Agitation and Delirium at the End of Life

Abstract

Delirium is the most common neuropsychiatric complication experienced by patients with advanced illness, occurring in up to 85% of patients in the last weeks of life. Using the case of Mr L, a 59-year-old man with metastatic lung cancer who developed an agitated delirium in the last week of life, we review the evaluation and management of delirium near the end of life. Although some studies have identified agitation as a central feature of delirium in 13% to 46% of patients, other studies have found up to 80% of patients near the end of life develop a hypoactive, nonagitated delirium. Both the agitated (hyperactive) and nonagitated (hypoactive) forms of delirium are harbingers of impending death and are associated with increased morbidity in patients who are terminally ill, causing distress for patients, family members, and staff. Delirium is a sign of significant physiological disturbance, usually involving multiple causes, including infection, organ failure, and medication adverse effects. Often these causes of delirium are not reversible in the dying patient, and this influences the outcomes of its management. Delirium can also significantly interfere with the recognition and control of other physical and psychological symptoms, such as pain. Unfortunately, delirium is often misdiagnosed or unrecognized and thus inappropriately treated or untreated in terminally ill patients. To manage delirium in terminally ill patients, clinicians must be able to diagnose it accurately, undertake appropriate assessment of underlying causes, and understand the benefits and risks of the available pharmacological and nonpharmacological interventions.

Sleep Quality and Its Association With Delirium Among Veterans Enrolled in Hospice

“…For example, noting changes in sleep quality may prompt earlier recognition and treatment of other causes of delirium, such as evaluating the patient for other causes of delirium such as dehydration, infection, pain, respiratory insufficiency, or adverse reactions to medications (11, 12), and more attention and intervention for improving sleep quality. Also, witnessing a loved one with delirium is very stressful for caregivers (15). Utilizing a change in sleep quality as an opportunity to counsel patients and caregivers on the potential development of delirium in the subsequent weeks may reduce caregiver stress.…”

Palliative Care and Symptom Management in Older Patients with Cancer

“…The prevalence of delirium in cancer ranges from 20–40% in the hospitalized patient and can be as high as 88% in the terminally ill patient with cancer. (30) The development of delirium may be an indicator of impending death in patients who are terminally ill.…”

Validity of the Delirium Observation Screening Scale in Identifying Delirium in Home Hospice Patients

“…5 Within the hospice setting, delirium is believed to be prevalent, challenging to assess, under-recognized, and undertreated. In addition to being associated with significant morbidity 8–11 and mortality, 12,13 when delirium is not recognized, lack of treatment can result in increased suffering for the patient, their family, and caregivers.…”