Dementia and Palliative Care: Page 3 of 3

January 16, 2012

The authors report no relevant financial relationships.



Delirium is a common complication in severely ill patients, especially those with dementia (Tables 2 and 3).12,24,25 Delirium can be a source of great distress not only to patients, but also to their families and to the treatment team. Although delirium is generally considered a medical condition, it has psychiatric manifestations and psychiatric medications are often used in managing delirium.

diagnosing delirium

A condition known as “terminal delirium” is often encountered in the last days or hours of life and may be a harbinger of death. Marked restlessness is sometimes observed, eliciting the term “terminal restlessness.” Definitive therapy for delirium typically involves resolving the underlying illness. Because this is not possible for most patients with a terminal illness, palliative management of terminal delirium focuses on relieving symptoms, addressing pain, and reducing agitation. Small doses of antipsychotic medications (eg, haloperidol 0.5 mg every 6 hours or risperidone 0.25 mg-0.5 mg twice daily) may be useful. Small doses of benzodiazepines are sometimes used to relieve anxiety or restlessness (eg, lorazepam 0.25 mg-0.5 mg every 6 hours as needed), but benzodiazepines have been shown to prolong delirious episodes. For patients clearly in the last hours of life, minor restlessness may not require intervention.26

managing delirium


Depression is common in palliative and hospice care patients and is frequently seen in patients with dementia. The prevalence of depression in patients with a terminal illness varies widely by study.6,27,28 Managing depression appropriately markedly improves patients’ quality of life, and various approaches are available for consideration.

Limited information is available to guide the clinician on the selection and dosing of antidepressants in dementia, and outcome data are contradictory. SSRIs such as citalopram (initial dose range, 10 mg-20 mg/day) are commonly used as first-line pharmacologic agents, with newer medications such as serotonin-norepinephrine reuptake inhibitors (SNRIs) used in the second-line.29 Stimulants, such as methylphenidate (initial dose typically 5 mg/day), may be helpful for regressed, apathetic, or severely withdrawn medically ill patients and can be administered alone or with an antidepressant.30 Mirtazapine, an SNRI, is also prescribed to address anorexia (initial dose range, 7.5 mg-15 mg nightly before bed), as are other drugs that stimulate appetite, such as megestrol acetate.31

Sleep Disturbances

Sleep disturbances and sundowning are common in dementia patients nearing the end of life. Parasomnias and dyssomnias, including obstructive sleep apnea, restless leg syndrome, nocturnal myoclonus, and REM sleep behavior disorders, can interfere with sleep in patients with dementia and may require therapy. Although a wealth of clinical experience is available to guide treatment for sleep disturbances in adults, studies on treating sleep disturbances specific to dementia patients are lacking.

Sedating antidepressants, such as trazodone (initial dose, ~50 mg nightly before bed) or mirtazapine (initial dose, 7.5 mg-15 mg nightly before bed), are an option for reducing anxiety and improving sleep disturbances. Sedating tricyclic antidepressants, such as amtriptyline or doxepin (typically in the initial range of 25 mg nightly before bed), have been used to induce sleep, but these have undesirable anticholinergic and cardiovascular effects and should generally not be used in this patient population. Hypnotics, such as zolpidem (initial dose, 5 mg nightly before bed), are sometimes used, but these agents are typically recommended for short-term treatment, whereas sleep disturbances in dementia patients may be prolonged and require ongoing therapy. Benzodiazepines are another option, and generally short- or intermediate-acting ones like lorazepam (initial dose, 0.25 mg-0.5 mg every 6 hours) are used; long-acting benzodiazepines such as clonazepam heighten the risk of falls and cognitive clouding and are usually avoided.

Over-the-counter sleep aids often contain a sedating antihistamine known as diphenhydramine, which has anticholinergic properties, and should generally be avoided in patients with dementia. An empirical trial of melatonin (typically 3 mg-6 mg nightly before bed) may be attempted.32,33


Many types of psychotherapy are potentially useful, including supportive, cognitive, and existential therapies. Continued therapy for bereaved family members may be warranted after the patient dies.8 Consultations with psychiatrists may also help staff in understanding and coping with difficult patient behaviors and family interactions,10 and such sessions should explore divergent approaches to illness and death among different cultures. Psychiatrists are sometimes called on to evaluate the decision-making capacity of patients suffering from incurable or terminal illnesses. Making such determinations can be difficult and controversial, requiring clinical expertise and knowledge of mental health law.34,35


Adopting a palliative care approach to manage end-of-life care issues in patients with a terminal illness can help prevent unnecessary suffering. This is especially important for patients with dementia, whose condition may not be recognized as terminal and are thus subjected to overtreatment with therapies that offer few benefits and a substantial risk of adverse effects. Pain and psychiatric syndromes are common in dementia patients, yet they often go unrecognized or untreated. Appropriately managing these secondary conditions are essential to ensuring that these patients receive humane care.




1. World Health Organization. Palliative care. 2011. Accessed November 22, 2011.

2. Chochinov HM, Breitbart W. Handbook of Psychiatry In Palliative Medicine. New York, NY: Oxford University Press, 2000: 150-165.

3. McGrath P, Holewa H. Mental health and palliative care: exploring the ideological interface. International Journal of Psychosocial Rehabilitation. 2004;9(1):107-119.

