confusion. memory problems. disorientation (being unable to recognise familiar people, not knowing where they are or what the time and date is) hallucinations (seeing or hearing things that aren't there)
Delirium is prevalent at the end of life, particularly during the final 24–48 h. Prospective data suggest a prevalence of delirium of 28–42% on admission to a palliative care unit and longitudinal studies have documented occurrence rates as high as 88% before death.
The hallmark of delirium is an acute change in mentation and attention with either disorganized thinking, easy distractibility, or a fluctuating level of consciousness. It is often accompanied by perception disturbances with illusions, delusions or hallucinations.
Causes of Confusion at End of Life
Secondary issues such as a terminal tumor placing pressure on the brain or even simple fear, anger, or emotional turmoil can also contribute to the type of mental agitation that can lead to confusion.
It focuses on four cardinal delirium features: acute onset and fluctuating course, inattention, disorganised thinking, and altered level of consciousness. A diagnosis of delirium requires that both the first and second criteria are present, and either the third or fourth.
A person with delirium may: be easily distracted. be less aware of where they are or what time it is (disorientation) suddenly not be able to do something as well as normal (for example, walking or eating)
Administration: The examiner reads a list of 5 words at a rate of one per second, giving the following instructions: “This is a memory test. I am going to read a list of words that you will have to remember now and later on. Listen carefully. When I am through, tell me as many words as you can remember.
In palliative care, delirium is a sign of impending death, and in this context, the anguish felt by patients, families, and caregivers is usually worsened by the patient's impaired communication and by behavioral control issues [2].
You'll start to feel more tired and drowsy, and have less energy. You'll probably spend more time sleeping, and as time goes on you'll slip in and out of consciousness.
Hallucinations – They may hear voices that you cannot hear, see things that you cannot see, or feel things that you are unable to touch or feel. These hallucinations may be frightening or comforting to the dying person depending on their content.
Terminally ill cancer patients near the end of life can experience refractory symptoms, which require palliative sedation. Midazolam is the most common benzodiazepine used for palliative sedation therapy.
Sedation and agitation
Sedation means using medicines to lower a person's consciousness so that they are calm, or even asleep. The patient will commonly be started on a small dose of sedative (such as a benzodiazepine like midazolam or lorazepam). They may also be given an anti-psychotic (such as haloperidol).
Terminal delirium occurs in the last hours and days of life.
Your loved one may sleep more and might be more difficult to awaken. Hearing and vision may decrease. There may be a gradual decrease in the need for food and drink. Your loved one will say he or she doesn't have an appetite or isn't hungry.
In the hours before death, most people fade as the blood supply to their body declines further. They sleep a lot, their breathing becomes very irregular, and their skin becomes cool to the touch. Those who do not lose consciousness in the days before death usually do so in the hours before.
Just before death some people become restless, agitated and confused. This is known as terminal restlessness. It often occurs within the last few days of life. Terminal restlessness can be caused by a range of things and sometimes calming drugs are needed.
There are 4 stages that the body moves through after death: Pallor Mortis, Algor Mortis, Rigor Mortis, and Livor Mortis.
The end-of-life period—when body systems shut down and death is imminent—typically lasts from a matter of days to a couple of weeks. Some patients die gently and tranquilly, while others seem to fight the inevitable. Reassuring your loved one it is okay to die can help both of you through this process.
Delirium is one of the most common complications in hospitalized older adults, with a prevalence of between 14 and 64% and hospital mortality rates from 25 to 33% (2, 3).
Metabolic failure: The kidneys, the liver, and other organs begin to fail near the end of life, and the physiological issues these events cause can interfere with brain function and result in delirium, restlessness, and agitation.
The Mini-Cog test.
A third test, known as the Mini-Cog, takes 2 to 4 minutes to administer and involves asking patients to recall three words after drawing a picture of a clock. If a patient shows no difficulties recalling the words, it is inferred that he or she does not have dementia.
The main sign of mild cognitive impairment is a slight decline in mental abilities. Examples include: Memory loss: You may forget recent events or repeat the same questions and stories. You may occasionally forget the names of friends and family members or forget appointments or planned events.