General Management Approach to Delirium
The decision to use a deep level of pharmacologically induced sedation in the treatment of agitated delirium often raises ethical concerns, fueled by the marked variability in the reported frequency (ranging from 10% to 52%) for this practice in patients dying from advanced cancer. Consistent with the goals of care, it is important that appropriate efforts are made to assess the reversibility of delirium, clarify the intent of sedation (the relief of refractory symptoms), and maintain clear communication with family members and health care team members regarding rationale and process.[2,4] (Refer to the Sedation for Refractory Delirium and Other Intractable Symptoms section of this summary for more information.)
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.