Download Guidelines: Non-Pharmacological Management

Delirium in the Last Hours
and Days of Life
19th May 2016
Guideline Development Group Members
•
Dr Clare Finnegan
–
•
Dr Fawad Ahmad
–
•
•
Rebecca Telfer
Clinical Pharmacist, Liverpool Heart and Chest Hospital
Dr Daniel Monnery
–
•
ST3 Palliative Medicine, Woodlands Hospice
Graham Holland
–
•
Clinical Nurse Specialist Palliative Care, St Helens and Knowsley NHS Trust
Dr Penelope Shepherd
–
•
Marie Curie Hospice, Woolton, Liverpool.
n
–
•
Consultant in Palliative Medicine, Wirral Hospice St. John’s
Kate Nolan
–
•
Consultant in Palliative Medicine, West Lancs, Southport and Formby Specialist Palliative Care
Service
ST4 Palliative Medicine, Aintree University Hospitals
Dr Kathryn Gaunt
–
ST6 Palliative Medicine, Woodlands Hospice
With Special Thanks to
• Patient, Carer and Public Representative
– Sandra Smith
• External Reviewer
– Dr Fraser Gordon
Consultant Geriatrician, Southport Hospital
Current Standards and Guidelines – Last Reviewed Jan 2009
Guidelines for the Management of Delirium in Advanced Cancer Patients
Dr C Finnegan, Dr F Ahmad, Dr K Marley, Dr C Lewis-Jones, Dr A Fountain,
Dr L Beddows,
Summary of Current Guidelines
• Outlines DSM IV Criteria to assist in the diagnosis of delirium
• Highlights the importance of addressing potentially reversible causes
• Addresses the need to use both non-pharmacological and
pharmacological approaches to management
• Prompt to follow the Mental Capacity Act 2005 if the patient is found to
lack the capacity to consent to treatment.
Figure 14.1 Pharmacological management of delirium in advanced cancer 7, 8, 10 [Level 4]
Diagnosis of delirium using
DSMIV criteria.
NB. Drug
treatment only
indicated where
the patient is
distressed.
Reversible causes investigated and
treated where appropriate.
Is patient able to swallow?
YES
Start haloperidol 0.5mg5mg orally at night.
NO
Prescribe haloperidol 0.5mg-3mg
subcutaneously prn.
Consider haloperidol 3mg-10mg as
a subcutaneous infusion via a
syringe driver over 24 hours.
Are there any side effects?
NO
Continue
regimen.
YES
Consider atypical
anti-psychotic
e.g. Olanzapine.
Dose: 2.5mg
orally at night
and as required.
NB. Subcutaneous: oral
potency of haloperidol is 2:1.
Current Standards
• The DSM IV Criteria should be used in the diagnosis of
delirium [Grade D]
• Reversible Causes of delirium should be treated where
appropriate [Grade D]
• All Patients should have a clinical examination at initial
assessment of delirium [Grade D]
• All patients should have a review of medication at initial
assessment of delirium [Grade D]
Current Standards
• The reason for the use of psychotropic medication should
be documented in the case notes [Grade D]
• Haloperidol is the drug of choice for the management of
delirium where the cause is unknown [Grade C]
• Inpatients with delirium should be reviewed every four
hours to ensure adequate symptom control [Grade D]
People’s Voice Feedback
The hospital
have caused
this
This is very very
frightening
This isn’t my mum
anymore
Why doesn’t he know
who I am?
I don’t understand
why this is
happening.
Nobody is
explaining
Systematic Literature Review
September-October 2015
Our Questions using PICO
1. In patients in the last hours to days of life (P), is one
method of assessment (I) superior to other methods or no
formal method (C) in diagnosing delirium (O).
2. In patients diagnosed with delirium in the last hours to
days of life (P), what treatments (pharmacological and
non-pharmacological) (I) compared to no treatment or
other methods (C) are superior in managing delirium (O)
LITERATURE REVIEW
• NICE guidelines 2010- Delirium: Prevention, Diagnosis and
Management. NICE Guideline (CG103)
• Cochrane review 2012- Drug therapy for delirium in
terminally ill adult patients (Review).
