated with delirium, namely, sedative/hypnotics, narcotics, and anticholinergic medications. Anticholinergic medications include antihistaminic medications such as diphenhydramine (24), antispasmodics (often used in terminal care to reduce abdominal spasms and to reduce secretions), tricyclic antidepressants (often used as adjunct therapy for neuropathic pain), antiparkinsonian medications, and antiarrhythmics. (25) Other agents often associated with delirium include cardiac medications (digoxin, lidocaine), beta-blockers, H2-blockers, steroids, antibiotics, lithium, anticonvulsants, and NSAID s. Opioid agents are of particular concern in the older population with accumulation of the medication and its metabolites occurring with higher doses and with worsening kidney function.(2, 26) Meperidine should be avoided for many reasons: (1) it is a poor analgesic, (2) it lowers the seizure threshold, and (3) it has the highest risk of delirium among all the opioids due to the slow clearance of its active metabolite, normeperidine. (25)

10 Research has shown that the type and number of medications are also important. Persons taking two or more psychoactive medications are 4.5 times more likely to be delirious. Also, adding more than 3 medications in a 24-hour period results in a relative risk of 4 for developing delirium. Similarly, persons taking 6 or more drugs are 14 times more likely to develop delirium. (21) d. Cholinergic burden Although the neuropathogenesis of delirium is not well understood, it is commonly felt that suppression or impairment of the cholinergic system is directly related to delirium. Thus, medications that have strong anticholinergic properties are often linked with the development of delirium. Recent research has improved our understanding of the interaction of different anticholinergic medications and delirium. The concept of total serum cholinergic burden implies that the cumulative or additive effect of anticholinergic medications is not only associated with the development of delirium but also the severity and duration.(27, 28) Thus, multiple small doses of many anticholinergic medications may be as deliriogenic as a large dose of one anticholinergic medication. The clinician should review medications and attempt to reduce or eliminate medications with anticholinergic properties. A trial of safer alternatives should be attempted. e. Common herbal therapies potentially associated with delirium Several case reports and case series have documented possible links of some psychoactive herbal therapies with delirium. Because herbal therapies are considered nutritional supplements in the US, they are not monitored stringently. Thus, the true risk of the herbal therapies is unknown. Kava Kava and valerian root are sedating

11 anxiolytics, which may be linked with delirium when taken excessively. St. John s root used for depression can cause delirium when combined with other antidepressants that enhance the serotonin system. Belladona is a pure anticholinergic agent, that is atropine, and thus is clearly associated with delirium. Many chinese herbal medicines have been adulterated with medications in toxic doses such as antidepressants, or NSAID s, which may cause delirium among other adverse effects. 9. Management Algorithm a. Confirmation of delirium As described above, the first part of the management of delirium is to identify a change, perform a cognitive assessment and using a delirium tool, determine the presence of delirium. The next part is two-pronged and both steps occur concurrently, (1) the identification and management of potential causes and risk factors and (2) the management of delirium symptoms, particularly agitation. In addition, it is important to maintain close contact with the family and keep them apprised of the plan of care throughout the process. b. Identification and management of potentially reversible underlying causes This strategy was developed for hospitalized older persons, but may apply to this population although with some restrictions.(29-31) Work-up may be limited by the setting, home or hospice, where tests may not be easily obtainable and transfer of the patient may not be acceptable. Diagnostic procedures that are unpleasant or painful may be avoided if the focus of care has shifted to comfort. Supportive therapies themselves may also be burdensome. Understanding the patient s and

12 family s goals of care and doing a careful history and physical examination will help guide the evaluation. Key features of the physical exam include fever, focal neurological signs, frontal release signs, and asterixis. Typical signs of dehydration, hypoglycemia, hyper- or hypocalcemia can be sought. Laboratory evaluation can be sought if this is consistent with previously established goals of care. The level of aggressiveness of diagnostic procedures will depend on the patient and family goals of care, the burden of the tests, and the likelihood of a remediable cause. When death is imminent, tests beyond the history and physical examination are likely inappropriate. If a laboratory evaluation is sought, a targeted strategy may include the following: Complete blood count Electrolytes (including calcium, magnesium, and phosphate), blood urea nitrogen, creatinine, and glucose Urinalysis Pulse oximetry Clinicians should emphasize low burden interventions such as: Rehydration with hypodermoclysis Treatment of hypercalcemia with subcutaneous bisphosphonates. Identification and treatment of opioid toxicity. Signs include agitation, myoclonus, tactile hallucinations, and hyperalgesia and are due to accumulation of toxic metabolites. Consider changing to a different opioid at a lower equianalsegic dose.

