Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial

Dexmedetomidine in Palliative Care: A Versatile New Weapon Against Delirium and Pain-Systematic Review

Introduction: At the end of life, the prevalence of delirium and pain is high. Current therapy is not satisfactory. Dexmedetomidine could be useful in the control of delirium and pain but is not approved outside of intensive care setting. Our objectives are to evaluate existing evidence in the literature that assessed the efficacy of dexmedetomidine in pain and delirium control and its safety in palliative care patients outside intensive care units. This systematic review was prospectively registered with PROSPERO and included a risk of bias assessment. Methods: PubMed and SCOPUS were examined for literature published until 2023. Experimental, cohort, cross-sectional, case-control studies, and case series/reports were included if they evaluate the use of dexmedetomidine in delirium and/or pain management in hospitalized palliative care adult patients. Studies were excluded if they were carried out in intensive care units. Results: Of the initial 529 records, 14 were included. Although only two studies were randomized trials, most were small and only one had low risk of bias. In most case reports and in the two retrospective cohort studies, dexmedetomidine appears to be a better option for these symptoms, although differences were not significant in the randomized trials. Discussion: Dexmedetomidine seems to be a promising option for refractory pain and delirium and may contribute to a reduction in opioid administration to control pain. This is the first systematic review of dexmedetomidine in palliative care. Quality evidence is limited, but clinical properties of dexmedetomidine justify the conduction of controlled trials in palliative care.

Comparison of Pharmacological Treatments for Agitated Delirium in the Last Days of Life

CONTEXT

Antipsychotics are often used in managing symptoms of terminal delirium, but evidence is limited.

OBJECTIVES

To explore the comparative effectiveness of haloperidol with as-needed benzodiazepines (HPD) vs. chlorpromazine (CPZ) vs. levomepromazine (LPZ) for agitated delirium in the last days.

METHODS

A prospective observational study was conducted in two palliative care units in Japan. Adult cancer patients who developed agitated delirium with a modified Richmond Agitation-Sedation Scale (RASS-PAL) of one or more were included; palliative care specialist physicians determined that the etiology was irreversible; and estimated survival was 3 weeks or less. Patients treated with HPD, CPZ, or LPZ were analyzed. We measured RASS, NuDESC, Agitation Distress Scale (ADS), and Communication Capacity Scale (CCS) on Days 1 and 3.

RESULTS

A total of 277 patients were enrolled, and 214 were analyzed (112 in HPD, 50 in CPZ, and 52 in LPZ). In all groups, the mean RASS-PAL score significantly decreased on Day 3 (1.37 to -1.01, 1.87 to -1.04, 1.79 to -0.62, respectively; P < 0.001); the NuDESC and ADS scores also significantly decreased. The percentages of patients with moderate to severe agitation and those with full communication capacity on Day 3 were not significantly different. The treatments were well-tolerated. While one-fourth of HPD group changed antipsychotics, 88% or more of CPZ and LPZ groups continued the initial antipsychotics.

CONCLUSION

Haloperidol with as-needed benzodiazepine, chlorpromazine, or levomepromazine may be effective and safe for terminal agitation. Chlorpromazine and levomepromazine may have an advantage of no need to change medications.

Successful Management of Terminal Delirium With Transdermal Blonanserin Patch in a Terminally Ill Cancer Patient

Delirium is a distressing condition in terminally ill cancer patients, often treated with antipsychotics. Administering them orally, subcutaneously, or intravenously can be challenging in severely agitated patients. Transdermal antipsychotic patches offer an alternative, but their use for terminal delirium remains underexplored. We present the case of a 73-year-old man with advanced diffuse large B cell lymphoma who developed severe mixed delirium during third-line chemotherapy. Nonpharmacological interventions and oral risperidone plus intravenous haloperidol failed to improve his condition. Subsequently, a transdermal blonanserin patch was applied, resulting in the resolution of hallucinations on day 1 and agitation on day 3, allowing improved communication. The patch was easily applied daily without notable adverse events. However, he deteriorated a week later with an estimated survival of days, ultimately requiring continuous midazolam for refractory agitation. This case underscores the potential of transdermal blonanserin patches for delirium in terminally ill cancer patients, emphasizing the need for future prospective studies.

Effectiveness of antipsychotics for managing agitated delirium in patients with advanced cancer: a secondary analysis of a multicenter prospective observational study in Japan (Phase-R)

PURPOSE

Delirium is a common and serious comorbidity in patients with advanced cancer, necessitating effective management. Nonetheless, effective drugs for managing agitated delirium in patients with advanced cancer remain unclear in real-world settings. Thus, the present study aimed to explore an effective pharmacotherapy for this condition.

METHODS

We conducted a secondary analysis of a multicenter prospective observational study in Japan. The analysis included patients with advanced cancer who presented with agitated delirium and received pharmacotherapy. Agitation was defined as a score of the Richmond Agitation-Sedation Scale for palliative care (RASS-PAL) of ≥ 1. The outcome was defined as -2 ≤ RASS-PAL ≤ 0 at 72 h after the initiation of pharmacotherapy. Multiple propensity scores were quantified using a multinomial logistic regression model, and adjusted odds ratios (ORs) were calculated for haloperidol, chlorpromazine, olanzapine, quetiapine, and risperidone.

RESULTS

The analysis included 271 patients with agitated delirium, and 87 (32%) showed -2 ≤ RASS-PAL ≤ 0 on day 3. The propensity score-adjusted OR of olanzapine was statistically significant (OR, 2.91; 95% confidence interval, 1.12 to 7.80; P = 0.030).

CONCLUSIONS

The findings suggest that olanzapine may effectively improve delirium agitation in patients with advanced cancer.

Participant Safety in Multisite, Randomized, Double-Blind, Placebo-Controlled Clinical Trials in Hospice/Palliative Care: Data from the Contracted Studies of the Australian National Palliative Care Clinical Studies Collaborative

Objective: To describe the harms in all arms of six consecutive multi-site, double-blind, placebo-controlled randomised clinical trials. Background: Controversies surround conduct of phase III clinical trials in palliative care. Concerns include risks to participants' safety, use of placebo arms, participants' burden, and justification when therapies are already widely used. Methods: This study collates safety data of the first six studies of the Australian national Palliative Care Clinical Studies Collaborative. On an intention-to-treat basis, all harms are described using standard international definitions, their severity, outcomes, and level of attribution. Results: Studies recruited 1,232 participants: 65/1,232 (5.3%) participants had serious adverse events of which none had a definite (blinded) attribution, all of which settled with ceasing the intervention; 49/1,232 (4.0%) participants had adverse events. No participants on placebo arms had adverse or serious adverse events with definite (blinded) attribution. Discussion: These studies are safe for participants and generate knowledge to support informed patient decision making.

Efficacy and Safety of Risperidone in Patients With Delirium: The RIDDLE Pilot Study

BACKGROUND

The cornerstone treatment of delirium is to assess and treat its underlying causes and prevent further complications. Drug therapy may be necessary to control agitation and behavioral symptoms associated with delirium. The aim of this pilot study was to evaluate the feasibility of a randomized placebo controlled trial to evaluate the efficacy and safety of risperidone in the treatment of delirium.

METHODS

This was a randomized double-blinded placebo-controlled trial. Patients were enrolled in the study if they were hospitalized and 65 years or older and had a diagnosis of delirium. Delirium Rating Scale revised 98 was used to determine delirium and motor agitation.

RESULTS

A total of 14 participants with 57% being men and having a mean age of 86 years were included. There were no statistically significant differences between the risperidone and placebo group for the Delirium Rating Scale revised 98 score. There were no severe adverse reactions reported in the study, and no patients discontinued the study for adverse reactions.

CONCLUSIONS

Risperidone at low doses (1 mg daily or less) was well tolerated for the treatment of delirium. Future large-scale trials are needed to evaluate the safety and efficacy of risperidone in the treatment of delirium. This pilot study taught us that the phase 2 RIsperDone DELirium trial will need a multicenter design with more research personnel to increase the number of participants enrolled.