ADDITIONAL SEARCH
• Delirium AND (palliative OR ’end of life’ OR dying) AND (treatment OR
diagnosis OR screening OR assessment)
• Medline, EMBASE and CINAHL databases:
368 articles
44 abstracts
24 articles
16 Full texts included
Key Points from NICE Guideline
• Communication with the patient and those important to them
including reassurance and reorientation for the patient is important.
• Clinical assessment and diagnosis of delirium should be based on DSMIV criteria or the Confusion assessment Method (CAM).
• Patients diagnosed with delirium should be treated by a
multidisciplinary team approach with a combination of nonpharmacological and pharmacological management
• If a person with delirium is distressed or considered a risk to
themselves or others and verbal and non-verbal de-escalation
techniques are ineffective or inappropriate, consider giving short-term
(usually for 1 week or less) haloperidol or olanzapine. Start at the
lowest clinically appropriate dose and titrate cautiously according to
symptoms.
Assessment of Delirium
Ryan et al
 The Confusion Assessment Method (CAM) is the most widely used
instrument for the detection of delirium worldwide.
 It was developed from the DSM Criteria
 The objective of the study was to determine the sensitivity and
specificity of the CAM in diagnosing delirium when used by nonconsultant hospital doctors in a specialist palliative care unit in Ireland
 52 patients underwent 54 assessments during the main phase of the
trial
Confusion Assessment Method (CAM) Diagnostic Algorithm
Date of
Assessment
Time of
Assessment
Yes or No
1. Acute Onset and fluctuating course? (Acute change in mental status from
baseline, fluctuating behavior through the day)
2. Inattention? (Difficulty focusing attention, easily distracted, difficulty keeping
track of what is being said)
3. Disorganised thinking? (disorganized or incoherent thinking, rambling or
irrelevant conversation, unclear or illogical flow of ideas)
4. Altered level of consciousness? (This feature is shown by any answer other than
‘alert’, including: hyperalert, lethargic, stupor or coma)
The Diagnosis of Delirium by CAM requires the presence of features 1 and 2 and either 3 or 4
Delirium Detected?
Yes or No
(please circle)
Ryan et al
• The CAM was completed as part of the full initial assessment and at
three points during patient stay.
• A full psychiatric assessment was then carried out within 24 hours of
the CAM assessment.
• Sensitivity was 0.88 (0.62-0.98) and Specificity 1.0 (0.88-1.0)
• However these results were dependent on the doctors receiving
‘enhanced’ training in the use of the CAM.
• In the pilot study (without enhanced training) the Sensitivity was 0.5
(0.22-0.78) and Specificity 1.0 (0.81-1.0)
Ryan et al
• Study concluded that the CAM is a valid screening tool for delirium in
the palliative care setting but its performance is dependent on the skill
of the operator.
• Enhanced training used case based learning to define the cardinal
symptoms and signs of delirium and lasted approximately 2 hours.
