Delirium is a syndrome of abrupt fluctuating disturbances in attention and awareness that represents a change from baseline status. It is typified by cognitive dysfunction along with changes in psychomotor behaviour, mood, sleep-wake cycle, and may include hallucinations. Delirium can be either hypoactive, hyperactive, or mixed. It is a common phenomenon in palliative care, occurring in anywhere from 20% to 88% of cancer patients.
Although delirium often occurs 24 to 48 hours before death, it should not be considered a normal part of the dying process. Management of delirium symptoms may allow for a more peaceful death. Prompt recognition and treatment of delirium is essential to improve patient and family outcomes.
Essentials
Establish goals of care in consultation and conversation with the patient, family, and care team.
Prevent over-stimulation and promote relaxation.
Avoid the use of physical restraints as they can increase the risk of delirium.
Referral Information
All palliative and end-of-life patients can be considered for inclusion in the Palliative Care Clinical Pathway (treat and refer) approach to care. Paramedics must complete required training prior to applying this pathway. EMRs are required to contact CliniCall for consultation to proceed with the ASTaR clinical pathway.
General Information
The signs and symptoms of hyperactive delirium may include:
Attention disturbances
Restlessness and agitation
Hallucinations
Signs and symptoms of hypoactive delirium may include:
Drowsiness
Emotional or physical withdrawal
Depression
Lethargy
Decreased levels of consciousness
Common causes of delirium:
Sepsis
Metabolic or electrolyte disturbances
Hypoxia
Organ failure
Withdrawal from alcohol or medications
Unmanaged or undermanaged pain
Sleep deprivation
Constipation or urinary retention
Dehydration
Changes to the patient’s environment or psychosocial situation
Interventions
First Responder (FR) Interventions
Provide reassurance
Provide supplemental oxygen if hypoxia is a potential cause of delirium
Prevent over-stimulation and promote relaxation; consider repositioning
Emergency Medical Responder (EMR) & All License Levels Interventions
Establish goals of care in consultation and conversation with the patient, family, and care team
Prevent over-stimulation and promote relaxation; consider repositioning
Reassure the patient
Primary Care Paramedic (PCP) Interventions
Assist family with the administration of any medications that are recommended as part of an established care plan
Paramedics can only administer the patient’s own medications where the symptom management plan is clear, they are trained and experienced in the technique of administration, and are operating within BCEHS scope
If the patient has delirium and agitation that is moderate to severe (RASS +2 to +4), is unmanageable, pose concerns of harm to self/caregivers, and/or is causing distress to the patient and family:
Patients requiring MIDAZOLam or ketAMINE for management of agitation should have a follow-up from their palliative care team; if care team unable to attend within an acceptable time frame, consider conveyance to hospital for further support