DeliriumHow Emergency Physicians Can How Emergency Physicians Can Make a Big DifferenceMake a Big Difference

Alan Bates, MD, PhD, FRCPCConsultant PsychiatristSt. Paul’s Hospital and the BC Cancer AgencyClinical Assistant ProfessorDepartment of PsychiatryUniversity of British Columbia

In 1959…In 1959…

Engel and RomanoEngel and Romano ““……while most physicians have a strong bias while most physicians have a strong bias

toward an organic etiology of mental toward an organic etiology of mental disturbances, … they seem to have little disturbances, … they seem to have little interest in … the one mental disorder interest in … the one mental disorder presently known to be based on presently known to be based on derangement of cerebral metabolism.derangement of cerebral metabolism.””

““… … deficiencies in the education of many deficiencies in the education of many physicians ill equip them to recognize any physicians ill equip them to recognize any but the most flagrant examples of deliriumbut the most flagrant examples of delirium……””

In 1959…In 1959…

Engel and Romano continuedEngel and Romano continued ““Only … a management problem on a Only … a management problem on a

medical or surgical service is likely to result medical or surgical service is likely to result in a psychiatric consultation.in a psychiatric consultation.””

““[The psychiatrist] … seeing the patient in [The psychiatrist] … seeing the patient in the home territory of the the home territory of the ““organicorganic”” specialists specialists … is less likely or able to pursue an … is less likely or able to pursue an understanding of the underlying physiologic understanding of the underlying physiologic derangements, which are generally derangements, which are generally conceived to be the proper domain of the conceived to be the proper domain of the internist.internist.””

In 1959…In 1959…

Engel and Romano continuedEngel and Romano continued ““Unhappily, the unfortunate patientUnhappily, the unfortunate patient’’s s

malfunctioning brain rests in limbo, an object malfunctioning brain rests in limbo, an object of attention and interest neither to the of attention and interest neither to the medical man nor to the psychiatrist.medical man nor to the psychiatrist.””

““Not only does the presence of delirium Not only does the presence of delirium often complicate and render more difficult often complicate and render more difficult the treatment of a serious illness, but also it the treatment of a serious illness, but also it carries the serious possibility of permanent carries the serious possibility of permanent irreversible brain damage.irreversible brain damage.””

In 1959…In 1959…

Engel and Romano continuedEngel and Romano continued ““With increasing life expectancy … we are With increasing life expectancy … we are

now beginning to see an increasing now beginning to see an increasing incidence of so-called senile and incidence of so-called senile and arteriosclerotic dementias.arteriosclerotic dementias.””

““The physician who is greatly concerned to The physician who is greatly concerned to protect the functional integrity of the heart, protect the functional integrity of the heart, liver, and kidneys … has not yet learned to liver, and kidneys … has not yet learned to have similar regard for the functional have similar regard for the functional integrity of the brain.integrity of the brain.””

From Cresswell III et al.From Cresswell III et al.

Organic Functional

Age < 12 or > 40 years old 12 – 40 years old

Onset Sudden Gradual

Consciousness Decreased Normal

Hallucinations Visual Auditory

Course Fluctuates Continuous

Orientation Disoriented Scattered thoughts

Vitals Abnormal Normal

Psych Hx No Yes

DSM-5 CriteriaDSM-5 Criteria Disturbance in attention and awarenessDisturbance in attention and awareness Develops over short time, change from Develops over short time, change from

baseline, fluctuates in severity over baseline, fluctuates in severity over course of a daycourse of a day

An additional cognitive disturbance (e.g. An additional cognitive disturbance (e.g. memory, orientation, language, memory, orientation, language, visuospatial, perception)visuospatial, perception)

Not another neurocognitive disorder, not Not another neurocognitive disorder, not comacoma

Direct consequence of another medical Direct consequence of another medical conditioncondition

Meagher et al., 2007Meagher et al., 2007 100 palliative care patients100 palliative care patients Attention – 97% Attention – 97% (e.g. distractibility, digit span)(e.g. distractibility, digit span) Sleep-wake cycle – 97% Sleep-wake cycle – 97% (?cause of fluctuation, (?cause of fluctuation,

early)early) Long-term memory – 89%Long-term memory – 89% Short-term memory – 88%Short-term memory – 88% Orientation – 76% Orientation – 76% (misses ¼)(misses ¼) Visuospatial ability – 87%Visuospatial ability – 87% Motor agitation – 62% Motor agitation – 62% (early)(early) Motor retardation – 62% Motor retardation – 62% (early)(early) Language – 57%Language – 57% Perceptual – 50% Perceptual – 50% (motor agitation = retardation)(motor agitation = retardation)