• Limitations of the study
• 106 potential patients but only 52 recruited (others felt to be
too unwell)
• Assessments took place on different days
Cochrane Review 2012
Drug therapy for delirium in terminally ill adult patients (Review)
Candy B, Jackson KC, Jones L, Leurent B, Tookman A, King M
The Cochrane Library 2012, Issue 11
Cochrane review 2012
Trials comparing any drug treatment with other treatments
(pharmacological and non-pharmacological) for delirium (as per DSM or
CAM criteria) in adult patients with terminal disease in any setting
Primary outcome = reduction in symptoms of delirium
Secondary outcome = adverse effects
• Previous review identified 13 potential studies  1 met inclusion
criteria
• 3066 citations screened identifying 4 potential studies none relevant
Included study: A double blind trial of haloperidol, chlorpromazine and
lorazepam in the treatment of delirium in hospitalised AIDS patients
(1996)
• 244 patients with advanced AIDS hospitalised to treat medical
co-morbidities consented and monitored for delirium meeting
DSM-III-R criteria and scoring 13+ on the Delirium Rating Scale
(DRS)
• 30 developed delirium and randomised to the three drug
treatments. Doses escalated as per symptoms using a drugdosing protocol until stable when converted onto BD dose
Results
•
•
•
•
•
•
•
Lorazepam arm dropped during the study due to adverse affects
Both chlorpromazine and haloperidol reduced the symptoms of delirium below
the DSM-III diagnostic threshold and improved cognitive status
No significant differences between the two drugs at day two, but at day six
chlorpromazine group had a slight drop in cognition
Both significantly reduced the symptoms of delirium at day two compared to
lorazepam
Improvement of delirium at day two for lorazepam was not apparent, and
patients had a decrease in cognitive status
All patients in the lorazepam arm developed side effects including oversedation
and increased confusion
No clinically significant side effects were noted in the chlorpromazine and
haloperidol arms
Conclusions
• Many limitations to study
• Limited evidence in terminally ill patients
• Unable to make recommendations specific to terminally ill
patients
• Little evidence of harm from currently used drugs (apart
from this one small study showing adverse effects with
lorazepam) and their use is likely to continue
• Guidelines recommend drug therapy not the first option in
management, and reversible causes identified and treated
• Larger multi-center controlled trials are needed
Pharmacological management
An Open Trial Comparing Haloperidol with Olanzapine for the Treatment of
Delirium in Palliative and Hospice Center Cancer Patients.
Lin CJ, Sun FJ, Fang CK, Chen HW, & Lai YL. Journal of Internal Medicine of
Taiwan. 2008; 19(4): 346-354.
Lin, et al.
• Randomised Controlled Trial. 1 week follow up period. Double-Blind.
• Participants: Patients with advanced cancer, diagnosed with delirium
according to DSM-IV criteria, as judged by liaison psychiatrist.
• Severity of delirium was graded using the delirium rating scale (DRS)
and Clinical Global Impression-Severity (CGI-S) at baseline, after 24h,
48h and 1 week.
• If the patient was judged to require an antipsychotic by the psychiatrist
they were randomised to receive either olanzapine 5mg or haloperidol
5mg at 1800. Every 24h they were re-assessed by the same psychiatrist,
and the dose titrated according to clinical effect up to a maximum dose
of 15mg haloperidol or 15mg olanzapine once daily.
Lin, et al., continued.
• Midazolam was used in conjunction with antipsychotics when needed
for agitation, but not routinely
• At the end of the study, data had been collected for 16 patients in the
olanzapine group and 14 in the haloperidol group. There were no
statistically significant differences in demographics, nor statistically
significant difference in severity scores between groups at baseline
• 11 patients in the olanzapine group and 7 in the haloperidol group died
during the follow up period (1 week)
• Both groups showed statistically significant improvements in severity
scores after 24 hours and after 7 days (compared to baseline).
• There was no statistically significant difference between haloperidol
and olanzapine groups at any point.
Lin et al., continued
• No reports of side effects
• No difference in midazolam usage between groups
• Average doses required was 5mg for each group
UPDATED GUIDELINE
RECOMMENDATIONS AND
STANDARDS
Introduction
Delirium is defined as an acute confusional state which results from diffuse
organic brain dysfunction1. It is commonly characterised by disturbed
consciousness, impaired cognitive function or perception, has an acute
onset and a fluctuating course2.
In terminal cancer patients, the prevalence of delirium may be as high as
85%3, with prevalence during inpatient stays in hospice or hospital
estimated between 28- 88%4-5
Delirium may be reversible in almost 50% of cases6-7, however this is
dependent on correct diagnosis, which is often complicated in patients
approaching the end of life.
Introduction
The management of delirium is complex and often involves nonpharmacological and pharmacological approaches. The majority of
research into the management of delirium using neuroleptic medications
has taken place in the elderly care setting8-10 with relatively little evidence
in the advanced cancer population11, 12.
Non-pharmacological de-escalation techniques have been described in
NICE Quality Standard 63; Delirium in Adults2 as well as recommendations
for pharmacological management, however it does not specifically address
these with respect to the palliative care population.
