Benzos. when beers does not apply: Managing terminal delirium

ABSTRACT

Background: Terminal delirium (TD) occurs in up to 88% of patients at the end of life. Hyperactive TD requires an individualized management approach, which may include using a long-acting benzodiazepine. This medication can aggravate delirium;however, in the appropriate patient, with close interprofessional collaboration and if congruent with goals of care, it may provide net benefit. Case An 85-year-old lady with dementia, macular degeneration, and failed spinal stenosis surgery requiring wheelchair use, presented from an assisted living facility with agitation and elopement attempt. She had multiple delirium episodes in the past year precipitated by separation from her husband and social isolation due to COVID-19. Infectious workup was negative. CT brain showed volume loss and severe chronic microangiopathic changes. During her hospitalization, she was screaming, restless, impulsive, combative, anxious, paranoid regarding her husband having extramarital affairs, and required restraints. Her behaviors made care provision very challenging. Trazodone and olanzapine were started and titrated, and home pregabalin and sertraline were continued. She still received frequent IM/IV antipsychotics as PO medications were not administered on a consistent schedule due to fluctuating emotional distress. Her family was routinely updated, and ultimately decided on a comfort care approach. Due to persistent agitation despite maximal doses of olanzapine, scheduled twice daily clonazepam was trialed given its long acting properties, in addition to morphine. There was finally a marked reduction in her emotional distress. She eventually passed peacefully. Discussion: Given the scarcity of evidence to guide the optimal management of TD, its treatment should be tailored to each patient. Beers Criteria recommends against benzodiazepines because of potential worsened delirium. However, if comfort is the treatment goal, TD patients with severe agitation refractory to behavioral approaches and multiple classes of medications including antipsychotics may be trialed on long acting benzodiazepines to achieve proportionate sedation and alleviate suffering. Our patient's distress was not ameliorated by multiple treatments over weeks, but she became comfortable after we scheduled clonazepam. Conclusion: Deviation from conventional geriatric treatment paradigms, including using long-acting benzodiazepines, might be required to treat hyperactive TD in a patient-centered manner.