Association between postoperative hyperactive delirium and major complications in elderly patients undergoing emergency hip fracture surgery: A large-scale cohort study.

AIM: This cohort study aimed to explore the connection between postoperative hyperactive delirium and major complications in elderly patients undergoing emergency hip fracture surgery. METHODS: Elderly patients aged 65 years and older undergoing emergency hip fracture surgery were included in the study. The presence of postoperative hyperactive delirium was assessed, and logistic regression analysis, following propensity score matching, was conducted to investigate the association between postoperative hyperactive delirium and major complications occurring 30 and 90 days post-surgery. The analysis controlled for potential confounding factors. RESULTS: After propensity score matching, the analysis included 13 590 patients, equally distributed with 6795 in each group. The group experiencing postoperative hyperactive delirium exhibited a significantly elevated risk of 30-day postoperative complications, including acute renal failure, pneumonia, septicemia, and stroke, with adjusted odds ratios ranging from 1.64 to 2.39. Furthermore, this group displayed notably higher rates of 90-day postoperative complications, encompassing mortality, acute renal failure, pneumonia, septicemia, and stroke, with a significantly increased incidence of mortality within 90 days. CONCLUSION: Postoperative hyperactive delirium in elderly patients undergoing emergency hip fracture surgery is significantly linked to an increased risk of major complications at both 30 and 90 days post-surgery. These findings underscore the critical importance of delirium prevention and management in this patient population, offering the potential to reduce the occurrence of postoperative complications. Geriatr Gerontol Int 2024; 24: 730-736.

Fixed dose ketamine for prehospital management of hyperactive delirium with severe agitation.

INTRODUCTION: Patients exhibiting signs of hyperactive delirium with severe agitation (HDSA) may require sedating medications for stabilization and safe transport to the hospital. Determining the patient's weight and calculating the correct weight-based dose may be challenging in an emergency. A fixed dose ketamine protocol is an alternative to the traditional weight-based administration, which may also reduce dosing errors. The objective of this study was to evaluate the frequency and characteristics of adverse events following pre-hospital ketamine administration for HDSA. METHODS: Emergency Medical Services (EMS) records from four agencies were searched for prehospital ketamine administration. Cases were included if a 250 mg dose of ketamine was administered on standing order to an adult patient for clinical signs consistent with HDSA. Protocols allowed for a second 250 mg dose of ketamine if the first dose was not effective. Both the 250 mg initial dose and the total prehospital dose were analyzed for weight based dosing and adverse events. RESULTS: Review of 132 cases revealed 60 cases that met inclusion criteria. Patients' median weight was 80 kg (range: 50-176 kg). No patients were intubated by EMS, one only requiring suction, three required respiratory support via bag valve mask (BVM). Six (10%) patients were intubated in the emergency department (ED) including the three (5%) supported by EMS via BVM, three (5%) others who were sedated further in the ED prior to requiring intubation. All six patients who were intubated were discharged from the hospital with a Cerebral Performance Category (CPC) 1 score. The weight-based dosing equivalent for the 250 mg initial dose (OR: 2.62, CI: 0.67-10.22) and the total prehospital dose, inclusive of the 12 patients that were administered a second dose, (OR: 0.74, CI: 0.27, 2.03), were not associated with the need for intubation. CONCLUSION: The 250 mg fixed dose of ketamine was not >5 mg/kg weight-based dose equivalent for all patients in this study. Although a second 250 mg dose of ketamine was permitted under standing orders, only 12 (20%) of the patients were administered a second dose, none experienced an adverse event. This indicates that the 250 mg initial dose was effective for 80% of the patients. Four patients with prehospital adverse events likely related to the administration of ketamine were found. One required suction, three (5%) requiring BVM respiratory support by EMS were subsequently intubated upon arrival in the ED. All 60 patients were discharged from the hospital alive. Further research is needed to determine an optimal single administration dose for ketamine in patients exhibiting signs of HDSA, if employing a standardized fixed dose medication protocol streamlines administration, and if the fixed dose medication reduces the occurrence of dosage errors.

Nurse Education in Care of Delirium: Achieving a Change from Transcription and Translation to Interpretation for Reduced Strain.

How to cite this article: Gopaldas JA. Nurse Education in Care of Delirium: Achieving a Change from Transcription and Translation to Interpretation for Reduced Strain. Indian J Crit Care Med 2024;28(2):95-96.

