II. Epidemiology
- Delirium Incidence in terminally ill patients: 25 to 85%
- Sedation required in 25% of patients
- Reversible in 50% of patients
III. Causes
- Hypoxia (e.g. Atelectasis)
- Dehydration (Blood Urea Nitrogen >18 mg/dl)
- Hepatic Encephalopathy
- Brain Metastases
- Uncontrolled pain
- Constipation
- Electrolyte disturbance
- Infection or fever
- Medications
IV. Risk Factors
- Impaired Vision (Snellen Chart <20/70)
- Severe illness
- Cognitive Impairment (Mini-Mental State Exam <24)
- Major Depression (Mood Disorders in Cancer)
- Emotional stress
- Unfamiliar environment
- Immobilization
V. Management
- See Delirium
- Consider potentially reversible causes above
- Consider gentle rehydration if Dehydration suspected
- Consider circadian rhythm disturbance (day-night confusion with Agitation)
- Frequent reorientation
- Reduce risk factors above
- Family member or sitter presence may calm patient and reorientation
- Avoid precipitating events
- Avoid Physical Restraints
- Avoid Malnutrition
- Avoid adding more than three medications per day
- Avoid Bladder Catheterization
- Avoid frequent changes in environment or staff
- Evaluate for Polypharmacy
- Discontinue nonessential medications
- Consider medications for Delirium with Agitation refractory to other measures
- Haloperidol 0.5 to 5 mg PO, IV, SC, IM q2 to 12 hours
- Agents with adverse effects but long response delay
- Methadone in place of other Opioids
- Consider short-acting sedation if refractory to above (risk of paradoxical Agitation)
- Comorbid condition considerations
- Cardiac disease (e.g. CHF, CAD)
- Prolonged QTc limits use of Antipsychotic agents (e.g. Agitated Delirium)
- Supplemental Oxygen in Hypoxia
- Lung Disease (e.g. COPD, ILD)
- Consider hypercarbia (CO2 Retention)
- Supplemental Oxygen in Hypoxia
- Renal disease (e.g. Chronic Kidney Disease, Acute Renal Failure)
- Evaluate for Electrolyte disturbance and Uremia
- Liver disease (e.g. end-stage Cirrhosis)
- Evaluate ammonia level
- Consider Lactulose titrated to loose stools (balance with quality of life)
- Neurologic disease (e.g. ALS, Dementia, Parkinsonism, stroke)
- Evaluate for Seizures
- Cardiac disease (e.g. CHF, CAD)