Delirium (PDQ®): Supportive care - Health Professional Information [NCI] - General Management Approach to Delirium
Some preliminary evidence suggests that the hypoactive subtype of delirium is less responsive to neuroleptic treatment. Although psychostimulants have been proposed for the treatment of hypoactive delirium,[Level of evidence: III];[Level of evidence: II] little empirical evidence attests to their benefit. In a prospective clinical study of 14 patients with advanced cancer and hypoactive delirium, patients demonstrated improvement in cognitive function after receiving 20 to 50 mg of methylphenidate hydrochloride per day.[Level of evidence: III] Relatively higher doses of stimulants (>10 mg of methylphenidate) should be used with caution in delirious patients because such doses can contribute to the unmasking of paranoia and confusion and can lead to agitation. Clinical experience suggests that psychostimulants should be avoided in the presence of hallucinations or delusions.
Sedation for Refractory Delirium and Other Intractable Symptoms
Delirium at the end of life often requires a pharmacological sedative approach. This issue cannot be considered in isolation from the ethical dilemma that it evokes. The need to sedate terminally ill patients for poorly controlled symptoms that include delirium, pain, dyspnea, and psychological effects has been reported frequently.[28,29,30,31];[32,33][Level of evidence: III] Although clinical experience suggests that good palliative care can effectively manage the symptoms of most cancer patients, patients may experience symptoms that can be termed "refractory." Although sedative drugs are a therapeutic option, the incidence of these refractory situations in advanced cancer patients is controversial. This highlights the need to distinguish between "difficult" and "refractory" symptoms. A clear understanding of the terminology describing sedation and sedative medications is necessary; however, the extent to which sedation has been used for managing agitated delirium is difficult to clarify because of inconsistent definitions and confusing terminology.[35,36] Nevertheless, agitated behavior requiring sedation that is variously described as delirium, terminal restlessness, mental anguish, and agitation is a recurring theme in the literature.
A systematic review of the definitions of sedation for symptom relief noted a marked variation in the literature. A sedation definition was proposed to include two core factors:
- Presence of severe suffering refractory to standard palliative management.
- Use of sedative medications with the primary aim of relieving distress.
This review defined palliative sedation as "the use of sedative medications to relieve intolerable and refractory distress by the reduction in patient consciousness." The identified inconsistencies in the definition of sedation (i.e., primary versus secondary, light versus deep, and intermittent versus continuous sedation) should be subcategories of palliative sedation.
The use of palliative sedation for psychosocial and existential symptoms can be particularly controversial. Many ethical and clinical questions can arise for the clinician—questions that are more easily resolved in the case of palliative sedation for pain and physical symptoms.