Nurses' Knowledge and Subjective Strain in Delirium Care: Impact of a Web-based Instructional Module on Nurses Competence.

Background: Delirium, a prevalent condition among elderly individuals admitted to hospitals, particularly in intensive care settings, necessitates specialized medical intervention. The present study assessed the proficiency of nurses in the management of delirium and their subjective experience of stress while providing care for patients with delirium in emergency rooms and critical care units. Materials and methods: The study adopted a quantitative descriptive approach, utilizing standardized self-reporting measures that assessed the nurses' expertise and perceived burden of care. A cohort of 86 nurses from a tertiary care hospital in North India participated in the study. Additionally, the impact of the web-based instructional module in enhancing the nurses' knowledge in delirium management was assessed by one group pretest-posttest quasi-experimental study. Findings: The research revealed that nurses exhibited significant deficiencies in their knowledge, particularly in relation to the symptoms and causes of delirium. The most significant source of subjective stress was attributed to hyperactive delirium-associated behaviors, characterized by uncooperative and aggressive conduct. The utilization of the web-based instructional program significantly enhanced the comprehension of nurses about the management of delirium. Conclusion: This study revealed a significant knowledge gap among nurses in delirium management and emphasizes the considerable subjective stress, particularly in dealing with hyperactive delirium-associated behaviors. The positive impact of the web-based instructional program underscores its potential as a valuable tool for enhancing nurses' knowledge and addressing these challenges in healthcare settings. How to cite this article: Jose S, Cyriac MC, Dhandapani M. Nurses' Knowledge and Subjective Strain in Delirium Care: Impact of a Web-based Instructional Module on Nurses Competence. Indian J Crit Care Med 2024;28(2):111-119.

Nutmeg Intoxication: A Case Report.

Nutmeg intoxication is an uncommon precipitant of hyperactive delirium with severe agitation (HDSA) with anticholinergic properties that require a high index of suspicion for diagnosis. We present a case of a young adult who presented to the emergency department (ED) with HDSA. The patient was intubated and transferred to the medical intensive care unit (MICU) due to increasing safety threats unresponsive to multimodal de-escalation. He ultimately self-extubated, reported excessive nutmeg ingestion, and was discharged home after a short period of observation. Improved detection and streamlined management pathways for nutmeg intoxication will minimize unnecessary invasive procedures and costs to the healthcare system.

Risk factors for hyperactive delirium after laparoscopic radical gastrectomy under general anesthesia in patients with gastric cancer.

OBJECTIVE: This study aimed to analyze the risk factors for the occurrence of postoperative hyperactive delirium after laparoscopic radical gastrectomy under general anesthesia in patients with gastric cancer. METHODS: The clinical data of 280 gastric cancer patients who underwent laparoscopic radical gastrectomy under general anesthesia in First Affiliated Hospital of Gannan Medical University from January 2020 to June 2023 were retrospectively analyzed, and the types and incidence of postoperative delirium were recorded. The factors influencing the occurrence of postoperative hyperactive delirium were analyzed. RESULTS: Multi-factor logistic regression analysis showed that older age, high dosage of anesthetic drug consumption, high American Society of Anesthesiologists (ASA) classification (or ASA grade 3-4), long Post-anesthesia Care Unit (PACU) stay, and long extubation time were independent risk factors for the occurrence of hyperactive delirium after laparoscopic radical gastrectomy (OR > 1, P < 0.05). The area under the curve of the nomogram was used to predict the occurrence of hyperactive delirium after laparoscopic radical gastrectomy under general anesthesia was 0.903 (95% CI: 0.846-0.978). CONCLUSION: Older age, high dosage of anesthetic drug consumption, high ASA classification (or ASA grade 3-4), long PACU stay, and long extubation time were independent risk factors affecting the occurrence of hyperactive delirium after laparoscopic radical gastrectomy under general anesthesia.

Refractory Hyperactive Delirium Without Intravenous Access: A Case Report.

Refractory delirium is a complex, often underdiagnosed, and difficult-to-treat phenomenon. It poses significant challenges to healthcare providers, especially in patients without prior intravenous access. In extreme cases, anesthetic management may be needed to treat refractory delirium. Here, we present a unique case of postoperative hyperactive refractory delirium in a patient without intravenous access, ultimately requiring anesthetic management for resolution.

