Delirium in palliative care

Delirium is a confused or disorientated mental state. It's common for people who are nearing the end of their life.

It can come on quickly and can come and go during the day or the night. Delirium can produce problems with attention, awareness, thinking, memory, feelings or sleep.

Causes of delirium

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• being withdrawn and drowsy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• Hypoactive – quiet, withdrawn, inactive and sleepy.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 healthcare team 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, whānau and friends.

Your healthcare provider may also do a physical examination and carry out tests, such as blood and urine tests, to better understand what's 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. 

For some people 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. At tis point, treatment mainly focuses on relief of symptoms and giving support.  

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

• using reminders of the time or day, such as clocks and calendars
• making sure hearing aids and glasses are nearby
• keeping light, noise and temperature at moderate 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
• for those in hospital, providing a quiet area or room and limiting the staff taking care of the person.

Your doctor may prescribe some medicines such as haloperidol and other calming medicines to help manage delirium if needed. If you're 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. 

Managing delirium and psychological symptoms in the last few days of life(external link) BPAC, NZ, 2023

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. 



(Mobile Health, NZ, 2021)

See our page Palliative care for healthcare providers