Medical Mimics of

Psychiatric Disorder
Compiled by Susan R. Redmond-Vaught, Ph.D./Western State Hospital

Delirium
(Primary Source: Merck Manual of Geriatrics, 3rd Edition; www.merck.com)
A significant number of elderly patients (15-60%) experience a delirium prior to or during a
hospitalization, but the diagnosis is missed in up to 70% of cases. These statistics are similar for
patients with known brain damage or brain compromise, irrespective of age. Delirium accounts
for 30-50% of inappropriate admissions to Western State Hospital.
The most concise definition of delirium is as follows: A clinical state characterized by an acute,
fluctuating change in mental status, with inattention and altered levels of consciousness.
The hallmark of delirium is acute cognitive dysfunction with impaired attentiveness, which
develops suddenly or over a short time (usually hours to days). A patient with delirium has acute
fluctuations in mental status, with varying levels of inattention and altered levels of
consciousness. Changes in orientation, memory, and abstract thinking may occur but are not
diagnostic. Psychomotor activity (level of arousal) may be variably abnormal. Hallucinations,
delusions, tremor, abnormalities in the sleep-wake cycle, and other symptoms may be present. In
some frail elderly patients, delirium precedes the appearance of another illness and is the only
early manifestation of that illness. Delirium may persist for many weeks or months; infrequently,
it never clearly resolves, or it modulates into chronic cognitive dysfunction.

Drug use (especially when the drug is introduced or the dosage is

adjusted
Electrolyte and physiologic abnormalities (e.g., hyponatremia,
hypoxemia)
Lack of drugs (withdrawal)
Infection (especially urinary tract or respiratory infection)
Reduced sensory input (e.g., blindness, deafness, darkness,
change in surroundings)
Intracranial problems (e.g., stroke, bleeding, meningitis,
postictal state)
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 Urinary retention and fecal impaction

Myocardial problems (e.g., myocardial infarction, arrhythmia,
heart failure)

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Comparison of
Delirium and Major Neurocognitive Disorder (Dementia)
(Merck Manual of Geriatrics, 3rd Edition; www.merck.com)

Delirium

Major Neurocognitive Disorder

Sudden onset

Insidious onset

Precise time of onset

Uncertain time of onset

Usually reversible

Slowly progressive

Short duration (usually days to weeks)

Long duration (years)

Fluctuations (usually over minutes

to hours)

Good days and bad days

Abnormal levels of consciousness

Normal level of consciousness

Typically, an association with drug

use or withdrawal, or acute illness

Typically no association with

drug use or withdrawal, or
acute illness

Almost always worse at night

(sundowning)

Often worse at night

Inattention

Attention not sustained

Variable disorientation

Disorientation to time and place

Typically slow, incoherent and

inappropriate language

Possible difficulty finding the

right word

Impaired but variable recall

Memory loss, especially for

recent events

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Confusion Assessment Method (CAM) for Delirium

Source: Inouye, S. Ann Int Med 1990;113:941-948.

Criteria
1. Acute change in mental status, AND
2. Symptoms that fluctuate over minutes or
hours, AND
3. Inattention
PLUS
4.Altered level of consciousness, OR
5. Disorganized thinking

Evidence
Observation by a family member,
caregiver, or primary care physician
Observation by nursing staff or other
caregiver
Patient history
Poor digit recall, inability to recite months
of year backwards
Hyperalertness, drowsiness, stupor, or
coma
Rambling or incoherent speech

The first 3 criteria PLUS the fourth OR the fifth criterion must be present to
confirm a diagnosis of delirium.
Other Options:
The Delirium Rating Scale (DRS), available for review in Trzepacz, P.,
Walker, R., and Greenhouse, J (1986) A Symptom Rating Scale for
Delirium, Psychiatry Research, Vol. 23, is the other most widely used
measure. The scale has approximately 10 items, and very high reliability and
validity. It is vastly superior to the MMSE in making this determination,
uses cut-off scores, and assists with communication with the referring
professional, and it has been translated into and validated in 20+ languages
at my last count. This measure does require administration by a trained or
degreed professional.
The DRS-R-98 even reliably distinguishes between schizophrenia, affective
disorder, major neurocognitive disorder (dementia), and delirium, but this
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version is typically too time intensive to make it useful in situations

requiring rapid turnaround.

Cerebrovascular Accident (CVA, Stroke)

Gross Overview
Left-Hemisphere Stroke
Inability to speak, inability to understand language, or speaking in
gibberish (Aphasia). Common misinterpretation: psychosis.
Inability to perform motor tasks or follow motor commands (Apraxia).
Common misinterpretation: uncooperative.
Appearance of anxiety and hesitance approaching all tasks. May panic,
refuse, or be explosive, but can be easily redirected from these reactions or
responses with distraction or verbal comforting.
Common misinterpretation: multiple psychiatric disorders.
Catastrophic response (especially common in first two weeks), an organic
phenomena best resolved in medical or rehabilitative settings. Common
misinterpretation: profound situational depression or catatonia.
Right-Hemisphere Stroke
Loss of pragmatics or social sense in speech and general behavior.
Common misinterpretation: mania.
Disinhibition (verbal, sexual). Common misinterpretation: mania.
Impulsive, with organic lack of understanding of deficits and limitations
(Anosognosia). Common misinterpretation: mania, impulse control
disorder, psychosis.
Visual, visual-spatial, or visual interpretive deficits. Errors in sensory
interpretation are often called Agnosia. These are less common but can be
dramatic, and include things such as failing to recognize the faces of
familiar persons until the person speaks, failure to recognize or
acknowledge blindness, or loss of part or all of visual fields resulting in
ignoring half the environment. Common misinterpretation: paranoia,
psychosis.
Any Stroke

