Delirium in palliative care
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Delirium is a serious and very common condition in patients receiving palliative care, especially towards the end of life. It can be very distressing for the patient and those close to them, but there are ways you can support them. It can help to recognise delirium quickly and identify any potentially reversible causes.
On this page:
What is delirium?
Delirium is confusion that comes on suddenly, over days or hours. It's sometimes called 'acute confusional state'.
Signs and symptoms of delirium
Patients with delirium might experience:
- restlessness and agitation
- sleepiness
- confusion
- memory problems
- disorientation (being unable to recognise familiar people, not knowing where they are or what the time and date is)
- hallucinations (seeing or hearing things that aren't there)
- paranoia (worrying people are trying to harm them)
- poor concentration
- reduced appetite
- temporary change in personality
- disturbed sleep (being awake at night and sleepy during the day).
A patient may have some or all these symptoms. Their symptoms might change over time, or get better or worse throughout the day and night. For some patients delirium will only last for a few hours, but for others it might last days or weeks.
Types of delirium
There are three types of delirium:
- Hyperactive delirium – the patient may be restless, agitated, or aggressive.
- Hypoactive delirium – the patient may be withdrawn, quiet and sleepy.
- Mixed delirium – the patient has a mixture of hyperactive and hypoactive symptoms.
Hypoactive delirium is the most common type in people with a terminal illness. And it's more difficult to recognise than other types of delirium. It's sometimes mistaken for depression, fatigue or dementia, or it might not be noticed at all. This can mean delirium goes undiagnosed and untreated, or is diagnosed late.
What is the difference between dementia and delirium?
The symptoms of dementia come on slowly and develop over months and years, whereas the symptoms of delirium develop over a few days, or hours. Some patients may have both dementia and delirium – delirium is common in people with advanced dementia. Some symptoms of delirium are similar to those of dementia, and it can be difficult to tell the two apart.
People with dementia are more likely to develop delirium. If the patient has not been diagnosed with dementia and you think they may have it, speak to someone who knows the patient well. Find out more about their symptoms, and talk to their GP or specialist nurse.
Agitation and delirium
Agitation is a common symptom of delirium. However, patients can become agitated without having delirium.
Agitation can be caused by other problems. If the patient is agitated, try to find out whether they have untreated symptoms, such as pain, constipation, breathlessness or urinary retention.
Delirium in the last few days of life can cause agitation or restlessness. This is sometimes called terminal restlessness or terminal agitation.
Read more about terminal agitation.
Causes of delirium
There are many causes of delirium and patients will often have more than one.
Common causes include:
- medications, including opioid painkillers and steroids
- withdrawal from drugs, including alcohol, nicotine, sedatives and antidepressants
- infections
- constipation
- urinary retention (not being able to pass urine)
- dehydration
- organ failure, such as liver or kidney failure
- uncontrolled pain
- hypoxia (not enough oxygen getting to the brain)
- hypercalcaemia (too much calcium in the blood) or hypocalcaemia (not enough calcium in the blood)
- hypernatraemia (too much sodium in the blood) or hyponatraemia (not enough sodium in the blood)
- hypoglycaemia (not enough glucose in the blood) or, rarely, very severe hyperglycaemia (too much glucose in the blood)
- brain cancer
- seizures.
Understanding the cause of delirium can help you identify potential ways to manage it.
Preventing delirium
It's not always possible to prevent delirium, but there are ways to try and reduce the risk of it happening. Many of these steps can be taken by families and carers as well as healthcare professionals. They can also be used to support a patient who has already developed delirium:
- Reassure them if they're worried or frightened.
- Help the patient become familiar with their environment. Make sure they can see a clock and a calendar. If they use them, check that hearing aids and glasses are being used and work well.
- Communicate clearly – try using short sentences and plain language, and make sure the patient understands you.
- Encourage the patient to eat and drink, and if they have dentures make sure they're clean and fit well.
- Support the patient to avoid or manage constipation and urinary retention. Try to avoid using a catheter if possible.
- Encourage a good sleep routine, limiting noise at night.
- Look out for signs of infection.