IncidenceIncidence Hospitalized elderly patients – 25% Hospitalized elderly patients – 25% (van (van

Blanken et al., 2005)Blanken et al., 2005)

ICU – 70% at some point ICU – 70% at some point (McNicoll et al., 2003)(McNicoll et al., 2003)

30% of critically ill children 30% of critically ill children (Smith et al., 2013)(Smith et al., 2013)

Post-operative delirium in patients over Post-operative delirium in patients over 60 after cardiac surgery – 52% 60 after cardiac surgery – 52% (Rudolph et al., (Rudolph et al.,

2009)2009)

Terminal illness – 88% Terminal illness – 88% (Massie etl al., 1983; Lawlor et (Massie etl al., 1983; Lawlor et

al., 2000)al., 2000)

Incidence and detection - ERIncidence and detection - ER Elie et al., 2000Elie et al., 2000

10% of 447 ER patients over 65 delirious10% of 447 ER patients over 65 delirious Detection by ED physicianDetection by ED physician

Sensitivity: 35%, Specificity: 99%Sensitivity: 35%, Specificity: 99%

Han et al., 2014Han et al., 2014 12% of 406 ER patients over 65 delirious12% of 406 ER patients over 65 delirious Detection by ED physician using CAM-ICUDetection by ED physician using CAM-ICU

Sensitivity: 72% (better than RAs)Sensitivity: 72% (better than RAs) Specificity: 99%Specificity: 99%

Han et al., 2014Han et al., 2014 CC of CC of ““altered mental statusaltered mental status””: 38% sensitivity, : 38% sensitivity,

99% specificity (when not coma, non-verbal etc.)99% specificity (when not coma, non-verbal etc.)

Impact Impact (reviewed by Maldonado et al., 2009)(reviewed by Maldonado et al., 2009)

Clear immediate increase in suffering of Clear immediate increase in suffering of patient and familypatient and family

Increased morbidity and mortalityIncreased morbidity and mortality Prolonged hospital staysProlonged hospital stays Increased cost of careIncreased cost of care Increased hospital-acquired complicationsIncreased hospital-acquired complications Poor functional and cognitive recoveryPoor functional and cognitive recovery Decreased quality of lifeDecreased quality of life Increased placement in intermediate- and Increased placement in intermediate- and

long-term care facilitieslong-term care facilities

Impact – ER specificImpact – ER specific Han et al., 2010 / 2011Han et al., 2010 / 2011

628 ER patients over age 65628 ER patients over age 65 17% delirious17% delirious 6-month mortality:6-month mortality:

37% in delirious group37% in delirious group 14% in non-delirious group14% in non-delirious group

Median length of stay:Median length of stay: 2 days for delirious2 days for delirious 1 day for non-delirious1 day for non-delirious

DistressDistress Rate of diagnosable PTSD was 9.2% at 3 Rate of diagnosable PTSD was 9.2% at 3

months post-ICU in 238 post-ventilated months post-ICU in 238 post-ventilated patients with a strong association patients with a strong association between PTSD and recall of delusional between PTSD and recall of delusional memories memories (Jones et al., 2007)(Jones et al., 2007)

Delirium is even more distressing for Delirium is even more distressing for spouses than for patients spouses than for patients (Breitbart et al., 2002)(Breitbart et al., 2002)

Milbrandt et al., 2004Milbrandt et al., 2004 224 consecutive mechanically ventilated 224 consecutive mechanically ventilated

ICU patients (after excluding 51 with ICU patients (after excluding 51 with coma leading to death)coma leading to death)

82% developed delirium, mean duration 82% developed delirium, mean duration 2 days2 days

Barrough, 1601Barrough, 1601

““It commeth to passe also that the It commeth to passe also that the soporiferous diseases being ended, there soporiferous diseases being ended, there ensueth forgetfulnesse: which when it ensueth forgetfulnesse: which when it chanceth then a cold distempure is the chanceth then a cold distempure is the cause that the memorie is perished or cause that the memorie is perished or grievously hurt.grievously hurt.””

