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Hui D, Cheng SY, Paiva CE. Pharmacologic Management of End-of-Life Delirium: Translating Evidence into Practice. Cancers (Basel) 2024; 16:2045. [PMID: 38893163 PMCID: PMC11170992 DOI: 10.3390/cancers16112045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/13/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
End-of-life delirium affects a vast majority of patients before death. It is highly distressing and often associated with restlessness or agitation. Unlike delirium in other settings, it is considered irreversible, and non-pharmacologic measures may be less feasible. The objective of this review is to provide an in-depth discussion of the clinical trials on delirium in the palliative care setting, with a particular focus on studies investigating pharmacologic interventions for end-of-life delirium. To date, only six randomized trials have examined pharmacologic options in palliative care populations, and only two have focused on end-of-life delirium. These studies suggest that neuroleptics and benzodiazepines may be beneficial for the control of the terminal restlessness or agitation associated with end-of-life delirium. However, existing studies have significant methodologic limitations. Further studies are needed to confirm these findings and examine novel therapeutic options to manage this distressing syndrome.
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Affiliation(s)
- David Hui
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Centre, Houston, TX 77030, USA
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei 10617, Taiwan;
| | - Carlos Eduardo Paiva
- Department of Clinical Oncology, Barretos Cancer Hospital, Barretos 1331, SP, Brazil;
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Tiefenthaler CM, Hirst JM, Edmonds KP, Atayee RS. Chlorpromazine's Potential Role in Palliating Distressing Symptoms Associated with Hyperactive Delirium in Patients at End of Life. J Palliat Med 2023. [PMID: 36847737 DOI: 10.1089/jpm.2022.0308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Background: The hyperactive subtype of delirium is characterized by agitation, restlessness, delusions, and/or hallucinations, which commonly present near end of life (EoL). Symptom relief often requires the use of medications, such as chlorpromazine (CPZ), to reduce patient distress by inducing proportional sedation. Objective: The purpose of this study was to evaluate CPZ's potential role in managing the distress of hyperactive delirium in patients receiving EoL care. Methods: A retrospective observational study among hospitalized patients with advanced cancer at EoL between January 2020 to December 2021. Results: Sustained improvement in symptoms of delirium was seen in 80% of patients as identified in the palliative psychiatrist's progress notes. Meanwhile, 75% of patient's improvement was reported in nursing-driven Delirium Observation Screening Scale. Conclusion: This study elucidates that at doses of ∼100 mg/day, CPZ is potentially an effective medication for patients with advanced cancer, experiencing hyperactive delirium in their final week of life.
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Affiliation(s)
- Casey M Tiefenthaler
- Department of Pharmacy, University of California Health, La Jolla, California, USA
| | - Jeremy M Hirst
- Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, UC San Diego Section of Palliative Care, La Jolla, California, USA.,Palliative Care Program, University of California San Diego, San Diego, California, USA
| | - Kyle P Edmonds
- Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, UC San Diego Section of Palliative Care, La Jolla, California, USA.,Palliative Care Program, University of California San Diego, San Diego, California, USA.,Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
| | - Rabia S Atayee
- Department of Pharmacy, University of California Health, La Jolla, California, USA.,Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, UC San Diego Section of Palliative Care, La Jolla, California, USA.,Palliative Care Program, University of California San Diego, San Diego, California, USA.,Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
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Kim SY, Simone S, Kishk OA, Graciano AL, Seung H, Edwards S. Chlorpromazine as Treatment for Refractory Agitation Associated with Pediatric Delirium. J Pediatr Pharmacol Ther 2022; 27:725-731. [DOI: 10.5863/1551-6776-27.8.725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 01/05/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE
Delirium and agitation can be devastating and prolong the length of hospitalization. As part of our continuous improvement efforts, we implemented the use of intermittent chlorpromazine therapy to target refractory agitation associated with hyperactive or mixed delirium (RAA-D). The purpose of this study was to evaluate the effectiveness of chlorpromazine on RAA-D and delirium symptoms as well as any adverse effects in critically ill children.
METHODS
Retrospective chart review was conducted for children admitted to the pediatric intensive care unit who were treated with chlorpromazine for RAA-D from March 2017 to January 2019. The primary end point was to determine differences in Cornell Assessment for Pediatric Delirium (CAPD) and State Behavioral Scale (SBS) scores 24 hours before and after chlorpromazine administration. The secondary end points were the 24-hour cumulative dosing of narcotic and sedative agents before and after chlorpromazine administration and adverse events associated with chlorpromazine use.
RESULTS
Twenty-six patients were treated with chlorpromazine for RAA-D; 16 (61.5%) were male with a median age of 14.5 months (IQR, 6–48). The mean CAPD (n = 24) and median SBS (n = 23) scores were significantly lower 24 hours after chlorpromazine use when compared to baseline scores, 12 vs 8.9 (p = 0.0021) and 1 vs −1, (p = 0.0005) respectively. No significant adverse effects were observed.
CONCLUSIONS
Chlorpromazine use in critically ill children with RAA-D was helpful for managing symptoms without adverse events. Further investigation is needed to evaluate the use of chlorpromazine to treat RAA-D to avoid long-term use of an antipsychotic.