Guidelines: Screening and Diagnosis
•Delirium is a clinical diagnosis. The Diagnostic and Statistical Manual of
Mental Disorders V (DSM V) outlines the criteria necessary for the
diagnosis of delirium [level 1]13
Table 3
DSM –V Criteria for the Diagnosis of Delirium13
A. Disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced
orientation to the environment).
B. The disturbance develops over a short period (usually hours to days), represents an acute change from baseline
attention and awareness, and tends to fluctuate during the course of the day.
C.
Change in cognition (e.g., memory deficit, disorientation, language disturbance, perceptual disturbance)
D. The disturbances in Criteria A and C are not better explained by a pre-existing, established or evolving neurocognitive
disorder and do not occur in the context of a severely reduced level of arousal such as coma.
E. There is evidence from the history, physical examination or laboratory findings that the disturbance is a direct
physiological consequence of another medical condition, substance intoxication or withdrawal (i.e. due to a drug of abuse or
to a medication), or exposure to a toxin, or is due to multiple aetiologies.
Guidelines: Screening and Diagnosis
•There is poor recognition of delirium when subjective nursing assessment
alone is used [level 3]14
•Several tools have been developed to facilitate reliable detection of
delirium in practice. The Confusion Assessment Method (CAM) diagnostic
algorithm has been developed from the DSM criteria [level 3]15
•It has been validated for use in the palliative care setting with a sensitivity
of 0.88 (0.62-0.98) and a specificity of 1.0 (0.88-1.0) [level 3]16
•The performance of the CAM was found to be dependent upon the skill
of the operator with training required before its use [level 3]16
•If the diagnosis of delirium is suspected due to presence of the clinical
features listed in Table 2, the CAM diagnostic algorithm, reproduced
below, may be a helpful tool for the screening of delirium [level 3]15
Confusion Assessment Method (CAM) Diagnostic Algorithm
Date of
Assessment
Time of
Assessment
Yes or No
1. Acute Onset and fluctuating course? (Acute change in mental status from
baseline, fluctuating behavior through the day)
2. Inattention? (Difficulty focusing attention, easily distracted, difficulty keeping
track of what is being said)
3. Disorganised thinking? (disorganized or incoherent thinking, rambling or
irrelevant conversation, unclear or illogical flow of ideas)
4. Altered level of consciousness? (This feature is shown by any answer other than
‘alert’, including: hyperalert, lethargic, stupor or coma)
The Diagnosis of Delirium by CAM requires the presence of features 1 and 2 and either 3 or 4
Delirium Detected?
Yes or No
(please circle)
Guidelines: Mental Capacity Act
Where a patient is shown to lack capacity to consent to treatment, the
Mental Capacity Act, 2005 must be followed. Lasting Power of Attorney,
Advanced Decisions, Independent Mental Capacity Advocates and
Deprivation of Liberty Safeguards should be utilised where appropriate.
Guidelines: Non-Pharmacological Management
• People diagnosed with delirium should be assessed for reversible
causes, and these addressed where appropriate [Level 4]2
• There is evidence that psychoactive medications, such as opioids, and
dehydration are two of the most common reversible causes of delirium
[Level 2+]6
• Reversibility may decline with repeated episodes of delirium [Level 2+]6
• Table 4 lists some of the potentially reversible causes of delirium6,17,18
Table 4: Reversible causes of delirium
o
o
o
o
o
o
o
Alcohol
Biochemical abnormalities
uraemia
Cardiovascular causes
Cerebral pathology
Constipation
Dehydration
Haematological causes
e.g.
o
hypercalcaemia, o
o
o
o
Infections
Medications e.g. opioids
Nutritional deficiencies
Withdrawal from alcohol/nicotine
Withdrawal
from
drugs
e.g.