Pharmacological Management of Agitation and Delirium in Older Adults: a Survey of Practices in Canadian Emergency Departments.

Agitation is a common presenting symptom of delirium for older adults in the emergency department (ED). No medications have been found to reduce delirium severity, symptoms, or mortality, yet they may cause harm. Guidelines suggest using medications only when patients are posing a risk of harm, situations which may arise frequently in the ED. We sought to characterize prescribing patterns of medications for agitation by ED physicians in Canadian hospitals. In this multicenter study, we surveyed physicians in Vancouver, Toronto, and Sherbrooke. Descriptive statistics were used to summarize group characteristics and starting doses were compared to order sets. Fisher exact tests were used for demographic comparison. Ordinal linear regression models were run to identify a relationship between starting dose of medications and location. Of the 137 physicians invited, 77 (56%) completed the survey. Use of order sets was greatest in Sherbrooke and least in Vancouver. The most common medications used across sites were haloperidol, lorazepam, and quetiapine. Benzodiazepines were used across all sites but were used significantly more frequently in Vancouver than the other sites. Practice location was a significant predictor of starting dose of haloperidol, with Sherbrooke and Toronto having a lower starting dose than Vancouver. Higher use of order sets correlated with lower and more consistent starting doses. Benzodiazepines are used across EDs in Canada despite little evidence for efficacy in delirium and risk of harm. Implementation of order sets may be a useful way to standardize ED management of older adults experiencing hyperactive delirium.

Case report: Hyperactive delirium after a single dose of zolpidem administered additionally to psychopharmacotherapy including clozapine.

The non-benzodiazepine hypnotic zolpidem is frequently administered as a short term psychopharmacotherapy for insomnia. Although it is well-established in a broad clinical routine and often well-tolerated, severe delirium and complex sleep behavior were reported in rare cases. Hereby, it remains unclear whether zolpidem's potential for delirium might be enhanced when combined with further psychopharmacotherapeutics. The present case report portrays a young male Caucasian inpatient with schizoaffective disorder, who was admitted due to severe hyperactive delirium after a single dose of zolpidem 10 mg that was administered in addition to already established psychopharmacotherapy including clozapine 200 mg/day, aripiprazole 15 mg/day and cariprazine 4.5 mg/day. In detail, disorientation, agitation, confabulations, bizarre behavior, and anterograde amnesia occurred shortly after ingestion of zolpidem and gained in intensity within a couple of hours. Once zolpidem was discontinued, the abovementioned symptoms subsided completely and did not reoccur. Since a clear temporal association could be drawn between the intake of zolpidem and the onset of hyperactive delirium, the present clinical experience should serve as a cautionary note for combining potent sedative-hypnotics and substances with anticholinergic properties, even in young adults in a good general condition. Moreover, our case argues for the necessity of further research into the pathomechanism of the interaction potential of non-benzodiazepines as zolpidem, especially with substances exerting anticholinergic properties, which are known for their potential to precipitate delirium. Therefore, the metabolic pathways of the concurrently administered substances should be further taken into account.

Chlorpromazine's Potential Role in Palliating Distressing Symptoms Associated With Hyperactive Delirium in Patients at End of Life.

Background: The hyperactive subtype of delirium is characterized by agitation, restlessness, delusions, and/or hallucinations, which commonly present near end of life (EoL). Symptom relief often requires the use of medications, such as chlorpromazine (CPZ), to reduce patient distress by inducing proportional sedation. Objective: The purpose of this study was to evaluate CPZ's potential role in managing the distress of hyperactive delirium in patients receiving EoL care. Methods: A retrospective observational study among hospitalized patients with advanced cancer at EoL between January 2020 to December 2021. Results: Sustained improvement in symptoms of delirium was seen in 80% of patients as identified in the palliative psychiatrist's progress notes. Meanwhile, 75% of patient's improvement was reported in nursing-driven Delirium Observation Screening Scale. Conclusion: This study elucidates that at doses of ∼100 mg/day, CPZ is potentially an effective medication for patients with advanced cancer, experiencing hyperactive delirium in their final week of life.

A Retrospective Analysis of Guanfacine for the Pharmacological Management of Delirium.

Background Delirium is a syndrome of acute brain failure that represents a change from an individual's baseline cognitive functioning characterized by deficits in attention and multiple aspects of cognition that fluctuate in severity over time. The symptomatic management of delirium's behavioral manifestations remains difficult. The alpha-2 agonists, dexmedetomidine and clonidine, are efficacious, but their potential cardiovascular adverse effects limit their utilization. Guanfacine is an oral alpha-2 agonist with a lower potential for such adverse outcomes; however, its use in delirium has not been studied. Methods A retrospective descriptive analysis of guanfacine for managing hyperactive or mixed delirium at Tampa General Hospital from January 2020 to October 2020 was conducted. The primary outcome was the time reduction in acute sedative administration. Secondary outcomes included renewed participation in physical therapy or occupational therapy (PT/OT), decreased opioid use, and an incidence of cardiovascular adverse effects. Results One hundred forty-nine patients were identified as having received guanfacine for managing delirium during the study period. All experienced a reduction in acute sedative use after the initiation of guanfacine. In 93 patients receiving PT/OT and no longer participating due to behavioral agitation, 74% had a documented renewal of services within four days. Of 112 patients on opioids, 70% experienced a 25% reduction in opioid administration within four days. No patients experienced consecutive episodes of hypotension that required a change in their clinical care. Two patients experienced a single episode of consecutive bradycardia that led to the discontinuation of guanfacine.  Conclusions Based on our retrospective study, guanfacine is a well-tolerated medication for the management of delirium. Even in medically and critically ill patients, cardiovascular adverse events were rare with guanfacine. Patients treated with guanfacine experienced decreased acute sedative use for behavioral agitation. Additionally, patients treated with guanfacine received fewer opioids and were better able to participate in PT/OT. Future studies with prospective, randomized, placebo-controlled designs are warranted to evaluate this promising intervention for delirium further.

Rhabdomyolysis Associated With "Pruno" Prison-Made Alcohol Intake in Corrections Facility: A Case Report.

In this study, a case of severe rhabdomyolysis in a 28-year-old incarcerated patient is presented. The patient initially presented with emesis, abdominal pain, and myalgias to the clinic at the corrections facility and was treated with antiemetics and analgesics. The onset of symptoms occurred approximately 24 h after ingestion of an illicit substance produced by inmates. Despite intervention, the patient was eventually transferred to the hospital on the third day after symptom onset for further evaluation and treatment. The manuscript presents the events that preceded the diagnosis of rhabdomyolysis, as well as symptoms of hyperactive delirium that developed during the patient's hospital course, leading to the high suspicion of illicit substance intoxication as a contributing inciting factor of rhabdomyolysis. This study aimed to bring awareness to the medical community about substance use in the correction system and its consequences.

Malignant Peritoneal Mesothelioma: A Challenging Case for Palliative Care.

Malignant peritoneal mesothelioma (MPM) is a rare and very aggressive malignancy of serosal membranes, which typically presents with abdominal pain, distension, and ascites. Due to its rarity and nonspecific symptoms, it is usually diagnosed late, when the disease burden is extensive and the therapy is inevitably palliative. It represents a complex challenge for clinicians because the treatment options are very poor and the illness has a great impact on patients' life. We present a complex case of a young patient with MPM who was admitted to our palliative care unit.

Emergence delirium after intracranial neurosurgery- a prospective cohort study.

OBJECTIVES: The primary objective of this study was to estimate the incidence of emergence delirium (ED) including hypo- and hyperactive ED, after intracranial neurosurgery. Secondary objective was to identify perioperative risk factors of ED in these patients. METHODS: This prospective observational study was conducted at an academic neurosciences hospital. All consecutive adult patients (age ≥ 18 years) with a preoperative Glasgow Coma Scale score of 15 undergoing elective intracranial surgery under general anesthesia during the six-month period from October 2020 to March 2021 were included in this study. Perioperative patient data were collected till one hour after surgery. ED was defined as per Riker's sedation agitation score (SAS) as hyperactive ED when SAS was >4 and hypo active ED when SAS was <4 on a 1 to 7 scale. RESULTS: Data of 320 patients were analyzed in this study. The overall incidence of ED was 22 % (71/320), with incidence of hyperactive ED of 4.3 % (n = 14) and hypoactive ED of 18 % (n = 57). The risk factors for ED were preoperative delirium (odds ratio [OR], 95 % confidence interval [CI] and p value of 4.41, 1.3-15.19, and 0.002), education level (OR = 2.21, [0.98-4.94], p = 0.05), minimum alveolar concentration of inhalational anesthetic (OR = 1.47, [1.17-1.88], p = 0.002), postoperative nausea and vomiting (OR = 4.56, [2.04-10.32], p = 0.001), and body weight (OR = 1.69, [1.1-2.68], p = 0.02). Hyperactive ED was predicted by preoperative delirium (OR = 5.28, [1.12-21.21], p = 0.024) and low education level (OR = 4.35, [1.2-17.04], p = 0.027). CONCLUSIONS: Atleast one in five patients undergoing brain surgery under anesthesia develop ED. Addressing modifiable risk factors might reduce ED.

Current practice of pharmacological treatment for hyperactive delirium in terminally ill cancer patients: results of a nationwide survey of Japanese palliative care physicians and liaison psychiatrists.

OBJECTIVE: The objective of this survey was to identify areas where doctors have divergent practices in pharmacological treatment for hyperactive delirium in terminally ill patients with cancer. METHODS: We conducted a survey of Japanese palliative care physicians and liaison psychiatrists. Inquiries were made regarding: (i) choice of drug class in the first-line treatment, (ii) administration methods of the first-line antipsychotic treatment, (iii) starting dose of antipsychotics in the first line treatment and maximum dose of antipsychotics in refractory delirium, and (iv) choice of treatment when the first-line haloperidol treatment failed. Respondents used a five-point Likert scale. RESULTS: Regarding choice of drug class in the first-line treatment, more doctors reported that they 'frequently' or 'very frequently' use antipsychotics only than antipsychotics and benzodiazepine (oral: 73.4 vs. 12.2%; injection: 61.3 vs. 11.6%, respectively). Regarding administration methods of the first-line antipsychotic treatment, the percentage of doctors who reported that they used antipsychotics as needed and around the clock were 55.4 and 68.8% (oral), 49.2 and 45.4% (injection), respectively. There were different opinions on the maximum dose of antipsychotics in refractory delirium. Regarding the choice of treatment when the first-line haloperidol treatment failed, the percentage of doctors who reported that they increased the dose of haloperidol, used haloperidol and benzodiazepines, and switched to chlorpromazine were 47.0, 32.1 and 16.4%, respectively. CONCLUSIONS: Doctors have divergent practices in administration methods of the first-line antipsychotic treatment, maximum dose of antipsychotics, and choice of treatment when the first-line haloperidol treatment failed. Further studies are needed to determine the optimal treatment.

Association between experiences of advanced cancer patients at the end of life and depression in their bereaved caregivers.

OBJECTIVE: Research on the association between circumstances of death in advanced cancer patients and depression in their bereaved caregivers is limited. METHODS: A longitudinal study was performed on patients admitted to 21 inpatient hospices/palliative care units (PCUs) in Japan. Patient symptoms were assessed at admission and in the last 3 days of life. Data on distressing events (unexpected death, bleeding) and received treatments (morphine prescriptions, continuous deep sedation, cardiopulmonary resuscitation) were also obtained. Bereaved caregiver depression was assessed 6 months or more after patient death via mail survey using the Patient Health Questionnaire-9 (PHQ-9). A multivariable logistic regression analysis was used to explore variables predicting bereaved caregiver depression. RESULTS: Of 1324 deceased patient-bereaved caregiver dyads, data were finally analyzed for 711 dyads. The proportion of probable depression (PHQ-9 scores ≥10) in bereaved caregivers was 13.6% (91/671; 95% confidence interval: 11.0-16.2). The multivariable logistic regression analysis showed that patient hyperactive delirium at PCU admission was significantly associated with the development of bereaved caregiver depression (odds ratio: 2.2, 95% CI: 1.2-3.8). Bereaved caregiver perceived low social support (OR: 4.7, 95% CI: 2.2-10.0) and low preparedness for death (OR: 4.5, 95% CI: 2.6-7.8) were also significantly associated with the development of depression. Other patient and bereaved caregiver variables had no association with depression. CONCLUSIONS: Hyperactive delirium in terminally ill cancer patients was associated with bereaved caregiver depression. The development of effective strategies to reduce delirium-related agitation and to provide educational interventions for caregivers may be needed.

Narcolepsy-like symptoms triggered by lemborexant in the context of hyperactive delirium in a patient with bipolar depression: a case report.

