Primary care for the declining cancer survivor

Delirium can be treated with antipsychotics; haloperidol has been most frequently studied.⁵⁴ Antipsychotics are effective at reducing agitation but not at restoring cognition.⁵⁵ Case reports suggest that use of atypical antipsychotics can be beneficial if adverse effects limit haloperidol dosing.⁵⁶ Agitated delirium is the most frequent indication for palliative sedation.⁵⁷

Dyspnea. In the last weeks, days, or hours of life, dyspnea is common and often distressing. Dyspnea appears to be multifactorial, worsened by poor control of secretions, airway hyperactivity, and lung pathologies.⁵⁸ Intravenous hydration may unintentionally exacerbate dyspnea. Hospice providers generally discourage intravenous hydration because relative dehydration reduces terminal respiratory secretions (“death rattle”) and increases patient comfort.⁵⁹

Honest conversations, with best- and worst-case scenarios, are important to patients and families and should occur while the patient is well enough to participate and set goals.

Some simple nonpharmacologic interventions have benefit. Oxygen is commonly employed, although multiple studies show no benefit over room air.⁵⁹ Directing a handheld fan at the face does reduce dyspnea, likely by activation of the maxillary branch of the trigeminal nerve.⁶⁰

Opioids effectively treat dyspnea near the end of life with oral and parenteral dosing, but the evidence does not support nebulized opioids.⁶¹ Opioid doses required to treat dyspnea are less than those for pain and do not cause significant respiratory depression.⁶² If a patient taking opioids experiences dyspnea, a 25% dose increase is recommended.⁶³

Reversible causes of delirium include uncontrolled pain, medication adverse effects, and urinary and fecal retention.

Anticholinergic medications can improve excessive airway secretions associated with dyspnea. Glycopyrrolate causes less delirium because it does not cross the blood-brain barrier, while scopolamine patches have reduced anticholinergic adverse effects, but effects are delayed until 12 hours after patch placement.⁶⁴ Atropine eye drops given sublingually were effective in a small study.⁶⁵

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