Fast Fact and Concept #1: Treating Terminal Delirium

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Title: Fast Fact and Concept #1: Treating Terminal Delirium

Author(s): Weissman, D.

This Fast Fact and Concept briefly outlines clinical information on terminal delirium.

Educational Objective(s)
Designed for attending physicians to use during teaching rounds or as the starting point for a conference on delirium.
Some degree of cognitive function loss occurs in most patients in the week or two before death. The typical scenario presented to housestaff is a late-night call from a ward nurse saying, "Mr. Jones is confused, what should we do". More often than not, no direct patient assessment is done by the house officer, but a reflexive dose of Lorazepam (Ativan) is administered, often causing worsening confusion. Why Ativan? I'm not sure, but it's clear that house staff and general medicine ward nurses feel much more comfortable using minor tranquilizers than major tranquilizers, perhaps from their experience in treating alcoholic withdrawal.

Key teaching points about terminal delirium:

1. The term "confusion" is not an accurate descriptive term--it can mean anything from delirium, dementia, psychosis, obtunded, etc.
2. Patients need a focused assessment, including a brief mini-mental examination
3. Delirium can be either a hyperactive /agitated delirium or a hypoactive delirium; the hallmark of delirium is an acute change in cognitive function, sleep disturbance, mumbling speech, memory and perceptual disturbances.
4. The most common identifiable cause of delirium in the hospital is drugs: anti-cholinergic and sedative-hypnotics-including benzodiazepines such as Ativan.
5. The drug of choice in terminal care is a major tranquilizer-e.g. Haloperidol, given in a dose escalation process similar to treating pain. Haldol 1-2 mg po or IV q2 prn will suffice for most patients.
6. Minor tranquilizers (e.g. Ativan) can be used, but paradoxical worsening may occur.

Also See:
Fast Fact #60: Pharmacologic Management of Delirium; Update on Newer Agents

References: Brietbart W, Marotta R, Platt M, et al. A double blind trial of Haloperidol, Chlorpromazine and Lorazepam in the treatment of delirium. Am J Psych 1996; 153: 231-237. Improving end-of-life care, a resource guide for physician education. Weissman DE and Ambuel B. 2nd Ed. pg. 48-49, 1999
Contact: [email protected].

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman, D. Fast Fact and Concepts #01: Treating Terminal Delirium. May, 2000. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 1/2000

Format: Handouts

Purpose: Self-Study Guide, Teaching

Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Adult, Neurologic

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).