Maclullich et al., 2009Maclullich et al., 2009 Reviewed 9 recent studies with total of 2025 Reviewed 9 recent studies with total of 2025

patientspatients 8/9 studies found a significant association 8/9 studies found a significant association

between delirium and cognitive impairmentbetween delirium and cognitive impairment What is the relationship?What is the relationship?

CNS insult causes both in parrallel?CNS insult causes both in parrallel? Premorbid dementing process unmasked in form of Premorbid dementing process unmasked in form of

delirium by stress/insult?delirium by stress/insult? Delirium causes things like dehydration, poor Delirium causes things like dehydration, poor

nutrition, suboptimal care etc. and this leads to long-nutrition, suboptimal care etc. and this leads to long-term cognitive impairment?term cognitive impairment?

Delirium is a neurotoxic state?Delirium is a neurotoxic state? Delirium management is neurotoxic?Delirium management is neurotoxic?

Witlox et al., 2010Witlox et al., 2010 Meta-analysis of elderly patients with deliriumMeta-analysis of elderly patients with delirium Delirium associated with increased risk of death Delirium associated with increased risk of death

(38% vs. 28% in controls at average follow-up of (38% vs. 28% in controls at average follow-up of 23 months)23 months)

Delirium associated with increased risk of Delirium associated with increased risk of institutionalization (33% vs. 11% in controls at institutionalization (33% vs. 11% in controls at average follow-up of 15 months)average follow-up of 15 months)

Delirium associated with increased risk of Delirium associated with increased risk of dementia (63% vs. 8% in controls at average dementia (63% vs. 8% in controls at average follow-up of 4 years)follow-up of 4 years)

Above results are independent of age, sex, Above results are independent of age, sex, comorbid illness, illness severity, and baseline comorbid illness, illness severity, and baseline dementiadementia

Risk factorsRisk factors IInfection nfection

WWithdrawalithdrawal AAcute metaboliccute metabolic TTraumarauma CCNS (structural)NS (structural) HHypoxiaypoxia

DDeficiency of vitaminseficiency of vitamins EEndocrinendocrine AAcute vascularcute vascular TToxins/Medications (Lexicomp is your friend)oxins/Medications (Lexicomp is your friend) HHeavy metalseavy metals

Deleriogenic MedicationsDeleriogenic Medications AnticholinergicAnticholinergic

e.g. diphenhydramine, hydroxyzine, atropine, amitriptyline, e.g. diphenhydramine, hydroxyzine, atropine, amitriptyline, imipramine, paroxetine, doxepin, furosemide, prochlorperazineimipramine, paroxetine, doxepin, furosemide, prochlorperazine

BenzodiazepinesBenzodiazepines BarbituratesBarbiturates OpiatesOpiates

Especially meperidineEspecially meperidine ? Morphine > Hydromorphone > Oxycodone (rotation can help)? Morphine > Hydromorphone > Oxycodone (rotation can help)

Incontinence medsIncontinence meds e.g. oxybutynine.g. oxybutynin

Cardiac medsCardiac meds e.g. digitalis, quinidine, procainamide, lidocaine, beta-blockerse.g. digitalis, quinidine, procainamide, lidocaine, beta-blockers

GI medsGI meds HH22-blockers (e.g. cimetidine, ranitidine), PPIs, metoclopramide-blockers (e.g. cimetidine, ranitidine), PPIs, metoclopramide

Many others: e.g. phenytoin, steroidsMany others: e.g. phenytoin, steroids

Cardiac Surgery Risk Cardiac Surgery Risk FactorsFactors

Giltay et al. (2006): 8139 consecutive Giltay et al. (2006): 8139 consecutive patients undergoing CABG and/or valve patients undergoing CABG and/or valve procedureprocedure

Post-op psychotic symptoms associated Post-op psychotic symptoms associated with age, renal failure, dyspnea, heart with age, renal failure, dyspnea, heart failure, and LVH pre-operatively and failure, and LVH pre-operatively and hypothermia, hypoxemia, low hematocrit, hypothermia, hypoxemia, low hematocrit, renal failure, high sodium, infection, and renal failure, high sodium, infection, and stroke perioperativelystroke perioperatively

Sockalingam et al. 2005Sockalingam et al. 2005

van der Mast et al., 1996van der Mast et al., 1996

““Of all the reported differences in the Of all the reported differences in the studies, only year of publication is studies, only year of publication is significantly related to the incidence of significantly related to the incidence of delirium after cardiac surgery, the later delirium after cardiac surgery, the later publications showing a tendency towards publications showing a tendency towards a lower incidence.a lower incidence.””

