Commentary (Roffman/Stern): Delirium in Palliative Care

Delirium in the setting of terminal illness is common; moreover, it can create extreme hardships for patients and their families, who are already facing the most difficult of circumstances. However, delirium that develops in the context of comorbid medical conditions may be readily reversible with thoughtful evaluation and effective management. Friedlander, Brayman, and Breitbart describe important factors to consider when assessing and treating delirium in the context of end-stage illness. We will elaborate on their discussion and emphasize some common pitfalls associated with the management of delirium.

Differential Diagnosis

The timely and accurate recognition of delirium is critical to its management. As Friedlander, Brayman, and Breitbart observe, delirium may go undiagnosed by a clinician who mistakes its symptoms for those of other psychiatric problems; moreover, psychiatric consultation for the management of depression in terminally ill patients frequently results in an opinion that the patient is suffering from acute mental status changes and not affective dysregulation. Indeed, while poor concentration and appetite, disturbed sleep, and psychomotor agitation commonly signal a depressive episode, the onset of these symptoms in a seriously ill patient should raise the specter of delirium. Similarly, the onset of psychotic symptoms (such as paranoid ideation or hallucinations) in the medically ill individual often heralds delirium rather than a primary psychiatric disorder, such as psychotic depression or schizophrenia.

Heterogeneous symptoms often confound the diagnosis of delirium, as does the significant overlap of these symptoms with other neuropsychiatric conditions. However, the presence of two hallmark features-inattention and a rapidly fluctuating course- often steer the clinician to make a correct diagnosis of delirium. At times a clinician may overlook the diagnosis of delirium because the patient happened to look well; these providers then assume that "what you see is what you get." Checking with nursing staff and other close observers (such as visiting family members) about mental status fluctuations, or examining the patient more than once during the day, can avoid this problem. While bedside instruments (such as the Mini-Mental State Examination[ 1]) may help identify cognitive impairment in delirium, these tests are neither sensitive nor specific; collateral information and serial examinations are often much more useful.

Additional Keys to Management

Successful treatment of delirium typically relies on the identification of the underlying etiology; this often involves use of laboratory tests and other procedures. The authors describe one particular dilemma in the treatment of terminally ill patients who are facing the prospect of an extensive workup: the clinician must weigh the risk of additional discomfort incurred by the workup against the finding of an irreversible cause of delirium.

However, it is important to keep in mind that a patient may experience extreme discomfort and anxiety related to the delirium itself. While target symptoms of delirium can be addressed with antipsychotic medication, this approach will not in general solve the underlying problem-which, as Friedlander, Brayman, and Breitbart point out, may be satisfactorily addressed much of the time.

In fact, subtraction of medications often represents an important step in the management of delirium. A medically compromised patient is especially susceptible to side effects of medications (including antipsychotics and anxiolytics) and can be especially (and unpredictably) vulnerable to both oversedation and to paradoxical agitation. Benzodiazepines and anticholinergics are notorious in this regard, and as the authors reported, often worsen delirium. When the degree of agitation or psychosis necessitates the use of neuroleptics, they should be initiated at low doses and gradually titrated upward. While intentional drug-induced stupor can be a valuable comfort measure in a patient for whom death is imminent, sedating agents should in general be used with caution.

In the setting of a rapidly terminal illness, especially in the case of younger patients, emotions often run high. A clinician may forget about the importance of nonpharmacologic interventions in the management of delirium; these measures can take on increasing value in the last few days of life, both for the patient and for involved loved ones. Frequent visits and reorienting maneuvers can also provide comfort for the patient and can give family members a meaningful way to help even at the brink of death.

Conclusion

Delirium should not be considered a "normal" consequence of terminal illness. When a patient is close to death, the treating clinician may be inclined to avoid addressing the underlying causes of delirium in favor of symptomatic relief. However, one must remain mindful of the considerable distress that delirium may cause. Sometimes carrying out a limited diagnostic evaluation can in and of itself be considered a "comfort measure" if there is a reasonable chance that it will lead to a treatable etiology and to a meaningful respite.

Financial Disclosure:The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1.

Folstein M, Folstein S, McHugh P: "Mini-Mental Status": A practical method for gradingthe cognitive state of patients for clinicians.J Psychiatr Res 12:189-198, 1975.