Waikato DHB Palliative Care Guidelines

14. Delirium

Delirium is a global disorder of cognition and attention with disorientation and often visual hallucinations.

There can be increased OR decreased psychomotor activity, altered sleep-wake cycle and fluctuating impairment of consciousness.

Often rapid onset and fluctuating course over the day.

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There is a HIGH mortality rate in Palliative Care patients and delirium is often part of the terminal process.

It is essential to differentiate between delirium, dementia and restlessness.

Causes can include:

Unfamiliar excessive stimuli/ Change of environment
Pain/ Fatigue/ Pressure areas
Anxiety/Depression
Organ Failure e.g. Hepatic, Renal
Brain Metastases/ Leptomeningeal Disease
Hypercalcaemia/ Dehydration/ Biochemical Abnormality
Infection/ Sepsis
Drug toxicity e.g. amitriptyline, opioids, steroids
Urinary retention/ faecal impaction/ Constipation
Drug, Alcohol or Nicotine withdrawal
Hypoxia.

Management

Explanation to patient and family as to the nature of the problem and all that is being undertaken is vital.

Patients describe the “experience” of delirium as extremely distressing.

Minimise staff changes and encourage the presence of family members where possible. Ensure a calm environment with frequent re-orientating measures.

Investigate and treat underlying cause(s).

CT Brain is rarely indicated in the first instance.

Remove or reduce drugs with known CNS effects if clinically appropriate.

Sedation with benzodiazepines should be AVOIDED initially as they often exacerbate the condition.

If the patient is symptomatic (nocturnal confusion, agitation, aggression, hallucinations, paranoia etc) and where there are no immediately reversible causes the best treatment is HALOPERIDOL.

Haloperidol 2.5mg subcut stat and repeat after 30 minutes if necessary - this dose can then be doubled after a further 30 minutes if the patient is not settled.
Large doses may be required (10-20mg/24hours subcut) to achieve a response.
Aim for a regular bd dose or a continuous subcut infusion.

Note: In severe or complicated cases, an urgent referral to Palliative Care Service is recommended.

For Guidelines on Delirium and Confusion

Information last reviewed: June 2009	Please foward any enquiries about this document to haggars@waikatodhb.govt.nz
Next review date: July 2010	For Palliative Care advice, please call 8691 or the specialist on-call.

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