Abstract
This chapter considers delirium in the context of a palliative care emergency. It reviews screening for delirium, tools to confirm the clinical diagnosis of delirium, and diagnostic challenges. It describes both the nonpharmacological and pharmacological management of delirium. It also reviews the delirium experience and associated distress. It concludes with a brief discussion of the role of palliative sedation for refractory delirium at the end of life.
This is a preview of subscription content, log in via an institution to check access.
References
Agar MR, Lawlor PG, Quinn S, Draper B, Caplan G, Rowett D, et al. Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: a randomized clinical trial. JAMA Intern Med. 2017;177:34–42. https://doi.org/10.1001/jamainternmed.2016.7491.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, text revision. 4th ed. Washington, DC: American Psychiatric Association; 2000.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
Bellelli G, Morandi A, Davis DHJ, Mazzola P, Turco R, Gentile S, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014;43:496–502. https://doi.org/10.1093/ageing/afu021.
Bellelli G, Morandi A, Di Santo SG, Mazzone A, Cherubini A, Mossello E, et al. “Delirium day”: a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool. BMC Med. 2016;14:106. https://doi.org/10.1186/s12916-016-0649-8.
Beller EM, van Driel ML, McGregor L, Truong S, Mitchell G. Palliative pharmacological sedation for terminally ill adults. Cochrane Database Syst Rev. 2015;CD010206. https://doi.org/10.1002/14651858.CD010206.pub2
Body JJ, Niepel D, Tonini G. Hypercalcaemia and hypocalcaemia: finding the balance. Support Care Cancer. 2017;25:1639–49. https://doi.org/10.1007/s00520-016-3543-1.
Breitbart W, Alici Y. Agitation and delirium at the end of life: “we couldn’t manage him”. JAMA. 2008;300:2898–910. https://doi.org/10.1001/jama.2008.885.
Breitbart W, Alici Y. Evidence-based treatment of delirium in patients with cancer. J Clin Oncol. 2012;30:1206–14. https://doi.org/10.1200/JCO.2011.39.8784.
Breitbart W, Marotta R, Platt MM, Weisman H, Derevenco M, Grau C, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry. 1996;153:231–7. https://doi.org/10.1176/ajp.153.2.231.
Breitbart W, Rosenfeld B, Roth A, Smith MJ, Cohen K, Passik S. The memorial delirium assessment scale. J Pain Symptom Manag. 1997;13:128–37. https://doi.org/10.1016/S0885-3924(96)00316-8.
Breitbart W, Gibson C, Tremblay A. The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics. 2002;43:183–94.
Bruera E, Bush SH, Willey J, Paraskevopoulos T, Li Z, Palmer JL, et al. Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. Cancer. 2009;115:2004–12. https://doi.org/10.1002/cncr.24215.
Bruinsma S, Rietjens J, van der Heide A. Palliative sedation: a focus group study on the experiences of relatives. J Palliat Med. 2013;16:349–55. https://doi.org/10.1089/jpm.2012.0410.
Buckley NA, Dawson AH, Isbister GK. Serotonin syndrome. BMJ. 2014;348:g1626.
Bush SH, Leonard MM, Agar M, Spiller JA, Hosie A, Wright DK, et al. End-of-life delirium: issues regarding recognition, optimal management, and the role of sedation in the dying phase. J Pain Symptom Manag. 2014;48:215–30. https://doi.org/10.1016/j.jpainsymman.2014.05.009.
Buss M, Vanderwerker L, Inouye SK, Zhang B, Block S, Prigerson H. Associations between caregiver-perceived delirium in patients with cancer and generalized anxiety in their caregivers. J Palliat Med. 2007;10:1083–92.
Canadian Coalition for Seniors’ Mental Health. Guideline on the assessment and treatment of delirium in older adults at the end of life. Toronto: Canadian Coalition for Seniors’ Mental Health; 2010.
Candy B, Jackson Kenneth C, Jones L, Leurent B, Tookman A, King M. Drug therapy for delirium in terminally ill adult patients. Cochrane Database Syst Rev. 2012;CD004770. https://doi.org/10.1002/14651858.CD004770.pub2
Caraceni A, Nanni O, Maltoni M, Piva L, Indelli M, Arnoldi E, et al. Impact of delirium on the short term prognosis of advanced cancer patients. Cancer. 2000;89:1145–9.
