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Palliative Care with a Focus on Delirium

Introduction

A significant number of people die in hospitals, and as a result, death is often treated as an ailment. Palliative care centers around envisioning, diagnosing, and managing side effects experienced by patients with an absolute or hazardous illness and helping patients and their families settle on restoratively critical choices. An ultimate objective of palliative consideration is to enhance personal satisfaction for both the patient and the family, paying little respect to analysis. Albeit palliative consideration, not at all like hospice care, does not rely upon the forecast, as the finish of life approaches, the job of palliative consideration heightens and centers around forceful side effect administration and psychosocial bolster.

Helping patients, as well as their families, comprehend the idea of ailment and visualization is a critical part of palliative care for individuals approaching the end of life. Palliative care experts encourage patients and their families to choose propitious medical care and to adjust the health goals of the patients to match with the purposes of the health care system. Lastly, developing and implementing the requirement for a therapeutic intermediary, advance directives, and revival status is indispensable for patients approaching the end of life.

Background of study

Delirium is a condition of disturbed consciousness characterized by reduced ability to focus, sustain, and shift attention. Rooij et al. (2005) suggest that delirium can appear as a series of symptoms that fluctuate between hyperactive symptoms with agitation, hyperarousal, or relentlessness and hypoactive symptoms characterized by drowsiness, lethargy, and low levels of arousal. The condition is common in palliative care patients, and its severity becomes evident towards the end of life. Often, diagnosis of delirium is missed or mistaken with dementia and depression. Leonard et al. (2008) suggest that hypoactive delirium is in most cases underdiagnosed and it’s the most common type of delirium that affects patients at the end of life.

Although some medical experts believe that delirium can be persistent in some patients, the existing literature suggests that the ailment can be reversed. Much of the evidence about treatment and prognosis exists in critical care literature. However, Leonard et al. (2008) suggest that the focus of care in critical care literature may be different from that in palliative care. In Patients approaching the end of life, delirium is often multifactorial, and medical experts may decide not to pursue active prognosis when they discover that precipitant is irreversible.

Previous studies have failed to explore the relationship between delirium and terminal relentlessness fully. Most of the reviews describe terminal relentlessness as a series of agitation and altered mental state that occurs towards the end of life. It is, therefore, a form of delirium that occurs in dying patients and characterized by spiritual, emotional, and physical anguish, relentlessness, anxiety, and cognitive failure. The condition is worth studying as it influences the dying process significantly.

Problem statement

Patients getting palliative care regularly have different risk factors and inclining conditions for delirium. The effect of delirium on patient care can be extensive in that it only influences not only the quality of life but also the dying process. As palliative care focuses on solace and management of side effects, it is essential to develop ideal assessment and treatment procedures of delirium in patients in approaching the end of life. The existing studies present limited information regarding terminal restlessness, and it remains unclear if hyperactive and hypoactive delirium should have similar pathophysiology, evaluation and management procedures (Rooij et al. 2005). Furthermore, there is limited literature on the effectiveness of a multicomponent intervention to prevent and reduce the effects and duration of delirium in a palliative care setting. Siddiqi et al. (2016) argue that further studies are needed to illustrate the effectiveness of pharmacological prophylaxis in non-palliative care populations.

Objectives of the study

The purpose of palliative care is to ease the agony experienced by terminal ill patients and their families through comprehensive assessment and treatment of psychological, spiritual, and physical symptoms of the patient. Palliative care is expected to benefit both the patients in terms of health gain, but it can also include prevention and treatment. In cases where is inevitable, the goal of palliative care is to relieve pain and distress that arises from a medical disorder. As patients approach the end of life, their condition may require more comprehensive palliation. However, there has been limited exploration on symptom control and distress relieve for patients suffering from delirium (Partridge et al. 2013). Thus, the objective of this research is to develop an analytical procedure that can be used ease the agony of delirium patients during their last days. The study prioritizes on the drawbacks of the existing studies and procedures related to delirium.

Research questions

  1. Does hypoactive and hyperactive delirium have homogenous prognostic significance, responses to treatment and pathophysiology?
  2. How effective is multicomponent intervention in a palliative care setting?
  3. Which placebo-controlled trials are required in the treatment of delirium and how effective are they?

 

Significance of the study

This review intends to establish an understanding on palliative care for delirium patients. The study is significant not only for academic purposes but also to future researchers, future nursing licensure examinees, clinical instructors, and nursing schools. The ideas presented in the study may be used by future scholars as a reference in conducting new studies and testing the validity of findings related to this study. Furthermore, clinical instructors and nursing schools can employ the results of the study in teaching palliative care for patients nearing the end of life.

Literature review

Delirium is portrayed by intense perplexity with changes in recognition, attention, discernment, and sensation in complicated mental status (Raats et al. 2016). The psychological status of the patient is abruptly changed to be harsh toward time, places, and people (McCaffrey and Locsin 2004). Moreover, insanity is a kind of neural aggravation joined with psychiatry, rendering it a reversible intense ailment with changes in attention, discernment, versatility, sleep cycles, and mental confusion (Fortini et al. 2014). The condition occurs in short periods, and it is accompanied by fluctuations in cognitive behavior as well as psychological symptoms such as absentmindedness, memory loss, irritable behavior, delusion, and illusions.

