Abstract
Delirium: Acute Confusional States in Palliative Medicine is written by Augusto Caraceni, a neurologist and palliative care physician, and Luigi Grassi, a psychiatrist. This is the second edition to an internationally recognized body of work that addresses delirium with an interdisciplinary approach. Written for palliative care physicians, specialist nurses, neurologists, psychiatrists, and other health professionals treating terminally ill patients, the book provides a clear account of how to recognize and treat this complicated syndrome.
The organization of the book is both logical and practical. The first chapter focuses on the very basic but challenging task of defining the term delirium. The authors take the readers back to the time of the first century AD, when Celsus first used the term delirium, and then discuss in detail how Hippocrates, Galenus, and several other great thinkers also used the term to describe their clinical findings. This history leads to how the Lipowski definition influenced the diagnosis in the Diagnostic and Statistical Manual of Mental Disorders. The authors also discuss differences and similarities in the international terminology of delirium and review the current classifications. The DSM III, III-R, IV, and IV-TR are compared and contrasted, and potential problems of these classifications are highlighted. ICD-10 classification and guidelines are described as well as the pending new versions of the DSM V and ICD 11.
Delirium is a disorder of consciousness and attention, and the authors pay great attention to detailing the neurochemical and neurophysiological processes. The chapter entitled “Clinical Phenomenology” discusses the role of consciousness, attention, and cognition in delirium, citing various references. Particular attention is applied to perceptual disturbances, psychomotor behaviors, and even subjective perceptions related to delirium. The neurological signs and involuntary movements of tremor, myoclonus, and asterexis are defined and differentiated.
In the following two chapters the authors use case reports, EEG recordings, and imaging studies to describe the differential diagnosis of delirium, which includes etiologies such as withdrawal delirium; metabolic encephalopathies; and drug toxicity, which includes opioid-induced delirium, anticholinergic side effects, and drug-drug interactions. The authors use imaging studies to discuss the role of structural brain lesions such as cerebrovascular accidents, primary brain tumors, and brain and meningeal metastases. This text is nicely referenced with recently published studies.
In the chapter entitled “Delirium in Special Populations,” the authors clearly identify specific risk factors and preventative measures that should be taken in HIV patients, postoperative patients, cancer patients, and patients with terminal delirium. Discussions of clinical aspects, assessment, risk factors, and management of terminal delirium offer the reader a clear and well-rounded approach to this important area of palliative care.
Delirium can be diagnosed using tools such as the EEG, labs, and specific instruments. In particular, the EEG can be used to differentiate delirium from seizure and psychosis. As an example of the clinical importance of these diagnostic tools, the authors present the case of a patient with delirium secondary to chemotherapeutic toxicity and probable nonconvulsive status epilepticus. Useful instruments are included in the appendix such as the Confusion Assessment Method (CAM), Delirium Rating Scale (DRS), Delirium Rating Scale Revised 98 (DRS-R-98), Memorial Delirium Assessment Scale (MDAS), and the Nursing Delirium Screening Scale (Nu-DESC).
The authors approach the management of delirium from both a pharmacological and nonpharmacological approach. Although the American Psychiatric Association guidelines are not very detailed about dosing of typical antipsychotics such as haloperidol, the authors use multiple references to illustrate different dosing approaches for both typical and atypical antipsychotics. They also explore the pharmacological similarities, differences, and side effects between neuroleptics, benzodiazepines, and antihistamines. A table on nonpharmacological management includes interventions for patients, families, and staff. While nonpharmacological management strategies of delirium are explored and described briefly, this important component of comprehensive delirium management could have been more extensively and concretely reviewed.
The role of palliative sedation as a treatment for terminal delirium is explored, and the text includes a stepwise approach to the treatment of refractory delirium including the implementation of neuroleptics, antihistamines, and benzodiazepines. Key issues in palliative sedation are identified, but are not as well discussed as previous topics.
An entire chapter is dedicated to addressing various issues that may arise in families with critically ill or delirious loved ones, and the sources of distress for families are explored using the following domains: patients, families, and health care team. The authors outline how to assess family function using four elements: the family history, the disease history, communication and coping patterns, and relationships with staff. Concepts of grief and bereavement are defined in detail including specific risk factors and consequences of complicated grief. This chapter also includes detailed steps in how to care for families during anticipatory grief and acute grief.
This book takes on the very challenging and often unrecognized symptom in palliative care that is delirium. The authors achieve their stated interdisciplinary treatment approach to delirium. Throughout the book, neurological, psychiatric, and pharmacological perspectives are applied with great detail and with the use of appropriate references to published studies. The authors offer an interesting perspective on the historical evolution and international terminology of delirium. We recommend this book to all who are involved in caring for the terminally ill.