- Check for signs the patient is in pain, and help to make sure this is being managed.
- Help the patient remain mobile – give them support to walk or do other exercises safely.
- If the patient is taken to hospital or a care home, help to arrange for familiar objects from home to be kept by them. Ask family or carers to complete a 'Getting to know me' or 'This is me' form – these contain things like the patient's preferences.
- Encourage those who know the patient well, to tell healthcare professionals about any changes to the patient's condition or behaviour.
- The patient's healthcare team may review medicines that can increase the risk of delirium.
Detecting delirium
Early detection of delirium can improve the patient's quality of life. It can be helpful to speak to people who know the patient well, as they might notice subtle changes in their behaviour early on.
Healthcare professionals may use screening or assessment tools to help identify delirium quickly, such as the 4AT (the 4 A's Test) .
If you're concerned your patient may have delirium, you should tell their GP or district nurse as soon as possible.
Managing delirium
How the patient's delirium is managed will depend on the cause of delirium, their care preferences, the stage of their illness and overall health. All treatment and care should be given with the patient's informed consent.
If a patient is unable to make decisions about their care, this is known as lacking mental capacity. Any decisions made on the patient's behalf must be in their best interests, and guided by any advance care plans they have made.
Reversible and non-reversible delirium
Delirium may be reversible if it's caused by an infection, urinary retention, or medication. The GP or specialist nurse will check for any underlying and reversible causes. They'll discuss how to manage causes and treatment with the patient and those close to them.
Delirium that develops in the last few days and hours of life may not be reversible, as the cause is usually untreatable like multiple organ failure, or is unknown. Treatment should be focused on supporting the patient's comfort and managing any distressing symptoms.
Non-drug treatment
The ways to help prevent delirium can also be used to support someone who has developed delirium. There are also other non-drug treatment methods:
- Keep the environment calm and quiet.
- Limit change where possible – staff and room changes can be disorienting.
- Make sure someone is with the patient all the time if they're particularly agitated, likely to wander or at risk of falling.
- Enable people close to the patient to visit often (when appropriate) as this can be reassuring for the patient.
- Carry out a risk assessment of the environment to make sure the patient, their carers and those close to them are safe. This could include removing potential hazards such as electrical cords and knives.
Drug treatment
Medicines used in the treatment of delirium include antipsychotics (used to treat mental distress) and benzodiazepines (sedatives). Medicines tend to only be used if the non-drug treatment methods have not worked and:
- the patient is in severe distress, and/or
- the patient is at risk of harming themselves or others.
In these cases, medicines may be used to relieve the patient's distress and help them stay calm. These may make the patient sleepy.
Supporting people close to the patient
Delirium can be distressing for those close to the patient. You can help by:
- describing what delirium is
- explaining what could be causing it
- discussing what might happen next
- explaining how they can support the patient
- asking how they're coping and offering support if needed.
Share our information on delirium for patients and their families and friends.
Useful resources
NICE guideline 103 – Delirium: prevention, diagnosis and management
SIGN guideline 157 – Risk reduction and management of delirium
Key points
- Delirium is common in people with a terminal illness and there are lots of possible causes.
- It can be distressing and frightening for patients and those around them.
- There are ways to reduce the risk of delirium developing.
- Early detection is important – speak to the patient's GP, district nurse or palliative care team if you think a patient has delirium.
- Hypoactive delirium is more common in people with a terminal illness, and more difficult to detect.
- Depending on the cause, delirium may be reversible.
- Towards the end of life delirium may not be reversible, and management should be focused on supporting the patient's comfort and quality of life.
- You can support someone with delirium by keeping their environment safe, calm and quiet and by helping to orientate them in place and time.
- There are ways for those close to the patient to be involved in supporting them.
- People close to the patient may be in distress and need support.
Let us know what you think
Email your feedback to knowledgezone@mariecurie.org.uk
Disclaimer
This information is not intended to replace any training, national or local guidelines, or advice from other health or social care professionals.
The Palliative Care Knowledge Zone is not intended for use by people living with a terminal illness or their family and friends, who should access our information for the public.
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