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State of the science
Delirium: non-pharmacological and pharmacological management
  1. Jason W Boland1,2,
  2. Peter G Lawlor3,4,5 and
  3. Shirley H Bush3,4,5
  1. 1 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
  2. 2 Care Plus Group and St Andrew’s Hospice, North East Lincolnshire, UK
  3. 3 Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
  4. 4 Bruyère Research Institute and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  5. 5 Bruyère Continuing Care, Ottowa, Ontario, Canada
  1. Correspondence to Dr Jason W Boland,Senior Clinical Lecturer and Honorary Consultant in Palliative Medicine, Hull York Medical School, Hull, UK; Jason.Boland{at}hyms.ac.uk

https://doi.org/10.1136/bmjspcare-2019-001966

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    Delirium is an acute onset, fluctuant, confusional state with cognitive, emotional, perceptual, psychomotor and sleep–wake cycle disturbances. It is often worse in the evening and at night, particularly with underlying dementia.1 Delirium is often not diagnosed due to fluctuating signs and symptoms. The most common clinical subtype in palliative care is hypoactive delirium, with reduced psychomotor activity.2 Delirium is especially common in palliative care, almost ubiquitous towards the end of life; up to 88% of patients develop delirium in the last weeks to hours of life.3

    Older age and dementia are major risk factors. Current and projected demographic changes, with an increased elderly population, signal a need for physicians to have a better awareness of delirium diagnosis and assessment. A high level of suspicion and multidisciplinary team involvement is needed in diagnosis and management.

    The primary management is rapid diagnosis, as mortality increases with delay. This includes history (importantly collateral histories from carers, family and staff), examination and appropriate investigation (according to goals of care). The aim is to make the diagnosis and if possible confirm the cause(s). It is also important to determine the impact on the patient and family/carer and ascertain their needs.

    Delirium screening and diagnostic tools can help improve diagnosis but seldom used.4 Clinicians should use low burden validated screening tools including the Single Question in Delirium, Nursing Delirium Screening Scale, Delirium Observation Screening Scale and the Confusion Assessment Method (CAM).2 The CAM needs proper training. The 4AT assesses cognition (specifically attention) and is popular in elderly medicine. Currently, it has not been formally validated in palliative care patients but has been used in a hospice setting.5 Diagnostic criteria appear in the …

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    Footnotes

    • Contributors JB and SB drafted the article, all authors edited and approved the final version.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; internally peer reviewed.