Download Confusion / Delirium - St Elizabeth Hospice

Confusion / Delirium
Delirium is generally a reversible condition. Identifying early signs of delirium allows appropriate
treatment to be started sooner. Delirium is precipitated or exacerbated by many factors. In most palliative
care patients delirium is multifactorial. Delirium is common at the end of life.
Clinical features of delirium
• Acute onset and fluctuating course
• Reduced attention, easily distracted
• Disorientated to time, place or person
• Memory impairment (unable to register new material)
• Disorganised thinking – rambling or irrelevant conversation
• Disturbance of sleep-wake cycle
• Altered level of consciousness
o Hyperactive – agitated, delusions + hallucinations
o Hypoactive – lethargic, confused + sedated
Causes
• Can the cause be identified?
• Can the cause be reversed? What is the patient’s prognosis?
• Is investigation or treatment of the cause appropriate?
Precipitating / exacerbating factors for delirium
Past history
• Dementia, other mental illness
• Cerebrovascular disease
• Brain tumour / metastases
• Alcohol / drug abuse or withdrawal
Biochemical
• Uraemia
• Hypercalcaemia
• Hyponatraemia
• Hyperglycaemia / hypoglycaemia
• Dehydration
Withdrawal
• Alcohol
• Benzodiazepines
• Nicotine
Infection
Hypoxia
Uncontrolled pain
Faecal impaction
Urinary retention
Cerebral tumours
Drugs
• Opioids
• Corticosteroids
• Neuroleptics / tricyclics
• Anticholinergics
• Antidepressants
General Care
• Nurse in quiet, safe, calm, well lit environment
• Maintain hydration – use subcutaneous or IV fluids if appropriate
• Involve family members and offer support and information. Confusion is distressing.
• Use lucid intervals to establish rapport and address fears / concerns
• Gentle repeated re-orientation where possible – use clock, calendar, daily routines
• Communicate in simple, clear, concise manner
• Avoid confrontation
• Try to maintain normal sleep / wake cycle
•
Correct hypoxia if possible
•
•
•
•
•
Drug treatment of delirium
Review all medication and discontinue all non-essential drugs
Use the minimum sedative medication necessary and regularly review
Use oral route if possible
Withdraw sedative medication as the episode of confusion resolves
Use prophylactic treatment with benzodiazepines in acute alcohol withdrawal
1. Emergency sedation of an acutely agitated / disturbed patient
o Sedate with Haloperidol 2.5-5mg IM or SC
o ± benzodiazepine e.g. Lorazepam 0,5-2,5mg sublingual/po. Can be given parenterally
o Repeat after 30 minutes if necessary and consider starting a syringe driver
o Maintenance treatment may be needed based on stat doses used
2. Delirium – may be hyperactive, hypoactive or mixed
o Benzodiazepines alone do not improve cognition in delirium and may worsen it
o Use Haloperidol stat + PRN 1.5-5mg SC or 0.5 –5mg PO
o Maintenance Haloperidol 2.5-10mg/24hrs CSCI or 0.5-3mg bd PO
o N.B. Extrapyramidal symptoms with prolonged use
3. Acute on chronic confusion e.g. in dementia, cerebrovascular disease
o Delirium – Haloperidol as above
o Chronic confusion – consider atypical antipsychotic
i. Risperidone 0.5mg bd PO (increasing to 1mg bd PO if needed)
ii. Olanzapine 2.5mg nocte (increasing to 5-10mg nocte if needed)
iii. Quetiapine 25- 50mg nocte po
o Insomnia – Clomethiazole(192mg) 1-4 capsules nocte
4. Distressing restlessness /agitation in last days of life
o Sedation may be the most appropriate management
o Opioid analgesics should not be used to sedate patients in the last days of life
Patient is confused /
agitated/hallucinating
→ Haloperidol 2.5mg SC stat
+ Haloperidol 5-10mg /24hrs CSCI
+ Haloperidol 2.5mg 4hrly prn SC
Patient is anxious / frightened but lucid
Try to explore fears
Lorazepam 0.5mg PO or SL 2- 4hrly prn
Patient still confused / agitated
↑Haloperidol to 10mg – 20mg /24hrs CSCI
if patient still agitated consider adding lorazepam
or levomepromazine
Patient has continuous anxiety/ distress
Midazolam 10mg /24hrs CSCI
Increase Midazolam dose in 30-50% steps up to
80mg/24hrs.
Use Midazolam 2.5-5mg SC prn 2hrly
Or use Diazepam rectal solution 10mg 6-8hrly PR
Patient still agitated / distressed
Give stat dose of Levomepromazine 12.5mg SC and repeat 2- 4hrly prn
Consider changing to Levomepromazine 25-200mg / 24 hrs CSCI or Phenobarbitone
If patient is very disturbed and fails to settle seek specialist palliative care advice
References
Zinberg M, Berenson S. Delirium in patients with cancer: nursing assessment and intervention. Oncology
Nursing Forum 1990; 17(4) 529-538
Breitbart W, Sparrow B. Management of delirium in the terminally ill. Progress in Palliative Care 1998;
6(4) 107-113
MacLeod AD.The management of delirium in hospice practice. Eur.J of Pall Care 1997; 4(4) 116-120