Delirium refers to a confused mental state that causes disorientation (confusion). This page focuses on delirium in palliative care.
Key points about delirium in palliative care
- Delirium is common towards the end of life. There are many causes of delirium in palliative care and often there is more than one contributing factor.
- 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.
- There are a number of supportive measures that can be useful for you or your carers to help manage delirium.
What are the causes of delirium?
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
- 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
- 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)
- 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.
What are the symptoms of delirium?
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- being withdrawn and drowsy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.
What are the different types of delirium?
There are 3 types of delirium:
- hyperactive – increased arousal, restless and agitated
- hypoactive – quiet, withdrawn, inactive and sleepy
- mixed – mixed pattern.
How is delirium diagnosed?
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.
How is delirium treated?
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.
What support is available with delirium?
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 & cancer Cancer Society, NZ
How we can help Cancer Society, NZ
NZ cancer services – find a hospital/service near you Healthpoint
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.