DELIRIUM ASSESSMENT Establish the patient’s situation , the likely underlying cause(s) of the delirium , and whether it is potentially reversible, or not . Delirium is irreversible if 1) the patient is actively dying, 2) the patient's goals of care focus on symptom management and not treating the underlying cause(s), and 3) time-limited therapeutic trial(s) have failed to reverse the underlying cause of the delirium. Common Causes Terminal Delirium Assessment Diagnostic Workup Reversible causes found in 50% • Constipation • Urinary retention • Fluid and/or metabolic imbalance An irreversible delirium during the active dying process; a prospective diagnosis Signs of Active Dying: Cardiac Failure:
Test for impairments in: • Attention • Cognition • Consciousness • Reality, perceptions • Behavior Determine subtype: Hyperactive • Behavioral disturbances • Increased motor activity • Hallucinations
Consistent with context and goals. Look for common causes and reversibility. Start with: • History & physical • Cognitive status • Allergies, adverse reactions • Review medication history, including dosage changes over time • Alcohol and/or benzodiazepine use or withdrawal • Chemistry and hematological workup • Infection workup • Vitamin levels
• Medications, e.g., opioids, benzodiazepines, steroids, anticholinergics • Infections, e.g. urinary tract infection, pneumonia • Hepatic or renal failure • Hypoxia • Hematological disturbances, e.g., anemia
• Cyanosis, venous pooling, mottling, peripheral cooling • Oliguria, anuria Neurological Changes: • Decreasing consciousness • Changes in breathing, e.g. decreasing tidal volume, apnea, Cheyne-Stokes respirations, agonal breathing • Loss of gait, inability to swallow
• Delusions Hypoactive
• Decreased consciousness • Decreased motor activity • Often mistaken for depression
• Oral, tracheal secretions • Loss of sphincter control
Irwin et al. J Palliat Med 2013. PMID: 23480299. Used with Permission
25 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024
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