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It often starts with confusion — mood changes, disorientation, lethargy, and sometimes terrifying hallucinations. This is delirium, a serious condition triggered by illness, injury or adverse reactions to medication or surgery.
Every year, millions of people experience delirium, which comes at an estimated annual cost of $8.8 billion in Australia alone.* It has a disproportionate impact on the elderly and those with advanced illness — for people receiving palliative care, the condition has been called a ‘harbinger of impending death’.
Globally, antipsychotics have long been the go-to treatment for delirium for these vulnerable populations.
But now, revolutionary UTS research has shown for the first time that these drugs can cause more harm than good.
Evidence base for first-line delirium treatments
In 2017, researchers with the UTS Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT) centre launched the first-ever placebo-controlled trial of 247 people with delirium who were receiving palliative care.^
The trial reflected the research’s teams reservations about psychotics as a first line treatment. While these medications appeared, at a surface level, to be effective, IMPACCT researchers knew that there was very little scientific evidence to support their use.
“Drugs developed for use in mental health conditions do have sedative effects, and so clinicians who use them to treat delirium patients see the problem of agitation disappearing, which makes it seem as if the drugs are working,” says IMPACCT Director Professor Meera Agar.
“However, until we had a rigorous comparison of antipsychotics to placebo it not possible to be sure that the effects been seen could be attributed to the antipsychotics.
“It seemed plausible to us that the improvements in agitation seen were partly related to the other support and care patients receive when they have delirium, which is why we established our study.”
The results of the clinical trial were staggering: not only were antipsychotics shown to be ineffective at relieving delirium symptoms, they were also likely to result in more distressing symptoms and death.
This study offered the first indisputable evidence that current global approaches to delirium treatment were causing harm to vulnerable people.
“This work was important because it evaluated a particular response to distressing delirium symptoms which is used regularly in clinical care. We were asking the question: does this intervention relieve patient distress?” Professor Agar says.
If we know what isn’t working, it helps us shift all our energy and resources to things that do relieve that distress.
Transforming delirium education and clinical practice
These findings are now paving the way towards a new era of non-pharmacological treatments for people with delirium who also have advanced illness, including those receiving palliative care.
The research has informed the ACSQHC’s first-ever Delirium Clinical Care Standard, released in 2016, and the European Society for Medical Oncology’s 2018 Delirium in Adult Cancer Patients Clinical Practice Guidelines. It’s also contributing to current aged care reforms to reduce inappropriate use of antipsychotics, including the Aged Care Clinical Care Standards.
These documents guide clinicians in Australian and European hospitals to minimise their antipsychotic use in favour of non-pharmacological interventions. Supported by a vast program IMPACCT-led dissemination and training, the research findings are also re-shaping palliative care education and professional development for current and future clinical staff.
For Professor Agar, this new emphasis on addressing delirium using methods that don’t involve medication speaks directly to her current research agenda.
Rather than treating the symptoms of delirium, she wants to see more attention being paid to the underlying causes — like infection or organ dysfunction — and to supporting patients while they recover.
“If you’re trying to treat the underlying medical condition, and if you focus on helping people feel supported and calm within their environment as part of that process, you may see that those symptoms would improve naturally,” she says.
To that end, the IMPACCT team are now running further studies to assess the impacts of six domains of care on delirium symptoms — sleep; vision and hearing; hydration; communication, orientation and cognition; mobility; and family partnerships.