““… … a cautious conclusion may be drawn a cautious conclusion may be drawn that no strong risk factor has been that no strong risk factor has been identified…identified…””

Pathophysiology: Pathophysiology: NeurotransmittersNeurotransmitters (Reviewed by Trzepacz, (Reviewed by Trzepacz,

1994)1994)

Acetylcholine Acetylcholine Anticholinergic drugs induce deliriumAnticholinergic drugs induce delirium Correlation between poor cognitive function Correlation between poor cognitive function

and serum anticholinergic leveland serum anticholinergic level Serum anticholinergic levels decrease as Serum anticholinergic levels decrease as

delirium resolvesdelirium resolves Reversal of anticholinergic delirium with Reversal of anticholinergic delirium with

physostigminephysostigmine

DopamineDopamine Effective treatment with dopamine receptor Effective treatment with dopamine receptor

blockers like loxapine or haloperidolblockers like loxapine or haloperidol

NorepinephrineNorepinephrine GlutamateGlutamate SerotoninSerotonin GABAGABA HistamineHistamine

Pathophysiology: Pathophysiology: NeurotransmittersNeurotransmitters (Reviewed by Trzepacz, (Reviewed by Trzepacz,

1994)1994)

Pathophysiology Pathophysiology (Maldonado, 2008)(Maldonado, 2008)

PathophysiologyPathophysiology

Wrist Wrist actigraphyactigraphy

Osse et al. (2009): Osse et al. (2009): motor activity at the motor activity at the wrist over five 24hr wrist over five 24hr cycles after elective cycles after elective cardiac surgerycardiac surgery

Jacobson et al., 2008Jacobson et al., 2008 Elderly delirious postoperative patients:Elderly delirious postoperative patients:

Fewer nighttime minutes restingFewer nighttime minutes resting Fewer minutes resting over 24hrsFewer minutes resting over 24hrs Greater mean activity at nightGreater mean activity at night Smaller change in activity from day to nightSmaller change in activity from day to night

Delirium may be simultaneous Delirium may be simultaneous wakefulness and sleepwakefulness and sleep REM intrusion into wakefulness might cause REM intrusion into wakefulness might cause

visual hallucinationsvisual hallucinations

Slatore et al., 2012Slatore et al., 2012 Assessed sleep quality and screened for Assessed sleep quality and screened for

delirium in veterans referred to hospice delirium in veterans referred to hospice (55% had cancer) using the Pittsburgh (55% had cancer) using the Pittsburgh Sleep Quality Index (PSQI) and the Sleep Quality Index (PSQI) and the Confusion Assessment Method (CAM)Confusion Assessment Method (CAM)

Sleep quality was significantly worse in Sleep quality was significantly worse in 33 participants who became delirious 33 participants who became delirious than in 42 who did notthan in 42 who did not

Hazard ratio for developing delirium of Hazard ratio for developing delirium of 2.37 for every point of worse sleep on the 2.37 for every point of worse sleep on the PSQI (where 1 = very good; 4 = very PSQI (where 1 = very good; 4 = very bad)bad)

Glymphatic Glymphatic systemsystem Xie et al. (2013) Xie et al. (2013)

demonstrated that demonstrated that sleep is associated with sleep is associated with a 60% increase in the a 60% increase in the interstitial space interstitial space causing striking causing striking increase in exchange increase in exchange between CSF and between CSF and interstitial fluidinterstitial fluid

Increased rate of Increased rate of ββ––amyloid clearanceamyloid clearance

Definitive treatment:Definitive treatment: Find the underlying cause or causes and Find the underlying cause or causes and

treat it/themtreat it/them

Non-pharmacological Non-pharmacological interventions interventions (Inouye et al., (Inouye et al., 1999)1999) In a study of 852 elderly patients admitted to In a study of 852 elderly patients admitted to

a general medical service, Inouye et al. a general medical service, Inouye et al. reduced the incidence of delirium from 15% reduced the incidence of delirium from 15% to 9% with a number of non-pharmacological to 9% with a number of non-pharmacological interventions including promotion of sleep interventions including promotion of sleep with sleep inducing stimuli (e.g. relaxation with sleep inducing stimuli (e.g. relaxation tapes, warm milk) and a sleep promoting tapes, warm milk) and a sleep promoting environment (e.g. through noise reduction)environment (e.g. through noise reduction)

