Delirium may develop quickly; its severity may fluctuate over the course of the day. Various medical conditions and some medications may induce delirium.
Major symptoms of delirium include:
Source: Breitbart and Sparrow, 1998
Many seriously ill and dying patients experience “meaningful delirium,” in which they have visions or see long-dead family members. Such hallucinations can be very comforting, not only to patients but also to caregivers. Unfortunately, comforting hallucinations can sometimes quickly become terrifying ones, and health care professionals need to be alert to the importance of treating or managing delirium.
Like depression, delirium puts the dying at risk for other physical problems. With delirium, patients are at increased risk for dehydration, malnutrition, untreated pain, pressure ulcers, and a host of other problems. Rates of delirium increase with the severity of illness - and near the end of life - meaning that in the final days of life, when delirium takes the form of terminal restlessness or agitation, it may not be reversible.
Delirium and dementia share similar symptoms. Unlike dementia, delirium can sometimes be reversed, permitting patients to be awake, alert, calm, and coherent. But reversing delirium can be a long process, especially in people who are very sick or old.
Clinicians may find it hard to differentiate between depression, dementia, and delirium. In fact, doctors may overlook delirium almost half the time, either because they do not see the symptoms during brief encounters with patients or because the symptoms are attributed to age or dementia. Dementia may be long-standing but, in mild cases, not evident, complicating the diagnosis and treatment of either depression or delirium.
Because delirium, like depression, is a treatable cause of suffering at the end of life, quality improvement teams can work with clinicians to promote assessment and treatment. As with the strategies described in earlier chapters (on pain, dyspnea, and so on), teams can develop projects that increase assessment, educate clinicians and families, and track patient improvement.
One quality improvement activity is simply to assess and treat patients for delirium. As with depression, begin by selecting a unit, team, or ward on which to begin such assessments, which include the following elements:
Obviously, for patients in the final stage of life, the goal is to avoid further invasive procedures. Still, by assessing all patients in a particular ward or unit, current practice patterns - and deficiencies - will become clear, and strategies for improvement can begin to be developed.
Patients with delirium are often treated with haloperidol, which is used most often for hallucinations. Thioridazine and chlorpromazine are also used. Lorazepam may be used with haloperidol to sedate an agitated patient rapidly.
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].