Palliative Care Guidelines - NHS Lanarkshire

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Palliative Care Guidelines: DeliriumDelirium in Palliative CareDefinitionDisturbed consciousness and inattention with cognitive impairment; acute onset and fluctuatingcourse as a physiological consequence of disease or treatment.(Other terms: acute confusional state, agitation, terminal restlessness)Assessment• Common (30-85% of hospice inpatients), often reversible but diagnosed late.• Three types:o Hyperactive – increased arousal and agitation.o Hypoactive – quiet, withdrawn and inactive: more common but often missed ormisdiagnosed as depression.o Mixed pattern.• Diagnosis depends mainly on careful clinical assessment; consider using Mini-Mental StateExamination or Abbreviated Mental Test.• Causes include:o Drugs (including: opioids, anticholinergics, steroids, benzodiazepines, antidepressants,sedatives).o Drug withdrawal (alcohol, sedatives, antidepressants, nicotine).o Dehydration, constipation, urinary retention, uncontrolled pain.o Liver or renal impairment, electrolyte disturbance (Na, Ca, glucose), infection, hypoxia,cerebral tumour or cerebrovascular disease.o Visual impairment and deafness are risk factors.Differential diagnosis: depression, dementia (increased risk of developing delirium).Management (treat underlying causes)• If terminal delirium – see: Last days of life.• Review all medication and stop any non-essential drugs.• Maintain hydration, oral nutrition and mobility.• Check for opioid toxicity (drowsiness, agitation, myoclonus, hypersensitivity to touch), reduceopioid dose by 1/3. Consider switching to another opioid if delirium persists.See: Choosing & Changing opioids.• Check for constipation, urinary retention or catheter problems.• Check full blood count and biochemistry, including calcium.• Check for infection (urine infection in the elderly).• If nicotine dependent, consider using replacement patches.Medication (if essential to control symptoms)• Review regularly and withdraw medication as soon as the patient recovers.First choice: haloperidol• Dose: 0.5-3mg oral or subcutaneous (start with a low, oral dose).• Repeat after 2 hours, if necessary.• Maintenance treatment may be needed if cause cannot be reversed; use lowest effective dose:0.5-3mg oral or 2.5mg SC, once daily.Second choice: benzodiazepines• Benzodiazepines do not improve cognition; may help anxiety.• Used in alcohol withdrawal (often at higher doses), sedative and antidepressant withdrawal;preferred in Parkinson’s disease.• Lorazepam 0.5-1mg oral or sublingually.• Midazolam SC 2.5-5mg, 1-2 hourly OR diazepam oral or PR 5mg, 8-12 hourly.© NHS Lothian Issue date: January 2009 Review date: March 20121
Palliative Care Guidelines: DeliriumMedication (cont):If more sedation is desirable and appropriate:• Add or increase benzodiazepine (midazolam SC infusion 10-30mg/ 24hours in a syringe driver /pump or diazepam PR 5-10mg, 6-8 hourly).• Change haloperidol to levomepromazine SC 12.5-25mg, once or twice daily by injection or as asubcutaneous infusion in a syringe driver/pump.Non-drug• Explain cause and likely course to patient, relatives and carers.• Address anxiety; patients with delirium are often very frightened.• Quiet area or side room; limit staff changes.• Adequate lighting, minimise noise, provide a clock the patient can see.• Gentle repeated reorientation and avoid confronting deficits.• Try to maintain normal sleep-wake cycle.• Patients who recover recall their experiences; explain the organic cause of their behaviour andsymptoms.Practice points• Attention to the environment is essential.• Opioid toxicity is a common cause of delirium, particularly in the elderly.• Corticosteroids can cause florid delirium.• Hypoactive delirium is frequently missed or misdiagnosed.• Atypical antipsychotics offer no advantage over haloperidol.• Adults with Incapacity Act covers the medical treatment of patients with cognitive impairment.See: Adults with Incapacity Act on website.• In the acute situation, emergency treatment can be given without an Incapacity certificate if thisis in the patient’s best interest.Patient / carer advice points• Encourage the patient to keep taking oral fluids if able.• The presence of a close relative or friend can help reassure the patient.ResourcesProfessionalBritish Geriatrics Society Guidelines: http://www.bgs.org.ukPatientMental Health Foundation: http://www.mentalhealth.org.ukKey references1. Young J, Inouye SK. Delirium in Older People. BMJ 2007; 334:842-62. Siddiqi N, House A. Delirium: an update on diagnosis, treatment and prevention. Clinical Medicine 2006; 6:540-543Further reading: http://www.palliativecareguidelines.scot.nhs.uk2 Issue date: January 2009 Review date: March 2012 © NHS Lothian
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Palliative Care Guidelines - NHS Lanarkshire

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