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Delirium in palliative care

Key points about delirium in palliative care

Delirium refers to a confused mental state that causes disorientation (confusion) and it's common towards the end of life.
There are many causes of delirium in palliative care and often there's more than one reason.
Delirium starts suddenly and can come and go throughout the day and night.
Symptoms include quickly changing mental states and problems with attention, awareness, thinking, memory, feelings or sleep.
If your delirium relates to your medical condition or related causes, treatment will focus on the condition or removing the cause. At the end of life, it will largely focus on symptomatic relief.
Supportive measures can be useful for you or your carers to help manage delirium.

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There are many causes of delirium in palliative care and often there is more than one contributing factor.

Common causes include:

unfamiliar environment in the hospital or hospice
unrelieved and uncontrolled pain
fatigue
pressure sores due to immobility
anxiety or depression
organ failure such as liver or kidney failure
brain metastases or leptomeningeal disease caused by cancer or its treatment
high blood calcium or hypercalcemia
dehydration
biochemical abnormality such as low blood sugar, low blood sodium
low oxygen in your blood (hypoxia)
infection or sepsis
medicines such as amitriptyline, opioids, steroids
urinary retention (difficulty completely emptying your bladder)
constipation
withdrawal from drugs such as nicotine, opioids and alcohol
prolonged seizures (status epilepticus).

Sometimes it has no causes, especially in the last weeks to hours of life.

The symptoms of delirium often start suddenly and fluctuate throughout the day and night.

Signs and symptoms include:

not being aware of the correct time and place
poor concentration and short-term memory
a disturbed sleep-wake cycle, including sleeping in the day
hallucinations (seeing or hearing things that aren’t there) or delusions (false beliefs)
being upset, confused or anxious
being withdrawn and drowsy
an unsteady walk or a tremor
loss of bowel or bladder control.

There are 3 types of delirium:

hyperactive – increased arousal, restless and agitated
hypoactive – quiet, withdrawn, inactive and sleepy
mixed – mixed pattern.

Your doctor will want to find out the underlying cause of your delirium, so will ask about your symptoms and your medical history, including gathering information from your carers, family/whānau members and friends.

Your doctor may also do a physical examination and carry out tests, such as blood and urine tests, to better understand what is causing your symptoms.

If your delirium relates to your medical condition or the related causes listed above, treatment focuses on the condition or removing the cause.

In some cases delirium may not be reversible, eg, when delirium occurs in the last few days or hours of life. This happens when a disease has advanced to a point where there is no suitable treatment, such as with multiple organ failure. The treatment of delirium in these cases largely focuses on symptomatic relief and supportive measures.

There are a number of supportive measures that can be useful for you or someone you are caring for to help manage delirium. These include:

reminders of the time or day, such as clocks and calendars
making sure hearing aids and glasses are nearby
moderate light, noise and temperature levels
plenty of rest and no over-stimulation
enough sleep, healthy food, water, movement and regular use of the toilet
providing reassurance, support and comfort as much as possible
removing dangerous objects such as knives, razors or cigarettes lighters
providing a quiet area or room in the hospital and limiting the staff taking care of the patient.

Your doctor may prescribe some medicines such as haloperidol and other calming medicines to help manage delirium if needed. If your are nearing the end of life, some of these medicines may be given to you via subcutaneous injection (under your skin) or a syringe driver. Read more about syringe drivers.

Delirium can be a frustrating and distressing experience. Talk through your feelings with your family/whānau and friends to get the support you need.

Below are some support services and information for people affected by cancer and their family/whānau:

Emotions and cancer(external link) Cancer Society, NZ
How we can help(external link) Cancer Society, NZ
NZ cancer services – find a hospital/service near you(external link) Healthpoint NZ
More cancer support groups

The following links provide further information about delirium in palliative care. Be aware that websites from other countries may have information that differs from New Zealand recommendations.

Delirium(external link) Marie Curie, UK
Managing the symptoms of cancer(external link) Macmillan Cancer Support, UK

Resources

Delirium information for patients, family and friends(external link) Waitematā DHB, NZ, 2019
THINKdelirium(external link) Canterbury District Health Board, 2016
Agitation and restlessness(external link) Mercy Hospice, NZ, 2019
Managing the symptoms of cancer(external link) Macmillan Cancer Support, UK, 2016

References

Delirium(external link) Auckland HealthPathways, NZ
Delirium(external link) Marie Curie, UK
Delirium(external link) Scottish Palliative Care Guidelines, UK

Video: Improving Delirium Management in Palliative Care

Dr. Shirley H. Bush provides an overview of delirium in palliative care, and also presents recent research on emerging medications for the prevention and management of delirium in palliative care populations. This video may take a few moments to load.

(Mobile Health, NZ, 2021)