8.2 Delirium and Terminal Restlessness
Key Takeaways
- Delirium is hyperactive, hypoactive, or mixed; hypoactive delirium is common in palliative care and is the type most often missed.
- The Confusion Assessment Method requires acute onset with fluctuation plus inattention, and either disorganized thinking or altered consciousness.
- High-yield reversible causes include urinary tract infection, hypoxia, constipation, urinary retention, medications, and hypercalcemia.
- Haloperidol is first-line for distressing delirium in many hospice protocols; benzodiazepines often worsen delirium except when the patient is dying, catatonic, seizing, or in alcohol withdrawal.
- Terminal agitation is not a diagnosis of exclusion until pain, retention, and other reversible drivers have been considered; teach families that delirium is a medical symptom.
Delirium is a symptom, not a personality change
Delirium is an acute disturbance of attention and awareness that fluctuates. It is one of the highest-yield non-pain symptoms in Domain 3 because it distresses families, predicts nearer death, and is often partly reversible even in hospice. CHPN items punish two errors: missing hypoactive delirium, and treating every moan in the last hours as "terminal restlessness" without looking for pain or a full bladder.
Motor subtypes
| Subtype | What you see | Exam trap |
|---|---|---|
| Hyperactive | Agitation, picking, pulling at clothes or catheters, hallucinations, climbing | Easy to notice; easy to over-sedate |
| Hypoactive | Withdrawal, sparse speech, drowsiness, poor eye contact, still inattentive | Looks like "tired" or "depressed"; most often missed |
| Mixed | Fluctuates between the two across the day | Night agitation with daytime sleepiness is still delirium |
Hypoactive delirium is more common in palliative and hospital populations than the shouting picture families expect. A quiet patient who cannot follow a simple instruction is not "peacefully sleeping it off" until you have assessed attention.
Confusion Assessment Method (CAM) features
The Confusion Assessment Method (CAM) is the bedside frame CHPN expects you to know conceptually:
- Acute onset and fluctuating course, and
- Inattention (cannot focus, loses the thread, cannot count or recite months backward),
plus either
- Disorganized thinking, or
- Altered level of consciousness (hyperalert or drowsy).
You need features 1 and 2, plus 3 or 4. Chronic dementia can coexist, but dementia alone is not CAM-positive unless something new and fluctuating has been added. That "new" is often infection, a drug, constipation, or hypoxia.
Reversible causes before a label of dying
Even in the last weeks, a short search for drivers is nursing work, not a betrayal of hospice philosophy. The usual CHPN list is practical rather than encyclopedic: urinary tract infection, hypoxia, constipation / fecal impaction, urinary retention, medications, and hypercalcemia. Medications that commonly tip a vulnerable brain include anticholinergics, benzodiazepines, corticosteroids, and opioids (especially after a rapid increase). Hypercalcemia in solid tumors produces polyuria, constipation, thirst, and confusion; treating it is appropriate when the patient can still benefit and when goals include more alert time.
Other contributors worth a glance: untreated pain, sensory deprivation (missing glasses or hearing aids), sleep disruption, hyponatremia, hepatic encephalopathy, and withdrawal from alcohol or benzodiazepines. You do not order every test in a dying patient. You do ask: is there a catheter or a palpable bladder, a last bowel movement, a new drug, an oxygen saturation, and a fever or dysuria story?
Pharmacologic choices that CHPN tests
Nonpharmacologic care is first whenever it can help: glasses and hearing aids on, clock and daylight, a familiar person at the bedside, fewer overnight interruptions, and no arguing with a hallucination (redirect, do not debate). When delirium is distressing—fear, dangerous agitation, or exhaustion of the patient and family—medication is indicated.
Haloperidol is first-line in many hospice protocols for distressing delirium. It is an antipsychotic used at low doses, by oral or subcutaneous or intravenous routes depending on setting. The point on the exam is priority and class, not a brand name. Reserve dose-chasing for the prescriber; the nursing judgment is that an antipsychotic, not a large benzodiazepine, is the usual first drug when the patient is not in one of the exception categories below.
Benzodiazepines can worsen delirium. They increase confusion, falls, and paradoxical agitation in many seriously ill adults. Exceptions you should memorize:
- The patient is imminently dying and terminal restlessness persists after attention to pain and after a neuroleptic, or the team is using a planned palliative sedation pathway.
- Catatonia (specialist-guided).
- Seizure (treat the seizure).
- Alcohol or benzodiazepine withdrawal (here a benzodiazepine is treatment, not a mistake).
If the stem is a still-verbal patient with new inattention and no withdrawal or seizure, more lorazepam as monotherapy is usually the wrong answer.
Terminal agitation versus untreated pain
Terminal restlessness (also called terminal agitation) appears in the last hours to days: nonpurposeful movement, moaning without a clear nociceptive trigger, picking at linens. It overlaps delirium. Untreated pain looks different if you watch care: grimacing, guarding, tachycardia or tachypnea with turning or wound care, and relief after an opioid. A distended bladder or impacted rectum can look identical to "fighting death." CHPN will offer a benzodiazepine in the options; the better first action is often assess and treat pain, urinary retention, and constipation, then use protocol drugs for remaining distress.
Cause checklist
| Check | Why it matters | First nursing move |
|---|---|---|
| Urinary tract infection | Classic reversible delirium in older and catheterized patients | History, urinalysis if it will change care, treat if consistent with goals |
| Hypoxia | Air hunger and confusion travel together | Oxygen if hypoxic and tolerated; fan and opioid for dyspnea (Section 8.4) |
| Constipation / impaction | Full rectum is an agitator | Last bowel movement, abdominal exam, suppository or enema if appropriate |
| Urinary retention | Palpable bladder, overflow, restlessness with turning | Bladder scan or in-and-out catheter per protocol |
| Medications | Anticholinergics, benzodiazepines, steroids, opioid surge | Deprescribe what you can; rotate opioid if myoclonus or toxicity |
| Hypercalcemia | Myeloma, breast, lung, and other solid tumors | Hydration and disease-directed treatment only if goals and prognosis support it |
| Pain versus dying | Grimace with care versus purposeless terminal movement | Trial analgesic; do not skip assessment |
Family teaching
Teach that delirium is a medical symptom of a sick brain, not the patient "going crazy" or "giving up." Hypoactive delirium still counts. Do not argue with visions; offer reassurance that the team is treating causes and distress. Explain that a calm presence, familiar voices, and restored glasses often help more than another sedative. If death is near, name terminal restlessness honestly: the goal is comfort, not a perfectly still body at the expense of unassessed pain. Invite the interdisciplinary team—medicine, social work, chaplaincy—when family conflict or spiritual distress is driving requests for "something to knock them out." That request is data; it is not automatically the order.
Which presentation is most likely to be missed as delirium on a CHPN-style item?
A still-verbal hospice patient has acute fluctuating inattention, disorganized speech, and frightening hallucinations. There is no seizure, catatonia, or alcohol withdrawal, and death is not imminent. Which pharmacologic choice matches many hospice delirium protocols?
Family members say the patient is 'fighting death' and ask for more lorazepam. During turning the patient grimaces and guards the lower abdomen; the bladder is distended. What is the best next action?