Effects of Opioids, Steroids, Benzodiazepines, Anticholinergics, and Antihistamines on the Efficacy of Antipsychotics for Treating Delirium in End-of-Life Adult Patients Undergoing Palliative Care

The purpose of the study was to determine the effect of combination therapy involving opioids, steroids, benzodiazepines, anticholinergics, and antihistamines on antipsychotics efficacy for delirium. The study included adult inpatients receiving end-of-life palliative care and diagnosed with hyperactive delirium. Changes in delirium symptoms were assessed using the Intensive Care Delirium Screening Checklist (ICDSC). A retrospective analysis was conducted on 97 patients with ICDSC scores of ≥4, comparing the scores before and after antipsychotic administration. A mean score <4 sustained for 3 days after antipsychotics administration was considered effective. The mean days with ICDSC <4 within a 3-day period were evaluated as well. The efficacy of antipsychotics was compared between cases with and without the use of opioids, steroids, benzodiazepines, anticholinergics, and antihistamines. The results revealed no significant differences in the efficacy of antipsychotics for delirium when used in conjunction with opioids (odds ratio 0.614, 95% CI [0.179-2.105]), benzodiazepines (0.387, [0.108-1.390]), steroids (1.258, [0.276-5.746]), or anticholinergics (2.085, [0. 148-29.458]). Additionally, no significant differences were observed in the mean days with ICDSC <4 within 3-day period. Although opioids, benzodiazepines, steroids, anticholinergics, and antihistamines are recognized as delirium risk factors, their use for symptom relief in patients with delirium may not affect antipsychotic efficacy.

Preventing and treating delirium in clinical settings for older adults

Delirium is a serious consequence of many acute or worsening chronic medical conditions, a side effect of medications, and a precipitant of worsening functional and cognitive status in older adults. It is a syndrome characterized by fluctuations in cognition and impaired attention that develops over a short period of time in response to an underlying medical condition, a substance (prescribed, over the counter, or recreational), or substance withdrawal and can be multi-factorial. We present a narrative review of the literature on nonpharmacologic and pharmacologic approaches to prevention and treatment of delirium with a focus on older adults as a vulnerable population. Older adult patients are most at risk due to decreasing physiologic reserves, with delirium rates of up to 80% in critical care settings. Presentation of delirium can be hyperactive, hypoactive, or mixed, making identification and study challenging as patients with hypoactive delirium are less likely to come to attention in an inpatient or long-term care setting. Studies of delirium focus on prevention and treatment with nonpharmacological or medication interventions, with the preponderance of evidence favoring multi-component nonpharmacological approaches to prevention as the most effective. Though use of antipsychotic medication in delirium is common, existing evidence does not support routine use, showing no clear benefit in clinically significant outcome measures and with evidence of harm in some studies. We therefore suggest that antipsychotics be used to treat agitation, psychosis, and distress associated with delirium at the lowest effective doses and shortest possible duration and not be considered a treatment of delirium itself. Future studies may clarify the use of other agents, such as melatonin and melatonin receptor agonists, alpha-2 receptor agonists, and anti-epileptics.

Factors Associated With Benzodiazepine and Antipsychotic Prescribing in Hospice: A Qualitative Study of Hospice Prescribers

OBJECTIVES

Benzodiazepine and antipsychotic medications are common components of the hospice toolkit and are routinely prescribed for behavioral symptom management at end of life. These medications have significant associated risks but, despite their frequent use, little is known about how clinicians weigh prescribing decisions for individuals in hospice. In this qualitative study, we examined the key factors that influence the decision to initiate a benzodiazepine and antipsychotic medication for management of behavioral symptoms at end of life.

DESIGN

A qualitative study using semi-structured interviews and descriptive qualitative analysis.

SETTING AND PARTICIPANTS

We conducted semi-structured interviews with prescribing hospice physicians and nurse practitioners working in hospice settings across the United States.

METHODS

Hospice clinicians were asked to describe factors that influence prescribing decisions to initiate benzodiazepine and antipsychotic medications for the management of behavioral symptoms. Data from audio-recorded sessions were transcribed, coded to identify relevant concepts, and reduced to determine major themes.

RESULTS

We completed 23 interviews with hospice physicians and nurse practitioners. On average, participants had worked in a hospice setting for a mean of 14.3 years (SD: 10.9); 39% had geriatrics training. Major themes related to benzodiazepine and antipsychotic prescribing were (1) caregiving factors strongly influence the use of medications, (2) patient and caregiver stigma and concerns regarding medication use limit prescribing, (3) medications are initiated to avoid hospitalization or transition to a higher level of care, and (4) nursing home hospice care brings unique challenges.

CONCLUSION AND IMPLICATIONS

Caregiver factors and the setting of hospice care strongly influence clinician decisions to initiate benzodiazepines and antipsychotics in hospice. Caregiver education about medication use at end of life and support in managing challenging behaviors may help promote optimal prescribing.

A revision of JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements

OBJECTIVE

The Japanese Psycho-Oncology Society and the Japanese Association of Supportive Care in Cancer have recently revised the clinical practice guidelines for delirium in adult cancer patients. This article reports the process of developing the revised guidelines and summarizes the recommendations made.

METHODS

The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multi-disciplinary members, created three new clinical questions: non-pharmacological intervention and antipsychotics for the prevention of delirium and trazodone for the management of delirium. In addition, systematic reviews of nine existing clinical questions have been updated. Two independent reviewers reviewed the proposed articles. The certainty of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development, and Evaluation system. The modified Delphi method was used to validate the recommended statements.

RESULTS

This article provides a compendium of the recommendations along with their rationales, as well as a short summary.

CONCLUSIONS

These revised guidelines will be useful for the prevention, assessment and management of delirium in adult cancer patients in Japan.

Awareness of Hospice Care Among Community-Dwelling Elderly Participants

Background and Purpose: The main goal of hospice care is to improve the quality of life for people who are at the end-of-life phase. However, investigations on the awareness of hospice care among community-dwelling elderly participants are limited. This work aimed to reveal the awareness status of hospice care and explore the factors influencing the awareness rate among elderly participants. Methods: A questionnaire survey was conducted among individuals aged 60 years and above. Results: A total of 4,969 individuals aged 60 years and above were randomly selected from 48 primary medical institutions in Handan. The awareness rate of hospice care in the baseline survey was 19.3% (n = 959). All included individuals were divided into two groups in accordance with their awareness of hospice care. The awareness of hospice care among participants with low educational level, living alone, and afraid of talking about death was low (p < .05). Implications for Practice: The level of awareness of hospice care among community-dwelling elderly participants is low. The influencing factors included educational level, living status, and fear of talking about death. The community-dwelling elderly participants' awareness of hospice care must be improved. It is recommended that public medical education and training should be enhanced to improve knowledge and awareness of hospice care among community-dwelling elderly residents with low educational level, living alone, and afraid of talking about death.

Should we all die asleep? The problem of the normalization of palliative sedation

Palliative sedation is a medical intervention to manage distress in dying patients, by reducing consciousness when symptom-directed therapies fail. Continuous deep sedation is ethically sensitive because it may shorten life and completely prevents communication. But sedation short of this is also common. There has been a steady increase in the use of sedation over recent decades. Sedation may have become a means to die while sleeping, rather than a method of last resort to alleviate suffering. Sedation may be requested or expected by patients, families or staff. The need for sedation may be being interpreted more loosely. The acceptance of a 'tolerable amount of discomfort' may have lost ground to a desire to get the final phase over with quickly. Sedation is not always a bad thing. Medical care is otherwise unable to completely control all distressing symptoms in every patient. Sedation may result from other necessary symptom control drugs. Dying when sedated can be seen by as 'peaceful'. We feel it is necessary, however, to highlight three caveats: the need to manage expectations, the cost in terms of loss of communication, and the grey area between continuous deep sedation and euthanasia. We conclude that there may be good grounds for sedation in palliative care, and in some cases, continuous deep sedation may be used as a last resort. But the criteria of necessary and proportionate drug treatment should remain. The normalisation of sedation into dying while sleeping should be resisted.

Hospice agency characteristics associated with benzodiazepine and antipsychotic prescribing

BACKGROUND

Benzodiazepine and antipsychotic medications are routinely prescribed for symptom management in hospice patients, but have significant risks for older adults. We explored the extent to which patient and hospice agency characteristics are associated with variations in their prescribing.

