**5. Diagnosis**

According to the recently updated guidelines of the National Institute for Health and Clinical Excellence (NICE), the assessment of delirium should be performed in all hospitalized patients who are at risk of experiencing it, including oncological and terminally ill patients (respectively up to 88% and 50% incidence) [12]. Despite this and other recommendations, the lack of a systematic assessment for delirium is a serious issue.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-V, 2013) [2] defined delirium based on four criteria, namely:


Of note, despite DSM-V is the gold standard for the diagnosis of delirium, it cannot be easily administered by non-psychiatrist personnel including nurses. This is a great limitation as nurses have constant contact with the patient throughout the day, and they could efficiently evaluate modifications in the patient's attention and

awareness over time. Furthermore, diagnostic instruments for delirium are mostly based on the DSM-III or IV. Thus, many efforts are being made to validate updated versions or to develop new tools [13].

In addition to the DSM-V, the International Classification of Diseases (ICD) classification from the World Health Organization (WHO) is conventionally adopted. The 11th Revision (ICD-11) defined delirium as a neurocognitive disorder characterized by '*disturbed attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment) that develops over a short period of time and tends to fluctuate during the course of a day, accompanied by other cognitive impairment such as memory deficit, disorientation, or impairment in language, visuospatial ability, or perception. Disturbance of the sleep-wake cycle (reduced arousal of acute onset or total sleep loss with reversal of the sleep-wake cycle) may also be present. The symptoms are attributable to a disorder or disease not classified under mental and behavioural disorders or to substance intoxication or withdrawal or to a medication'* [14]. Thus, this approach includes more details on non-cognitive features, and it seems to better address the problem of the diagnostic and pathophysiological difference between delirium and states of dementia.

Practically, suspicion of delirium can be induced by changes or fluctuations in usual behaviors. These fluctuations can occur in the day's course, although more severe symptoms usually manifest during the evening and the night. The diagnosis of delirium requires healthcare professionals who are trained and competent in the diagnosis of delirium. It can be made by referring to tools or simple cognitive tests, for example by having the patient recite the days of the week or the months of the year. Among the most commonly used instruments, there are the Confusion Assessment Method (CAM) [15] and the Delirium Observation Screening (DOS) scale [16]. Although the choice of tool to be used depends on the level of training of the staff, commonly used tests may require a short training period. About CAM, the training manual is available at the website of the American Geriatrics Society [17]. On the contrary, the DOS can be administered without specific training.

The CAM method was also validated in palliative care [18]. It consists of a 9-item questionnaire and a diagnostic algorithm encompassing four items/features. In particular, the features "acute onset and fluctuating course" and "inattention" are needed, along with "disorganized thinking" or "altered level of consciousness" [3]. The DOS scale is a 13-item tool. Since each item can be scored 0 or 1, the total score can range from 0 to 13 and a score of ≥3 indicates delirium. Similar to CAM, it was validated in palliative care patients [19].

Among the other tools, there is the 5-item Nursing Delirium Screening Scale (Nu-DESC) [20]. As Bush et al. [21] highlighted, it offers poor sensitivity for detection of the hypoactive form and is not validated in palliative care. Other tools are the NEECHAM Confusion Scale [22], the 13-item Delirium Rating Scale (DRS) [23] and the Memorial Delirium Assessment Scale (MDAS). This latter was also validated in palliative care [24].

### **6. Prevention**

Prevention is based on early recognition of any precipitating causes. Pharmacological interventions, including antipsychotics, are not recommended as prophylactic strategies. For this purpose, the NICE guidelines recommend only non-pharmacological interventions [12]. Avoiding polypharmacy, in particular delirogenic drugs such as benzodiazepines, opioids, and corticosteroids is of paramount importance for delirium prevention. Moreover, in all frail patients, and even more in the presence of risk factors for delirium, multi-component preventive

**7**

*Introductory Chapter: Delirium in Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.98654*

sleep hygiene) interventions tailored to the patient.

Treatment of the underlying cause may include:

• Removal of potential physical issues

• Removal of potential pharmacological agents

impaired individuals) and management [25]

• Correction of potential fluid or electrolyte disturbances

**7. Therapy**

**7.1 Causal therapy**

logical strategies.

**7.2 Symptomatic treatment**

have been released so far.

interventions must be implemented. These approaches are based on temporal–spatial reorientation, mobilization programs, sleep hygiene, maintenance of adequate

Treatment of delirium often requires the combination of pharmacological (e.g. *major* tranquilizers) and non-pharmacological (reorientation, communication, and

Clinical and physical assessment including appropriate laboratory and radiological investigations can help identify the cause of the delirium. Moreover, rapid recognition and treatment of the underlying cause can often avoid resorting to more complex symptomatic pharmacological and non-pharmacological strategies.

• Adequate pain assessment (also looking for non-verbal signs in cognitively

For evaluating the delirogenic potential of drugs, optimizing the medication use, the DEL-FINE score can be used. Drugs (and drug withdrawal) are assigned a score ranging from "three =strong delirogenic potential" to "zero =no delirogenic potential". For instance, a score of three is assigned to amitriptyline, atropine, clomipramine, and the withdrawal of benzodiazepines, ethanol, and opioids [26]. Nevertheless, the causal treatments can often be difficult as, even when the root cause is identified, it cannot be reversible. Therefore, symptomatic treatments are often used. These treatments include pharmacological therapy and non-pharmaco-

Drugs useful for managing delirium may include antipsychotics and in selected

About antipsychotics, it was demonstrated that both conventional (e.g., haloperidol) and atypical antipsychotics including olanzapine, risperidone, quetiapine, aripiprazole are effective in the treatment of delirium. Of note, the efficacy and safety of haloperidol at low doses (up to 10 mg/day) are comparable to those of atypical antipsychotics such as risperidone, olanzapine, and quetiapine [27]. In palliative care, haloperidol is one of the most used drugs. It is commonly

cases benzodiazepines including diazepam, lorazepam, and midazolam. The latter class of drug can be indicated in the case of alcohol withdrawal or epilepsy delirium. Other drugs such as α-2 receptor agonists, psychostimulants, cholinesterase inhibitors, and melatonergic drugs are also used although no recommendations

administrated for the treatment of delirium and for the prevention and/or

hydration, and provision of visual and hearing aids, if used by the patient.

interventions must be implemented. These approaches are based on temporal–spatial reorientation, mobilization programs, sleep hygiene, maintenance of adequate hydration, and provision of visual and hearing aids, if used by the patient.