13 Careful review of medications and identification of potentially noxious medications. One can either discontinue, decrease the dosage, or change to an alternate, less toxic agent. c. Management of delirium symptoms i. Non-pharmacological strategies Clinicians can greatly impact the severity and course of delirium by educating patients, families, and staff. Several non-pharmacological strategies may help to prevent delirium and also assist in the treatment of delirium, especially hypoactive delirium. These may include: Limit or preferably, avoid the use of restraints. Use family members or sitters to keep agitated patients calm and safe. Improvement of sleep with a sleep protocol to minimize interruptions, provide a calming environment at bedtime with a warm drink, quiet music, and a back rub.(32) Encourage cognitive activities, such as reminiscence, event discussions. An early mobilization protocol with ambulation or range-of-motion exercises and avoidance of restricting devices like urinary catheters. Optimization of visual and hearing impairment with aids. The family can often be educated and empowered to actively participate in this process by: Helping to maintain adequate fluid and nutritional intake. Improving the structure and familiarity of the patient s immediate environment with recognizable objects, pictures, blankets, etc.

14 Constantly reorienting to decrease anxiety and disorientation. ii. Pharmacological options An important principle of the care of delirious terminal patients is that the treatment of symptoms of delirium, specifically distressing agitation or perceptual changes, should never be withheld during the evaluation process. Although some have suggested treating hypoactive delirium with stimulants such as methylphenidate, it can also cause or worsen perceptual disturbances and is not generally used.(33) In general, agitated delirium is most responsive to pharmacological treatment.(2) Most of the recommendations concerning which class or agent to use and under what circumstances come from expert opinions.(34) Rigorous randomized clinical trials in older persons have yet to be performed to guide pharmacological management of delirium. (35) Agitation, hyperactivity, and aggressiveness are treated with sedatives or neuroleptics, the latter with the potential added benefit of improving cognition. Among the neuroleptics, haloperidol has remained the most widely used agent to control agitation in hospitalized and terminal patients. It has many advantages; it is versatile (available orally, parenterally), it has a wide therapeutic window, and carries minimal risk of respiratory depression. In older persons, especially those with cognitive impairment, the lowest dose necessary is recommended. Starting doses for haloperidol are 0.5 to 1.0 mg every 30 minutes until effect. Recent evidence shows that dopaminergic receptors may be saturated at 5 mg in a 24-hour period, thus usual maximal doses should not exceed 5 mg per 24 hours.(36) In addition, clinicians

15 should keep in mind that parenteral doses are generally twice as potent as oral doses and switching to oral therapy should be accomplished as soon as possible. If further sedation is required, alternating doses with a benzodiazepines (at low doses) is the safest next step. Atypical neuroleptics, such as olanzapine and risperidone, are also used empirically in agitated delirium. They are more beneficial for long-term usage due to reduced extrapyramidal effects compared to haloperidol. When sedation is the primary goal, benzodiazepines may be the class of choice due to their rapid onset and ease of titration. They can also be used in conjunction with a neuroleptic. Among the most commonly used are lorazepam and midazolam. The former drug is available orally and parenterally with most clinicians being quite familiar with its use. Again, the lowest possible dose should be used with a plan to decrease or discontinue the medication once symptoms have resolved. d. Special management issues in the terminally ill older person Case: Mrs. G. was a 79 year old woman with relatively unimpressive past medical history and normal cognition who had been struggling with stage 4 lung cancer for several months. She was admitted to the nursing home after a hospitalization for increasing shortness of breath. She was in severe pain from a growing rib metastasis. She was requiring increasing amounts of oxygen and although her pulse oximetry was normal, she continued to complain of shortness of breath, fatigue, and lack of energy. Through discussions with the patient and family, goals of care were established. She clearly indicated that pain control and relief of shortness of breath were the most important aspects. She understood that aggressive

