While reactions to stressors faced in humanitarian crises take many forms, often they present with acute confusion and agitation. Those individuals with life-threatening or palliative illnesses, whether pre-existing or as a result of the crisis, are especially vulnerable. This chapter reviews the assessment of these patients, first to identify and treat those with delirium, in the attempt to reverse it and optimally manage associated symptoms. Second, the management of acute anxiety and agitation of a primarily psychological origin is addressed (see also Chapter 16).
Delirium is an acute confusional state precipitated by a medical illness or injury that is its primary underlying cause. It is very common in patients with life-limiting illnesses.1 It is often very distressing for patients and caregivers because it interferes with the ability the ability to meaningfully interact, assess, and treat patients in every aspect of their care. Prevention and early identification through addressing potentially reversible causes, careful prescribing and de-prescribing of medications, and behavioral interventions are vital to maximizing potential resolution (see Table 7.1). Delirium is more likely to be reversible earlier in illness/injury trajectory, and much less near end of life, requiring discretion in utilization of appropriate and available investigations or treatments. It is also important to engage patients and families, as their interpretations of causes and appropriate treatments from a spiritual and/or cultural perspective may differ significantly from the biomedical perspective.
Table 7.1. PCHC Delirium Algorithm
Step 1: Diagnose delirium on the basis of clinical symptoms (acute onset and fluctuating course, inattention, disorganized thinking, altered level of consciousness).
Step 2: Identify and treat potential causes (medications, infections, shock, trauma, intoxication or withdrawal, electrolyte abnormalities, neurological, elimination).
Step 3: Implement behavioral/nonpharmacological interventions.
Step 4: Use neuroleptic agents only if safety concerns are not addressed by other measures.
Step 5: Consider use of benzodiazepines only if safety concerns persist despite previous measures (exception: alcohol withdrawal).
IM, intramuscular; IV, intravenous; PO, oral; PR, rectal; PRN, as needed; SC, subcutaneous; SL, sublingual.
Distinguishing delirium from other causes of confusion is sometimes challenging, but a critical first step to appropriate management. The Confusion Assessment Method2,3 is a practical tool using four cardinal features to help identify and distinguish delirium from other causes:
A. Acute onset and fluctuating course
• Change from patient’s baseline developing over hours to days
• Symptoms and severity vary over the course of the day
• Difficulty maintaining focus or concentration in conversation or activities
C. Disorganized thinking
• Inappropriate, confusing, illogical, or tangential responses
D. Altered level of consciousness
• Can be hyper-alert and vigilant, or drowsy and lethargic
The presence of both A and B along with C and/or D strongly supports the diagnosis.
• Perceptual disturbances such as hallucinations and delusions
• Disturbance in sleep/wake cycle
• Disorientation to person, place, or time
• Memory impairment especially for recent events
• Psychomotor agitation or retardation
The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5)4 emphasizes that there should be evidence that the cognitive changes have been precipitated by a medical condition, rather than a primary cognitive/psychiatric condition (e.g., dementia, depression, schizophrenia). However, delirium can present as an acute worsening of baseline symptoms in patients with these conditions, making diagnosis more challenging.
Another clinically relevant diagnostic distinction is that delirium has three subtypes5 that alter its presentation significantly. The hyperactive type is much more likely to come to attention because of accompanying agitation, but the hypoactive type is perhaps more common and easily missed because patients are more quietly confused. The mixed type recognizes that both can coexist in the same patient due to the fluctuating course of the illness, sometimes causing diagnostic difficulty.
Delirium management requires a multifaceted approach in what is often a very stressful situation for patients, families, and care providers. It is necessary to simultaneously identify and treat underlying causes, while managing associated distressing symptoms, and supporting the patient and family.6 Enlisting family/caregivers to the extent possible in care is essential at every step, especially in humanitarian crisis settings where these patients needs are high and resources are limited.
Identify and Treat Underlying Causes
This requires adaptation to the available resources for investigations and treatment of potential causes, particularly given the constrained realities often present humanitarian crises. It also requires judgment based on the likelihood of reversibility, recalling that patients nearer to end of life are less likely to have a reversible cause identified. In circumstances where the cause is identified and irreversible, or it is not possible to identify or treat the cause(s), a focus on comfort measures should take precedence.
In most cases there are multiple causes contributing to the delirium many of which overlap and intersect.7 In humanitarian crises, some of the key causes to assess for in history and examination, relevant potential investigations, and basic management are outlined below. Access to these investigations and treatments may vary widely in humanitarian settings.
Precipitating medications include the following:
• Anticholinergics—antispasmodics, antihistamines, antinauseants, neuroleptics/antipsychotics
• Sedatives—benzodiazepines, other sleep aids
• Other—steroids, antimalarials, traditional medicines
Discontinue or taper any medications that are not needed using the lowest doses possible.
• Malaria, encephalitis, meningitis, pneumonia, wound infection, sepsis, cholera, typhoid fever, syphilis
• Laboratory tests and cultures
• Antimicrobials and other measures to treat infection
• Laboratory tests and assess for underlying cause
• Intravenous fluids and/or oral rehydration, blood transfusion
• Laboratory tests and diagnostic imaging
• Stabilization of injuries and surgery
• Alcohol, opiates, etc.