METHODS

Cross-sectional analysis of hospice-enrolled Medicare beneficiaries aged ≥65 years in 2017 (N = 1,393,622 in 4219 hospice agencies). The main outcome was the hospice agency-level rate of enrollees with benzodiazepine and antipsychotic prescription fills divided into quintiles. Rate ratios were used to compare the agencies with the highest and lowest prescription across patient and agency characteristics.

RESULTS

In 2017, hospice agency prescribing rates varied widely: for benzodiazepines, from a median of 11.9% (IQR 5.9,22.2) in the lowest-prescribing quintile to 80.0% (IQR 76.9,84.2) in the highest-prescribing quintile; for antipsychotics, it ranged from 5.5% (IQR 2.9,7.7) in the lowest to 63.9% (IQR 56.1,72.0) in the highest. Among the highest benzodiazepine- and antipsychotic- prescribing hospice agencies, there was a smaller proportion of patients from minoritized populations (benzodiazepine: non-Hispanic Black rate ratio [RR] [Q5/Q1] 0.7, 95% CI 0.6-0.7, Hispanic RR 0.4, 95% CI 0.3-0.5; antipsychotic: non-Hispanic Black RR 0.7, 95% CI 0.6-0.8, Hispanic RR 0.4, 95% CI 0.3-0.5). A greater proportion of rural beneficiaries were in the highest benzodiazepine-prescribing quintile (RR 1.3, 95% CI 1.2-1.4), whereas this relationship was not present for antipsychotics. Larger hospice agencies were over-represented in the highest prescribing quintile for both benzodiazepines (RR 2.6, 95% CI 2.5-2.7) and antipsychotics (RR 2.7, 95% CI 2.6-2.8), as were for-profit agencies (benzodiazepine: RR 2.4, 95% CI 2.3-2.4; antipsychotic: RR 2.3, 95% CI 2.2-2.4). Prescribing rates varied widely across Census regions.

CONCLUSIONS

Prescribing in hospice settings varies markedly across factors other than the clinical characteristics of enrolled patients.

'It's tough. It is hard': A qualitative interview study of staff and volunteers caring for hospice in-patients with delirium

BACKGROUND

Delirium is a distressing condition often experienced by hospice in-patients. Increased understanding of current multidisciplinary care of delirium is needed to develop interventions in this setting.

AIM(S)

To explore hospice staff and volunteers' practice, its influences and what may need to change to improve hospice delirium care.

DESIGN

Qualitative interview study using behaviour change theory from a critical realist stance.

SETTING/PARTICIPANTS

Thirty-seven staff, including different professional groups and roles, and volunteers were purposively sampled from two in-patient hospices.

RESULTS

We found that participants' practice focus was on managing hyperactive symptoms of delirium, through medication use and non-pharmacological strategies. Delirium prevention, early recognition and hypoactive delirium received less attention. Our theoretically-informed analysis identified this focus was influenced by staff and volunteers' emotional responses to the distress associated with hyperactive symptoms of delirium as well as understanding of delirium prevention, recognition and care, which varied between staff groups. Non-pharmacological delirium management was supported by adequate staffing levels, supportive team working and a culture of person-centred and family-centred care, although behaviours that disrupted the calm hospice environment challenged this.

CONCLUSIONS

Our findings can inform hospice-tailored behaviour change interventions that develop a shared team understanding and engage staff's emotional responses to improve delirium care. Reflective learning opportunities are needed that increase understanding of the potential to reduce patient distress through prevention and early recognition of delirium, as well as person-centred management. Organisational support for adequate, flexible staffing levels and supportive team working is required to support person-centred delirium care.

An Interdisciplinary Reappraisal of Delirium and Proposed Subtypes

An interdisciplinary plenary session entitled "Rethinking and Rehashing Delirium" was held during the 2021 Annual Meeting of the Academy of Consultation-Liaison Psychiatry to facilitate dialog on the prevalent approach to delirium. Panel members included a psychiatrist, neurointensivist, and critical care specialist, and attendee comments were solicited with the goal of developing a statement. Discussion was focused on a reappraisal of delirium and, in particular, its disparate terminology and history in relation to acute encephalopathy. The authors endorse a recent joint position statement that describes acute encephalopathy as a rapidly evolving (<4 weeks) pathobiological brain process that presents as subsyndromal delirium, delirium, or coma and suggest the following points of refinement: (1) to suggest that "delirium disorder" describe the diagnostic construct including its syndrome, precipitant(s), and unique pathophysiology; (2) to restrict the term "delirium" to describing the clinical syndrome encountered at the bedside; (3) to clarify that the disfavored term "altered mental status" may occasionally be an appropriate preliminary designation where the diagnosis cannot yet be specified further; and (4) to provide rationale for rejecting the terms acute brain injury, failure, or dysfunction. The final common pathway of delirium appears to involve higher-level brain network dysfunction, but there are many insults that can disrupt functional connectivity. We propose that future delirium classification systems should seek to characterize the unique pathophysiological disturbances ("endotypes") that underlie delirium and delirium's individual neuropsychiatric symptoms. We provide provisional means of classification in hopes that novel subtypes might lead to specific intervention to improve patient experience and outcomes. This paper concludes by considering future directions for the field. Key areas of opportunity include interdisciplinary initiatives to harmonize efforts across specialties and settings, enhance underrepresented groups in research, integration of delirium and encephalopathy in coding, development of relevant quality and safety measures, and exploration of opportunities for translational science.

Post-discharge use of antipsychotics in patients with hospital-acquired delirium and associated risk of mortality - A population-based nested case-control study

OBJECTIVE

To evaluate post-discharge use of antipsychotics in patients with incident hospital-acquired delirium and the associated risk of mortality.

METHODS

We conducted a nested case-control study for patients newly diagnosed with hospital-acquired delirium and subsequently discharged from hospital using Taiwan's National Health Insurance Database (NHID) from 2011 to 2018.

RESULTS

The use of antipsychotics after discharge did not increase the risk of mortality (adjusted OR: 1·03; 95% CI: 0·98-1·09).

CONCLUSIONS

The findings suggested that using antipsychotics after discharge in patients with hospital-acquired delirium may not increase the risk of mortality.

Antipsychotic Medication Use Among Older Adults Following Infection-Related Hospitalization

Importance

There are limited data on discontinuation rates of antipsychotic medications (APMs) used to treat delirium due to acute hospitalization in the routine care of older adults.

Objective

To investigate discontinuation rates and patient characteristics of APMs used to treat delirium following infection-related hospitalization among older US adults.

Design, Setting, and Participants

This retrospective cohort study was conducted using US claims data (Optum's deidentified Clinformatics Data Mart database) for January 1, 2004, to May 31, 2022. Patients were aged 65 years or older without prior psychiatric disorders and had newly initiated an APM prescription within 30 days of an infection-related hospitalization. Statistical analysis was performed on December 15, 2022.

Exposures

New use (no prior use any time before cohort entry) of oral haloperidol and atypical APMs (aripiprazole, olanzapine, quetiapine, risperidone, etc).

Main Outcomes and Measures

The primary outcome was APM discontinuation, defined as a gap of more than 15 days following the end of an APM dispensing. Survival analyses and Kaplan-Meier analyses were used.

Results

Our study population included 5835 patients. Of these individuals, 790 (13.5%) were new haloperidol users (mean [SD] age, 81.5 [6.7] years; 422 women [53.4%]) and 5045 (86.5%) were new atypical APM users (mean [SD] age, 79.8 [7.0] years; 2636 women [52.2%]). The cumulative incidence of discontinuation by 30 days after initiation was 11.4% (95% CI, 10.4%-12.3%) among atypical APM users and 52.1% (95% CI, 48.2%-55.7%) among haloperidol users (P < .001 for difference between haloperidol vs atypical APMs). We observed an increasing trend in discontinuation rates from 2004 to 2022 (5% increase [95% CI, 3%-7%] per year) for haloperidol users (adjusted hazard ratio, 1.05 [1.03-1.07]; P < .001) but not for atypical APM users (1.00 [0.99-1.01]; P = .67). Prolonged hospitalization and dementia were inversely associated with the discontinuation of haloperidol and atypical APMs.

