22 Delirium management by specialists in palliative medicine: an association for palliative medicine (apm) of great britain and ireland survey

BackgroundDelirium is common in patients receiving palliative care. Management includes assessment, reversal of underlying causes, non-pharmacological interventions and family support. Given recent evidence, antipsychotics should be avoided in mild-moderate delirium.MethodsA 20-question online anonymous survey was emailed to all Association for Palliative Medicine (APM) members. UK and Irish palliative medicine specialists in current clinical practice (n=859) were asked about delirium assessment, management and research priorities.ResultsResponse rate was 39% (335/859). Of these, 70% (234/335) were consultants, 15% (51/335) were specialist trainee registrars in palliative medicine and 15% (50/335) were associate specialists. Overall, 85% (285/335) had over 5 years of specialist palliative medicine experience. They worked in a variety, and often multiple settings, across hospital, hospice and community. Delirium guidelines were inconsistently used, with 42% (115/276) using local guidelines and 38% (104/276) using no guidelines. Most, 184/314 (59%) never use a tool to screen for delirium at inpatient admission. Most would use non-pharmacological interventions to manage delirium, either alone (106/275; 39%) or more commonly with an antipsychotic (160/275; 58%). The majority, 248/273 (91%) would prescribe an antipsychotic to a delirious patient with distressing hallucinations, with 190/273 (70%) using typical antipsychotics and 43/273 (16%) using atypical antipsychotics first line. Most inpatient (153/270; 57%) and community teams (97/161; 60%) do not formally support family carers. Informal verbal support was offered by 24% (64/270) in the inpatient setting and 22% (35/161) in community settings. Research priorities were prevention, prediction of reversibility and management (non-pharmacological and pharmacological).ConclusionMost responding APM members do not formally screen for delirium at inpatient admission. Many use an antipsychotic along with non-pharmacological interventions to manage delirium, and nearly all prescribe an antipsychotic to treat distressing hallucinations. Further rigorously designed clinical trials are urgently needed in view of management variability, emerging evidence and perceived priorities for research.