• Laboratory tests
• Supportive measures (e.g., thiamine), reversal (e.g., naloxone)
• Hypercalcemia, hyponatremia, hypoglycemia
• Laboratory tests
• Correction intravenously/orally, dialysis
• Trauma, cerebrovascular, brain metastases
• Diagnostic Imaging
• Anti-inflammatories, anticoagulants, surgery
Behavioral (Nonpharmacological) Interventions
Behavioral interventions are often readily available in humanitarian settings, and can be undertaken by family and other nonclinical providers. However, some reassurance and guidance may be needed to enlist effective participation. Explaining the possible causes and management plan identified by healthcare providers, listening to family or other caregivers thoughts about behaviors of concern and other contributing factors, and giving specific instructions for support are essential to caring for a delirious patient.
The normal day/night cycle is often compromised or reversed in delirium. Strategies to maintain it help minimize symptom burden. Encouraging mental stimulation during the day by access to light, conversations and reminiscing, games, physical engagement, and avoiding naps are helpful. Specifically whenever possible being out of bed and in a chair, and out of a room or shelter are key. Maintaining mealtimes and supporting hydration and nutrition through feeding assistance help with reorientation and treat potential contributing factors. Nighttime is equally important, especially supporting restful sleep as much as possible. This includes a darkened room, minimizing environmental noise (including eye shades and ear plugs if available), and avoiding waking for care unless absolutely needed.
Other important practical measures include using sensory aids when available (e.g., glasses, hearing aids, dentures) to enhance communication and orientation. Even small familiar items from home can provide reassurance, recognizing these are often unavailable in humanitarian emergencies. Avoid if all possible tethering medical devices such as intravenous lines that can compromise safety and increase agitation.
Taken together behavioral interventions are effective8 and should be the mainstay of supportive management of delirium in palliative patients.
Physical Restraints and Pharmacological Management
Physical restraints should only be considered in cases where physical safety is at risk, and other measures have failed. If needed they should be minimized and reassessed regularly as they can prolong the delirium.
Though widely used, current evidence does not support the routine use of neuroleptic/antipsychotic medications for prevention or treatment of delirium.9 Evidence particularly in palliative populations is limited, and largely based on consensus expert opinion.10 Recent studies have questioned their effectiveness and raised concerns about harms.11 They should be reserved for cases where a delirious patient poses a safety risk to themselves, caregivers, or staff. Other behavioral (see previous section on behavioral interventions) and treatment measures (see previous section on identifying and treating underlying causes) should be provided to full extent possible.
With these caveats, the mainstay of pharmacologic treatment of agitated delirium is the neuroleptic/antipsychotic haloperidol (see Chapter 13). It should be used in the lowest dose and frequency needed to control symptoms, patients monitored for adverse effects especially extrapyramidal symptoms, and discontinued as soon as possible.8,12 The other neuroleptic that could be considered if haloperidol is ineffective and sedation is required for safety is chlorpromazine (see Chapter 13) using the same minimal use principles.
The other class of medications sometimes used to treat severe agitated delirium is benzodiazepines, but should be reserved only for cases when extreme sedation is needed. Generally these medications are avoided in delirium due to lack of evidence of benefit, risks of adverse events, and concerns about worsening delirium, except in cases of alcohol withdrawal,13 While two recent randomized controlled trials have raised questions about a potential role,11,14 benzodiazepines would generally be reserved for refractory cases where sedation is the desired outcome using either lorazepam or diazepam (see Chapter 13 ).
Anxiety and agitation are very common and normal responses to traumatic events experienced in acute humanitarian crises and emergencies, but can still result in severe symptoms and distress. They are normally time-limited, and as such they can be usually be managed with supportive measures alone. In more severe cases, medications can be used on a temporary, short-term basis to target specific symptoms. It is also important to acknowledge patients and families may interpret the cause, and appropriate treatment, from a more spiritual and/or cultural perspective, rather than a purely psychological and/or medical one.
Often presentations are a combination of emotional, psychological, and physical symptoms.15,16 Emotions of fear, panic, sadness, despair, behaviors of screaming, crying, withdrawal, aggression, and symptoms of disorientation, shortness of breath, heart palpitations, nausea and vomiting, sweating, chills, prostration, and pseudo-seizures may occur. These tend to occur in episodes of limited duration, with periods of near normalcy in between, helping distinguish from delirium. However, if these episodes become more frequent and pervasive, they can indicate potentially more severe mental health conditions such as post-traumatic stress disorder, depression, and anxiety disorders requiring more intensive management (see Chapter 16).
Behavioral and Psychosocial (Nonpharmacological) Interventions
This is the mainstay of treatment, and first recourse in addressing anxiety, encompassed in the principles of psychological first aid.17 It is important during an episode to provide a safe physical space to the extent possible. Providing reassurance and support, and nonjudgmental listening may be of great value. Patients need to be educated that their reactions are normal given the trauma they have encountered, and usually reduce with time. It is important to recognize the key role of family and other community supports, and with guidance and permission from the patient, seek to strengthen those connections. Other practical needs should be addressed to the extent possible to enhance a sense of safety and security. It may also be helpful to recommend relaxation techniques such as breathing exercises, distraction, physical activity, prayer, and traditional practices.
These should be limited to short-term, time-limited (usually <1 week) measures to treat severe and persistent insomnia or panic symptoms not responding to behavioral and psychosocial interventions.15 Typically lorazepam or diazepam can be used in the lowest effective dose (see Chapter 13). Amitriptyline can also be used for sleep, and has the advantage that it can be used longer term more safely, and for treatment of anxiety disorders and depression.
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