Conclusions and Relevance

The findings of this cohort study suggest that the discontinuation rate of newly initiated APMs for delirium following infection-related hospitalization was lower in atypical APM users than in haloperidol users, with prolonged hospitalization and dementia as major associated variables. The discontinuation rate was substantially higher in recent years for haloperidol but not for atypical APMs.

Visualizing How to Use Antipsychotics for Agitated Delirium in the Last Days of Life

CONTEXT

How physicians use antipsychotics for agitated delirium in the last days of life varies markedly, which could hamper the quality of care.

OBJECTIVES

To examine adherence to an algorithm-based treatment for terminal agitated delirium, and explore its effectiveness and safety.

METHODS

A single-center, prospective, observational study was conducted in a 27-bed palliative care unit in Japan. All adult cancer patients who developed agitated delirium with a modified Richmond Agitation-Sedation Scale (RASS) of +1 or more were included; the palliative care specialists determined that the etiology was irreversible, the estimated survival was three weeks or less, and the Eastern Cooperative Oncology Group (ECOG) performance status was three or four. Patients were treated with an algorithm to visualize how to use antipsychotics, with the treatment goal defined as no agitation (RASS≤0) or acceptable agitation for patients and families. We provided all patients nonpharmacological management to alleviate the symptoms of delirium and administered antipsychotic medications when the nonpharmacological approach was insufficient. We measured the adherence rate, RASS, Nursing Delirium Screening Scale items 2, 3, 4 (Nu-DESC), and Agitation Distress Scale item 2 (ADS) on days 0, 1, 3, 7, 14, 21, and 24 hours before death.

RESULTS

A total of 164 patients were enrolled. Adherence rates were 99, 94, and 89%, and treatment goals were achieved in 66, 83, and 93% on days one, three, and seven, respectively. The mean RASS decreased from +1.41 to -0.84 on day three; Nu-DESC decreased from 4.19 to 1.83, and ADS decreased from 1.54 to 0.38. There were seven severe adverse events (Common Terminology Criteria for Adverse Events (CTCAE) of 3), including aspiration (n = 3), apnea (n = 2), tremor (n = 1), and muscle rigidity (n = 1) on day three.

CONCLUSION

The algorithm-based treatment could be feasible, effective, and safe. Visualizing how palliative care specialists provide pharmacological management could be beneficial for nonspecialist clinicians, and clinical, educational, and research implications warrant further empirical testing.

Should Neuroleptics Be Used in Patients With Delirium Seen by Palliative Care?

Delirium commonly occurs in the palliative care setting and impacts many aspects of patient care, such as symptom assessment, patient-clinician communication, and medical decision-making. One controversial topic regarding the management of delirium in the palliative care setting is whether neuroleptics should be used. In this "Controversies in Palliative Care" article, 3 expert clinicians independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. Interestingly, all 3 experts arrived at similar conclusions-they underscored the importance of identification and treatment of any reversible causes of delirium and endorsed a trial of non-pharmacologic measures. They also agreed that neuroleptics should be considered for patients with hyperactive or mixed delirium when the conservative measures fail to control delirium symptoms and for delirious patients with days of life expectancy and thus limited time to try other measures. Risk of adverse effects such as extrapyramidal symptoms and seizures should be considered as part of the treatment decision. There is also a need to conduct high quality research to examine both neuroleptics and neuroleptic-sparing strategies for the management of delirium.

Diagnosis of delirium: a practical approach

Delirium is an acute disorder of fluctuating attention and awareness with cardinal features that allow it to be positively distinguished from other causes of an acute confusional state. These features include fluctuations, prominent inattentiveness with other cognitive deficits, a change in awareness and visual hallucinations. We describe a framework for diagnosing delirium, noting the need to consider certain caveats and differential diagnoses. Delirium is a clinical diagnosis where a thorough history and clinical examination are much more helpful diagnostically than any single test or combination of tests.

Postoperative delirium in geriatric patients with hip fractures

Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.

Three key areas in progressing delirium practice and knowledge: recognition and relief of distress, new directions in delirium epidemiology and developing better research assessments

Delirium presents formidable challenges: it affects one in four of older hospitalised adults, greatly elevates the risk of multiple short- and long-term complications including dementia and causes significant distress. Delirium care remains generally poor. Yet, there are clear grounds for optimism; the last decade has seen impactful policy advances and a tripling of research output. Here, we highlight three linked areas which have strong potential to transform delirium practice and knowledge in the near term. Delirium-related distress is strikingly underrepresented in practice guidance and research. Proactive recognition combined with effective clinical responses based on good communication provides a critical and largely untapped opportunity to improve care. Delirium epidemiology research is well positioned to produce novel insights through advanced prospective designs in populations such as emergency medical patients with detailed pre-, intra- and post-delirium assessments allied with fluid, imaging and other biomarkers. Research-grade assessment of delirium currently involves a chaotic array of tools, methods and diagnostic algorithms. Areas for development: expand and analytically distinguish the range of features assessed (including distress), optimise feature assessment including use of validated neuropsychological tests where possible, produce standardised algorithms which articulate explicit pathways from features to diagnosis, and create new fine-grained approaches to the measurement of severity. Delirium practice and knowledge show accelerating growth. This is encouraging but much of the necessary progress is still to come. Innovation in these three highlighted areas, as well as many others, will open up exciting possibilities in enhancing the care of patients with this common and often devastating condition.

Pharmacologic treatment of delirium symptoms: A systematic review

OBJECTIVE

We conducted an updated, comprehensive, and contemporary systematic review to examine the efficacy of existing pharmacologic agents employed for management of delirium symptoms among hospitalized adults.

METHODS

Searches of PubMed, Scopus, Embase, and Cochrane Library databases from inception to May 2021 were performed to identify studies investigating efficacy of pharmacologic agents for management of delirium.

RESULTS

Of 11,424 articles obtained from searches, a total of 33 articles (N = 3030 participants) of randomized or non-randomized trials, in which pharmacologic treatment was compared to active comparator, placebo, or no treatment, met all criteria and were included in this review. Medications used for management of delirium symptoms included antipsychotic medications (N = 27), alpha-2 agonists (N = 5), benzodiazepines (N = 2), antidepressants (n = 1), acetylcholinesterase inhibitors (N = 2), melatonin (N = 2), opioids (N = 1), and antiemetics (N = 2). Despite somewhat mixed findings and a relative lack of high-quality trials, it appears that antipsychotic medications (e.g., haloperidol, olanzapine, risperidone, or quetiapine) and dexmedetomidine have the potential to improve delirium outcomes.

CONCLUSIONS

Pharmacologic agents can reduce delirium symptoms (e.g., agitation) in some hospitalized patients. Additional double-blinded, randomized, placebo-controlled clinical trials are critically needed to investigate the efficacy of pharmacologic agents for diverse hospitalized populations (e.g., post-surgical patients, patients at the end-of-life, or in intensive care units).

Variation in Benzodiazepine and Antipsychotic Prescribing Among Hospice Agencies

BACKGROUND

Benzodiazepines and antipsychotics are routinely prescribed for symptom management in hospice. There is minimal evidence to guide prescribing in this population, and little is known about how prescribing varies across hospice agencies.

OBJECTIVE

Examine patient- and hospice agency-level characteristics associated with incident prescribing of benzodiazepines and antipsychotics in hospice.

DESIGN

Retrospective cohort study of a 20% sample of Medicare beneficiaries newly enrolled in hospice.

PARTICIPANTS

Medicare hospice beneficiaries ≥ 65 years old between 2014 and 2016, restricted to those without benzodiazepine (N = 169,688) or antipsychotic (N = 190,441) prescription fills in the 6 months before hospice enrollment.

MAIN MEASURES

The primary outcome was incident (i.e., new) prescribing of a benzodiazepine or antipsychotic. A series of multilevel Cox regression models with random intercepts for hospice agency were fit to examine the association of incident benzodiazepine and antipsychotic prescribing with patient and hospice agency characteristics.

