Delirium is a condition commonly exhibited by hospitalized patients and by those who are approaching the end of life.1 Patients who experience a disturbance in attention that develops over a relatively short period and represents an acute change may have delirium.2 Furthermore, there is often an additional cognitive disturbance, such as disorientation, memory deficit, language deficits, visuospatial deficit, or perception. Terminal delirium is defined as delirium that occurs in the dying process and implies that reversal is less likely.3 When death is anticipated, diagnostic workups are not recommended, and treatment of the physiologic abnormalities that contribute to delirium is generally ineffective.4
Background
Delirium is often underdiagnosed and undetected by the clinician. Some studies have shown that delirium is not detected in 22 to 50% of cases.5 Factors that contribute to the underdetection of delirium include preexisting dementia, older age, presence of visual or hearing impairment, and hypoactive presentation of delirium. Other possible reasons for nondetection of delirium are its fluctuating nature and lack of formal cognitive assessment as part of a routine screening across care settings.5 Another study found that 41% of health care providers (HCPs) felt that screening for delirium was burdensome.6
To date, there are no veteran-focused studies that investigate prevalence or risk factors for terminal delirium in US Department of Veterans Affairs (VA) long-term care hospice units. Most long-term care hospice units in the VA are in community living centers (CLCs) that follow regulatory guidelines for using antipsychotic medications. The Centers for Medicare and Medicaid Services state that if antipsychotics are prescribed, documentation must clearly show the indication for the antipsychotic medication, the multiple attempts to implement planned care, nonpharmacologic approaches, and ongoing evaluation of the effectiveness of these interventions.7 The symptoms of terminal delirium cause significant distress to patients, family and caregivers, and nursing staff. Literature suggests that delirium poses significant relational challenges for patients, families, and HCPs in end-of-life situations.8,9 We hypothesize that the early identification of risk factors for the development of terminal delirium in this population may lead to increased use of nonpharmacologic measures to prevent terminal delirium, increase nursing vigilance for development of symptoms, and reduce symptom burden should terminal delirium develop.
Prevalence of delirium in the long-term care setting has ranged between 1.4 and 70.3%.10 The rate was found to be much higher in institutionalized populations compared with that of patients classified as at-home. In a study of the prevalence, severity, and natural history of neuropsychiatric syndromes in terminally ill veterans enrolled in community hospice, delirium was found to be present in only 4.1% on the initial visit and 42.5% during last visit. Also, more than half had at least 1 episode of delirium during the 90-day study period.11 In a study of the prevalence of delirium in terminal cancer patients admitted to hospice, 80% experienced delirium in their final days.12
Risk factors for the development of delirium that have been identified in actively dying patients include bowel or bladder obstruction, fluid and electrolyte imbalances, suboptimal pain management, medication adverse effects and toxicity (eg, benzodiazepines, opioids, anticholinergics, and steroids), the addition of ≥ 3 medications, infection, hepatic and renal failure, poor glycemic control, hypoxia, and hematologic disturbances.4,5,13 A high percentage of patients with a previous diagnosis of dementia were found to exhibit terminal delirium.14
There are 2 major subtypes of delirium: hyperactive and hypoactive.4 Patients with hypoactive delirium exhibit lethargy, reduced motor activity, lack of interest, and/or incoherent speech. There is currently little evidence to guide the treatment of hypoactive delirium. By contrast, hyperactive delirium is associated with hallucinations, agitation, heightened arousal, and inappropriate behavior. Many studies suggest both nonpharmacologic and pharmacologic treatment modalities for the treatment of hyperactive delirium.4,13 Nonpharmacologic interventions may minimize the risk and severity of symptoms associated with delirium. Current guidelines recommend these interventions before pharmacologic treatment.4 Nonpharmacologic interventions include but are not limited to the following: engaging the patient in mentally stimulating activities; surrounding the patient with familiar materials (eg, photos); ensuring that all individuals identify themselves when they encounter a patient; minimizing the intensity of stimulation, providing family or volunteer presence, soft lighting and warm blankets; and ensuring the patient uses hearing aids and glasses if needed.4,14
Although there are no US Food and Drug Administration-approved medications to treat hyperactive delirium, first-generation antipsychotics (eg, haloperidol, chlorpromazine) are considered the first-line treatment for patients exhibiting psychosis and psychomotor agitation.3,4,14-16 In terminally ill patients, there is limited evidence from clinical trials to support the efficacy of drug therapy.14 One study showed lack of efficacy with hydration and opioid rotation.17 In terminally ill patients experiencing hyperactive delirium, there is a significant increased risk of muscle tension, myoclonic seizures, and distress to the patient, family, and caregiver.1 Benzodiazepines can be considered first-line treatment for dying patients with terminal delirium in which the goals of treatment are to relieve muscle tension, ensure amnesia, reduce the risk of seizures, and decrease psychosis and agitation.18,19 Furthermore, in patients with history of alcohol misuse who are experiencing terminal delirium, benzodiazepines also may be the preferred pharmacologic treatment.20 Caution must be exercised with the use of benzodiazepines because they can also cause oversedation, increased confusion, and/or a paradoxical worsening of delirium.3,4,14