Alcohol withdrawal as an underrated cause of agitated delirium and terminal restlessness in patients with advanced malignancy

Risk Factors and Antipsychotic Usage Patterns Associated With Terminal Delirium in a Veteran Long-Term Care Hospice Population

Background

The development of delirium is very common in terminally ill patients. However, risk factors for terminal delirium in the veteran population are poorly identified. The purpose of this study was to (1) Identify risk factors for terminal delirium in a US Department of Veterans Affairs inpatient hospice population; (2) Assess usage patterns of antipsychotics for treatment of terminal delirium; and (3) Describe nursing assessment, nonpharmacologic interventions, and documentation of terminal delirium.

Methods

This was a retrospective case-control study of veterans who expired while admitted into hospice care at a long-term care hospice unit during the period of October 1, 2013 to September 30, 2015. Veterans' medical records were reviewed for the 2 weeks prior to the recorded death.

Results

Of 307 veterans admitted for hospice care, 67.4% required antipsychotics in the last 2 weeks of life for the treatment of terminal delirium. The average number of antipsychotic doses given was 14.9 doses per patient. The risk factors that were identified included the use of steroids, opioids, or anticholinergics; Vietnam-era veterans with liver disease; veterans with cancer and a comorbid mental health disorder; and veterans with a history of drug and/or alcohol abuse.

Conclusions

More than half of veterans admitted for hospice care experienced terminal delirium requiring treatment with antipsychotics. The identification of veterans most likely to develop terminal delirium will allow for early nonpharmacologic interventions and potentially decrease the need for treatment with antipsychotic medications.

Alcohol Dependence in Palliative Care: A Review of the Current Literature

PURPOSE

Alcohol misuse affects up to 28% of palliative care inpatients. This article aims to summarize the existing literature on the care of palliative patients with alcohol dependence.

METHODS

The author searched CINAHL, Scopus, MEDLINE, and PubMed from inception until July 2017 using search terms including "alcohol*," "dependence," and "palliative." The results were reported in a narrative manner.

RESULTS

Identification of alcohol-dependent patients can be improved through the use of validated tools such as "Cut Down, Annoyed, Guilty, Eye Opener" (CAGE) and "Alcohol Use Disorders Identification Test" (AUDIT). These patients may have specific palliative care needs such as increased susceptibility to terminal agitation, high prevalence of comorbidities, and poor social support networks. Management may involve detoxification, controlled usage of alcohol, or treatment of alcohol withdrawal.

CONCLUSIONS

Patients may derive clinical benefit when alcohol dependence is identified by health-care professionals. Routine screening should be considered. Further research is needed to directly compare treatments for alcohol dependence in palliative care.

Delirium in palliative medicine: a review

Delirium is a devastating complication of general medical and surgical populations but of particular importance in palliative medicine. It is a clinical syndrome that is often not recognized and, therefore, not treated appropriately. The presence of delirium is a predictor of increased morbidity and mortality, longer hospitalization, and more likely discharge to a nursing facility. This article reviews the pathophysiology, etiology, diagnosis, and treatment of delirium in the palliative medicine population.

Palliative care for people with severe persistent mental illness: a review of the literature

A systematic overview of the literature on palliative care for people with severe persistent mental illness (SPMI) was conducted to inform clinical practice, research, and education. Empirical studies and nonempirical papers were included. Few empirical studies exist. There is even less information about the palliative care needs of, or the nature of palliative care provided to, people with SPMI. Mental health, primary care, and palliative care providers need to partner with people who have SPMI in developing and providing palliative care. The field of palliative care for people with SPMI is wide open and in need of methodologically sound studies that will help define the issues that exist for this vulnerable population. Recognizing the similarities between mental health and palliative care should lead to collaborative ventures and discussions in an attempt to address common and parallel issues.

Delirium in Older Adults With Cancer: Implications for Practice and Research

PURPOSE/OBJECTIVES

To provide a comprehensive review of the literature and existing evidence-based findings on delirium in older adults with cancer.

DATA SOURCES

Published articles, guidelines, and textbooks.

DATA SYNTHESIS

Although delirium generally is recognized as a common geriatric syndrome, a paucity of empirical evidence exists to guide early recognition and treatment of this sequelae of cancer and its treatment in older adults. Delirium probably is more prevalent than citations note because the phenomenon is under-recognized in clinical practice across varied settings of cancer care.

CONCLUSIONS

Extensive research is needed to formulate clinical guidelines to manage delirium. A focus on delirium in acute care and at the end of life precludes identification of this symptom in ambulatory care, where most cancer therapies are used. Particular emphasis should address the early recognition of prodromal signs of delirium to reduce symptom severity.

IMPLICATIONS FOR NURSING

Ongoing assessment opportunities and close proximity to patients' treatment experiences foster oncology nurses' mastery of this common exemplar of altered cognition in older adults with cancer. Increasing awareness of and knowledge delineating characteristics of delirium in older patients with cancer can promote early recognition, optimum treatment, and minimization of untoward consequences associated with the historically ignored example of symptom distress.

Psychological Issues in End-of-Life Care

This paper provides a systematic, evidence-based review of the psychological issues confronted by patients at the end of life, drawing on recent literature. The epidemiology, approach to clinical assessment, clinical presentation, and therapeutic options related to common psychological issues that arise in end-stage illness are described. The spectrum of normal and dysfunctional reactions are identified, and approaches to enhancing coping and quality of life are emphasized. The learner will be able to describe: (1) normal coping responses of patients at the end of life; (2) epidemiology of common psychiatric disorders at the end of life; (3) the approach to clinical assessment of psychological distress at the end of life; and (4) therapeutic approaches to common psychological problems at the end of life.