**7. Therapy**

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

physiological difference between delirium and states of dementia.

On the contrary, the DOS can be administered without specific training.

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

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

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

versions or to develop new tools [13].

validated in palliative care patients [19].

validated in palliative care [24].

**6. Prevention**

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

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 patho-

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].

The CAM method was also validated in palliative care [18]. It consists of a 9-item

**6**

Treatment of delirium often requires the combination of pharmacological (e.g. *major* tranquilizers) and non-pharmacological (reorientation, communication, and sleep hygiene) interventions tailored to the patient.