Casarett D, Inouye SK. American College of Physicans-American Society of internal medicine end-of-life care consensus panel. Diagnosis and management of delirium near the end of life. Ann Intern Med. 2001;135:32–40.
Cherny N, ESMO Guidelines Working Group. ESMO Clinical Practice Guidelines for the management of refractory symptoms at the end of life and the use of palliative sedation. Ann Oncol. 2014;25(Suppl 3):iii143–52. https://doi.org/10.1093/annonc/mdu238.
Cherny N, Portenoy R. Sedation in the management of refractory symptoms: guidelines for evaluation and treatment. J Palliat Care. 1994;10:31–8.
Cherny N, Radbruch L. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med. 2009;23:581–93. https://doi.org/10.1177/0269216309107024.
Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review. Age Ageing. 2011;40:23–9. https://doi.org/10.1093/ageing/afq140.
Clegg A, Westby M, Young JB. Under-reporting of delirium in the NHS. Age Aging. 2011;40:283–6. https://doi.org/10.1093/ageing/afq157.
Cohen MZ, Pace EA, Kaur G, Bruera E. Delirium in advanced cancer leading to distress in patients and family caregivers. J Palliat Care. 2009;25:164–71.
Darbyshire JL, Young JD. An investigation of sound levels on intensive care units with reference to the WHO guidelines. Crit Care. 2013;17:R187. https://doi.org/10.1186/cc12870.
Dasgupta M, Hillier LM. Factors associated with prolonged delirium: a systematic review. Int Psychogeriatr. 2010;22:373–94. https://doi.org/10.1017/S1041610209991517.
Day J, Higgins I. Mum’s absence(s): conceptual insights into absence as loss during a loved one’s delirium. J Clin Nurs. 2016;25:2066–73. https://doi.org/10.1111/jocn.13268.
de la Cruz M, Fan J, Yennu S, Tanco K, Shin S, Wu J, et al. The frequency of missed delirium in patients referred to palliative care in a comprehensive cancer center. Support Care Cancer. 2015a;23:2427–33. https://doi.org/10.1007/s00520-015-2610-3.
de la Cruz M, Ransing V, Yennu S, Wu J, Liu D, Reddy A, et al. The frequency, characteristics, and outcomes among cancer patients with delirium admitted to an acute palliative care unit. Oncologist. 2015b;20:1425–31. https://doi.org/10.1634/theoncologist.2015-0115.
Dumont S, Turgeon J, Allard P, Gagnon P, Charbonneau C, Vézina L. Caring for a loved one with advanced cancer: determinants of psychological distress in family caregivers. J Palliat Med. 2006;9:912–21. https://doi.org/10.1089/jpm.2006.9.912.
Engel G, Romano J. Delirium, a syndrome of cerebral insufficiency. J Chronic Dis. 1959;9:260–77.
Ferraz Gonçalves JA, Almeida A, Costa I, Silva P, Carneiro R. Comparison of haloperidol alone and in combination with midazolam for the treatment of acute agitation in an inpatient palliative care service. J Pain Palliat Care Pharmacother. 2016;30:284–8.
Finucane AM, Lugton J, Kennedy C, Spiller JA. The experiences of caregivers of patients with delirium, and their role in its management in palliative care settings: an integrative literature review. Psychooncology. 2017;26:291–300. https://doi.org/10.1002/pon.4140.
Flaherty J, Gonzales J, Dong B. Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review. J Am Geriatr Soc. 2011;59(Suppl 2):S269–76. https://doi.org/10.1111/j.1532-5415.2011.03675.x.
Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface between delirium and dementia in elderly adults. Lancet Neurol. 2015;14:823–32.
Gagliese L, Rodin R, Chan V, Stevens B, Zimmermann C. How do healthcare workers judge pain in older palliative care patients with delirium near the end of life? Palliat Support Care. 2016;14:151–8. https://doi.org/10.1017/S1478951515000929.
Gagnon P, Allard P, Gagnon B, Mérette C, Tardif F. Delirium prevention in terminal cancer: assessment of a multicomponent intervention. Psychooncology. 2012;21:187–94. https://doi.org/10.1002/pon.1881.