Demographic, physical, cognitive, functional, and psychological factors are attributed to delirium in the elderly. The demographic and physical factors include age, gender, institutionalization, surgery, trauma, among others (Fortini et al. 2014). Three to ten percent of the seniors who have had surgery are likely to experience delirium towards the end of their life (Oresanya et al. 2014). The assessment scale employed when measuring delirium in the aging population include medical diagnostic devices and systems such as DSM-IV, DSM-III-R, and DSM- IV-TR (). Cognitive assessment scale include the mini-mental status examination (Folstein et al. 1975), the confusion assessment method-ICU (Inouye et al. 2005), the Groningen Frailty Indicator (Pol et al. 2011) and the Hasegawa’s Dementia Scale-Revised (Numata et al. 2013)

The American Psychiatric Association suggests that antipsychotic treatments are the pharmacologic medications of choice. The argument was founded on custom and practice, and since then, numerous trials from researcher such as Page et al. (2013) have assessed agent drug treatment such as pro-cholinergic and cholinesterase inhibitors, antipsychotics, melatonin, and benzodiazepines to treat delirium. The studies suggest a treatment effect although none of them have provided sufficient evidence to prove the effectiveness of the drugs. Similarly, medical researchers have suggested intervention programs including delirium units, geriatric assessment, and management advice as viable treatment procedures for delirium. The UK National Institute for Health and Clinical Excellence (2010) acknowledged the presence of limited evidence for treatment of delirium but failed to recommend viable pharmacological agents to use. Ideally, the existing research has failed to provide convincing treatment intervention for delirium.

Current pharmacological intercessions depend on constrained preliminary proof of adequacy and have conceivably positive side-effects, particularly in patients approaching the end of life. Additionally, tranquilize preliminaries, and palliative care procedures are therefore required based on new and conceivable theories of path-etiology of delirium to distinguish conceivably novel therapeutic targets, grounded in sound and logical principles.

Conclusion

Despite the rigorous progress, research of palliative care for patients with delirium has failed to produce convincing impacts on clinical practice. The limited research paradigms have contributed to the failure as they present delirium as a curable ailment or a disease that can easily be identified and treated. The perceptions are followed by the presumption that after treatment, patients in nearing the end of life clinically recover. The current condition, therefore, calls for the need to develop viable palliative care procedures for patients with delirium.

 

References

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (January 01, 1975). “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 3, 189-98.

Fortini, A., Morettini, A., Tavernese, G., Facchini, S., Tofani, L., & Pazzi, M. (June 01, 2014). Delirium in elderly patients hospitalized in internal medicine wards. Internal and Emergency Medicine: Official Journal of the Italian Society of Internal Medicine, 9, 4, 435-441.

Inouye, S. K., Leo-Summers, L., Zhang, Y., Bogardus, S. T., Leslie, D. L., & Agostini, J. V. (February 01, 2005). A Chart-Based Method for Identification of Delirium: Validation Compared with Interviewer Ratings Using the Confusion Assessment Method. Journal of the American Geriatrics Society, 53, 2, 312-318.

Leonard, M., Agar, M., Mason, C., & Lawlor, P. (January 01, 2008). Delirium issues in palliative care settings. Journal of Psychosomatic Research, 65, 3, 289-98.

McCaffrey, R., & Locsin, R. (January 01, 2004). The effect of music listening on acute confusion and delirium in elders undergoing elective hip and knee surgery. Journal of Clinical Nursing, 13, 91-6.

National Institute for Health and Clinical Excellence (2010). Delirium: prevention, diagnosis, and management CG103. Retrieved (October 10, 2018) https://www.nice.org.uk/guidance/cg103/evidence/full-guideline-134653069

Numata, K., Tsuchida, K., Yoshida, T., Osaragi, T., Yoneyama, K., Kasahara, A., Yamamoto, Y., … Masuda, M. (January 01, 2013). Utility of HDS-R and E-PASS for Prediction of Postoperative Delirium in Elderly Patients Undergoing Gastroenterological Surgery. The Japanese Journal of Gastroenterological Surgery, 46, 7, 477-486.

Oresanya, L. B., Lyons, W. L., & Finlayson, E. (January 01, 2014). Preoperative assessment of the older patient: a narrative review. Jama, 311, 20, 2110-20.

Page, V. J., Ely, E. W., Gates, S., Zhao, X. B., Alce, T., Shintani, A., Jackson, J., … McAuley, D. F. (September 01, 2013). Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomized, double-blind, placebo- controlled trial. The Lancet Respiratory Medicine, 1, 7, 515-523.

Pol, R. A., van, L. B. L., Visser, L., Izaks, G. J., van, D. J. J. A. M., Tielliu, I. F. J., & Zeebregts, C. J. (January 01, 2011). Standardized Frailty Indicator as Predictor for Postoperative Delirium after Vascular Surgery: A Prospective Cohort Study. European Journal of Vascular and Endovascular Surgery, 42, 6, 824-830.

Raats, J. W., Steunenberg, S. L., de, L. D. C., & van, L. L. (January 01, 2016). Risk factors of postoperative delirium after elective vascular surgery in the elderly: A systematic review. International Journal of Surgery Surgical Associates-, 35, 1-6.

Rooij, S. E. ., Schuurmans, M. J., Mast, R. C. ., & Levi, M. (January 01, 2005). Clinical subtypes of delirium and their relevance for daily clinical practice: a systematic review. International Journal of Geriatric Psychiatry, 20, 7, 609-615.

Siddiqi, N., Harrison, J. K., Clegg, A., Teale, E. A., Young, J., Taylor, J., & Simpkins, S. A. (March 11, 2016). Interventions for preventing delirium in hospitalized non-ICU patients. Cochrane Database of Systematic Reviews.

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