Delirium at the end of life

Management

• Treat underlying causes
  • Opioid neurotoxicity:
    • Switch opioid
    • Dose reduction
    • Hydration
  • Medications
    • Stop medication
  • Dehydration
    • IV
    • Hypodermoclesis (fluid given subcutaneously)
  • Hypercalcemia
    • IV bisphosphonate (zoledronate/pamidronate)
  • Infection
    • Antibiotics
  • Hepatic encepalopathy
    • Lactulose
  • Brain metastases
    • Corticosteroids
• Non-pharmacologic
  • Reduce stimulation
  • Low ambient light
  • Low noise
  • Correct sensory deficits (glasses, hearing aids)
  • Gentle, repeated reassurances (but labour intensive)
  • Do not use physical restraints
• Pharmacologic
  • Mild
    • Haloperidol 0.5-1mg po or subcut daily or BID + haloperidol 0.5-1mg po/SC q1h prn
  • Moderate
    • Haloperidol 2-2.5mg po/sc bid or tid + haloperidol 2mg po/sc q1h prn
    • Or methotrimeprazine 5-12.5mg po/sc bid or tid + prn
  • Severe
    • Midazolam 2.5-5mg sc stat once + haloperidol 5mg sc stat
    • Or methotrimeprazine 25mg sc stat then po/sc
    • Follow with haloperidol 2.5-5mg sc q30min prn (max 10-15mg/day)
  • Sundowning
    • Methotrimeprazine qhs
  • Alternatives
    • Quetiapine
    • Respiradone
    • Olanzapine