benzodiazepines, opioids
antipsychotics,
Guidelines: Non-Pharmacological Management
•Due to the risks of adverse side effects from medications used in the
treatment of delirium (including drowsiness, decline in cognition, extrapyramidal side effects and the small risk of neuroleptic malignant
syndrome), non-pharmacological interventions should be optimized prior
to commencing a pharmacological treatment if possible [Level 1]19
•Table 5 outlines non-pharmacological management strategies [Level 4]2
Table 5: Non-pharmacological management








Familiar environment
Familiar healthcare team
Adequate lighting
Visible clock and calendar
Sensory impairment aids
Mobility aids
Maintain good sleep hygiene
Cognitively stimulating activities





Effective communication
Re-orientation
Reassurance
Consider involving family/friends/carers to help
with this
Verbal/non-verbal techniques to manage
distress
Guidelines: Pharmacological Management
• Neuroleptic medications should be used at the lowest effective dose
for the shortest duration possible; acknowledging that side effects are
more common and severe with more prolonged use [Level 3]20.
• There is no evidence for preferential use of one particular
antipsychotic. There is equal evidence for the efficacy of haloperidol vs.
olanzapine [Level 1]21 and haloperidol vs. chlorpromazine [Level 1]19,
although it is recognised that due to widespread use of haloperidol,
there is more data for the use of this particular medication22. There are
also reports of risperidone and quetiapine being used for delirium,
however efficacy data is not available1.
• Chlorpromazine should be used with caution. There is evidence that it
is effective in treating delirium when haloperidol has failed [Level 4]22,
however there is higher level evidence that it worsens confusion and
other side effects after 48 hours when compared with haloperidol
[level 1]19.
Guidelines: Pharmacological Management
• The use of benzodiazepines in delirium can be considered for managing
symptoms of agitation without increasing the risk of treatment failure
when given concurrently with antipsychotic medications [Level 4]22.
However, benzodiazepines should not be used as monotherapy in
delirium, as they are not as effective as antipsychotics in managing
delirium [Level 1]19.
Haloperidol [Level 1]
Olanzapine [Level 1]
Chlorpromazine [Level
1]
25mg po tds or 75mg
po nocte.
Titrate according to
response, usual
maintenance 75-300mg
(but up to 1g may be
required in psychoses).
Levomepromazine
[Level 4]
25mg sc stat and
1hourly prn (12.5mg in
the elderly).
Titrate according to
response, maintain with
50-300mg/24h via CSCI.
Quetiapine [Level 4]
Risperidone [Level 4]
Starting dose
and titration
Mild-moderate
symptoms and not an
immediate danger to
self or others:
500micrograms po stat
and 2 hourly prn
If necessary, increase
the dose progressively
(e.g. to 1mg, to 1.5mg
etc.)
Severe symptoms
and/or an immediate
danger to self or others:
1.5-3mg po stat,
possibly combined with
a benzodiazepine, and 2
hourly prn.
If necessary, increase
the dose further. Usual
maximum 8mg/24h.
2.5mg po stat, 2hourly
prn, and at bedtime.
If necessary increase to
5mg-10mg at bedtime.
12.5mg po bd.
If necessary, increase in
12.5-25mg increments.
Mean effective dose 40100mg/24h.
1mg po nocte and prn.
If necessary, increase by
1mg every other day.
Usual maximum
4mg/24h. Median
maintenance dose is
1mg/24h.
Dosing in renal
impairment
GFR < 10mL/min start
with lower doses. For
stat doses use 100% of
normal dose.
Accumulation with
repeated dosage.
Initial dose 5mg daily.
GFR > 10mL/min dose
as in normal renal
function. GFR <
10mL/min stat with a
small dose and increase
according to response.
GFR > 10 dose as in
normal renal function.
GFR < 10 stat with small
dose and increase as
necessary.
Dose as in normal renal
function, according to
response.
GFR < 50ml/min,
initially 50% of dose.
Increases should also be
50% less and at a
slower rate. Use with
caution.
Side effects*
See below, also blood
disorders, altered LFTs.
Although purposed to
See below.
be less with secondgeneration
antipsychotics, see
below. Also weight gain,
dry mouth,
constipation,
orthostatic agitation,
nervousness, dizziness,
peripheral oedema.