Gaudreau JD, Gagnon P, Harel F, Roy MA. Impact on delirium detection of using a sensitive instrument integrated into clinical practice. Gen Hosp Psychiatry. 2005;27:194–9. https://doi.org/10.1016/j.genhosppsych.2005.01.002.
Hosie A, Davidson PM, Agar M, Sanderson CR, Phillips J. Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: a systematic review. Palliat Med. 2013;27:486–98. https://doi.org/10.1177/0269216312457214.
Hshieh TT, Yue J, Oh E, Puelle M, Dowal S, Travison T, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175:512–20. https://doi.org/10.1001/jamainternmed.2014.7779.
Hu MI, Glezerman IG, Leboulleux S, Insogna K, Gucalp R, Misiorowski W, Yu B, Zorsky P, Tosi D, Bessudo A, Jaccard A, Tonini G, Ying W, Braun A, Jain RK. Denosumab for treatment of hypercalcemia of malignancy. J Clin Endocrinol Metab. 2014;99:3144–52. https://doi.org/10.1210/jc.2014-1001.
Hui D, dos Santos R, Reddy S, Nascimento M, Zhukovsky DS, Paiva CE, et al. Acute symptomatic complications among patients with advanced cancer admitted to acute palliative care units: a prospective observational study. Palliat Med. 2015;29:826–33. https://doi.org/10.1177/0269216315583031.
Indelicato R, Portenoy RK. Opioid rotation in the management of refractory cancer pain. J Clin Oncol. 2002;20:348–52. https://doi.org/10.1200/JCO.2002.20.1.348.
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;113:941–8. https://doi.org/10.7326/0003-4819-113-12-941.
Inouye SK, Baker DI, Fugal P, Bradley EH. Dissemination of the hospital elder life program: implementation, adaptation, and successes. J Am Geriatr Soc. 2006;54:1492–9.
Inouye SK, Westendorp R, Saczynski J. Delirium in elderly people. Lancet. 2014a;383:911–22. https://doi.org/10.1016/S0140-6736(13)60688-1.
Inouye SK, Marcantonio E, Metzger E. Doing damage in delirium: the hazards of antipsychotic treatment in elderly persons. Lancet Psychiatr. 2014b;1:312–5.
Irwin S, Pirrello R, Hirst J, Buckholz G, Ferris F. Clarifying delirium management: practical, evidence-based, expert recommendations for clinical practice. J Palliat Med. 2013;16:423–35. https://doi.org/10.1089/jpm.2012.0319.
Katus L, Frucht S. Management of serotonin syndrome and neuroleptic malignant syndrome. Curr Treat Options Neurol. 2016;18:39. https://doi.org/10.1007/s11940-016-0423-4.
Kerr CW, Donnelly JP, Wright ST, Luczkiewicz DL, McKenzie KJ, Hang PC, et al. Progression of delirium in advanced illness: a multivariate model of caregiver and clinician perspectives. J Palliat Med. 2013;16:768–73. https://doi.org/10.1089/jpm.2012.0561.
Kim S-Y, Kim S-W, Kim J-M, Shin I-S, Bae K-Y, Shim H-J, et al. Differential associations between delirium and mortality according to delirium subtype and age: a prospective cohort study. Psychosom Med. 2015;77:903–10.
Laurila JV, Laakkonen ML, Laurila JV, Timo SE, Reijo TS. Predisposing and precipitating factors for delirium in a frail geriatric population. J Psychosom Res. 2008;65:249–54. https://doi.org/10.1016/j.jpsychores.2008.05.026.
Lawlor PG, Bush SH. Delirium in patients with cancer: assessment, impact, mechanisms and management. Nat Rev Clin Oncol. 2015;12:77–92. https://doi.org/10.1038/nrclinonc.2014.147.
Lawlor P, Gagnon B, Mancini I, Pereira J, Hanson J, Suarez-Almazor M, et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med. 2000;160:786–94.
Leentjens AFG, Rundell J, Rummans T, Shim JJ, Oldham R, Peterson L, et al. Delirium: an evidence-based medicine (EBM) monograph for psychosomatic medicine practice, commissioned by the Academy of Psychosomatic Medicine (APM) and the European Association of Consultation Liaison Psychiatry and Psychosomatics (EACLPP). J Psychosom Res. 2012;73:149–52. https://doi.org/10.1016/j.jpsychores.2012.05.009.
