Palliative Care Considerations

• Delirium is a very common disorder in hospice, occurring in more than 80% of ter-

minally ill patients, most often in the last few days of life.

• Potential causes of delirium in the hospice setting include, but are not limited to, medical illness, dehydration, hypoxia, metabolic disturbances, sepsis, side effects of drugs, urinary retention, constipation or impaction, uncontrolled pain, or alcohol or drug withdrawal.18,19

• A classic symptom of delirium is clouding of consciousness. This can be manifested by an inability to either maintain or shift attention. Patients also have impaired cognitive functioning, which may or may not include memory disturbances.

"Sundowning" is very common phenomenon in end of life and especially in the presence of delirium. It presents as daytime sleepiness and nighttime agitation and restlessness.

• Another common characteristic is fluctuation in severity of delirium symptoms during the course of the day. This can even occur within the course of a single hour or also from day to day.

• Patients who exhibit agitation from their delirium are easy to identify, but those who present as withdrawn and with diminished responsiveness ("quiet" delirium) are more difficult to diagnose. It is not uncommon for patients to exhibit both quiet and agitated delirium. Treatment is the same for both types of delirium.

• Delirium is difficult to distinguish from dementia. Delirium more commonly presents as a sudden onset (e.g., hours to days), with an altered level of consciousness and a clouded sensorium. However, dementia more commonly presents gradually and with an unimpaired level of consciousness.

Nonpharmacologic Treatment in Palliative Care

• Establishing a safe, soothing environment where there are familiar objects such as photographs and familiar music can be helpful to calm the patient.

• Minimizing risk of injury is important when the patient is agitated.

• Providing education to families and caregivers about the causes of delirium, signs and symptoms, and how to best manage it will help to reduce their anxiety and distress when it occurs.

Pharmacotherapy in Palliative Care

• The most important initial step is to determine the goal of care. If possible, reverse the underlying cause of delirium in order to restore the patient to a meaningful cognitive status.1

• If the precipitating factors cannot be reversed, initiate therapy to treat the symptoms. Patients who are not agitated may not require any treatment other than comfort measures. If the patient is irreversibly delirious and agitated, drug therapy is generally indicated.

• Neuroleptic drugs (conventional or atypical antipsychotics) are the drugs most commonly used to treat confusion and agitation associated with delirium. However, treatment of delirium with these drugs is an "off-label" indication.

• Atypical antipsychotics such as risperidone, olanzapine, quetiapine, ziprasidone, paliperidone, and aripiprazole account for a major portion of increasing medication

costs in the geriatric population.

• Haloperidol, when given in doses less than 2 mg/day is well-tolerated and nonsed-ating and is within the recommended dosing parameters for long-term care facilities.

• When sedation is beneficial for terminal aggressive, agitated delirium, chlorpro-mazine is useful to provide patient comfort as they approach death. When patients are bedbound and in the final stages of life, orthostatic hypotension common with chlorpromazine is not a concern.

• Haloperidol and chlorpromazine are commonly given sublingually or rectally if swallowing becomes difficult, although these are not approved routes of administration. Haloperidol, but not chlorpromazine, can be given subcutaneously. '

• Administering benzodiazepines alone in a patient with delirium can actually make the delirium and confusion worse, although it is sometimes helpful to add benzo-diazepines along with antipsychotics if sedation is desired. Phenobarbital may also be used for this purpose

Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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