See below.
See below, also
dyspnoea,
dyslipidaemia,
peripheral oedema,
increased appetite,
sleep disorders,
irritability.
See below, also
hypertension,
respiratory disorders,
epistaxis, appetite
changes, sleep
disorders, anxiety,
depression, malaise,
urinary disorders,
arthralgia, myalgia,
toothache, oedema.
Haloperidol [Level Olanzapine [Level
1]
1]
Chlorpromazine
[Level 1]
Levomepromazine
[Level 4]
Quetiapine [Level 4]
Risperidone [Level 4]
Contraindications
QT prolongation,
bradycardia,
Parkinsons
Disease.
Acute MI, unstable
angina, severe
hypotension or
bradycardia, sick
sinus syndrome,
recent heart
surgery.
Hypothyroidism.
Nil specific.
Nil specific.
Nil specific.
Notes
Haloperidol dose is
halved when
switching from PO
to SC.
Dilute with WFI or
glucose 5%.
Delirium is an
unlicensed
indication.
Unlicensed injection Delirium is an
available and
unlicensed indication.
tolerated SC.
Some experience of
administering via
CSCI diluted with
WFI.
Delirium is an
unlicensed
indication.
Protect CSCI from
direct sunlight.
Delirium is an
unlicensed indication.
Patients can be
switched from
immediate-release to
modified-release
tablets at the
equivalent daily dose.
Delirium is an
unlicensed indication.
Delirium is an
unlicensed indication.
Standards
1. In all patients suspected of having delirium the CAM should be used
to aid diagnosis (Grade D)
2. Reversible causes for delirium should be assessed for and treated
where appropriate (Grade D)
3. Non-pharmacological management strategies should be included as
part of the overall management of delirium (Grade A)
4. Anti-psychotic medications should be used as the first-line
pharmacological intervention for delirium (Grade A)
Standards
5. Haloperidol or Olanzapine should be the first line anti-psychotic drugs
of choice for the management of delirium (Grade A)
6. If possible the diagnosis of delirium and the proposed management
plan should be discussed with the patient. This discussion or the reasons
for non-discussion should be documented (Grade D)
7. If possible the diagnosis of delirium and the proposed management
plan should be discussed with those close to the patient. This discussion or
the reasons for non-discussion should be documented. (Grade D)
References
1.Casarett DJ, Inouye SK. Diagnosis and management of delirium near the end of life. Ann Intern Med, 2001; 135: 32–40.
2.National Institute for Health and Clinical Excellence (2010) Delirium: Prevention, Diagnosis and Management. NICE Guideline (CG103)
3.Massie MJ, Holland J, & Glass E. Delirium in terminally cancer patients. Am J Psychiatry, 1983; 140: 1048–50.
4.Minagawa H, Uchitomi Y, Yamawaki S, & Ishitani K. Psychiatric morbidity in terminally ill cancer patients. A prospective study. Cancer, 1996; 78:
1131–7.
5.Michaud L, Burnand B, & Stiefel F. Taking care of the terminally ill cancer patient: delirium as a symptom of terminal disease. Ann Oncol, 2004;
15(4): 199–203.
6.Lawlor PG, Gagnon P, Mancini IL, Pereira JL, Hanson J, Suarez-Almazor ME, et al. Occurrence, causes, and outcome of delirium in patients with
advanced cancer – a prospective study. Arch Intern Med, 2000; 160: 786–94.
7.Gagnon P, Allard P, Masse B, & DeSerres M. Delirium in terminal cancer: a prospective study using daily screening, early diagnosis, and continuous
monitoring. J Pain Symptom Manage, 2000; 19: 412–26.
8.Lonergan E, Britton AM, & Luxenberg J. Antipsychotics for delirium. CD005594. Cochrane Database Syst Rev, 2007; 2
9.Lacasse H, Perreault MM, & Williamson DR. Systematic review of antipsychotics for the treatment of hospital-associated delirium in medically or
surgically ill patients. Ann Pharmacother, 2006; 40: 1966-1973.
