Delirium in the Last Hours and Days of Life (updated) Dr Dan Monnery

Updated guideline recommendations and standards

Assessment and Diagnosis Features of altered perception e.g. hallucinations may pre-date other features of delirium [Level 4] Any healthcare provider, trained in the use of the tool and confident in assessing for delirium may be considered competent to make the diagnosis [Level 4]

Non-Pharmacological Management The decision of how invasive investigations for reversible causes should be, should be made in the context of the overall clinical picture, with recognition that invasive investigations may not be appropriate in patients thought to be in the last hours of life [Level 4] It should be recognized that the types of non-pharmacological measures used should be tailored to the patient in the context of their clinical situation. For example, it may not be in the patient’s best interests to keep them in a bay to help orientate them, if they are also felt to be in the last hours of life [Level 4]

Communication Discussion with the patient (where possible) and those close to the patient should be undertaken when a diagnosis of delirium is reached, and should include an explanation of the diagnosis and the potential for reversibility [Level 4] If the patient recovers from an episode of delirium it is important to offer information to the patient about what happened and the treatment decisions which were made if they were not able to contribute to those decisions [Level 4]

Pharmacological management Please see sections on reversible causes and non-pharmacological management before considering pharmacological intervention. Pharmacological interventions should be considered a last resort, and the decision to use pharmacological interventions should be based on a clear assessment of risks/benefits of doing so [Level 4] The role of pharmacological management will be to treat patient symptoms and minimise distress in the last hours to days of life. Patients with hypoactive forms of delirium are less likely to be overtly symptomatic and distressed, so there is a limited role for pharmacological management in this population of patients [Level 4]

Pharmacological Management Patients managed in an inpatient setting should receive a review by a healthcare professional every 24 hours [Level 4]. This review should include an assessment for side effects of medication, noting that over-sedation may be in indication to switch to an alternative medication. Where generalists are managing dying patients with delirium which does not respond to initial interventions, referral to, or discussion with, specialist palliative care teams is recommended [Level 4].

Drugs Table Haloperidol [Level 1] Olanzapine [Level 1]   Haloperidol [Level 1] Olanzapine [Level 1] Chlorpromazine [Level 1] Levomepromazine [Level 4] Quetiapine [Level 4] Risperidone [Level 4] Starting dose and titration 0.5-1.5mg po stat, possibly combined with a benzodiazepine, and 2 hourly prn. If necessary, increase the dose further. Usual maximum 8mg/24h. Consider regular dosing schedule if 2 or more prn doses are used in 24 hours. 2.5mg po stat, 2hourly prn, and at bedtime. If necessary increase to 5mg-10mg at bedtime. 25mg po tds or 75mg po nocte. Titrate according to response, usual maintenance 75-300mg (but up to 1g may be required in psychoses). 25mg sc stat and 1hourly prn (12.5mg in the elderly). Titrate according to response, maintain with 50-200mg/24h via CSCI. 12.5mg po bd. If necessary, increase in 12.5-25mg increments. Mean effective dose 40-100mg/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 be less with second-generation antipsychotics, see below. Also weight gain, dry mouth, constipation, orthostatic hypotension, 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. Contraindications QT prolongation, bradycardia, Parkinson’s Disease and Parkinsonism. Acute MI, unstable angina, severe hypotension or bradycardia, sick sinus syndrome, recent heart surgery. Use with caution in Parkinsonism Hypothyroidism, Parkinsonism Parkinsonism 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 available and tolerated SC. Some experience of administering via CSCI diluted with WFI.  Protect CSCI from direct sunlight. Patients can be switched from immediate-release to modified-release tablets at the equivalent daily dose. Quetiapine is the preferred medication in patients with Parkinsonism

Standards 1. In all patients suspected of having delirium, the CAM diagnostic algorithm should be used to aid diagnosis (Grade D) 2. Reversible causes for delirium should be assessed and treated where appropriate (Grade D) 3. Non-pharmacological management strategies should be optimised 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. 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)

Patient information leaflet Please look at the Patient information leaflets (passed around) and feedback on any areas that could be improved.