Here are the first ten tips that came to mind for the management of delirium in specialist palliative care.* Of course, there are many more to list. Please share your top tips in the comments.
- Keep people mobile as possible & try to conserve sleep-wake cycle (not sleeping all day).
- Monitor for constipation, urinary retention and pain.
- Get to know the person. Preferred name, likes and habits. Familiar faces help.
- Delirium is distressing to the person, family and staff. Educate, educate, educate.
- Use antipsychotics JUDICIOUSLY, only if non-pharmacological methods haven’t worked.
- Benzodiazepines worsen delirium. So do anticholinergics.
- It’s not all “terminal delirium” – don’t miss potentially reversible delirium.
- Delirium is commonly missed, misdiagnosed (eg as depression or dying) or mismanaged.
- Every bed move, especially after hours, increases risk of delirium. Common in hospitals.
- Check out
@meera_agar@AnnmarieHosie for Aussie research on delirium in palliative care.
*in 140 characters, the length of a ‘tweet’
For an introduction to delirium, see Monday’s post “Delirium: Why we should (palliative) care” for a great 5-minute video
For a personal account of caring for a loved one with delirium, plus links to the new Australian Delirium Clinical Care Standard, read Michael’s story, “The fear on his face was palpable”
If you’re a medical doctor and would like to learn more about delirium in palliative care from the experts (ie not me), check out the #ANZSPM16 Conference in Perth in Septembe
If you prefer audio, listen to a recent BMJ SoundCloud on Delirium & agitation at the end of life
palliverse.com 
Hey Elissa, thanks for that amazing post. What is the evidence for melatonin in managing the sleep wake cycle in delirium? I am wary of using benzos to aid sleep for obvious reasons… thanks, sonia
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Hi Sonia…amazing! Hahaha.
Good question for which I don’t have an answer. I share your concerns about benzos (especially as the new delirium clinical care standard specifically warns against their use in delirium). There’s a lot of research going on, including a couple of trials in WA (in the cardiothoracic/ICU setting rather than palliative care). Also there were some melatonin abstracts presented at the recent Australasian Delirium Association. I guess the answer is…watch this space.
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It’s a very attractive idea, but melatonin is not on my hospital formulary yet so I (** my junior doctors**) have to fill out paperwork each time. Curses!
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Same for me! Not on our formulary but it is on the formulary at the other public hopsital down the road. Really I should do the paperwork to get it on the formulary. It’s relatively inexpensive (compared to, say, antipsychotics or mirtazapine, which I’ve seen used off-label for sleep).
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I use mirtazapine off label for sleep (at 15 mg) quite a lot. Tends to work less as you go higher….
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Thanks Elissa. Great post on an important topic. I completely share your view that the focus is too often on medicines rather than the other aspects of care for persons with delirium. Do you feel that the approach in geriatrics is a little different than that in palliative care, particularly pharmacotherapy?
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The approach is definitely different. In palliative care I think the we intuitively want to relieve distressing symptoms as quickly as possible, and this usually means medication. I think that hyperactive delirium is often prematurely labelled as ‘terminal restlessness’, when it may well be reversible – particularly in people with dementia and other conditions with a similar trajectory. On the plus side, palliative care is a person-centred specialty, and that is one of the most important aspects of delirium management. Knowing the person, their preferred name, their family, their habits, their favourite music…Both specialties can learn from each other!
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