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Affiliation(s)
- Shin Young Kim
- Department of Pharmacy (SYK), University of Maryland School of Pharmacy, Baltimore, MD
| | - Shari Simone
- Department of Pediatrics (SS, ALG), University of Maryland School of Medicine, Baltimore, MD
| | - Omayma A. Kishk
- Department of Pharmacy (OAK), University of Maryland Medical Center, Baltimore, MD
| | - Ana Lia Graciano
- Department of Pediatrics (SS, ALG), University of Maryland School of Medicine, Baltimore, MD
| | - Hyunuk Seung
- Department of Pharmacy Practice and Science (HS), University of Maryland School of Pharmacy, Baltimore, MD
| | - Sarah Edwards
- Department of Psychiatry (SE), University of Maryland School of Medicine, Baltimore, MD
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Louro LAV, Possari JF, Lima AFC. Pharmacological and non-pharmacological treatment of delirium in an oncological hospital service: an integrative review. Rev Bras Enferm 2021; 74:e20200200. [PMID: 33787792 DOI: 10.1590/0034-7167-2020-0200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/18/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to analyze the production of scientific articles about the pharmacological and non-pharmacological management of delirium in adult hospitalized cancer patients. METHODS integrative review whose sample was obtained from the databases Scopus, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Web of Science, and from the portals Biblioteca Virtual em Saúde, and PubMed. RESULTS among the ten studies analyzed, 80% described exclusively the pharmacological management, especially with regard to the use of haloperidol; 20% mentioned, superficially, non-pharmacological interventions/actions (educational actions) associated to pharmacological management, and adjusting them could result in the diminution and control of psychomotor agitation, contributing for the safety and comfort of the patient. CONCLUSIONS there are few studies addressing pharmacological and non-pharmacological interventions/actions to manage delirium. As a result, it is essential to develop studies focused on increasing and advancing scientific knowledge with regard to the theme, especially in the national context.
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Affiliation(s)
| | - João Francisco Possari
- Instituto do Câncer do Estado de São Paulo - Octávio Frias de Oliveira. São Paulo, São Paulo, Brazil
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Hui D, De La Rosa A, Wilson A, Nguyen T, Wu J, Delgado-Guay M, Azhar A, Arthur J, Epner D, Haider A, De La Cruz M, Heung Y, Tanco K, Dalal S, Reddy A, Williams J, Amin S, Armstrong TS, Breitbart W, Bruera E. Neuroleptic strategies for terminal agitation in patients with cancer and delirium at an acute palliative care unit: a single-centre, double-blind, parallel-group, randomised trial. Lancet Oncol 2020; 21:989-998. [PMID: 32479786 DOI: 10.1016/s1470-2045(20)30307-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND The role of neuroleptics for terminal agitated delirium is controversial. We assessed the effect of three neuroleptic strategies on refractory agitation in patients with cancer with terminal delirium. METHODS In this single-centre, double-blind, parallel-group, randomised trial, patients with advanced cancer, aged at least 18 years, admitted to the palliative and supportive care unit at the University of Texas MD Anderson Cancer Center (Houston, TX, USA), with refractory agitation, despite low-dose haloperidol, were randomly assigned to receive intravenous haloperidol dose escalation at 2 mg every 4 h, neuroleptic rotation with chlorpromazine at 25 mg every 4 h, or combined haloperidol at 1 mg and chlorpromazine at 12·5 mg every 4 h, until death or discharge. Rescue doses identical to the scheduled doses were administered at inception, and then hourly as needed. Permuted block randomisation (block size six; 1:1:1) was done, stratified by baseline Richmond Agitation Sedation Scale (RASS) scores. Research staff, clinicians, patients, and caregivers were masked to group assignment. The primary outcome was change in RASS score from time 0 to 24 h. Comparisons among group were done by modified intention-to-treat analysis. This completed study is registered with ClinicalTrials.gov, NCT03021486. FINDINGS Between July 5, 2017, and July 1, 2019, 998 patients were screened for eligibility, with 68 being enrolled and randomly assigned to treatment; 45 received the masked study interventions (escalation n=15, rotation n=16, combination n=14). RASS score decreased significantly within 30 min and remained low at 24 h in the escalation group (n=10, mean RASS score change between 0 h and 24 h -3·6 [95% CI -5·0 to -2·2]), rotation group (n=11, -3·3 [-4·4 to -2·2]), and combination group (n=10, -3·0 [-4·6 to -1·4]), with no difference among groups (p=0·71). The most common serious toxicity was hypotension (escalation n=6 [40%], rotation n=5 [31%], combination n=3 [21%]); there were no treatment-related deaths. INTERPRETATION Our data provide preliminary evidence that the three strategies of neuroleptics might reduce agitation in patients with terminal agitation. These findings are in the context of the single-centre design, small sample size, and lack of a placebo-only group. FUNDING National Institute of Nursing Research.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Allison De La Rosa
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Annie Wilson
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thuc Nguyen
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jimin Wu
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marvin Delgado-Guay
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ahsan Azhar
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Arthur
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Daniel Epner
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ali Haider
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maxine De La Cruz
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yvonne Heung
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kimberson Tanco
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shalini Dalal
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Akhila Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Janet Williams
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sapna Amin
- Department of Investigational Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Terri S Armstrong
- Neuro-Oncology Branch, Centre for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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