Care of Patients with Delirium at the End of Life
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One in four Americans dies in a nursing home1; 30% of all nursing home residents die within 1 year of admission.2 In the last 30 years, hospice and palliative care practitioners have advanced a model of comprehensive, interdisciplinary care that promotes comfort, symptom management, emotional and spiritual support, and advance care planning for patients.3 Long-term care facilities increasingly apply palliative care principles, and as they become more sophisticated at recognizing patients with shortened life expectancy, refer them for concurrent hospice enrollment.
Screening, assessment, and treatment of mental disorders are central to good terminal care in nursing home residents because psychological distress is the source of substantial suffering at the end of life. When faced with the knowledge of foreshortened life, most patients experience anxiety, fear, sadness, or anger. These symptoms meet criteria for a mental disorder at the point they become pervasive or impair an individual’s ability to function or make decisions.4,5 The most common mental disorders in terminal care are delirium, depression, and anxiety. Among nursing home residents, these disorders often develop in those who already have dementia. Delirium is arguably the most important mental disorder at the end of life because of its high prevalence and deleterious impact on quality of life, behavior, and communication. Delirium undermines several important goals of care at the end of life, including comfort and meaningful interaction with family.6
There are very few studies of delirium in residents receiving palliative care in nursing homes. Most studies of delirium in persons at the end of life recruit from inpatient palliative care settings, where the most common terminal diagnosis is cancer. While it seems reasonable to extrapolate to some degree from patients dying of cancer in palliative care units to patients dying in nursing facilities, differences must be acknowledged. Cancer is the second most common cause of death in nursing home residents, but only 17% of all cancer deaths occur in nursing facilities.7 Cancer patients’ lengths of stay in nursing homes are likely brief, therefore they rarely make up a large proportion of the facilities’ population. For example, in a randomized controlled trial to increase hospice enrollment in the nursing home, 62% of study participants were diagnosed with dementia, 39% had cardiopulmonary disease, and only 4% had cancer.1 Delirium in the nursing home often occurs in the context of dementia, a diagnosis that is underrepresented in inpatient palliative care and hospice patients. Because of the paucity of studies of delirium in patients dying in long-term care, I will draw on studies of delirium in other ill populations including patients in medical and surgical inpatient settings, intensive care units, and inpatient palliative care settings, acknowledging the limitations in generalizing to the nursing home setting.
CLINICAL FEATURES OF DELIRIUM
Delirium is a mental disorder that comes on over hours to weeks, and results most often from medications or physical illnesses, usually outside of the brain. Symptoms of delirium include confusion, inattention, diminished awareness, impaired memory, perceptual disturbances, and sleep disruption.8 Delirium is the most common mental disorder among dying patients, occurring in up to 90% of cancer patients in the final weeks of life.9 The prevalence of delirium in the final weeks of life in nursing home residents is unknown and complicated by the high prevalence of dementia. Among dying patients, delirium progresses to coma preceding death.10
Delirium has been subtyped based on whether the patient is restless (agitated or hypermotoric delirium) versus lethargic (hypomotoric or quiet delirium). Within hospice and terminal care, the major concern has been with agitated delirium, which is referred to as terminal restless or terminal agitation.
References
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The staff of the Annals of Long-Term Care is saddened by the recent death of Dr. Andrew Weinberg. We sincerely appreciate his many years of service on the Editorial Board of the Journal. The notice below appeared in The State newspaper (Columbia, SC):
Funeral Services for Dr. Andrew D. Weinberg, 52, of Elgin were held on Thursday, February 8, 2007 on Long Island, NY. On-line condolences may be sent to www.mem.com. Dr. Weinberg passed away at his residence surrounded by his loving family on Tuesday, February 6, 2007 after a long illness. He was the son of Edward Weinberg and Renee E. Schell. Dr. Weinberg worked as the chief of Geriatrics and Extended Care at the Dorn VA Medical Center in Columbia, SC. He also served proudly as a flight surgeon in the United States Navy and was mobilized for both Iraqi Wars. Surviving are his loving and devoted wife, Alicia D. Weinberg; children, James D., Jenna D., Bethany S.L., and Jocelyn J. Weinberg; his parents; a sister, Jill J. Weinberg; and a host of other loving family and friends who will all miss him dearly.
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