KEY RESULTS

A total of 91,728 (54.1%) and 58,175 (30.5%) hospice beneficiaries were newly prescribed an incident benzodiazepine or antipsychotic. The prescribing rate of the hospice agency was the strongest predictor of incident prescribing: Compared to patients in bottom-quartile benzodiazepine-prescribing agencies, those in top-quartile agencies were 10.7 times more likely to be prescribed an incident benzodiazepine (adjusted hazard ratio [AHR] 10.7, 95% CI 10.1-11.3). For incident antipsychotic prescribing, patients in top-quartile agencies were 51.7 times more likely to receive an antipsychotic (AHR 51.7, 95% CI 44.3-60.4) compared to those in the bottom quartile. Results remained consistent accounting for comfort kit prescribing.

CONCLUSIONS

The pattern of benzodiazepine or antipsychotic prescribing of a hospice agency strongly predicts whether a hospice enrollee is prescribed these medications, exceeding every other patient-level factor. While the appropriate level of prescribing in hospice is unclear, this variation may reflect a strong local prescribing culture across individual hospice agencies.

[DNVF Memorandum: Health Services Research in the Last Year of Life]

This memorandum outlines current issues concerning health services research on seriously ill and dying people in the last year of their lives as well as support available for their relatives. Patients in the last phase of life can belong to different disease groups, they may have special characteristics (e. g., people with cognitive and complex impairments, economic disadvantage or migration background) and be in certain phases of life (e. g., parents of minor children, (old) age). The need for a designated memorandum on health services research in the last year of life results from the special situation of those affected and from the special features of health services in this phase of life. With reference to these special features, this memorandum describes methodological and ethical specifics as well as current issues in health services research and how these can be adequately addressed using quantitative, qualitative and mixed methods. It has been developed by the palliative medicine section of the German Network for Health Services Research (DNVF) according to the guidelines for DNVF memoranda.

Is There a Role for Medication in Managing Delirium with Dementia?

People with dementia are more likely to develop delirium. We conducted a brief literature search and give a pragmatic overview of the key issues. Making rational and safe prescribing decisions is highly influenced by organisational culture and embedded staff practices. Comprehensive assessment for unmet physical, psychological, and social needs is an important intervention in itself. Taking a broad overview of possible pharmacological interventions should include stopping inappropriate medications and prescribing for key drivers of the underlying causes of delirium. Prescribing psychotropic medications may be indicated where there is significant distress or risk to the person with dementia and risk to those around them. It is vital to consider the dementia subtype and, where possible, involve family and friend carers in the decision-making process. Medications should be prescribed at the lowest possible dose for the least amount of time after carefully weighing risks versus benefits and documenting these. While these cases are challenging for staff and families, it can be rewarding to improve the quality of life and lessen distress for the person with dementia. There are also opportunities for informing family and friend carers, educating the wider multidisciplinary team, and promoting organisational change.

Demographic and clinical characteristics of patients with delirium: analysis of a nationwide Japanese medical database

OBJECTIVES

Delirium commonly occurs during hospitalisation and is associated with increased mortality, especially in elderly patients. This study aimed to determine the demographic and clinical characteristics of patients with delirium in the Japanese real-world clinical setting using a nationwide database comprising claims and discharge abstract data.

DESIGN

This was an observational, cross-sectional, retrospective study in hospitalised patients with an incident delirium identified by a diagnosis based on International Classification of Diseases, 10th Revision codes or initiating antipsychotics recommended for delirium treatment in Japan during their hospitalisation.

SETTING

Patients from the Medical Data Vision database including more than 400 acute care hospitals in Japan were evaluated from admission to discharge.

PARTICIPANTS

Of the 32 910 227 patients who were included in the database between April 2012 and September 2020, a total of 145 219 patients met the criteria for delirium.

PRIMARY AND SECONDARY OUTCOME MEASURES

Demographic and baseline characteristics, comorbidities, clinical profiles and pharmacological treatments were evaluated in patients with delirium.

RESULTS

The mean (SD) patient age was 76.5 (13.8) years. More than half of the patients (n=82 159; 56.6%) were male. The most frequent comorbidities were circulatory system diseases, observed in 81 954 (56.4%) patients. Potentially inappropriate medications (PIMs) with risk of delirium including benzodiazepines and opioids were prescribed to 76 798 (52.9%) patients. Approximately three-fourths of these patients (56 949; 74.2%) were prescribed ≥4 PIMs. The most prescribed treatment for delirium was injectable haloperidol (n=82 490; 56.8%). Mean (SD) length of hospitalisation was 16.0 (12.1) days.

CONCLUSIONS

The study results provide comprehensive details of the clinical characteristics of patients with delirium and treatment patterns with antipsychotics in the Japanese acute care setting. In this patient population, the prescription rate of injectable haloperidol and PIMs was high, suggesting the need for improved understanding among healthcare providers about the appropriate management of delirium, which may benefit patients.

Development and Evaluation of a Physiologically Based Pharmacokinetic Model for Predicting Haloperidol Exposure in Healthy and Disease Populations

The physiologically based pharmacokinetic (PBPK) approach can be used to develop mathematical models for predicting the absorption, distribution, metabolism, and elimination (ADME) of administered drugs in virtual human populations. Haloperidol is a typical antipsychotic drug with a narrow therapeutic index and is commonly used in the management of several medical conditions, including psychotic disorders. Due to the large interindividual variability among patients taking haloperidol, it is very likely for them to experience either toxic or subtherapeutic effects. We intend to develop a haloperidol PBPK model for identifying the potential sources of pharmacokinetic (PK) variability after intravenous and oral administration by using the population-based simulator, PK-Sim. The model was initially developed and evaluated to predict the PK of haloperidol and its reduced metabolite in adult healthy population after intravenous and oral administration. After evaluating the developed PBPK model in healthy adults, it was used to predict haloperidol–rifampicin drug–drug interaction and was extended to tuberculosis patients. The model evaluation was performed using visual assessments, prediction error, and mean fold error of the ratio of the observed-to-predicted values of the PK parameters. The predicted PK values were in good agreement with the corresponding reported values. The effects of the pathophysiological changes and enzyme induction associated with tuberculosis and its treatment, respectively, on haloperidol PK, have been predicted precisely. For all clinical scenarios that were evaluated, the predicted values were within the acceptable two-fold error range.

Physicians' Beliefs and Attitudes Toward Hypoactive Delirium in The Last Days of Life

CONTEXT

The perspective toward hypoactive delirium in the last days of life could be different among physicians.

OBJECTIVES

To clarify the attitudes, beliefs, and opinions of palliative care physicians and liaison psychiatrists toward hypoactive delirium in the last days of life and to explore the association among these factors.

METHODS

A nationwide cross-sectional questionnaire survey was conducted among 1667 physicians who were either certified palliative care specialists or liaison psychiatrists. Physicians' agreement with the appropriateness of pharmacological management (e.g., antipsychotics) (one item), their beliefs (11 items), and their opinions (four items) were measured.

RESULTS

787 (47%) physicians responded. 481 (62%) agreed to use of medications for hypoactive delirium in the last days of life, whereas 296 (38.1%) disagreed. More than 95% agreed with "hypoactive delirium at the end of life can be considered as a part of natural dying process." Multivariate analysis identified two belief subscales of "hypoactive delirium at the end of life is a natural dying process" and "antipsychotics are futile and harmful in managing hypoactive delirium" had a significant negative correlation with the use of medications. On the other hand, one belief subscale of "hypoactive delirium can be distressing even if patients' consciousness is impaired" had significant positive correlations with the use of medications.

CONCLUSION

Pharmacological management of hypoactive delirium in the last days of life differs depending on physicians' beliefs. Future research is needed to clarify the efficacy and safety of pharmacological management of hypoactive delirium.

Adaptation, implementation, and mixed methods evaluation of an interprofessional modular clinical practice guideline for delirium management on an inpatient palliative care unit

BACKGROUND

Using delirium clinical guidelines may align interprofessional clinical practice and improve the care of delirious patients and their families. The aim of this project was to adapt, implement and evaluate an interprofessional modular delirium clinical practice guideline for an inpatient palliative care unit.

METHODS

The setting was a 31-bed adult inpatient palliative care unit within a university-affiliated teaching hospital. Participants for the evaluation were interprofessional team members. Using integration of guideline adaptation and an education initiative, an interprofessional guideline adaptation group developed a face-to-face 'starter kit' module and four online self-learning modules. The mixed methods evaluation comprised pre-and post-implementation review of electronic patient records, an online survey, and analysis of focus groups/ interviews using an iterative, inductive thematic analysis approach.

