Delirium

Key points

• Delirium is frequent in palliative care patients, and its incidence increases as death approaches. Hypoactive delirium is particularly common, and may be misdiagnosed as depression, dementia or fatigue. Onset can be acute or subacute.
• Patient’s families often sensitively detect changes in the person’s mental functioning, and their concerns should be followed up. Delirium is an important diagnosis to make, and to explain to patient and family. Non-specific language ('muddled', 'agitated' etc) should be avoided.
• Delirium in a palliative care patient is usually multifactorial. Consideration of the reversible contributors is important. However, in many patients not all causes can be treated.
• Patients with pre-existing cognitive problems, central nervous system (CNS) pathology, or dementia are at very high risk for delirium.

Assessment

• Rapid onset of changes in attention or cognitive function, sleep-wake cycle alteration, and/or fluctuating mental state should be considered delirium until proven otherwise.
• Ask when the patient was last functioning 'as normal' and when that changed. In an acute presentation, the onset will often be identifiable.

Approach to management

• Educate and reassure both patient and family about the nature of the problem.
• Manage precipitants as appropriate to the context. This usually includes reviewing medications, identifying infection, improving hydration, and attention to the environment of the patient (familiar, calm, non-threatening, safe).
• Pharmacological management with an antipsychotic should be considered if the patient is distressed or agitated.
• Monitor the safety of the patient and caregivers. Delirium may be a very difficult problem in the home environment, its progression is unpredictable, and admission is frequently required.