Delirium robs dying people of their autonomy, dignity and last conversations with loved ones, at a time when every moment is precious.
Symptoms are highly distressing to experience and watch. Confusion, incoherent communication, poor attention, agitation, drowsiness and hallucinations are some markers of this common complication for people dying in hospital from cancer and other advanced illnesses. On average one in three people in end-of-life hospital care are affected.
Doctors commonly prescribe antipsychotic medications to try to relieve these symptoms. However, our study just published in JAMA Internal Medicine, raises serious concerns about their safety and efficacy.
So, what are we to do for people experiencing delirium, who are robbed of their mental awareness and ability to communicate?
What are we to do for people with what the Australian Commission on Safety and Quality in Health Care describes as one of the last frontiers in medicine?
How is delirium treated?
Delirium is mostly treated by managing the underlying medical issues that led to the delirium in the first place, for example treating an infection. Medical issues such as infection cause delirium by altering chemicals that are involved in inflammation and transmitting messages between brain nerve cells.
Other ways to manage the condition are to quickly diagnose delirium before symptoms worsen; regularly helping people know the day, time and where they are; helping people maintain their ability to walk and be physically active; making sure they are hydrated; and using hearing aids and glasses.
However, non-medication strategies are too often forgotten or seen as too hard. Instead, doctors often prescribe antipsychotic medications, despite international clinical guidelines recommending them only for people who are very distressed, agitated, or when safety is a concern.
Previous studies suggested antipsychotic medications may reduce the severity of delirium symptoms. But these studies mainly compared one antipsychotic to another. This forgets that in many cases, delirium will naturally get better when its cause (like infection) is treated.
Our study took a new approach. We asked whether antipsychotic medication offers extra benefit in reducing distressing symptoms for palliative patients in hospital, compared to focusing on treating the underlying medical problem with non-medication alone.
Just imagine you had quite advanced cancer. You get a chest infection that causes delirium. You experience agitation, restlessness, you are climbing out of bed, seeing spiders that are not real, and believe your medications are poison.
Our study wanted to see if these symptoms are relieved better and more quickly if we use antipsychotic medication.
We found people prescribed antipsychotic medication for their delirium had worse symptoms. Even more alarming, we found people who received the antipsychotic medication were more likely to die.
What now for patients?
Despite ways to identify people at risk of delirium, such as checking risk factors and screening regularly for early symptoms, it is often missed and under-treated. We need to change our thinking. Delirium is an in-hospital complication we can prevent and treat.
Beyond the personal costs, delirium costs the US health care system up to US$64,421 (A$81,576) per patient per year, based on 2005 figures.
There is no safe or effective medication to manage delirium. We need to invest in our hospitals to focus attention on excellent care. We should value seemingly simple things that can be life changing for a person at risk of delirium.
We need to create hospitals where supporting patients to minimise their risk of delirium is a priority; hospitals where all staff, whether doctor, nurse, or cleaner introduce themselves and remind patients what day of the week and what time it is. We need to take a patient’s glasses out of their bedside drawer and help them put them on, remind them to take a sip of water, and help them walk a lap of the ward.
Carers and family
The Australian Commission for Quality and Safety in Health Care says carers and family members have a central role in preventing, recognising early signs of and supporting recovery from delirium.
They can report to staff any recent changes in cognition or behaviour and they offer a familiar presence in hospital.
Choosing Wisely Australia provides consumers five questions to ask their health care provider before starting any treatment.
If doctors propose antipsychotic treatment for a family member, ask if the diagnosis is delirium, what the alternatives are and what the family can do to support care.
There is no simple pill that can fix delirium. Delirium prevention and care is everyone’s business.
Meera Agar receives funding from NHMRC, Australian Department of Health and Cancer Institute New South Wales. She is affiliated with The Australian and New Zealand Society of Palliative Medicine (Vice President), European Delirium Association (Board Member), Australasian Delirium Association (Committee member) and Choosing Wisely Australia (Advisory Group).
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