Disorientation and delirium in first 14-30 days

Fatigue
Sudden episodes of crying or sobbing/marked emotional lability.
Reactions to sensory deprivation due to loss of vision, hearing, tactile
input, smell, or taste, plus isolation of being hospitalized

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General Suggestions
Use extreme caution if CVA <30 days. Risk for delirium related to CVA, extension of
CVA, medications used to treat CVA and CVA complications, and other factors is very
high.
If the problematic behavior or presentation is a direct result of the location of the CVA,
e.g., caused by the brain damage itself, a rehabilitation unit (physical medicine and
rehabilitation) or brain injury unit is likely a more appropriate placement.
Beware of using affect as a measure of psychiatric stability or mood state in patients with
history of CVA. Flat affect and voice (aprosody) and sobbing (pseudobulbar affect,
disinhibited affect), for example, do not necessarily indicate any disturbance in mood or
perception for a CVA patient.
Always be aware that state psychiatric facilities do not offer occupational therapy, speech
therapy, or physical therapy necessary to rehabilitate deficits from an acute CVA, and that
a stay in a psychiatric hospital may cost the patient their window of rehabilitation, or
needed medical rehabilitative services during the critical acute and post-acute recovery
period.

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Recent Surgery
Overview
In the one to two weeks following a surgical procedure, some patients develop post-surgical
delirium (typical onset 0-7 days). This is acute and often dangerous condition is more common in
elderly patients, or patients with previous known brain injury or intellectual disability.
Post-surgical insanity may assume the form of mania or melancholia, which is also true of
alcoholic insanity. (Mdcine Moderne, January 22, 1891) Obviously, this is not a new problem.
In his 1891 article, Professor Le Dentu went on to state, The attack came and went suddenly,
lasted from a fortnight to two months or more, and left the patients in full possession of all their
mental faculties. He also noted that some of the attacks resulted in death. Modern statistics
suggest that 8%, or roughly 1 in 10 patients with post-surgical delirium will die, often within 90
days of the surgery. Causes of death usually trace to sudden alterations in blood pressure, cardiac
abnormalities, CVA, or other metabolic derangement.

As many as 15-20% of elderly or brain-compromised patients will develop this problem.

Incidence of post-surgical delirium following hip fracture or cardiac events/cardiac
surgery is much higher (30-40%).
Pre-existing major neurocognitive disorder (dementia) substantially increases the risk for
post-surgical delirium as well (40-50%).

Treatment
Debate in medical and nursing journals centers around the use of chemical or physical restraints
to contain patients during the worst of the post-surgical delirium. Social restraint, or the use of
sitters, is also advocated.
Typically, better outcomes result from social restraint.
Research suggests that the less medication given, and the more medications removed, the
better the outcome.
Close medical monitoring with immediate response to often rapidly-developing
conditions such as hypotension, hypertension, renal insufficiency, renal failure,
arrhythmias, and CVA, is important.
Physicians who are not comfortable managing post-surgical delirium may benefit from
consultation with a gerontologist.
The acute medical nature of post-surgical delirium, and the rapidly developing medical
conditions, usually necessitates treatment in acute care medical facilities. Behavioral symptoms
of the delirium such as combativeness and aggression may prompt hospitals or physicians to
attempt transfer to inpatient psychiatric care. The condition can be reasonably managed on a
geriatric psychiatric unit situated in an acute care hospital, and this may be the ideal solution.

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Patients with limited funding or in more rural areas, or with physicians who are less familiar with
current literature on this condition, may proceed with commitment requests. Because of the lack
of intensive medical monitoring and services available, it is not appropriate to refer patients with
this condition to Western State Hospital. Post-surgical delirium treatment at WSH would entail
multiple re-transfers back to acute medical care, multiple environmental changes for the fragile
patient, disorganization in medical approaches (e.g., patients who are being treated with
progressive medication reductions receiving large prn dosages of antipsychotics in acute care, or
vice-versa), and ultimately, a prolonged delirious state, which then significantly worsens
outcome.
Suggestions
Physical, pharmacological, and other general medical interventions for post-surgical delirium can
only be determined by treating physicians. There are some environmental management tips
which may be helpful as well:

Use maximum falls precautions and protections.

Consider placing the patient in a room close to the nursing station.
Avoid placing the patient in busy, loud, or chaotic therapy rooms or settings
(overstimulation).
If the patient is hallucinating, consider adding controlled visual stimuli (movies, screen
savers) and low to moderate volume music.
Keep lighting adequate both day and night. Do not place patient in the dark.
Make certain hearing aids, eyeglasses and other devices that assist sensory perception are
used as much as possible, and safely).
Add an easily-seen clock or calendar.
Reorient in all spheres multiple times across the day, preferably each time staff interacts
with the patient.
Do not directly refute, argue with, or deny delusions. