Drug therapy for delirium in terminally ill adults | Figure 1

%27%3e%3cg%20id=%27Group-14%27%20transform=%27translate(13.000000,%20103.176124)%27%3e%3cg%20id=%27Group-Copy-5%27%20transform=%27translate(0.000000,%20182.676124)%27%3e%3crect%20id=%27Rectangle-8%27%20fill=%27%23E2E0DE%27%20x=%270%27%20y=%270%27%20width=%2736%27%20height=%2736%27%20rx=%2718%27%3e%3c/rect%3e%3cpath%20d=%27M28,27.6503435%20C28,22.127496%2023.5228474,17.6503435%2018,17.6503435%20C12.4771525,17.6503435%208,22.127496%208,27.6503435%20M18,16.3472505%20C20.8165136,16.3472505%2023.099749,14.0640151%2023.099749,11.2475015%20C23.099749,8.43098783%2020.8165136,6.1477524%2018,6.1477524%20C15.1834863,6.1477524%2012.9002509,8.43098783%2012.9002509,11.2475015%20C12.9002509,14.0640151%2015.1834863,16.3472505%2018,16.3472505%20Z%27%20id=%27Combined-Shape%27%20fill=%27%23FFFFFF%27%20fill-rule=%27nonzero%27%3e%3c/path%3e%3c/g%3e%3c/g%3e%3c/g%3e%3c/g%3e%3c/svg%3e)

Deleted account

Some actions are only available when you log in.

Report case

Report this to our moderators

Drug therapy for delirium in terminally ill adults

You can view up to 4 cases without signing up Sign up for unlimited access

Background

Delirium is common in people with a terminal illness. A person experiencing delirium may be confused, lack concentration, have disturbed patterns of sleep and waking, and experience hallucinations. Delirium can start suddenly and can cause distress to both the person and their family. Delirium may be caused by the underlying disease with which the person is affected, or as a side effect of drugs or other symptoms. Often it is not clear why a person has delirium. The multifaceted nature of delirium makes its management challenging. When it is not possible to identify the underlying cause, drug treatments are sometimes used to manage the symptoms.

Study characteristics

The aim of this review was to find out what we know about the effectiveness and side effects of drugs in the management of delirium in adults with a terminal illness. For the purpose of this review, terminally ill adults includes anyone with an advanced progressive illness such as advanced cancer, advanced dementia or organ failure, as well as those receiving hospice and end‐of‐life care. We compared drug therapy with placebo (a substance with no known active effect), usual care, or any other drug or non‐drug treatment.

Key results

Our search to July 2019 found four trials, involving 399 adults in total. Participants had advanced cancer (three studies) or advanced AIDS (one study), and all had symptoms of delirium. The drugs evaluated were antipsychotics (three studies) or benzodiazepines (one study), compared to placebo or each other, on their own or in combination with another drug or placebo.

Most studies reported the outcomes we deemed most important: delirium symptoms, agitation, and adverse events (side effects).

It was not possible to combine the data from different studies due to a lack of similarity between them. We found low‐quality evidence that certain drugs (haloperidol and risperidone) may slightly worsen delirium symptoms for terminally ill adults with mild‐ to moderate‐severity delirium. We found moderate‐quality evidence that haloperidol probably slightly increases adverse side effects for people with mild‐ to moderate‐severity delirium.

Quality of the evidence

We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. We found no high‐quality evidence. This was due to the small number of people taking part, the number of people dropping out of the studies, and the small number of studies.

Conclusion

We found low‐quality evidence that, compared to placebo, drug therapy (specifically haloperidol and risperidone) may slightly worsen delirium symptoms in terminally ill people with delirium of mild to moderate severity. We found low‐ to moderate‐quality evidence that these drugs may slightly increase adverse side effects. Given the small numbers of studies and participants on which current evidence is based, further research is essential.

Read the full Cochrane Review here

Comment

Sign up to add a comment

More about this case

ResolvedVerified literature

Why you should join Figure 1

Sign up to explore now

Similar cases

\ \ Bottom line\ Duloxetine and milnacipran may reduce pain in people with fibromyalgia. However, some of these people may also experience side effects, such as nausea and drowsiness. A minority of people with fibromyalgia experience symptom relief without side effects from duloxetine and milnacipran.\ Cochrane Review; 18 studies with 7903 participants. The studies were four to 27 weeks long and compared the SNRIs desvenlafaxine, duloxetine and milnacipran against placebo.\ Key results and quality of the evidence\ Duloxetine and milnacipran were better than placebo in reducing pain by 50% or more and in improving global well-being (low-quality evidence). Duloxetine and milnacipran were better than placebo in improving health-related quality of life and in reducing fatigue (low-quality evidence). Duloxetine and milnacipran were not better than placebo in reducing sleep problems (low-quality evidence). More people dropped out of the trial due to side effects with duloxetine and milnacipran than with placebo (low-quality evidence). More people reported nausea and drowsiness with duloxetine and milnacipran than with placebo (low-quality evidence). Duloxetine, milnacipran and placebo did not differ in the frequency of serious side effects experienced (very low-quality evidence).](https://app.figure1.com/case-detail/1863addd-f676-4911-8fb9-fe74196e7884)