Leonard MM, Raju B, Conroy M, Donnelly S, Trzepacz PT, Saunders J, et al. Reversibility of delirium in terminally ill patients and predictors of mortality. Palliat Med. 2008;22:848–54. https://doi.org/10.1177/0269216308094520.
Leonard MM, Agar M, Spiller JA, Davis B, Mohamad MM, Meagher DJ, et al. Delirium diagnostic and classification challenges in palliative care: subsyndromal delirium, comorbid delirium-dementia, and psychomotor subtypes. J Pain Symptom Manag. 2014;48:199–214.
Maltoni M, Scarpi E, Rosati M, Derni S, Fabbri L, Martini F, et al. Palliative sedation in end-of-life care and survival: a systematic review. J Clin Oncol. 2012;30:1378–83. https://doi.org/10.1200/JCO.2011.37.3795.
Marcantonio ER, Ngo LH, O’Connor M, Jones RN, Crane PK, Metzger ED, et al. 3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium: a cross-sectional diagnostic test study. Ann Intern Med. 2014;161:554–61. https://doi.org/10.7326/M14-0865.
Maust DT, Kim HM, Seyfried LS, Chiang C, Kavanagh J, Schneider LS, et al. Antipsychotics, other psychotropics, and the risk of death in patients with dementia: number needed to harm. JAMA Psychiat. 2015;72:438–45. https://doi.org/10.1001/jamapsychiatry.2014.3018.
Mc Donnell S, Timmins F. A quantitative exploration of the subjective burden experienced by nurses when caring for patients with delirium. J Clin Nurs. 2012;21:2488–98. https://doi.org/10.1111/j.1365-2702.2012.04130.x.
Meagher DJ, Leonard M, Donnelly S, Conroy M, Adamis D, Trzepacz PT. A longitudinal study of motor subtypes in delirium: frequency and stability during episodes. J Psychosom Res. 2012;72:236–41. https://doi.org/10.1016/j.jpsychores.2011.11.013.
Michaud L, Büla C, Berney A, Camus V, Voellinger R, Stiefel F, et al. Delirium: guidelines for general hospitals. J Psychosom Res. 2007;62:371–83.
Morandi A, Pandharipande P, Trabucchi M, Rozzini R, Mistraletti G, Trompeo AC, et al. Understanding international differences in terminology for delirium and other types of acute brain dysfunction in critically ill patients. Intensive Care Med. 2008;34:1907–15. https://doi.org/10.1007/s00134-008-1177-6.
Morandi A, Davis D, Bellelli G, Arora RC, Caplan GA, Kamholz B, et al. The diagnosis of delirium superimposed on dementia: an emerging challenge. J Am Med Dir Assoc. 2017;18:12–8. https://doi.org/10.1016/j.jamda.2016.07.014.
Morita T, Tei Y, Tsunoda J, Inoue S, Chihara S. Underlying pathologies and their associations with clinical features in terminal delirium of cancer patients. J Pain Symptom Manag. 2001;22:997–1006.
Morita T, Akechi T, Ikenaga M, Inoue S, Kohara H, Matsubara T, et al. Terminal delirium: recommendations from bereaved families’ experiences. J Pain Symptom Manag. 2007;34:579–89. https://doi.org/10.1016/j.jpainsymman.2007.01.012.
Nakajima N, Satake N, Nakaho T. Indications and practice of artificial hydration for terminal ill cancer patients. Curr Opin Support Palliat Care. 2014;8:358–63. https://doi.org/10.1097/SPC.0000000000000089.
Namba M, Morita T, Imura C, Kiyohara E, Ishikawa S, Hirai K. Terminal delirium: families’ experience. Palliat Med. 2007;21:587–94.
National Institute for Health and Care Excellence. Delirium: diagnosis, prevention and management. Clinical guideline 103. 2010. http://www.nice.org.uk/CG103. Accessed 2 May 2017.
Neufeld K, Yue J, Robinson T, Inouye SK, Needham D. Antipsychotic medication for prevention and treatment of delirium in hospitalized adults: a systematic review and meta-analysis. J Am Geriatr Soc. 2016;64:705–14. https://doi.org/10.1111/jgs.14076.