16 treatment of the pain with opioids may contribute to respiratory depression and her demise, in addition to increasing her confusion or level of alertness. Her pain was aggressively managed and soon under control with some resolution of her shortness of breath. She became increasingly confused with alternating episodes of lethargy and agitation treated with haloperidol parenterally with good results. A few days later, the patient went into a coma and expired. The family felt that she was comfortable during the last few days of her life due to the aggressive management of the pain and dyspnea and that her wishes had been followed. Although the ultimate goal is to be able to manage all the symptoms of terminal illness without significant side effects, the reality is often that treatment of one symptom can cause significant side effects such as lethargy or delirium. This is even more common in the older person due to multiple comorbid conditions and a decreased ability to metabolize and excrete medications. Lower doses of medications are often therapeutic and cause fewer side effects. When many symptoms need to be managed concurrently and competitively, it is important to engage the patient and family members in a discussion about the management of delirium. It is important to incorporate the patient s values into the decision-making process. Establishing the primary goals of care of the patient and prioritizing these will be extremely important. For some, pain control at all costs is the main priority while others would prefer less pain control while maintaining a level of alertness and cognition to enjoy their last few days with complete control of their mental abilities. Frank and open discussions with the family and patient will guide the management of delirium in most cases.

17 10. Conclusions Delirium adversely affects the quality of life of older persons near the end of life and should be treated aggressively similar to pain. Once goals of care have been established, clinicians should evaluate and manage delirium as a distressing symptom, which can be reduced at times with simple, nonpharmacological measures and in other cases, with pharmacological treatments.

18 References 1. Gustafson Y, Brannstrom B, Norberg G et al. Underdiagnosis and poor documentation of acute confusional states in elderly hip fracture patients. J Am Geriatr Soc. 1991;39: Casarett DJ, Inouye SK. Diagnosis and management of delirium near the end of life. Ann Intern Med. 2001;135: Breitbart W, Jacobsen PB. Psychiatric symptom management in terminal care. Clinics in Geriatric Medicine. 1996;12(2): American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC. American Psychiatric Association, 1994, Levkoff SE, Evans DE, Liptzin B, et al. Delirium: The occurrence and persistence of symptoms among elderly hospitalized patients. Arch Intern Med 1992;152: McNicoll L, Pisani MA, Zhang Y, Siegel M, Ely EW, Inouye SK. Delirium in the Intensive Care Unit: Occurrence and Clinical Course in Older Persons. J Am Ger Soc. 2003;. 7. Lawlor PG, Gagnon B, Mancini IL, et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer. Arch Int Med. 2000;160: Pereira J, Hanson J, Bruera E. The frequency and clinical course of cognitive impairment in patients with terminal cancer. Cancer 1997;79(4):

19 9.Inouye SK, et al: Nurses recognition of delirium and its symptoms: Comparison of nurse and researcher ratings. Arch Intern Med. 2001;161: Blessed G, Tomlinson BE, Roth M. The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects. Brit J Psychiatry 1968;114: Jorm AF. A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQ CODE): development and cross-validation. Psychol Med 1994;24: Folstein, MF, Folstein SE, McHugh PR. Mini-Mental State : A practical method for grading the cognitive status of patients for the clinician. J Psychiatr Res 1975;12: Weschler D. Manual for Weschler Adult Intelligence Scale. New York ( NY): Psychological Corp.; Inouye SK, Van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N. Validation of the Delirium Rating Scale-Revised-98: comparison with the Delirium Rating Scale and Cognitive Test for Delirium. J Neuropsychiatry Clin Neurosci. 2001;13: Albert M, Levkoff S, Reilly C, et al. The delirium symptom interview. J Geriatr Psychiatry Neurol. 1992;5:14-21.

