First Do No Harm… Terminal Restlessness or Drug-Induced Delirium

Abstract

Terminal restlessness is a term frequently used to refer to a clinical spectrum of unsettled behaviors in the last few days of life. Because there are many similarities between the clinical pictures observed in terminal restlessness and delirium, we postulate that at times what is referred to as terminal restlessness may actually be an acute delirium sometimes caused by medication used for symptom control. It is important therefore to consider the causes for this distressing clinical entity, treat it appropriately, and ensure the treatment provided does not increase its severity. This brief review aims to consider the medications that are commonly used toward the end of life that may result in a picture of delirium (or terminal restlessness). These include opioids, antisecretory agents, anxiolytics, antidepressants, antipsychotics, antiepileptics, steroids and nonsteroidal anti-inflammatory drugs (NSAIDs). This review also aims to raise awareness regarding the recognition and diagnosis of delirium and to highlight the fact that delirium may be reversible in up to half of all cases. Good management of delirium has the potential to significantly improve patient care at the end of life.

The Use of Palliative Sedation for Existential Distress: A Psychiatric Perspective

“…18 Delirium can, indeed, complicate the evaluation of patients with marked distress at the end of life, 19 but clearly not all unusual thoughts, affects, or behaviors at the end of life are due to delirium. A diagnosis of delirium (defined as an inability to maintain a coherent stream of thought) can be aided by serial mental status exams and an EEG looking for slowing and disorganization of posterior electrical activity.…”

A Review of the Etiology Delirium

“…The causal association of drugs to delirium is most clear for anticholinergic drugs with muscarine receptor affinity (White et al, 2007). Antihistaminics, antipsychotics, tricyclic antidepressants, digoxin, frusemide, isosorbide dinitrate, warfarin, dipyridamole, codeine, and captopril are among the mostly used d u r s t h a t h a v e p r i m a r y o r s e c o n d a r y anticholinergic effects contributing to risk of delirium (Burns, 2004,).…”

“…All tricyclic antidepressants have an anticholinergic effect, with amitryptiline having the strongest and nortriptyline the weakest (White et al, 2007). Delirium has been reported to develope after abrupt discontinuation of fluoxetine (Blum et al, 2008) and with concominant use of fluoxetine and lamotrigine (Chistyakova & Amos, 2008).…”

Predictive Factors for Agitation Severity of Hyperactive Delirium in Terminally Ill Cancer Patients in a General Hospital Using Ordered Logistic Regression Analysis

“…6 From a behavioral point of view, delirium can be classified as hypoactive; hyperactive (i.e., associated with the hypovigilant or hypervigilant level of consciousness); or mixed. 6 In terminally ill cancer patients, delirium can be induced by several factors, such as metabolic disturbance, organ failure, and drugs; [6][7][8] and the same factors disturb recovery. Even though it is difficult to treat delirium in this population, pharmacological treatments using antipsychotics and/or sedative drugs may be appropriate for agitated delirium, because the condition may cause severe distress for both patients and family members.…”