Confusion and Delirium (Palliative Care) Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Patients over 18 years of age
  • Confusion and delirium in patients with advanced disease

This guidance does not cover:

  • Patients under 18 years of age

Assessment

Overview
  • Confusion and delirium in advanced illness are common and the cause is often multifactorial. They are particularly common in elderly patients moved from a familiar environment. Severe agitation, anguish or aggression with risk to self or others is fortunately rare.
  • Subtypes of delirium are based on the type of arousal disturbance: hyperactive, hypoactive or mixed (with alternating features of both hyper and hypo activity).
  • Clinicians must comply with the Mental Capacity Act 2005 when providing care for those patients who lack capacity as a result of confusion and delirium
  • Consider and appropriately treat reversible causes which may include:
    • Urinary retention
    • Constipation
    • Biochemical abnormalities: hypercalcaemia, hyponatraemia, hypo/ hyperglycaemia
    • Renal failure
    • Liver failure
    • Cerebral tumour
    • Infection
    • Hypoxia
    • Anxiety and depression
    • Drug-related causes:
      • Opioids
      • Corticosteroids and withdrawal
      • Benzodiazepines and withdrawal
      • SSRI withdrawal
      • Nicotine or alcohol withdrawal
      • Digoxin toxicity

Management

Prescribing for delirium and confusional states

  • Drugs should only be prescribed if necessary. Non-pharmacological measures are the mainstay of treatment, including maintaining adequate fluid balance and nutrition, reassurance and using the environment to help orientate the patient with measures such as a visible clock, consistent nursing and good lighting during the daytime. Encouraging family to visit can be helpful if they are provided with a full explanation of the condition.
  • Sedation should only be necessary if the patient is very distressed and not amenable to reassurance, or is a danger to themselves or others.

Where delirium and psychotic features are predominant

Antipsychotics are the drugs of choice for delirium and can be considered if non-drug measures have failed.

1st line- Haloperidol

  • If using the oral route, start with Haloperidol between 500 micrograms and 1.5 mg at night or twice daily depending upon the degree of distress. Additional doses can be given every 4 hours as needed.
  • If using the subcutaneous route, start between 500 micrograms and 1mg; observe for 30- 60 minutes and repeat as necessary.
  • Continue to review the dose needed at least every 24 hours and consider contacting the Specialist Palliative Care team for advice if this is not working.
  • Discontinue the medication within 7 days if the symptoms have resolved.

Benzodiazepines

  • Although antipsychotics are first­line treatment for delirium, in patients with advanced disease agitation and restlessness may represent an anxiety state. In these cases, benzodiazepines may be more appropriate and effective. Benzodiazepines should be used with caution due to their ability to sedate and increase confusion.
  • Appropriate starting doses would be:
    • Lorazepam
      • 0.5- 1mg sublingually when required
  • Midazolam
    • 2.5- 5mg subcutaneously when requiredOccasionally a syringe driver may be considered if sedation is desirable and appropriate
  • Benzodiazepines used alone carry an increased risk of paradoxical agitation, especially in the elderly.
  • Occasionally the combination of an antipsychotic and benzodiazepine is more successful than either alonehe daytime. Encouraging family to visit can be helpful if they are provided with a full explanation of the condition

Terminal Agitation

Think of potentially reversible causes for distress: consider urinary retention, pain, constipation, hallucinations, respiratory distress, psychological distress

If there are no reversible causes then midazolam 2.5mg - 5mg is the first line medication.

  • After non-pharmacological measures, haloperidol 1.5 - 5mg may be indicated for delirium
  • If midazolam alone is not effective, consider adding haloperidol or levomepromazine.

For more information about symptom management in dying patients see Care of the dying person Care Pathway

Referral

Referral Criteria

Wakefield CCG
  • Eligibility for referral to specialist palliative care services (including inpatient, community, day hospice or outpatient service provision) is based on patient need not diagnosis:
    • The patient has active, progressive and usually advanced disease for which the prognosis is limited (although this may be several years) and the focus of care is quality of life.
    • The patient has unresolved complex needs that cannot be met by the caring team. These needs may be physical, psychological, social and /or spiritual. Examples may include complicated symptoms, difficult family situations, or ethical issues regarding treatment decisions.
  • Patients who meet the above criteria may be admitted to any part of the specialist palliative care service as required
  • An eConsultation request can also be sent via SystmOne
  • See palliative care contact details and resources for further information
North Kirklees
  • Common eligibility criteria were agreed in 2000 by all providers of SPC (specialist palliative care) working in Calderdale and Kirklees in order to ensure equity of access. The criteria reflects those adopted by other SPC services across the country and was incorporated into the new service agreement with Kirkwood on April 2015.
  • There are three elements to the common eligibility criteria:
    • Patients should have active, progressive and potentially life-threatening illness
    • Patients should have unresolved, complex needs that cannot be met by the current caring team, or it is anticipated that the patient will develop such needs in the near future. These needs may be psychological, social, spiritual or physical
    • Patients must have been recently assessed by a member of a SPC team
  • See palliative care contact details and resources for further information

Referral Forms

Wakefield CCG
North Kirklees CCG

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient Information/Public Health/Self Care

Evidence

Useful Links

Hospice information
Other

Assurance & Governance

  • This guidance was developed on: 07.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 08.2017
  • Publication Date: 08.2017
  • Review Date: 07.2019
  • Ref No: PL3 - 07.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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