Patel et al., 2014Patel et al., 2014 Screened for ICU delirium before (n=167) Screened for ICU delirium before (n=167)

and after (n=171) implementing and after (n=171) implementing measures to promote sleepmeasures to promote sleep Noise and light reduction at night, minimize Noise and light reduction at night, minimize

care that interrupts sleep at night, reduce care that interrupts sleep at night, reduce daytime sedation when possible, address daytime sedation when possible, address pain early, early mobilizationpain early, early mobilization

Found reduced incidence (14% vs. 33%) Found reduced incidence (14% vs. 33%) and duration (1.2 vs. 3.4 days) of deliriumand duration (1.2 vs. 3.4 days) of delirium

Maldonado et al., 2009Maldonado et al., 2009 90 patients who underwent valve 90 patients who underwent valve

procedures randomly assigned to post-op procedures randomly assigned to post-op sedation with dexmedetomidine, sedation with dexmedetomidine, propofol, or midazolampropofol, or midazolam

(From Aantaa & Jalonen, 2006)

Maldonado et al., 2009Maldonado et al., 2009 Incidence of delirium was 50% for both Incidence of delirium was 50% for both

propofol and midazolam groups and only propofol and midazolam groups and only 3% for dexmedetomidine group3% for dexmedetomidine group

Possible benefits of dexmedetomidine: Possible benefits of dexmedetomidine: not GABAergic, not anticholinergic, not GABAergic, not anticholinergic, sedating, promotes physiologic sleep sedating, promotes physiologic sleep pattern without significant respiratory pattern without significant respiratory depression, lowers opioid requirementsdepression, lowers opioid requirements

MelatoninMelatonin Al-Aama et al. (2011) demonstrated Al-Aama et al. (2011) demonstrated

decreased incidence of delirium in older decreased incidence of delirium in older adult patients on a general medicine unit adult patients on a general medicine unit who received 0.5mg of melatonin nightlywho received 0.5mg of melatonin nightly

Evidence that melatonin could actually aid in Evidence that melatonin could actually aid in treating ongoing delirium is mostly limited to treating ongoing delirium is mostly limited to case studies (e.g. Hanania and Kitain, 2002)case studies (e.g. Hanania and Kitain, 2002)

Other findings suggest melatonin isn’t helpful Other findings suggest melatonin isn’t helpful (e.g. Ibrahim et al., 2006)(e.g. Ibrahim et al., 2006)

HaloperidolHaloperidol Standard treatment in most placesStandard treatment in most places Relatively little anticholinergic effectRelatively little anticholinergic effect Little effect on orthostatic hypotensionLittle effect on orthostatic hypotension Less sedation good for hypoactive deliriumLess sedation good for hypoactive delirium Risk of QT prolongationRisk of QT prolongation Relatively high risk of extrapyramidal effectsRelatively high risk of extrapyramidal effects

No difference between IV and PONo difference between IV and PO Menza et al. (1987) and Maldonado (2000) both seriously Menza et al. (1987) and Maldonado (2000) both seriously

flawedflawed Are reports of EPS with IV (Blitzstein & Brandt, 1997)Are reports of EPS with IV (Blitzstein & Brandt, 1997)

Small doses (e.g. 0.5mg IV BID or 1mg IV QHS)Small doses (e.g. 0.5mg IV BID or 1mg IV QHS)

ChlorpromazineChlorpromazine The double-blind randomized trial by Breitbart The double-blind randomized trial by Breitbart

et al. (1996) is frequently cited as evidence et al. (1996) is frequently cited as evidence haloperidol should be chosen over other haloperidol should be chosen over other antipsychoticsantipsychotics

However, the findings showed the superiority of However, the findings showed the superiority of both haloperidol and chlorpromazine (a both haloperidol and chlorpromazine (a sedating low-potency antipsychotic) over sedating low-potency antipsychotic) over lorazepam while showing equal effectiveness lorazepam while showing equal effectiveness between the two antipsychoticsbetween the two antipsychotics

Sedating antipsychotic with IV optionSedating antipsychotic with IV option An example of dosing: chlorpromazine 25mg IV An example of dosing: chlorpromazine 25mg IV

Q6H standing (give over 30min; hold for SBP < Q6H standing (give over 30min; hold for SBP < 90; hold for sedation)90; hold for sedation)