4. Lyness JM. End-of-life care: issues relevant to the geriatric psychiatrist. Am J Geriatr Psych. 2004;12(5):457-482.

5. Tang W, Aaronson L, Forbes S. Quality of life in hospice patients with terminal illness. West J Nurs Res. 2004;26(1):113-118.

6. Irwin SA, Rao S, Bower K, et al. Psychiatric issues in palliative care: recognition of depression in patients enrolled in hospice care. J Palliat Med. 2008;11(2):158-163.

7. Keeley PW. Delirium at the end of life. Clin Evid (online). 2007. pii:2405.

8. Xie J, Brayne C, Matthews FE; Medical Research Council Cognitive Function and Ageing Study collaborators. Survival times in people with dementia: analysis from population based cohort study with 14 year follow-up. BMJ. 2008;336(7638):258-262.

9. Purtilo RB, ten Have H, eds. Ethical Foundations of Palliative Care for Alzheimer’s Disease. Baltimore, MD: Johns Hopkins University Press, 2004.

10. Mitchell SL, Kiely DK, Hamel BK, Park PS, Morris JN, Fries BE. Estimating prognosis for nursing home residents with advanced dementia. JAMA. 2004;291(22):2734-2740.

11. Lau DT, Mercaldo ND, Harris AT, Trittschuh E, Shega J, Weintraub S. Polypharmacy and potentially inappropriate medication use among community-dwelling elders with dementia. Alzheimer Dis Assoc Disord. 2010;24(1):56-63.

12. Tune LE. Anticholinergic delirium: assessing the role of anticholinergic burden in the elderly. Curr Psychos Ther Rep. 2004;2(1):33-36.

13. Casey DA. Pharmacological management of behavioral disturbance in dementia.
J Clin Pharm Ther. 2007;32(10):560-566.

14. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. JAMA. 2005;294(6):716-724.

15. Li I. Feeding tubes in patients with severe dementia. Am Fam Phys. 2002;65(8): 1605-1610, 1515.

16. Kim KY, Yeaman P, Keene R. End-of-life care for persons with Alzheimer’s disease. Psychiatr Serv. 2005;56(2):139-141.

17. Ferrell BA. Pain evaluation and management in the nursing home. Ann Int Med. 1995;123(9):681-687.

18. Cleeland CS, Gonin R, Baez L, Loehrer P, Pandya KJ. Pain and treatment of pain in minority patients with cancer. The Eastern Cooperative Oncology Group Minority Outpatient Pain Study. Ann Intern Med. 1997;1276(9):813-816.

19. Evers MM, Purohit D, Perl D, Khan K, Marin DB. Palliative and aggressive end-of-life care for patients with dementia. Psychiatr Serv. 2002;53(5):609-613.

20. Buffum MD, Hutt E, Chang VT, Craine MH, Snow AL. Cognitive impairment and pain management: review of issues and challenges. J Rehabil Res Dev. 2007;44(2):315-330.

21. Herr K, Coyne PJ, Key T, et al; American Society for Pain Management Nursing. Pain assessment in the nonverbal patient: position statement with clinical practice recommendations. Pain Manag Nurs. 2006;7(2):44-52.

22. Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomized clinical trial. BMJ. 2011;343:d4065.

23. Dein S. Psychiatric liaison in palliative care. Advances in Psychiatric Treatment. 2003;9(4):241-248.

24. American Psychiatric Association. DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Arlington, VA: American Psychiatric Publishing, 2000:143.

25. Casey DA, DeFazio JV Jr, Vansickle K, Lippmann SB. Delirium: quick recognition, careful evaluation, and appropriate treatment. Postgrad Med. 1996;100(1):121-124,133-134.

26. Fine RL. Depression, delirium and anxiety in the terminally ill patient. Proc (Bayl Univ Med Center). 2011;14(2):130-132.

27. Draper B. The diagnosis and treatment of depression in dementia. Psychiatr Serv. 1999;50(9):1151-1153.

28. Lloyd-Williams M, Friedman T. Depression in palliative care patients: a prospective study. Eur J Cancer Care (Engl). 2001;10(4):270-274.

29. Block SD; ACP-ASIM End-of-Life Care Consensus Panel; American College of Physicians; American Society of Internal Medicine. Assessing and managing depression in the terminally ill patient. Ann Intern Med. 2000;132(3):209-218.

30. Rozans M, Dreisbach A, Lertora JJ, Kahn MJ. Palliative uses of methylphenidate for patients with cancer: a review. J Clin Onc. 2002;20(1):335-339.

31. Jatoi A. Pharmacologic treatment for the cancer/anorexia weight loss syndrome: a data-driven, practical approach. J Support Onc. 2006;4(10):495-502.

32. Deschenes CL, McCurry SM. Current treatmensts for sleep disturbances in individuals with dementia. Curr Psychiatry Rep. 2009;11(1):20-26.   

33. Vitiello MV, Borson S. Sleep disturbances in patients with Alzheimer’s disease:  epidemiology, pathophysiology and treatment. CNS Drugs. 2001;15(10):777-796.

34. Terman SA. Evaluating the decision-making capacity of a patient who refused food and water. Palliat Med. 2001;15(1):55-60.

35. Tan ZS. A piece of my mind: the “right” to fall. JAMA. 2010;303(23):2333-2334.