10.Inouye SK. Delirium in older persons. N Engl J Med, 2006; 354: 1157-1165.
11.Akechi T, Uchitomi Y, Okamura H, et al. Usage of haloperidol for delirium in cancer patients. Support Care Cancer, 1996; 4: 390-392.
12.Olofsson SM, Weitzner MA, Valentine AD, Baile WF, & Meyers CA. A retrospective study of the psychiatric management and outcome of delirium
in the cancer patient. Support Care Cancer, 1996; 4: 351-357.
13.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th ed. Washington, DC: American
Psychiatric Association; 2013
14.Oligario G, Buch c, Piscotty R. Nurses’ Assessment of Delirium with underlying Dementia in End of Life Care. Journal of Hospice and Palliative
Nursing. 2015; 17:16-21
15.Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying Confusion: the confusion assessment method. A new method for
detecting delirium. Ann Internal Med. 1990; 113:941-948
16.Ryan K, Leonard M, Guerin S, et al. Validation of the confusion assessment method in the palliative care setting. Palliat Med, 2009; 23: 40–45.
17.Centeno C, Sanz A, & Bruera E. Delirium in advanced cancer patients. Palliat Med, 2004; 18: 184–94.
References continued
18.Inouye SK et al. A multicomponent intervention to prevent delirium in hospitalised older patients. New England Journal of Medicine. 1999; 340(9):
669-676
19.Candy B, Jackson KC, Jones L, Leurent B, Tookman A, & King M. Drug therapy for delirium in terminally ill adult patients (Review). The Cochrane
Library. 2012; 11: 1-17.
20.Crawford GB, Agar M, Quinn SJ, Phillips J, Litster C, Michael N, Doogue M, Rowett D, & Currow DC. Pharmacovigilance in Hospice/Palliative Care:
Net Effect of Haloperidol for Delirium. Journal of Palliative Medicine. 2013; 16(11): 1335-1341.
21.Lin CJ, Sun FJ, Fang CK, Chen HW, & Lai YL. An Open Trial Comparing Haloperidol with Olanzapine for the Treatment of Delirium in Palliative and
Hospice Center Cancer Patients. Journal of Internal Medicine of Taiwan. 2008; 19(4): 346-354.
22.Shin SH, Hui D, Chisholm G, Kang JH, Allo J, Williams J, & Bruera E. Frequency and Outcome of Neuroleptic Rotation in the Management of Delirium
in Patients with Advanced Cancer. Cancer Res Treat. 2015; 47(3): 399-405.
Invited Expert Comments
Dr Fraser Gordon:
• Certainly covered most of the important pertinent issues surrounding
recognition and non-pharmacological management
• Clarify that your most important aim is the recognition and treatment
of any reversible underlying cause if possible, accepting that in those in
the last hours to days of life, there may not be any
• Treatment of any delirium should, if non reversible, be focused on
trying simple non drug treatments, with pharmacological options as a
last resort
• The role of pharmacological intervention is to dampen agitation and to
induce a degree of sedation and thus would have no role in hypoactive
delirium (unless used for other clinical reason)
• Good practice would be to review any sedative drug for delirium at
least every 24 hr
• Medications should not be used unless a risk/benefit assessment has
been made
Public Representative Comments
Sandra Smith
Questions/ Comments from the group
Suggested topics:
1. Should we include the medications with no research evidence base (in
our population of study) within this guideline, i.e. levomepromazine,
quetiapine and risperidone?
2. The maximum 24h dose of levomepromazine accord to the PCF5 is
300mg- should the new guideline reflect this?
3. How does the group feel about the option of haloperidol or
olanzapine as joint first line antipsychotics?
4. Should information leaflets on delirium be made available for patients
and/or families?
5. How might we disseminate this information and guidance using a
training package, given that we have identified the need to increase
education on delirium management, and the CAM should be
accompanied by education?
Cheshire and Merseyside Palliative and End of
Life Care Network
Next Meeting
14/07/2016