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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