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Late Stage
Confusion

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Confusion - Late Stage
The Merck Manual
Section 21. Special Subjects 

Mental changes that can accompany the terminal stage of illness may distress both the patient and family, though many patients are unaware of them.

Confusion is common and has several causes, including drugs, hypoxia, metabolic disturbances, and intrinsic CNS disease. If the cause can be determined, simple treatment may be worthwhile, provided it allows the patient to communicate more meaningfully with family and friends. Otherwise, a patient who is comfortable and less aware of the surroundings may be better off not treated.

When possible, the physician should know the preferences of the patient and family to guide treatment.

Simple causes of confusion and agitation should be sought. Agitation and restlessness often result from urinary retention that resolves promptly with a urinary catheter.

Confusion in the debilitated patient is made worse by sleep deprivation. Agitated patients may benefit from benzodiazepines; however, benzodiazepines may also cause confusion. Poor pain control may be the cause of insomnia or agitation. If the patient is receiving appropriate analgesia, night-time sedation may help.

Sedating antihistamines such as diphen-hydramine 25 to 50 mg at bedtime may be used, although in the elderly these may produce unwanted anticholinergic side effects.
 
Tricyclic antidepressants are also effective. Amitriptyline 25 mg at bedtime is commonly used; doxepin 10 to 30 mg at bedtime has less anticholinergic activity than amitriptyline and thus is safer in the elderly.
 
Low doses of haloperidol (0.25 to 1 mg) may help a patient with disquieting or paranoid hallucinations.
 
For the patient who can swallow, thiori-dazine 25 to 50 mg is more sedating and less likely to cause extrapyramidal side effects than haloperidol.

Nonspecific therapy for confusion includes frequent hand-holding and reminders from the patient's family and visitors of where the patient is and what is happening.

Patients with severe terminal agitation resistant to other measures may require barbiturates; the patient's family should be involved in the decision to use these drugs. Pentobarbital, a rapid-onset, short-acting barbiturate, may be given as 100 to 200 mg IM q 4 h prn. Phenobarbital, which is longer-acting, may be given po, sc, or rectally. Midazolam, a short-acting benzodiazepine, is also often effective.