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    Final Integrative Review

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    of 13
    Running head: INTEGRATIVE REVIEW Managing Delirium with Haloperidol in Palliative Care: An integrative review Kelly Ryan Bon Secours Memorial College of Nursing ‘Nursing Research NUR 4222 Dr. Perkins December 1, 2015 On my honor, I have neither given nor received aid on this assignment or test, and I pledge that Tam in compliance with the BSMCON Honor System.” - KR INTEGRATIVE REVIEW Abstract, The objective of this integrative review is to offer a summary and analysis of available research concerning the use of haloperidol to treat delirium in the palliative care population. Delirium is particularly concerning in the palliative are population as it is stressful for the patient, their families and their caretakers, and ultimately makes the patient’s end-of-life experiences less peaceful (Agar et al., 2011; van den Boogard et al., 2013; Bush et al., 2014; Crawford et al., 2013; Gongalves et al., 2015). The research design in an integrative review. The literature search was conducted using two computer- based research databases, Pubmed and the Wiley Online Library database. A total of five articles met the overall inclusion criteria, The findings and results regarding the use of haloperidol in the treatment of delirium were marginally significant, which may be due to the difficulty providers experience in identifying delirium early. Further education needs to be implemented to all healthcare providers on how to recognize delirium, so that appropriate treatment can take place. Significant research limitations inchide time only five articles and a constraints due to other assignments, a restriction to the use of novice researcher. INTEGRATIVE REVIEW Managing Delirium with Haloperidol in Palliative Care The purpose of this integrative review is to search available literature relating to the use of haloperidol to manage delirium in palliative care patients. Delirium is characterized by changing mental and neurobehavioral actions, including changes in sleep patterns, motor activity, perception and overall impaired awareness (Bush, et al., 2014). Additionally, delirium is often misunderstood and mismanaged, delaying overall treatment of the disorder (Crawford, et al., 2013). Delirium is often under diagnosed which contributes to stressful end-of-life experiences, morbidity and increased mortality. Haloperidol, an antipsychotic, is currently the standard treatment of delirious symptoms in the palliative care population. The effectiveness of haloperidol, however, has not been thoroughly investigated. This topic is interesting to the researcher because of her experience in working with palliative care patients. Consequently, the proposed PICO question by this researcher is as follows: Is haloperidol administration an appropriate treatment for delirium for patients who are receiving palliative care in an inpatient setting? Research Design, Search Methods & Search Outcomes ‘The research design is an integrative review. ‘The search for research articles was conducted utilizing the computer-based search engine PubMed, specifically the Wiley Online Library database. Key search terms included, ‘agitation’, ‘delirium’, haloperidol’, ‘palliative’, ‘palliative care’, ‘qualitative’ and ‘quantitative’. ‘The article search was also filtered to include only articles written from 2010 to 2015 in an effort to focus on current literature. The search yielded 19 articles from Pubmed, indicating a of literature on this topic. Articles reviewed were further limited to peer INTEGRATIVE REVIEW ive, quantitative and systematic journal articles written in English. The reviewed, quali is haloperidol articles had to identify with the researcher's PICO question, “ administration an appropriate treatment for delirium for patients who are receiving, palliative care in an inpatient setting?” The articles were then selected based on the following inclusion criteria: palliative care patients, symptoms of delirium and treatment with haloperidol. Articles that did not meet given criteria were excluded from the review. tration to manage The screening produced five articles regarding haloperidol adm delirium symptoms in palliative care patients, including three quantitative, one qualitative and one systematic review. Findings/Results The findings and results of the five reviewed articles indicate that haloperidol is an overall appropriate treatment for managing delirium symptoms in palliative care patients (Agar et al., 2011; van den Boogard et al., 2013; Bush et al., 2014; Crawford et al., 2013; Gongalves et al., 2015), A summation of the assembled research articles is presented in Table 1. The researcher framed the review according to the following two categories: recognition of delirium for treatment and the statistical significance of outcomes. Recognition of Delirium for Treatment Throughout the articles surveyed there was an agreement reached that quick and accurate assessment of delirium in the palliative care population can be difficult (Agar et al., 2011; van den Boogard et al., 2013; Bush et al., 2014; Crawford et al., 2013: Gongalves et al., 2015). An integrative review by Bush, et al.. (2014) identified studies that pointed to various therapeutic interventions for delirium. Research was completed INTEGRATIVE REVIEW for the review by combining multidisciplinary input from 31 delirium experts with a literature review over multiple databases. Ultimately, the search produced 430 potentially applicable articles, of which 55 were included in the appraisal. Data analysis involved grouping the main findings into the following categories: the unique contextual issues in palliative care, pharmacologic interventions, non-pharmacologic interventions W offered several studies showing that and recommendations for future studies. The re it is vital that delirium is appropriately recognized shortly after symptoms occur. This is important because the overall phase of delirium in palliative care has been negatively associated with short-term survival (Bush, et al., 2014). All studies likewise point to the fact that delirium needs to be diagnosed in a timely fashion because its occurrence is stressful to the patient, their family, and their caretakers (Agar et al., 2011; van den Boogard et al., 2013; Bush et al., 2014; Crawford et al., 2013; Gongalves et al., 2015). A qualitative study by Agar, et al., (2011) conducted semi-structured interviews for 40 nurses in the fields of palliative care, aged care, aged care psychiatry and oncology about their experiences in managing delirium. Potential participants were approached by their nursing managers and were then given information on how to further participate in the study if they desired. The interviews were audio-taped and transcribed verbatim, and