Risk Factors and Antipsychotic Usage Patterns Associated With Terminal Delirium in a Veteran Long-Term Care Hospice Population
Background: The development of delirium is very common i n terminally ill patients. However, risk factors for terminal delirium in the veteran population are poorly identified. The purpose of this study was to (1) Identify risk factors for terminal delirium in a US Department of Veterans Affairs inpatient hospice population; (2) Assess usage patterns of antipsychotics for treatment of terminal delirium; and (3) Describe nursing assessment, nonpharmacologic interventions, and documentation of terminal delirium.
Methods: This was a retrospective case-control study of veterans who expired while admitted into hospice care at a long-term care hospice unit during the period of October 1, 2013 to September 30, 2015. Veterans’ medical records were reviewed for the 2 weeks prior to the recorded death.
Results: Of 307 veterans admitted for hospice care, 67.4% required antipsychotics in the last 2 weeks of life for the treatment of terminal delirium. The average number of antipsychotic doses given was 14.9 doses per patient. The risk factors that were identified included the use of steroids, opioids, or anticholinergics; Vietnam-era veterans with liver disease; veterans with cancer and a comorbid mental health disorder; and veterans with a history of drug and/or alcohol abuse.
Conclusions: More than half of veterans admitted for hospice care experienced terminal delirium requiring treatment with antipsychotics. The identification of veterans most likely to develop terminal delirium will allow for early nonpharmacologic interventions and potentially decrease the need for treatment with antipsychotic medications.
Limitations
Limitations to the current study include hyperactive delirium that was misinterpreted and treated as pain; the probable underreporting of hypoactive delirium and associated symptoms; the use of antipsychotics as a surrogate marker for the development of terminal delirium; and lack of nursing documentation of assessment and interventions of terminal delirium. In addition, the total milligrams of antipsychotics administered per patient were not collected. Finally, there was the potential that other risk factors were not identified due to low numbers of veterans with certain diagnoses (eg, dementia).
Conclusions
Based on the findings in this study, several steps have been implemented to enhance the care of veterans under hospice care in this CLC: (1) Nurses providing direct patient care have been educated on the assessment by use of the mRASS and treatment of terminal delirium;22 (2) A hospice delirium note template has been created that details symptoms of terminal delirium, nonpharmacologic interventions, the use of antipsychotic medications if indicated, and the outcome of interventions; (3) Providers (eg, physician, advanced practice nurses) review each veteran’s medical history for the risk factors noted above; (4) Any risk factor(s) identified by this study will lead to a nursing order for delirium precautions, which requires completion of the delirium note template by nurses each shift.
The goal for this enhanced process is to identify veterans at risk for terminal delirium, observe changes that may indicate the onset of delirium, and intervene promptly to decrease symptom burden and improve quality of life and safety. Potentially, there will be less requirement for the use of antipsychotic medications to control the more severe symptoms of terminal delirium. A future study will evaluate the outcome of this enhanced process for the assessment and treatment of terminal delirium in this veteran population.
Acknowledgment
We thank Martin J. Gorbien, MD, associate chief of staff of Geriatrics and Extended Care, for his continued support throughout this project.