\ \ Erythropoiesis-stimulating agents (ESAs) are medicines which stimulate red blood cell production. They can be given into a vein or under the skin. They are used in critically-ill people, despite not being licensed by marketing authorities for this indication (i.e. off-label).\ 53 studies were found, involving 945,240 participants treated with epoetin-alfa, epoetin-beta, and darbepoetin-alfa or placebo. Five studies are awaiting classification.\ Key results\ Based on mainly low-quality evidence, the Cochrane Review authors were unable to exclude relevant harms in terms of adverse effects of ESAs. 'Adverse effects' included any adverse events and problems from blood clotting in the veins. However, they found low-quality evidence for protective effects on the overall risk of dying in critically-ill people.](https://app.figure1.com/case-detail/59dde9df-d962-45ec-ba0d-3bc59301eaa4)

\ \ Headline: Valproate is an effective antimanic treatment. Valproate may be inferior to olanzapine in adults. Valproate may be inferior to risperidone in acute mania in paediatric and adolescent populations.\ Who may be interested in this review?\ People with bipolar disorder and their healthcare providers.\ Why is this review important?\ Bipolar disorder is a mood disorder that is a common mental health problem. Patients may experience recurrent symptoms of elevated or irritable mood, depression, or a combination of both. Treatment is usually with psychiatric medication, including mood stabilisers, antidepressants and antipsychotics. Valproate is a drug traditionally used in the treatment of mania, but its effectiveness compared to some of the newer antipsychotics is yet to be firmly established.\ What questions does this review aim to answer?\ This review investigates the effectiveness and acceptability of valproate compared to placebo and other drugs in the treatment of acute manic episodes in bipolar disorder.\ Which studies were included in the review?\ The authors searched medical databases to find reports of clinical trials (specifically randomised controlled trials) published up to date. We identified 25 studies that involved 3252 participants as relevant. The studies compared the effects of valproate with placebo or other conventional medications, both on its own and in combination with other treatments.\ What does the evidence from the review tell us?\ We found high‐quality evidence showing that valproate is more effective than placebo when used alone in adults. There is mixed evidence comparing olanzapine and valproate. Low‐quality evidence did not find a difference in response rate of olanzapine compared to valproate. However, high‐quality evidence suggests that olanzapine is better at reducing manic symptoms. This suggests olanzapine may be more effective. Moderate‐quality evidence shows no difference in response rates between lithium and valproate. There is insufficient evidence to confidently assess any difference between valproate and other antimanic drugs in adults.\ In children and adolescents, we found low‐quality evidence that valproate is inferior to risperidone. The evidence is of insufficient quality to confidently assess any difference between valproate and other antimanic drugs in children and adolescents.\ In terms of tolerability in adults, there is moderate‐quality evidence that valproate causes more side effects than placebo and low‐quality evidence it causes more side effects than oxcarbazepine. There is low‐quality evidence that valproate may cause fewer side effects than carbamazepine. Low‐quality evidence found no difference in the number of individuals with side effects when taking valproate compared to lithium. There is insufficient evidence to confidently assess any difference between valproate and other antimanic drugs in adults.\ In children and adolescents, very‐low quality evidence found no difference in the number of individuals with side effects when taking valproate compared to placebo.](https://app.figure1.com/case-detail/741abe01-6208-4c5a-97aa-9669a42d6df1)

\ \ Cochrane Review; 12 trials (3885 participants); comparing different drugs (three studies), various approaches to sedation (five studies), physical or cognitive therapy or both (one study), noise and light reduction in the ICU (two studies), and preventive nursing care (one study).\ Key results\ There may be little or no difference between haloperidol and placebo for preventing ICU delirium, but further studies are needed to increase confidence in the findings. More studies of physical and cognitive therapy are needed as there is insufficient evidence to determine whether these non‐pharmacological approaches can prevent delirium in the ICU. Additional research is required to explore the benefits and harms of other approaches to prevent delirium such as sedation and changes in the ICU environment, and nursing care tailored to prevent delirium.\ Quality of the evidence\ The quality of the evidence was moderate to very low. The five studies in ‘Studies awaiting classification’ and 15 ongoing studies may alter the conclusions of the review once they are completed and assessed.](https://app.figure1.com/case-detail/87ae8e1e-deca-44ad-bb67-f2ae3626a724)

Trending now

\ \ A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis.\ He had a history of hypertension, long-term smoking, and a sedentary lifestyle.\ On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.](https://app.figure1.com/case-detail/ae0fe999-6875-4474-94f0-ad823dbb9b3a)

\ \ A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets.\ Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.](https://app.figure1.com/case-detail/c271070f-2bc7-4052-9895-635277e1a7d5)

\ \ A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.](https://app.figure1.com/case-detail/48f41642-b9db-4089-b120-a94ee52328de)

\ \ patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family, are there any features in this ekg that would warrant further work-up or is this just a pediatric ekg?](https://app.figure1.com/case-detail/2af390e1-ace8-40ed-ba1c-98fb2d72f4c5)