participants were given the opportunity to make any corrections before the data was analyzed using the NVivo 8 (QSR International 2008) analysis software. Four main themes were identified, superficial recognition of delirium as a syndrome, confusion on how to approach a nursing assessment of delirium, maintaining dignity and reducing ium and its effect on others. It was discovered that there is chaos and the distress of deli INTEGRATIVE REVIEW limited knowledge of the features of delirium across all of these specialties, indicating the requirement for delirium education across all fields of nursing. Statis cal significance of haloperidol in patients with delirium The quantitative study by Crawford et al. (2013) examined overall haloperidol benefits and risks in 119 palliative care patients with delirium. The National Cancer itute’s Common Toxicity Criteria for Adverse Events was used to evaluate overall benefits and harms. Data was recorded at baseline, 48 hours after the start of haloperidol treatment and 10 days after the start of haloperidol treatment, Data was analyzed using a univariable logistic regression model. A net clinical benefit was observed with haloperidol treatment as 1 out of every 3 palliative participants saw overall reduction of delirium symptoms after 10 days. Additionally, it was discovered that the average haloperidol dose of 6.5mg/day can be reduced to 2. mg/day and still be effective in managing symptoms of delirium, To accurately catch and assess for delirium in one study, van den Bogard et al., (2013) screened a total number of 177 patients using the Confusion Assessment Method, hereafter referred to as CAM tool, three times a day. Additionally, medical and nursing files were screened to search for trends signaling delirium. Delirium symptomology of patients who received haloperidol was compared with the symptomology of patients not treated with haloperidol. Data was analyzed using the Kaplan-Meier curve. Van den Boogard, et al., (2013) identified a 10% decrease in delirium with patients treated prophylactically with delirium compared to those untreated. A quantitative study by Gongalves, et al., (2015) also studied whether haloperidol is an effective and safe treatment in managing delirium. This study included 135 INTEGRATIVE REVIEW inpatient participants on a palliative care service. Haloperidol was used a median of three times on each patient, with a total number of uses being 584 times over a six year period, To evaluate the effectiveness of the haloperidol it was recorded when the treatment was controlled and the number of doses needed to control initiated, when the situation wa . however this agitation. Researchers used statistical analysis to analyze their data fe and effective treatment procedure is not specified, Haloperidol was deemed to be a of delirium symptoms as 534 (91%) of agitation episodes were controlled with one dose. Discussion/ Implications ically asks whether the administration of haloperidol in The PICO question spe: the inpatient, palliative care setting is an appropriate treatment for delirium. All studies point to the fact that delirium needs to be diagnosed in a timely fashion because its occurrence is stressful to the patient, their family, and their caretakers (Agar et al., 2011; van den Boogard et al., 2013; Bush et al., 2014; Crawford et al., 2013; Gongalves et al., 2015). The findings of the integrative review suggest that haloperidol administration in palliative care patients for the treatment of delirium is beneficial, however the benefits ‘ation of delirium is needed so that may only be marginal. Ultimately, quicker identi haloperidol can be administered. Therefore, the findings of the integrative review are a whole. relevant to the PICO question and support it a The implications of this review suggest that more education is needed on the topic of delirium, and how providers can better recognize and diagnose its occurrence in patients receiving palliative care. The nursing community can be more proactive in receiving education about symptoms of delirium and how to manage the condition. This will in turn promote faster identification of patients at a high risk for developing delirium, INTEGRATIVE REVIEW such as patients receiving end-of-life care. Haloperidol can be an effective treatment in this population, however its benefits depend on providers diagnosing delirium rapidly. Limitations The researcher identifies this integrative review does have limitations which influence the review as a whole. The integrative review is a class assignment being conducted exclusively by the researcher. Additionally, the ignment was limited to 5 Journal articles written within the last five years. The project s additionally affected by the inexperience of the researcher as this is the researcher's first effort in completing an integrative review. Conelus on An integrative review of 5 articles shows that haloperidol continues to be the cornerstone in the treatment of delirium symptoms in the palliative population. Overall, the researcher identified haloperidol use is benefii | in the management of delirium symptoms. The consensus of healthcare provides report difficulty in assessing and diagnosing delirium, further complicating its pharmacological treatment. To be able to appropriately detect and assess delirium in the palliative care population more education is needed on the subject. Additionally, significant limitations imposed on this researcher could have affected the integrative review. INTEGRATIVE REVIEW References ar, M., Draper, B., Phillips, B., Phillips, P., Collier, A., Harlum, J., Currow, D. (2011). Making decisions about del m: A qualitative comparison of decision making between nurses working in palliative care, aged care, aged care psychiatry and oncology. Palliative Medicine, 26(7), 888-894. doi: 10.1177/026921631141988 van den Boogaard, M., Schoonhoven, L., van Achterberg, T., van der Hoeven, J., Pickers, P. (2013). Haloperidol prophylaxis in critically ill patients with a high risk for delirium. Critical Care, 17(1), 1-11. doi: 10.1186/ee1 1933 Bush, B., Pereira, J., Currow, D., Rabheru, K., Wright, D., Agar, M., Gagnon, P., Breitbart, W., Lawlor, P. (2014). Treating an established episode of delirium in palliative care: Expert opinion and review of the current evidence base with recommendations for future development. Journal of Pain and Symptom Management, 48(2), 231-245. doi: 10.1016.2013.07.018 Crawford, G., Agar, M., Quinn, S., Phillips, J., Litster, C., Michael, N., Doogue, M., Rowett, D., Currow, D. (2013). Pharmacovigilance in hospice/palliative care: net effect of haloperidol for delirium. Journal of Palliative Medicine, 16(11), 1335- 1340, doi:10.1089/jpm.2013.0230 Gongalves, F., Almeida, A., Pereira, S. (2015). A protocol for the control of agitation in palliative care. 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