RESULTS

Guideline implementation took 12 months. All palliative care unit staff attended a 'starter kit' session. Overall completion rate of the four e-Learning modules was 80.4%. After guideline implementation, nursing documentation of non-pharmacological interventions occurring before medication administration was observed. There was 60% less scheduled antipsychotic use and an increase in 'as needed' midazolam use. The online survey response rate was 32% (25/77). Most participants viewed the guideline's implementation favourably. Six key themes emerged from the qualitative analysis of interviews and focus groups with ten participants: prior delirium knowledge or experiences, challenges of facilitating change, impacts on practice, collaborative effort of change, importance of standardized guidelines, and utility of guideline elements.

CONCLUSIONS

Guideline implementation warrants concerted effort, time, and management support. Interprofessional team support facilitates the modular approach of guideline adaptation and implementation, leading to a change in clinical practice.

Association of Antipsychotic Dose With Survival of Advanced Cancer Patients With Delirium

CONTEXT

Delirium is common in patients with advanced cancer, and antipsychotics are widely used for its management.

OBJECTIVES

We aimed to explore the association of the antipsychotic dose with survival of terminally ill cancer patients with delirium.

METHODS

A secondary analysis of a multicenter prospective observational study was conducted. We enrolled adult advanced cancer patients who developed delirium and received antipsychotics at 14 palliative care units in Japan between September 2015 and May 2016. Hazard ratios of survival after starting antipsychotics between groups with different oral chlorpromazine equivalent doses: low: <100 mg, moderate: 100-200 mg, high: ≥200 mg, were calculated with adjustment for potential confounders using Cox regression. The antipsychotic dose-specific mortality risk was estimated with smooth splines.

RESULTS

Of 453 patients enrolled, 422 patients were analyzed. The median antipsychotic dose was 92.6 mg: low-dose (N = 231), moderate-dose (122), and high-dose (69). The median survival of all patients was 11 days. Compared with the low-dose group, the high-dose group showed a significantly shorter survival (HR: 1.46, 95%CI: 1.08-1.98). Smooth splines demonstrated that HR continuously increased as the antipsychotic dose increased. In patients treated with atypical antipsychotics, the high-dose group showed a significantly shorter survival than the low-dose group (HR: 2.86), while in patients treated with typical antipsychotics, survival was not significantly different (0.99).

CONCLUSIONS

Higher doses of antipsychotics were associated with increased mortality in terminally ill cancer patients with delirium. To minimize the potential mortality risk, antipsychotics should be started at low doses and titrated carefully.

Management of Physical Symptoms in Patients with Advanced Cancer During the Last Weeks and Days of Life

Patients with advanced cancer are faced with many devastating symptoms in the last weeks and days of life, such as pain, delirium, dyspnea, bronchial hypersecretions (death rattle), and intractable seizures. Symptom management in the last weeks of life can be particularly challenging because of the high prevalence of delirium complicating symptom assessment, high symptom expression secondary to psychosocial and spiritual factors, limited life-expectancy requiring special considerations for prognosis-based decision-making, and distressed caregivers. There is a paucity of research involving patients in the last weeks of life, contributing to substantial variations in clinical practice. In this narrative review, we shall review the existing literature and provide a practical approach to in-patient management of several of the most distressing physical symptoms in the last weeks to days of life.

Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment

Perioperative neurocognitive disorders (NCDs) refer to neurocognitive abnormalities detected during the perioperative periods, including preexisting cognitive impairment, preoperative delirium, delirium occurring up to 7 days after surgery, delayed neurocognitive recovery, and postoperative NCD. The Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5) is the golden standard for diagnosing perioperative NCDs. Given the impracticality of using the DSM‐5 by non‐psychiatric practitioners, many diagnostic tools have been developed and validated for different clinical scenarios. The etiology of perioperative NCDs is multifactorial and includes predisposing and precipitating factors. Identifying these risk factors is conducive to preoperative risk stratification and perioperative risk reduction. Prevention for perioperative NCDs should include avoiding possible contributors and implementing nonpharmacologic and pharmacological interventions. The former generally includes avoiding benzodiazepines, anticholinergics, prolonged liquid fasting, deep anesthesia, cerebral oxygen desaturation, and intraoperative hypothermia. Nonpharmacologic measures include preoperative cognitive prehabilitation, comprehensive geriatric assessment, implementing fast‐track surgery, combined use of regional block, and sleep promotion. Pharmacological measures including dexmedetomidine, nonsteroidal anti‐inflammatory drugs, and acetaminophen are found to have beneficial effects. Nonpharmacological treatments are the first‐line measures for established perioperative NCDs. Pharmacological treatments are still limited to severely agitated or distressed patients.

Current practice of pharmacological treatment for hyperactive delirium in terminally ill cancer patients: results of a nationwide survey of Japanese palliative care physicians and liaison psychiatrists

OBJECTIVE

The objective of this survey was to identify areas where doctors have divergent practices in pharmacological treatment for hyperactive delirium in terminally ill patients with cancer.

METHODS

We conducted a survey of Japanese palliative care physicians and liaison psychiatrists. Inquiries were made regarding: (i) choice of drug class in the first-line treatment, (ii) administration methods of the first-line antipsychotic treatment, (iii) starting dose of antipsychotics in the first line treatment and maximum dose of antipsychotics in refractory delirium, and (iv) choice of treatment when the first-line haloperidol treatment failed. Respondents used a five-point Likert scale.

RESULTS

Regarding choice of drug class in the first-line treatment, more doctors reported that they 'frequently' or 'very frequently' use antipsychotics only than antipsychotics and benzodiazepine (oral: 73.4 vs. 12.2%; injection: 61.3 vs. 11.6%, respectively). Regarding administration methods of the first-line antipsychotic treatment, the percentage of doctors who reported that they used antipsychotics as needed and around the clock were 55.4 and 68.8% (oral), 49.2 and 45.4% (injection), respectively. There were different opinions on the maximum dose of antipsychotics in refractory delirium. Regarding the choice of treatment when the first-line haloperidol treatment failed, the percentage of doctors who reported that they increased the dose of haloperidol, used haloperidol and benzodiazepines, and switched to chlorpromazine were 47.0, 32.1 and 16.4%, respectively.

CONCLUSIONS

Doctors have divergent practices in administration methods of the first-line antipsychotic treatment, maximum dose of antipsychotics, and choice of treatment when the first-line haloperidol treatment failed. Further studies are needed to determine the optimal treatment.

Gabapentinoid Use Is Associated With Reduced Occurrence of Hyperactive Delirium in Older Cancer Patients Undergoing Chemotherapy: A Nationwide Retrospective Cohort Study in Japan

BACKGROUND

It is unclear whether gabapentinoids affect the development of delirium. We aimed to determine the association between gabapentinoid use and hyperactive delirium in older cancer patients undergoing chemotherapy.

METHODS

We conducted propensity score-matched analyses using data from a nationwide inpatient database in Japan. We included cancer patients with pain ≥70 years of age undergoing chemotherapy between April 2016 and March 2018. Patients receiving gabapentinoids were matched with control patients using propensity scores. The primary outcome was occurrence of hyperactive delirium during hospitalization, and the secondary outcomes were length of hospital stay, in-hospital fractures, and in-hospital mortality. Hyperactive delirium was identified by antipsychotic use or discharge diagnoses from the International Classification of Diseases, 10th Revision.

RESULTS

Among 143,132 identified patients (59% men; mean age, 76.3 years), 14,174 (9.9%) received gabapentinoids and 128,958 (90.1%) did not (control group). After one-to-one propensity score matching, 14,173 patients were included in each group. The occurrence of hyperactive delirium was significantly lower (5.2% vs 8.5%; difference in percent, -3.2% [95% confidence interval, -3.8 to -2.6]; odds ratio, 0.60 [0.54-0.66]; P < .001), the median length of hospital stay was significantly shorter (6 days [interquartile range, 3-15] vs 9 days [4-17]; subdistribution hazard ratio, 1.22 [1.19-1.25]; P < .001), and the occurrence of in-hospital mortality was significantly lower in the gabapentinoid group than in the control group (1.3% vs 1.8%; difference in percent, -0.6% [-0.9 to -0.3]; odds ratio, 0.69 [0.57-0.83]; P < .001). Gabapentinoid use was not significantly associated with the occurrence of in-hospital fractures (0.2% vs 0.2%; difference in percent, 0.0% [-0.1 to 0.1]; odds ratio, 1.07 [0.65-1.76]; P = .799). The results of sensitivity analyses using stabilized inverse probability of treatment weighting were consistent with the results of the propensity score-matched analyses.

