Dementia and Palliative Care: Page 3 of 3
The authors report no relevant financial relationships.
Delirium is a common complication in severely ill patients, especially those with dementia (Tables 2 and 3).12,24,25 Delirium can be a source of great distress not only to patients, but also to their families and to the treatment team. Although delirium is generally considered a medical condition, it has psychiatric manifestations and psychiatric medications are often used in managing delirium.
A condition known as “terminal delirium” is often encountered in the last days or hours of life and may be a harbinger of death. Marked restlessness is sometimes observed, eliciting the term “terminal restlessness.” Definitive therapy for delirium typically involves resolving the underlying illness. Because this is not possible for most patients with a terminal illness, palliative management of terminal delirium focuses on relieving symptoms, addressing pain, and reducing agitation. Small doses of antipsychotic medications (eg, haloperidol 0.5 mg every 6 hours or risperidone 0.25 mg-0.5 mg twice daily) may be useful. Small doses of benzodiazepines are sometimes used to relieve anxiety or restlessness (eg, lorazepam 0.25 mg-0.5 mg every 6 hours as needed), but benzodiazepines have been shown to prolong delirious episodes. For patients clearly in the last hours of life, minor restlessness may not require intervention.26
Depression is common in palliative and hospice care patients and is frequently seen in patients with dementia. The prevalence of depression in patients with a terminal illness varies widely by study.6,27,28 Managing depression appropriately markedly improves patients’ quality of life, and various approaches are available for consideration.
Limited information is available to guide the clinician on the selection and dosing of antidepressants in dementia, and outcome data are contradictory. SSRIs such as citalopram (initial dose range, 10 mg-20 mg/day) are commonly used as first-line pharmacologic agents, with newer medications such as serotonin-norepinephrine reuptake inhibitors (SNRIs) used in the second-line.29 Stimulants, such as methylphenidate (initial dose typically 5 mg/day), may be helpful for regressed, apathetic, or severely withdrawn medically ill patients and can be administered alone or with an antidepressant.30 Mirtazapine, an SNRI, is also prescribed to address anorexia (initial dose range, 7.5 mg-15 mg nightly before bed), as are other drugs that stimulate appetite, such as megestrol acetate.31
Sleep disturbances and sundowning are common in dementia patients nearing the end of life. Parasomnias and dyssomnias, including obstructive sleep apnea, restless leg syndrome, nocturnal myoclonus, and REM sleep behavior disorders, can interfere with sleep in patients with dementia and may require therapy. Although a wealth of clinical experience is available to guide treatment for sleep disturbances in adults, studies on treating sleep disturbances specific to dementia patients are lacking.
Sedating antidepressants, such as trazodone (initial dose, ~50 mg nightly before bed) or mirtazapine (initial dose, 7.5 mg-15 mg nightly before bed), are an option for reducing anxiety and improving sleep disturbances. Sedating tricyclic antidepressants, such as amtriptyline or doxepin (typically in the initial range of 25 mg nightly before bed), have been used to induce sleep, but these have undesirable anticholinergic and cardiovascular effects and should generally not be used in this patient population. Hypnotics, such as zolpidem (initial dose, 5 mg nightly before bed), are sometimes used, but these agents are typically recommended for short-term treatment, whereas sleep disturbances in dementia patients may be prolonged and require ongoing therapy. Benzodiazepines are another option, and generally short- or intermediate-acting ones like lorazepam (initial dose, 0.25 mg-0.5 mg every 6 hours) are used; long-acting benzodiazepines such as clonazepam heighten the risk of falls and cognitive clouding and are usually avoided.
Over-the-counter sleep aids often contain a sedating antihistamine known as diphenhydramine, which has anticholinergic properties, and should generally be avoided in patients with dementia. An empirical trial of melatonin (typically 3 mg-6 mg nightly before bed) may be attempted.32,33
Many types of psychotherapy are potentially useful, including supportive, cognitive, and existential therapies. Continued therapy for bereaved family members may be warranted after the patient dies.8 Consultations with psychiatrists may also help staff in understanding and coping with difficult patient behaviors and family interactions,10 and such sessions should explore divergent approaches to illness and death among different cultures. Psychiatrists are sometimes called on to evaluate the decision-making capacity of patients suffering from incurable or terminal illnesses. Making such determinations can be difficult and controversial, requiring clinical expertise and knowledge of mental health law.34,35
Adopting a palliative care approach to manage end-of-life care issues in patients with a terminal illness can help prevent unnecessary suffering. This is especially important for patients with dementia, whose condition may not be recognized as terminal and are thus subjected to overtreatment with therapies that offer few benefits and a substantial risk of adverse effects. Pain and psychiatric syndromes are common in dementia patients, yet they often go unrecognized or untreated. Appropriately managing these secondary conditions are essential to ensuring that these patients receive humane care.
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