20 17. Breibart W, Rosenfeld B, Roth A. The Memorial Delirium Assessment Scale. J Pain Symptom Manage. 1997;13: Fick D, Foreman M: Consequences of not recognizing delirium superimposed on dementia in hospitalized elderly individuals. J Gerontol Nursing. Jan 2000: Fick, D.M. Agostino, J.V., Inouye, S.K. Delirium Superimposed on Dementia: A Systematic Review. Journal of the American Geriatrics Society, 2002; (50)10: Inouye SK, Viscoli CM, Horwitz RI, Hurst LD, Tinetti ME. A predictive model for delirium among hospitalized elderly persons based on admission characteristics. Ann Intern Med. 1993; 119: Inouye SK, Charpentier PA: Precipitating factors for delirium in hospitalized elderly persons: Predictive model and inter-relationship with baseline vulnerability. JAMA, 1996;275: Elie M, Cole MG, Primeau FJ, et al. Delirium risk factors in elderly hospitalized patients. J Gen Intern Med 1998;13: Schor JD, Levkoff SE, Lipsitz LA, et al. Risk factors for delirium in hospitalized elderly. JAMA 1992;267: Agostini JV, Leo-Summers LS, Inouye SK. Cognitive and other anticholinergic effects of diphenhydramine in hospitalized older patients. Arch Intern Med. 2001; 161: Marcantonio ER, Juarez G, Goldman L, et al. The relationship of postoperative delirium with psychoactive medications. JAMA. 1994;272:

21 26. de Stouts N, Bruera E, Suarez-Almazor M. Opioid rotation for toxicity reduction in terminal cancer patients. J Pain Symptom Manage. 1995;10: Flacker J, Wei JY. Endogenous anticholinergic substances may exist during acute illness in elderly medical patients. 2001;56A:M Han L, et al. Use of medications with anticholinergic effect predicts clinical severity of delirium symptoms in older medical inpatients. Arch Int Med. 2001;161: Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. A clinical trial of a multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340: Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49: Meagher DJ. Delirium: optimizing management. BMJ 2001;322: McDowell JA, Mion LC, Inouye SK: A non-pharmacological sleep protocol for hospitalized older patients. J Am Geriatr Soc. 1998;46: Morita T, Otani H, Tsunoda J, et al. Successful palliation of hypoactive delirium due to multi-organ failure by oral methylphenidate. Support Care Cancer. 2000;8: American Psychiatric Association: Practice guideline for the treatment of patients with delirium. Am J Psychiatry. 1999;156(5 Suppl): Breitbart W, Marotta R, Platt MM, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry. 1996;153:

22 36. Kapur S, Remington G, Jones C, et al. High levels of dopamine D2 receptor occupancy with low-dose haloperidol treatment: a PET study. Am J Psychiatry. 1996;153:

23 Key take home points Identification 1. Delirium is under-recognized, frequent, and preventable in the older population. 2. Delirium is a distressing symptom of end of life care in older adults. 3. Assessment and recognition of delirium can be accomplished with simple cognitive assessment, eg. MMSE and CAM, with identification of 4 key features; acute change and fluctuating course, inattention, disorganized thinking and altered level of consciousness. 4. Delirium can present as hypoactive, hyperactive, or mixed. 5. Dementia or mild cognitive impairment in older persons can make recognition of delirium difficult 6. Terminal delirium occurs in the last days or hours of life and represents impending death. Management of risk factors 7. Management of delirium is directed by established goals of caremedications play an important role in the cause of delirium. 9. Non-pharmacological strategies can help to reduce the rate and severity of symptoms. Pharmacological therapy of symptoms 10. Some medications (haloperidol, atypical neuroleptics, or benzodiazepines) may help in alleviating some of the more severe symptoms of delirium.the minimum dosages are used at all times and a tapering regimen should be initiated quickly.

24 Pearls Older persons with marked change in level of alertness and inattention should be evaluated for delirium. These are key distinguishing features from dementia. Delirium occurs in 88% of persons who are in the late stages of their illness, however, up to half of older persons admitted and discharged from a palliative care unit will recover from their delirium. The cumulative anticholinergic effect of medications contribute more to delirium than individual medications. In persons with advanced cancer and delirium, psychoactive medications, dehydration, and non-respiratory infections were risk factors most associated with reversal of delirium Pitfalls Clinicians can run into trouble by Under- or misrecognizing delirium and potentially resulting in mismanagement of agitation or delirium Using high doses of neuroleptics. Haloperidol dosages should be limited to 0.5mg per dose and a maximum of 5mg per 24 hour period. Not reviewing current medications and considering safer alternatives or lower dosages. Not treating or deferring treatment of the symptoms of delirium, primarily agitation and anxiety, while undergoing an investigation. Not communicating or educating the patient and family about delirium and not clarifying the person s goals of care.