Approach to pharmacological management of delirium in palliative care

Note: The role of drugs in the management of delirium in palliative care is controversial.

The role of drugs in the management of delirium in palliative care is controversial. Although antipsychotics are commonly used to manage delirium, high-quality evidence demonstrating effectiveness is unavailable. Systematic reviews of low-quality data suggest that antipsychotics do not reduce mortality, length of hospital stay, or delirium severity or duration, and do not improve cognitive function. Additionally, antipsychotics have significant adverse effects, including aggravation of delirium.

Nevertheless, clinical experience indicates that it may be reasonable to use an antipsychotic (combined with other management strategies) if all of the following apply:

causes(s) of delirium have been promptly addressed (if possible)
nonpharmacological management has been unsuccessful
the patient is significantly distressed, or their behaviour presents risks to their own safety and the safety of others.

Benzodiazepines can exacerbate delirium. Avoid using benzodiazepines for delirium, except if delirium is refractory, associated with seizures, occurs in the last days of life, or is related to alcohol or benzodiazepine withdrawal.

Use of more than one drug is rarely necessary; avoid the use of multiple sedating drugs. Rapidly changing to another drug can lead to cumulative drug interactions.

Severe hyperactive delirium may be an emergency. For advice on managing a patient whose behaviour presents as an immediate safety concern to themselves or others, and requires immediate sedation, see Acute agitation in palliative care.

For management of agitation and restlessness in the last days of life, see Agitation and restlessness in the last days of life.