Otani H, Morita T, Uno S, Yamamoto R, Hirose H, Matsubara T, et al. Usefulness of the leaflet-based intervention for family members of terminally ill cancer patients with delirium. J Palliat Med. 2013;16:419–22. https://doi.org/10.1089/jpm.2012.0401.
Oxford University Press. Oxford dictionary. 2017. https://en.oxforddictionaries.com/definition/medical_emergency. Accessed 22 Mar 2017.
Partridge JS, Martin FC, Harari D, Dhesi JK. The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this? Int J Geriatr Psychiatry. 2013;28:804–12. https://doi.org/10.1002/gps.3900.
Pealing L, Iliffe S. A woman with forgetfulness and falls. BMJ. 2011;24:d7412. https://doi.org/10.1136/bmj.d7412.
Pendlebury S, Lovett N, Smith S, Dutta N, Bendon C, Lloyd-Lavery A, et al. Observational, longitudinal study of delirium in consecutive unselected acute medical admissions: age-specific rates and associated factors, mortality and re-admission. BMJ Open. 2015;5:e007808. https://doi.org/10.1136/bmjopen-2015-007808.
Ryan DJ, O’Regan NA, Caoimh RÓ, Clare J, O’Connor M, Leonard M, et al. Delirium in an adult acute hospital population: predictors, prevalence and detection. BMJ Open. 2013;3:e001772. https://doi.org/10.1136/bmjopen-2012-001772.
Sands MB, Dantoc BP, Hartshorn A, Ryan C, Lujic S. Single question in delirium (SQiD): testing its efficacy against psychiatrist interview, the confusion assessment method and the memorial delirium assessment scale. Palliat Med. 2010;24:561–5. https://doi.org/10.1177/0269216310371556.
Schuurmans MJ, Shortridge-Baggett LM, Duursma SA. The delirium observation screening scale: a screening instrument for delirium. Res Theory Nurs Pr. 2003;17:31–50.
Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, et al. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2016;CD005563. https://doi.org/10.1002/14651858.CD005563.pub3
Stewart AF. Clinical practice. Hypercalcemia associated with cancer. N Engl J Med. 2005;352:373–9. https://doi.org/10.1056/NEJMcp042806.
Stone C, Lawlor P, Savva G, Bennett K, Kenny R. Prospective study of falls and risk factors for falls in adults with advanced cancer. J Clin Oncol. 2012;30:2128–33. https://doi.org/10.1200/JCO.2011.40.7791.
Toye C, Matthews A, Hill A, Maher S. Experiences, understandings and support needs of family carers of older patients with delirium: a descriptive mixed methods study in a hospital delirium unit. Int J Older People Nursing. 2014;9:200–8. https://doi.org/10.1111/opn.12019.
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 the cognitive test for delirium [internet]. J Neuropsychiatry Clin Neurosci. 2001;13:229–42.
Winnipeg Regional Health Authority. WRHA policy number: 110.000.200: advance care planning – goals of care. 2011. http://www.wrha.mb.ca/index.php. Accessed 2 May 2017.
World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. 1992. http://www.who.int/classifications/icd/en/bluebook.pdf. Accessed 3 May 2017.
Zimberg M, Berenson S. Delirium in patients with cancer: nursing assessment and intervention. Oncol Nurs Forum. 1990;17:529–38.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2019 Springer Nature Switzerland AG
About this entry
Cite this entry
Bush, S.H. (2019). Delirium as a Palliative Care Emergency. In: MacLeod, R., Van den Block, L. (eds) Textbook of Palliative Care. Springer, Cham. https://doi.org/10.1007/978-3-319-31738-0_87-2
Download citation
DOI: https://doi.org/10.1007/978-3-319-31738-0_87-2
Received:
Accepted:
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-31738-0
Online ISBN: 978-3-319-31738-0
eBook Packages: Springer Reference Biomedicine and Life SciencesReference Module Biomedical and Life Sciences
Publish with us
Chapter history
-
Latest
Delirium as a Palliative Care Emergency- Published:
- 09 February 2019
DOI: https://doi.org/10.1007/978-3-319-31738-0_87-2
-
Original
Delirium as a Palliative Care Emergency- Published:
- 22 February 2018
DOI: https://doi.org/10.1007/978-3-319-31738-0_87-1