By David E. Nowels, MD, MPH
Confusion is a common issue experienced by the terminally ill, and one that impacts the patients, their loved ones, and their clinicians. The many causes of confusion commonly include dementia, depression, or/and delirium. It is important to recognize confusion as a symptom and further assess its potential causes because sometimes the confusion can be alleviated. This is especially true for many depressed and some delirious patients. Unless they have a superimposed depression or delirium, demented patients are not expected to improve cognitively with treatment though their behavioral manifestations can be managed. Additionally, the recognition and management of confusion, with its manifestations and complications, can improve quality of life for patients and their loved ones.
Our recent study confirmed that confusion is common.
It also confirmed that confusion is problematic.
Depression
Major depression occurs in 10-25% of the terminally ill. Diagnosing depression in the terminally ill is difficult because somatic symptoms are virtually always present due to the underlying terminal process. Therefore evaluation of psychological and cognitive symptoms is important. Evaluating confused patients for the following signs and symptoms may assist in diagnosing depression: a) tearfulness, depressed appearance; b) social withdrawal, decreased talkativeness; c) brooding, self-pity, pessimism; and, d) lack of reactivity. Some have proposed a single question to screen for depression - “Have you been feeling down, blue, or depressed most of the time over the last few weeks?” A “Yes” answer would initiate additional follow-up and evaluation focusing on the signs and symptoms above. Suicidal ideation is quite likely to be associated with depression in the terminally ill, even in mild and passive forms.
Depression is usually managed with a combination of supportive counseling and medications. Counseling often involves re-establishing self worth, assisting development of new coping strategies, and providing education about modifiable factors. Focusing attention on appropriate, short term, attainable goals can re-establish hope, an important intervention. Each member of the hospice team and loved ones can provide this supportive counseling. Choice of pharmacological agent is, in part, dictated by the time to effect. Other usual considerations in managing antidepressants also apply: start low and go slow; choose an antidepressant in part for its desired side effects. Frequently SSRI agents are used. Psychostimulants can have a more rapid impact on depressive symptoms and have value for select terminally ill depressed patients. They can improve appetite, reduce sedation associated with opioids, and promote a sense of well being. These effects can occur over days rather than the weeks more typical of antidepressants. However, side effects including agitation, insomnia, and anxiety are common. Many clinicians initiate treatment with both a psychostimulant and a more typical antidepressant, tapering off the psychostimulant after several weeks.
Delirium
Delirium, also called acute confusional state, is also common among the dying. The incidence in cancer patients is reported between 25% and 80%, depending on the study and setting. Delirium has been found in 20% of inpatients in general acute care hospitals. In the terminally ill, delirium complicates evaluation of pain and other symptoms, is associated with abnormal grief of survivors, and is associated with shortened lifespan. Treatment often is not helpful in clearing the sensorium since the cause is usually multifactorial, but a small percentage of patients are able to clear their confusion enough to interact with their loved ones.
Many of the signs and symptoms identified of the confused patients in our study correspond with the DSM IV criteria for delirium.
DSM IV criteria for Delirium
Common characteristics of confused patients in our study
Unfortunately, delirium is very often not recognized. In non-terminal patient populations 30% - 66% of patients suffering from delirium are not identified. For some patients delirium may be superimposed on dementia, depression, psychosis or other causes of cognitive impairment, making identification more difficult. Traditionally two subtypes of delirium have been identified – one associated with agitation and the other with hypoactivity. Patients with agitated delirium tend to be recognized most frequently and, in our study, those with agitated symptoms were more commonly identified as having delirium that caused a problem for someone.
A common cause for delirium in the dying is unrelieved pain. Other common causes include: Drugs – especially psychotropics, Electrolyte or glucose imbalance, Liver failure, Ischemia or hypoxia, Renal failure, Impaction of stool, Urinary or other infection, and Metastases to brain.
Management of delirium may be non-pharmacological and/or pharmacological. Measures to reduce anxiety and disorientation include keeping lights on low at night, surrounding the patient with quiet familiar objects, family presence, and keeping a clock and calendar in the visual field. First-line pharmacological management uses neuroleptics because they help calm the patient and improve mentation. Haloperidol is most commonly used, but chlorpromazine is often useful particularly in the agitated delirious patient. For severely agitated delirious patients (including those with terminal agitation or terminal restlessness), sedation may be a higher priority than clearing mentation. Consider adding lorazepam or midazolam when the goals of therapy shift to sedation.
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