Lemborexant is a dual orexin antagonist and is considered a safe and effective hypnotic. Dual orexin antagonists induce physiological sleep by blocking orexin receptors. Although the blockade of orexin signaling has triggered narcolepsy-like symptoms in rodents, there is currently no evidence of lemborexant inducing narcolepsy-like symptoms in humans. We describe the case of a 79-year-old Japanese woman with bipolar depression who experienced lemborexant-induced cataplexy and sleep attack. Her previous results on the Multiple Sleep Latency Test excluded the diagnosis of narcolepsy. She experienced narcolepsy-like symptoms on 2 occasions after she was administered lemborexant, in the context of hyperactive delirium, but not in a relaxed state. Her case suggests that lemborexant could trigger narcolepsy-like symptoms in patients with hyperactive delirium, even those with no history of narcolepsy. This case also emphasizes that clinicians must be very careful when they prescribe lemborexant to patients who experience hyperactive delirium. CITATION: Shibata S, Oda Y, Ohki N, et al. Narcolepsy-like symptoms triggered by lemborexant in the context of hyperactive delirium in a patient with bipolar depression: a case report. J Clin Sleep Med. 2022;18(5):1459-1462.

Valproic Acid in the Management of Delirium.

CONTEXT: Antipsychotics and benzodiazepines do not improve delirium. Valproic acid (VPA) has been used recently to treat agitation in delirium. OBJECTIVES: To review the evidence for VPA in the management of Delirium. METHODS: Systematic review. English language, age 19 and above, from 1946 to January 12, 2021. MESH TERMS: "Valproic acid", "valproate", "sodium valproate", "delirium", "acute mania with delirium" in PubMed and Ovid. EXCLUSION: Studies of VPA used for diagnoses other than delirium. RESULTS: 21 abstracts were identified and 10 studies were included in the review (252 patients): One prospective open label study (n: 7), 2 case series (n: 22), 4 retrospective studies (n: 219) and 3 case reports (n: 4). No randomized controlled trial (RCT) evaluates the effect of VPA in delirium. 237/250 (94.8%) patients were in the ICU. Mean age was 59.7 (27-87). 153/204 (74%) were male. The mean starting dose was 733 mg/day in 148 patients and the mean dose at follow up was 1061 mg/day in 205 patients. CAM ICU was used to diagnose delirium in 6 reviews. Delirium improved in case series in 19/22 patients. Delirium improved in retrospective studies at day 3 compared to day 1. VPA levels were not consistently reported. Hyperammonemia (12-19%) and thrombocytopenia (9-13%) were the most common side effects. No deaths were attributed to VPA. CONCLUSION: VPA is being used more frequently for delirium. The evidence is limited to retrospective studies and case series. There is a need for RCT to evaluate the effect of VPA in delirium compared to other alternatives and placebo.

Symptom trajectories for palliative care inpatients with and without hyperactive delirium in the last week of life.

AIMS: Hyperactive delirium (HD) is a common and distressing symptom among palliative care patients. This study aimed to describe the characteristics of HD and associated symptoms among palliative care inpatients and evaluate relationships between HD development and symptom trajectories in this population. DESIGN: A retrospective study was conducted. METHODS: A retrospective review of medical records was conducted for all patients who died in a large Australian specialist palliative care unit between 1 January and 31 December 2019. Patients were assessed daily using the Symptoms Assessment Scale (SAS) and Palliative Care Problem Severity Scale (PCPSS). Multilevel models were used to estimate the differences in symptoms trajectories in the last 7 days of life between the two groups. RESULTS: Of the 501 included patients, 64.5% (323) had an episode of HD. For 30% (95) of patients, HD occurred prior to admission. Compared with patients without HD, those with HD had significantly higher odds ratios (ORs) for four of the seven SAS symptoms (sleep problems, appetite, fatigue and pain; OR range: 1.94-4.48, p < .05), and all four PCPSS items (OR range: 2.00-3.00, p < .05) in the last week of life. CONCLUSIONS: Palliative care inpatients commonly experience HD in their last week of life. There are higher levels of symptom distress, complexity, psychological concerns and family/carer concerns among patients with HD compared with those without HD. IMPACT: The high prevalence of HD, and its association with higher levels of symptom distress, highlights the importance of routine screening and optimal management for HD among palliative care patients. Given the widely recognized challenges facing palliative care professionals in assessment and management of delirium, provision of relevant training among these professionals is recommended.