Terminal delirium

Definition and subtypes

Delirium occurring in the last days of life, often (but not always) irreversible
Presents as hyperactive (agitation, hallucinations - most distressing to witness), hypoactive (withdrawn, reduced arousal - frequently missed), or mixed
Distinct from "terminal restlessness" only by definition overlap - many clinicians use the terms interchangeably, but delirium implies a formal cognitive disturbance with fluctuating course

Extremely common - occurs in up to 80-90% of patients in the final 24-48 hours of life
Under-recognised, especially the hypoactive form, which is more prevalent than hyperactive delirium

Multifactorial - organ failure (hepatic, renal), hypoxia, hypercalcaemia, sepsis, dehydration, medication (opioid accumulation, especially with renal impairment), urinary retention, faecal impaction, uncontrolled pain, primary or secondary brain involvement
Near end of life, causes are often multiple and only partially reversible - the dying process itself contributes
Distinguish from normal decreased consciousness of dying (progressive, non-fluctuating drowsiness without agitation) - delirium has a fluctuating course and disturbed attention/awareness

Clinical - acute onset, fluctuating course, inattention, altered consciousness/cognition (DSM-5/CAM criteria as for delirium generally)
Screen for and treat reversible contributors where consistent with goals of care: urinary retention (bladder scan), faecal impaction (PR exam), pain, opioid toxicity, hypercalcaemia, hypoxia
Distinguish hypoactive delirium from normal end-of-life drowsiness - and from terminal restlessness/agitation without formal cognitive change
Extensive investigation is rarely appropriate this close to death unless a reversible cause is genuinely suspected and treatment would be pursued

Treat pain, empty the bladder/bowel, reduce/rotate opioid if toxicity suspected, correct hypercalcaemia if goals of care support it
Reduce polypharmacy - stop non-essential deliriogenic drugs

2. Non-pharmacological measures - first-line for mild-moderate symptoms

Calm, well-lit, familiar environment; reorientation; consistent staff/family presence; minimise unnecessary interventions and noise
Reassure and educate family - delirium at end of life is common and does not necessarily mean uncontrolled suffering

Antipsychotics (haloperidol first-line by convention) have NOT been shown to reduce delirium severity or duration in terminal delirium, and a landmark RCT found risperidone/haloperidol WORSENED symptoms compared with placebo in mild-moderate terminal delirium
- Reserve antipsychotics for distressing agitation/hallucinations where symptom relief, not delirium resolution, is the goal
Benzodiazepines - reasonable where sedation itself is the goal (e.g. severe refractory agitation, or when combined with an antipsychotic for added agitation control), but can worsen delirium/paradoxically disinhibit in some patients
Use the lowest effective dose, review regularly, and set explicit goals (comfort, not cure) with the family
Refractory, intolerable symptoms despite optimised measures -> palliative sedation discussion per local policy and with appropriate consent/family involvement

Falls, injury during agitated episodes
Significant family and staff distress - often more distressing to witness than to the patient
Communication breakdown at a critical time for the patient/family relationship

Terminal delirium in the last 24-48 hours of life is frequently irreversible despite treatment of contributing factors
Presence of terminal delirium is itself a poor prognostic marker, signalling proximity to death
Goal of care shifts from resolving delirium to ensuring comfort and supporting family through a distressing but common part of the dying process

8 more sections, plus exam facts

Premium unlocks every note across every specialty, and the full exam fact library behind it.