CONCLUSIONS

Our findings suggest that gabapentinoid use is associated with reduced hyperactive delirium in older cancer patients undergoing chemotherapy, with no evidence of an increase in the fracture rate, length of hospital stay, or in-hospital death.

Attitudes of Palliative Care Practitioners Towards Enrolling Patients in Clinical Trials

Background: Recruitment of participants for clinical trials remains a key consideration for investigators. This is particularly relevant in palliative care, where practitioners are sometimes reluctant to refer patients for consideration of enrolment. Reasons for this reluctance range from concerns about excessive burden to patients, through to debate about the appropriateness of undertaking trials in the palliative care setting. Aim: The aim of this study was (1) to explore palliative care practitioners' attitudes and views of clinical trials, (2) to compare these findings with those of a similar survey undertaken more than a decade earlier, and (3) to explore predictors associated with key concepts of interest associated with clinical trials. Design: The palliative care clinician's attitudes to clinical research survey undertaken in 2007 formed the basis of a repeat survey conducted in 2019. Setting/Participants: Australian and New Zealand palliative care practitioners were surveyed. Results: Surveys were completed by 135 palliative care practitioners. Comparing results of the current study and those findings of more than a decade earlier revealed that attitudes have either not substantially changed or indeed in some areas have become less accepting of clinical trials. This is despite the dramatic increase in the volume of research carried out within palliative care over the last decade. Conclusion: Our survey suggests that the reasons for engagement in research are complex and likely to differ according to local conditions. Careful attention to understanding of the local environment and particularly the attitudes of local practitioners is likely to be essential to be successful in this endeavour.

The Dilemma of Treating Delirium: the Conundrum of Drug Management

OPINION STATEMENT

Delirium is a common medical complication in people living with cancer, particularly with more advanced disease. Delirium is associated with significant symptom burden which causes distress and impacts quality of life. As recommended by international guidelines, a high degree of suspicion is needed to ensure delirium is detected early. Attention to collateral history can provide clues to changes in cognition and attention. Non-pharmacological approaches that can be considered essential elements of care are effective in reducing the risk of delirium. Delirium screening using a validated measure is recommended as even expert clinicians can underdiagnose or miss delirium. The diagnostic assessment requires consideration of the cancer diagnosis and comorbidities, in the context of potential reversibility, goals of care, and patient preferences. The gold standard approach based on expert consensus is to institute management for delirium precipitants supported by non-pharmacological essential care, with the support of an interdisciplinary team. Medication management should be used sparingly and for a limited period of time wherever possible for severe perceptual disturbance or agitation which has not improved with non-pharmacological approaches. Clinicians should be familiar with the registered indication for medications and seek informed consent for off-label use. All interventions put in place to manage delirium need to consider net clinical benefit, including harms such as sedation and loss of capacity for meaningful interaction. Clear communication and explanation are needed regularly, with the person with delirium as far as possible and with surrogate decision makers. Delirium can herald a poor prognosis and this needs to be considered and be discussed as appropriate in shared decision-making. Recall after delirium has resolved is common, and opportunity to talk about this experience and the related distress should be offered during the period after recovery.

Acupuncture Treatment of Delirium in Older Adults Hospitalized in Internal Medicine Departments: An Open-Label Pragmatic Randomized-Controlled Trial

BACKGROUND

Acupuncture seems to improve cognitive function in experimental models and to reduce agitation in dementia. The addition of acupuncture to standard-of-care (SOC) may improve clinical outcomes related to delirium in hospitalized older adults.

METHODS

This pragmatic open-label randomized-controlled trial evaluated 81 older adults hospitalized in an internal medicine ward and diagnosed with delirium. Fifty were randomized to daily acupuncture combined with SOC and 31 to SOC only for up to 1 week. Delirium was diagnosed using Confusion Assessment Method (CAM) tool, and its severity was assessed by the long CAM-Severity (CAM-S) tool. The primary study outcome was delirium resolution evaluated as time-to-first delirium remission (over 7 days) and the number of days spent delirium-free.

RESULTS

Time-to-first delirium remission was shorter in the acupuncture arm as compared to the SOC only arm (p < 0.001). A multivariate Cox regression analysis showed a shorter time-to-first remission of delirium in the acupuncture arm as compared with SOC arm [Hazard Ratio 0.267 (95% CI 0.098-0.726, p = 0.010)]. In the 7 days of evaluation, a significantly higher number of delirium-free days was found in the acupuncture arm compared to the SOC arm (p < 0.001), and CAM-S sum from day 2 to day 7 of evaluation was significantly lower in the acupuncture group compared to the control group (p = 0.002). No adverse safety event was found in the acupuncture group.

CONCLUSION

Acupuncture seems to be safe and effective in the treatment of delirium in older patients hospitalized in internal medicine departments.

Melatonin intervention to prevent delirium in hospitalized patients: A meta-analysis

BACKGROUND

Evaluation of the effectiveness of melatonin is necessary to prevent the development of delirium in hospitalized patients. Melatonin (N-acetyl-5-methoxytryptamine) is a hormone produced by the pineal gland of the brain from the amino acid tryptophan. Synthetic melatonin supplements have been used for various medical conditions, especially sleep-related diseases, and have proved to be successful.

AIM

To determine the effect of melatonin on the prevention of delirium in hospitalized patients.

METHODS

A literature search of the CNKI, Wanfang Database, VIP Database, China Biomedical Literature Database, PubMed, Embase, Cochrane Library, Web of Science, and other databases was conducted. The CNKI, Wanfang Database, VIP Database (VIP), and China Biomedical Literature Database were searched for Chinese studies, and PubMed, Embase, Cochrane Library, Web of Science and other databases were searched for international studies. It will be established in June 2021 in a randomized controlled trial (RCT) whether melatonin treatment for 6 mo prevents delirium in hospitalized patients. Literature screening, quality review, and data extraction were carried out using the Cochrane Manual 5.1.0 systematic evaluation method, and Stata 15.0 software and Review Manager 5.3 were used for meta-analysis and processing.

RESULTS

A total of 18 new RCT articles and 18 experimental subjects were identified. The results of the meta-analysis showed that following the occurrence of delirium, melatonin reduced the incidence of delirium in patients (RR = 0.69, 95%CI: 0.60-0.80), which is of significance, but heterogeneity was significant I² = 62%. Subgroup analysis was performed to examine the source of heterogeneity, and it was found that different patient types were the source of heterogeneity; the research on subgroup analysis was of high quality and homogeneous. To determine the reliability and robustness of the research results, a sensitivity analysis was carried out. The results showed that after excluding individual studies one by one, the effect size was still within 95%CI, which strengthened the reliability of the original meta-analysis results. Melatonin has a significant preventive effect on delirium in hospitalized medical patients [RR = 0.60, 95%CI: 0.47-0.76), P < 0.001].

CONCLUSION

Melatonin can reduce the rate of delirium in medical patients, and the role of melatonin in reducing the incidence of delirium in surgical patients and critical care unit patients requires further study.

Palliative care for patients with advanced dementia

ABSTRACT

Dementia is currently the seventh leading cause of death and one of the major causes of disability and dependency among older adults globally. Its final stages are complicated by a multitude of problems that can cause immense suffering. This article explores the interconnection between advanced dementia and palliative care and the role of nurses in providing end-of-life care for these patients.

Use of naldemedine is associated with reduced incidence of hyperactive delirium in cancer patients with opioid-induced constipation: a nationwide retrospective cohort study in Japan

BACKGROUND

Medical benefits of peripherally-acting mu-opioid receptor antagonists other than improving opioid-induced constipation remain unclear. Our aim was to evaluate the association between the use of naldemedine and incidence of hyperactive delirium in cancer patients receiving chemotherapy and opioid therapy.

METHODS

We conducted a propensity score-matched analysis using a nationwide inpatient database in Japan. Cancer patients receiving both inpatient chemotherapy and opioid therapy from June 1, 2017 to March 31, 2018 were included. Patients receiving naldemedine were matched to control patients by propensity score. Our primary outcome was the incidence of hyperactive delirium during hospitalization, and secondary outcomes were the length of hospital stay, hospital costs, in-hospital mortality, and incidence of ileus.

RESULTS

Of 34,031 patients receiving inpatient chemotherapy and opioid therapy, 1905 (5.6%) were included in the naldemedine group. After one-to-four propensity score matching, 1904 patients were included in the naldemedine group and 7616 in the control group. Naldemedine users had significantly reduced incidence of hyperactive delirium compared with the control patients (19.4% vs 23.3%; risk difference, -3.9 [95% confidence interval, -5.9 - -1.9]; risk ratio, 0.83 [0.75-0.92]; P<0.001; subdistribution hazard ratio, 0.85 [0.75-0.97]; P=0.015). The median length of hospital stay was significantly shorter in the naldemedine group compared with the control group (12 days [interquartile range, 6-23] vs 14 days [6-26]; P=0.001). The median hospital costs were also significantly lower in the naldemedine group compared with the control group (US $6179 [3351-10,026] vs US $6576 [3436-11,107]; P<0.001). No significant differences were found for in-hospital mortality or incidence of ileus between the groups.

CONCLUSIONS

Our findings suggest that the use of naldemedine may have benefits in preventing hyperactive delirium, shortening hospital stay, and decreasing hospital costs in cancer patients receiving chemotherapy and opioid therapy.

Outcomes and measures of delirium interventional studies in palliative care to inform a core outcome set: A systematic review

BACKGROUND

Trials of interventions for delirium in various patient populations report disparate outcomes and measures but little is known about those used in palliative care trials. A core outcome set promotes consistency of outcome selection and measurement.

AIM

To inform core outcome set development by examining outcomes, their definitions, measures and time-points in published palliative care studies of delirium prevention or treatment delirium interventions.

DESIGN

Prospectively registered systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

We searched six electronic databases (1980-November 2020) for original studies, three for relevant reviews and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We included randomised, quasi-randomised and non-randomised intervention studies of pharmacological and non-pharmacological delirium prevention and/or treatment interventions.

RESULTS

From 13/3244 studies (2863 adult participants), we identified 9 delirium-specific and 13 non-delirium specific outcome domains within eight Core Outcome Measures in Effectiveness Trials (COMET) taxonomy categories. There were multiple and varied outcomes and time points in each domain. The commonest delirium specific outcome was delirium severity (n = 7), commonly using the Memorial Delirium Assessment Scale (6/8 studies, 75%). Four studies reported delirium incidence. Non-delirium specific outcomes included mortality, agitation, adverse events, other symptoms and quality of life.

CONCLUSION

The review identified few delirium interventions with heterogeneity in outcomes, their definition and measurement, highlighting the need for a uniform approach. Findings will inform the next stage to develop consensus for a core outcome set to inform delirium interventional palliative care research.

Delirium in Palliative Care

Simple Summary

Delirium is a generalized cerebral dysfunction that occurs frequently near the end of life. In palliative care, delirium is frequently a sign of impending death; it is distressing for patients, families, and caregivers; and the goals of management, assessment, and treatment are controversial. We provide an update on these topics mainly focusing on patients with cancer.

Abstract

Delirium, a widespread neuropsychiatric disorder in patients with terminal diseases, is associated with increased morbidity and mortality, profoundly impacting patients, their families, and caregivers. Although frequently missed, the effective recognition of delirium demands attention and commitment. Reversibility is frequently not achievable. Non-pharmacological and pharmacological interventions are commonly used but largely unproven. Palliative sedation, although controversial, should be considered for refractory delirium. Psychological assistance should be available to patients and their families at all times.

[Delirium Management in Palliative Care]

Delirium Management in Palliative Care Abstract. Delirium is one of the most common neuropsychiatric complications in patients with advanced incurable disease. End-of-life delirium is common but is often overlooked, undiagnosed or incorrectly diagnosed/untreated. Delirium should also be treated in a palliative situation - as far as possible - because persistent delirious states increase the patient's fragility, limit physical functionality and shorten the lifespan. In addition, acute states of confusion trigger high levels of distress in affected patients and their relatives, impair the quality of life and a dignified dying process. While hallucinations and visions at the end of life are interpreted as delirium in medicine and treated as such, this phenomenon is interpreted by philosophical and theological hermeneutics as a resource that can help patients and their relatives to reconcile with past life events and to deal with the process of dying. However, the occurrence of end-of-life visions as opposed to delirium has not yet been studied very much and requires more detailed exploration.

Intranasal insulin for treatment of delirium in older hospitalised patients: study protocol for a randomised controlled trial

INTRODUCTION

Delirium is one of the most common conditions diagnosed in hospitalised older people and is associated with numerous adverse outcomes, yet there are no proven pharmacological treatments. Recent research has identified cerebral glucose hypometabolism as a pathophysiological mechanism offering a therapeutic target in delirium. Insulin, delivered via the intranasal route, acts directly on the central nervous system and has been shown to enhance cerebral metabolism and improve cognition in patients with mild cognitive impairment and dementia. This trial will determine whether intranasal insulin can reduce the duration of delirium in older hospitalised patients.

METHODS AND ANALYSIS

This is a prospective randomised, placebo-controlled, double-blind study with 6 months follow-up. One hundred patients aged 65 years or older presenting to hospital with delirium admitted under geriatric medicine will be recruited. Participants will be randomised to intranasal insulin detemir or placebo administered twice daily until delirium resolves, defined as Confusion Assessment Method (CAM) negative for 2 days, or discharge from hospital. The primary outcome measure will be duration of delirium using the CAM. Secondary outcome measures will include length of hospital stay, severity of delirium, adherence to treatment, hospital complications, new admission to nursing home, mortality, use of antipsychotic medications during hospital stay and cognitive and physical function at 6 months postdischarge.

ETHICS AND DISSEMINATION

This trial has been approved by the South Eastern Sydney Human Research and Ethics Committee. Dissemination plans include submission to a peer-reviewed journal for publication and presentation at scientific conferences.

TRIAL REGISTRATION NUMBER

ACTRN12618000318280.

Hospital Admission to a Window-Side Bed Does Not Prevent Delirium: A Retrospective Cohort Study of Older Medical Inpatients in General Wards

Background: Delirium in older inpatients is a serious problem. The presence of a window in the intensive care unit has been reported to improve delirium. However, no study has investigated whether window-side bed placement is also effective for delirium prevention in a general ward. Objectives: This study aims to clarify the association between admission to a window-side bed and delirium development in older patients in a general ward. Design: This research is designed as a retrospective cohort study of older patients admitted to the internal medicine departments of Shinshu University Hospital, Japan. Participants: The inclusion criteria were the following: (1) admitted to hospital internal medicine departments between April 2009 and December 2018, (2) older than 75 years, (3) admitted to a multi-patient room in a general ward, and (4) unplanned admission. The number of eligible patients was 1,556. Exposure: This study is a comparison of 495 patients assigned to a window-side bed (window group) with 1,061 patients assigned to a non-window-side bed (non-window group). When patients were transferred to the other type bed after admission, observation was censored. Main Measures: The main outcome of interest was "delirium with event" (e.g., the use of medication or physical restraint for delirium) within 14 days after admission as surveyed by medical chart review in a blinded manner. Key Results: The patients had a median age of 80 years and 38.1% were female. The main outcome was recorded in 36 patients in the window group (10.7 per thousand person-days) and 84 in the non-window group (11.7 per thousand person-days). Log-rank testing showed no significant difference between the groups (p = 0.78). Multivariate analysis with Cox regression modeling also revealed no significant association for the window group with main outcome development (adjusted hazard ratio 0.90, 95% confidence interval of 0.61-1.34). Conclusions: Admission to a window-side bed did not prevent delirium development in older patients admitted to a general ward.