TABLE 3.

Selected examples of recommendations and their level of evidence taken from the Adapted Guidelines on the Assessment and Treatment of Delirium in Older Adults at the End of Life (available at http://www.ccsmh.ca)

Prevention	Although there is conflicting opinion regarding the link between delirium and hydration status in the palliative care population, depending on patient goals of care, prognosis, burden of treatment, and likelihood of efficacy it may be appropriate to facilitate oral fluid intake or to use rehydration measures such as hypodermoclysis in the older palliative patient. D (Recommendation 3.7)
Detection	Clinicians working with older persons should be alert to the high risk of delirium at the end of life, especially in the presence of multiorgan failure and polypharmacy (including opioids, etc). C (Recommendation 4.1) Delirium should be considered as a potential cause of any abrupt change in mental status, cognition, behavior, or functional ability (particularly declining mobility, impaired balance, and risk of falls) of any person approaching the end of life. Changes in the patient’s mental status, level of alertness, or behaviour should be taken seriously, as they may indicate the presence of delirium or other clinically important condition. These changes are not necessarily part of the dying process. C (Recommendation 4.10) In keeping with the goals of care when death is imminent, extensive evaluation and invasive investigations should be avoided. However, it is imperative to relieve distressing symptoms and provide emotional support to the patient’s family. D (Recommendation 4.43)
Pharmacological management	The clinician should strive to adequately manage the older adult’s pain, as pain can cause or exacerbate delirium. This can be complicated by the observation that some of the medications used to treat pain, including co-analgesics, can also cause delirium. The treatment goal is to control the older adult’s pain with the safest available intervention. D (Recommendation 6.2) If opioids are needed, the minimum effective dose should be used. Opioid rotation (or switch) and/or a change in the opioid administration route may be also be helpful (i.e., may favourably alter the pharmacokinetics/pharmacodynamics). C (Recommendation 6.7) Antipsychotics are the treatment of choice to manage the symptoms of delirium (with the exception of alcohol or benzodiazepine withdrawal delirium). C (Recommendation 6.23) In cases of refractory delirium (hyperactive or mixed), the clinician should reassess the diagnosis, comorbidities, and precipitating and aggravating factors, and ensure optimization of treatment. A second opinion from a colleague is recommended. If delirium continues to remain refractory, alternative strategies can be considered—for example, switching antipsychotics; combining two antipsychotics including one with a sedative profile; and combining a benzodiazepine with an antipsychotic. D (Recommendation 6.31) Palliative sedation is the deliberate reduction of consciousness to alleviate intolerable suffering. The practice of palliative sedation is ethically complex, and decisions involving its use need to be arrived at carefully through active involvement of the patient and family, and other members of the health-care team, and consultation with a palliative care specialist. D (Recommendation 6.32)
Education	All health-care team members require sustainable, ongoing educational opportunities to enhance their knowledge of specialized, evidence-based content relevant to the care of older delirious adults with end-stage cancer or chronic, non-curable end-stage disease. These educational opportunities should address the specific learning needs of the health-care team and be based on the principles of adult education. B (Recommendation 7.3) Opportunities should be provided for family members and older adults approaching end of life (when able) to discuss goals of care with the health-care team and to participate in decisions related to these goals. C (Recommendation 7.9)