Delirium in palliative care

Key points about delirium in palliative care 

  • Delirium refers to a confused mental state that causes disorientation (confusion) and it's common towards the end of life. 
  • There are many causes of delirium in palliative care and often there's more than one reason.
  • Delirium starts suddenly and can come and go throughout the day and night.
  • Symptoms include quickly changing mental states and problems with attention, awareness, thinking, memory, feelings or sleep.
  • If your delirium relates to your medical condition or related causes, treatment will focus on the condition or removing the cause. At the end of life, it will largely focus on symptomatic relief. 
  • Supportive measures can be useful for you or your carers to help manage delirium.
Older man looking confused canva 950x690
Print this page

There are many causes of delirium in palliative care and often there is more than one contributing factor. 

Common causes include:

  • unfamiliar environment in the hospital or hospice
  • unrelieved and uncontrolled pain 
  • fatigue
  • pressure sores due to immobility
  • anxiety or depression
  • organ failure such as liver or kidney failure
  • brain metastases or leptomeningeal disease caused by cancer or its treatment
  • high blood calcium or hypercalcemia 
  • dehydration
  • biochemical abnormality such as low blood sugar, low blood sodium 
  • low oxygen in your blood (hypoxia)
  • infection or sepsis
  • medicines such as amitriptyline, opioids, steroids
  • urinary retention (difficulty completely emptying your bladder)
  • constipation
  • withdrawal from drugs such as nicotine, opioids and alcohol
  • prolonged seizures (status epilepticus).

Sometimes it has no causes, especially in the last weeks to hours of life. 

The symptoms of delirium often start suddenly and fluctuate throughout the day and night. 

Signs and symptoms include:

  • not being aware of the correct time and place
  • poor concentration and short-term memory
  • a disturbed sleep-wake cycle, including sleeping in the day
  • hallucinations (seeing or hearing things that aren’t there) or delusions (false beliefs)
  • being upset, confused or anxious
  • being withdrawn and drowsy
  • an unsteady walk or a tremor
  • loss of bowel or bladder control.

There are 3 types of delirium:

  • hyperactive – increased arousal, restless and agitated
  • hypoactive – quiet, withdrawn, inactive and sleepy
  • mixed – mixed pattern.

Your doctor will want to find out the underlying cause of your delirium, so will ask about your symptoms and your medical history, including gathering information from your carers, family/whānau members and friends.

Your doctor may also do a physical examination and carry out tests, such as blood and urine tests, to better understand what is causing your symptoms. 

If your delirium relates to your medical condition or the related causes listed above, treatment focuses on the condition or removing the cause. 

In some cases delirium may not be reversible, eg, when delirium occurs in the last few days or hours of life. This happens when a disease has advanced to a point where there is no suitable treatment, such as with multiple organ failure. The treatment of delirium in these cases largely focuses on symptomatic relief and supportive measures. 

There are a number of supportive measures that can be useful for you or someone you are caring for to help manage delirium. These include:

  • reminders of the time or day, such as clocks and calendars
  • making sure hearing aids and glasses are nearby
  • moderate light, noise and temperature levels
  • plenty of rest and no over-stimulation
  • enough sleep, healthy food, water, movement and regular use of the toilet
  • providing reassurance, support and comfort as much as possible
  • removing dangerous objects such as knives, razors or cigarettes lighters
  • providing a quiet area or room in the hospital and limiting the staff taking care of the patient.

Your doctor may prescribe some medicines such as haloperidol and other calming medicines to help manage delirium if needed. If your are nearing the end of life, some of these medicines may be given to you via subcutaneous injection (under your skin) or a syringe driver. Read more about syringe drivers

Delirium can be a frustrating and distressing experience. Talk through your feelings with your family/whānau and friends to get the support you need.  

Below are some support services and information for people affected by cancer and their family/whānau:

Emotions and cancer(external link) Cancer Society, NZ
How we can help(external link) Cancer Society, NZ
NZ cancer services – find a hospital/service near you(external link) Healthpoint NZ
More cancer support groups

The following links provide further information about delirium in palliative care. Be aware that websites from other countries may have information that differs from New Zealand recommendations.

Delirium(external link) Marie Curie, UK
Managing the symptoms of cancer(external link) Macmillan Cancer Support, UK


Delirium information for patients, family and friends(external link) Waitematā DHB, NZ, 2019
THINKdelirium(external link) Canterbury District Health Board, 2016
Agitation and restlessness(external link) Mercy Hospice, NZ, 2019
Managing the symptoms of cancer(external link) Macmillan Cancer Support, UK, 2016


Video: Improving Delirium Management in Palliative Care

Dr. Shirley H. Bush provides an overview of delirium in palliative care, and also presents recent research on emerging medications for the prevention and management of delirium in palliative care populations. This video may take a few moments to load.

(Mobile Health, NZ, 2021)

See our page Palliative care for healthcare providers



THINK delirium
Canterbury District Health Board, 2016

Agitation and restlessness

Agitation and restlessness
Mercy Hospice, NZ, 2019

Need help now?

Healthline logo in supporters block

Need to talk logo

Healthpoint logo

Credits: Healthify editorial team. Healthify is brought to you by Health Navigator Charitable Trust.

Reviewed by: Jarna Standen, Registered Nurse, Mercy Hospice, Auckland

Last reviewed:

Page last updated: