Title: Delirium in palliative medicine: A review

Biography:

Susan B LeGrand completed medical school at the University Of South Carolina School Of Medicine. Residency and Oncology Fellowship were completed at the University of Texas-Houston and the Arizona Cancer Center sequentially.

She is a fellow of the American College of Physicians and the American Academy of Hospice and Palliative Medicine. She currently is a staff physician at the Cleveland Clinic Taussig Cancer Center. She has published numerous articles and spoken national and internationally.

Abstract

Delirium is a neuropsychiatric diagnosis that is very common in general medical and surgical populations but of particular importance in palliative medicine.  The incidence is twice that of a regular nursing floor averaging 30%.  At end-of-life the percentage may be as high as 88%. Several different pathophysiologies have been investigated to define the underlying mechanisms to enable targeted therapy. The most commonly accepted cause is a decrease in acetylcholine and increased dopamine. 

Presentation:

Delirium is a syndrome with myriad presentation usually divided into motoric subtypes -hypoactive, hyperactive and mixed. It is underdiagnosed particularly the hypoactive subgroup which may be more common in the palliative medicine population and may be confused with depression. Medications are the most common causes and unfortunately, the majority of medications used in palliative medicine have the potential to cause delirium.

Treatment:

Treatment of delirium is removing the offending cause when possible. When this is not possible or while waiting for improvement, various antipsychotic medications have been used. The medication with the most data is haloperidol. No atypical antipsychotic has been found to be better that haloperidol but they may be useful if toxicity develops or there is no response. A recent article addressed the use of antipsychotics in those with mild to delirium and there was no benefit.

Consequences: 

The presence of delirium is a predictor of increased morbidity and mortality, longer hospitalization and more likely discharge to a nursing facility. This presentation will review the pathophysiology, etiology, diagnosis and treatment of delirium in palliative medicine.