MethotrimeprazineMethotrimeprazine Also sedating and can be given SC or IVAlso sedating and can be given SC or IV Significant analgesic effectSignificant analgesic effect Need to be cautious of hypotensionNeed to be cautious of hypotension e.g. 5 - 10mg Q1H PRN for agitatione.g. 5 - 10mg Q1H PRN for agitation Can go as high as 50mg Q4H Can go as high as 50mg Q4H

QuetiapineQuetiapine When we use low dose quetiapine at night, iWhen we use low dose quetiapine at night, i

tt’’s primarily acting as an antihistamines primarily acting as an antihistamine Maneenton et al. (2013) found no difference Maneenton et al. (2013) found no difference

between 25-100mg/day of quetiapine HS between 25-100mg/day of quetiapine HS and 0.5-2mg/day of haloperidol HS in a and 0.5-2mg/day of haloperidol HS in a double-blind, randomized trial of delirious double-blind, randomized trial of delirious patients eliciting CL consultpatients eliciting CL consult

e.g. quetiapine 25mg PO QHSe.g. quetiapine 25mg PO QHS e.g. quetiapine 50mg PO QHSe.g. quetiapine 50mg PO QHS

Caution re orthostatic hypotensionCaution re orthostatic hypotension

OlanzapineOlanzapine A number of studies also support use of A number of studies also support use of

olanzapine (e.g. Breitbart et al., 2002; olanzapine (e.g. Breitbart et al., 2002; Skrobik et al., 2004; Grover et al., 2011)Skrobik et al., 2004; Grover et al., 2011)

e.g. Olanzapine oral dissolving 2.5mg QHSe.g. Olanzapine oral dissolving 2.5mg QHS e.g. Olanzapine oral dissolving 5mg QHSe.g. Olanzapine oral dissolving 5mg QHS

Promotes appetitePromotes appetite Reduces nauseaReduces nausea Promotes sleepPromotes sleep

Pro-cholinergic at lower doses, but becomes Pro-cholinergic at lower doses, but becomes anticholinergic at larger dosesanticholinergic at larger doses

In 31 patients over 55 with post-operative In 31 patients over 55 with post-operative delirium referred to the CL service, loxapine delirium referred to the CL service, loxapine was associated with a mean decrease of was associated with a mean decrease of 8.48 on the DRS-98-R over the first 2 days 8.48 on the DRS-98-R over the first 2 days of treatmentof treatment

Only 3 participants had a worsening of Only 3 participants had a worsening of delirium, and each of those 3 showed delirium, and each of those 3 showed improvement from day 2 to day 4improvement from day 2 to day 4

Mean number of days to resolution of Mean number of days to resolution of delirum (DRS < 10) was 3.2delirum (DRS < 10) was 3.2

There was not a significant increase in QTcThere was not a significant increase in QTc

Loxapine Loxapine (Bates et al., submitted)(Bates et al., submitted)

Loxapine Loxapine (Bates et al., submitted)(Bates et al., submitted)

Terminal IllnessTerminal Illness Delirium interferes with identification of Delirium interferes with identification of

sources of distress like painsources of distress like pain How much should one investigate?How much should one investigate?

Definitive etiology discovered in less than 50%, Definitive etiology discovered in less than 50%, and often irreversible when found and often irreversible when found (Bruera et al. 1992)(Bruera et al. 1992)

However, Tuma and DeAngelis (1992) report However, Tuma and DeAngelis (1992) report 68% can be improved even when 30-day 68% can be improved even when 30-day mortality is 31%mortality is 31%

Lawlor et al. (2000):Lawlor et al. (2000): 49% reversibility in advanced cancer patients 49% reversibility in advanced cancer patients

admitted to palliative careadmitted to palliative care Reversibility associated with opioids, other meds, and Reversibility associated with opioids, other meds, and

dehydration being primary causesdehydration being primary causes

Terminal IllnessTerminal Illness Some view delirium as natural part of dying Some view delirium as natural part of dying

processprocess Some worry that antipsychotic will make Some worry that antipsychotic will make

patient more deliriouspatient more delirious Evidence is that antipsychotic generally safe Evidence is that antipsychotic generally safe

and effective at reducing distressand effective at reducing distress ““Unfortunately, the hallucinations in delirium are Unfortunately, the hallucinations in delirium are

rarely sugarplum fairies.rarely sugarplum fairies.””