SY19-2 Delirium before the last days of life

Abstract

Delirium occurs in approximately 90% of patients in the last days of life. Pharmacotherapy, mainly antipsychotics, has been generally recommended to palliate delirium-related symptoms. However, recent randomized placebo-controlled trials have questioned its effectiveness. For example, in terminally ill cancer patients with mild to moderate delirium and advanced cancer patients with hypoactive delirium, symptoms of delirium were rather more likely to deteriorate after starting pharmacotherapy (Agar M, et al. JAMA Intern Med 177(1):34-42, 2017; Okuyama T, et al. Oncologist. 24(7):e574-e582, 2019). From these results, for those with hypoactive delirium or mild to moderate delirium, comprehensive measure other than pharmacotherapy is recommended: 1) treatment of any potentially reversible causes such as infections, hypercalcemia, polypharmacy, and opioid neurotoxicity, 2) non-pharmacological measures including orientation cues, window light, efforts to minimize unnecessary stimuli, and caregiver education, and 3) total symptom management. On the other hand, in patients with severe agitated delirium, sedative neuroleptics such as chlorpromazine and concomitant use of benzodiazepine may reduce agitation in patients in the last days (Hui D, et al. Lancet Oncol. 21(7):989-998, 2020).