Patients (and families) may experience distress related to altered levels of consciousness, orientation, and content. Patients may be seen as too alert, too sleepy, or unresponsive. Patients who are aware they are experiencing altered states may become distressed by the change in orientation. However, the greatest cause of distress usually relates to content - what the patient is experiencing. If that experience is distressing, we can reasonably call it delirium. A variety of screening tools have been developed for the detection of delirium.41 As demonstrated by Grassi and colleagues, the commonly used mini-mental status examination (MMSE) has a high sensitivity (96%) but a low specificity (38%) for delirium.42 Thus, this test is useful for ruling out delirium, but low (positive) scores may represent false positives.
The clinician should consider whether the nature of the delirium is suggestive of a toxic or a terminal delirium. An acute onset of delirium in a patient who does not appear to be very close to death is more suggestive of a toxic delirium. My impression is that toxic deliriums are much more amenable to treatment than are terminal deliriums. Lawlor, in a prospective study of 104 cancer patients treated on a palliative care ward, found a reversible cause 49% of the time in 71 patients who developed delirium.43 (A clinical distinction between toxic and terminal delirium was not made in this study.) Suspicion of a toxic delirium should prompt a search for a correctable cause unless the patient is very close to death. Medications should be reviewed and adjusted as necessary. Consideration should be given to checking electrolytes, in particular sodium and calcium (with albumin). As Lawlor's group demonstrated, delirium may respond to a course of hydration. Both toxic and terminal delirium may be exacerbated by physical symptoms that have gone unrecognized or are undertreated. If patients are verbal, physical pain and other symptoms may be reinterpreted and reported in other terms. A painful rib metastasis may become a devil poking the patient in the side. Often, one must quietly observe the patient for some time to get a clue as to the underlying cause of distress. I recall one woman who was moaning and thrashing in her bed. Occasionally her hand moved to her groin, the only clue to her urinary retention. Catheter placement resolved the distress. Sometimes the disturbed content reflects some unresolved psychological issue or unpleasant memory. For example, one patient of mine with a somewhat shady past was in an altered state when he was "visited" by some old friends. When I asked if he was enjoying the visit, he replied, "Nope, 'cause I owe them money." He was playing cards with his "friends" - a metaphorical, dreamlike way of settling old scores.
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Palliative Care Perspectives
James L. Hallenbeck, M.D.
Copyright © 2003 by Oxford University Press, Inc.
The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.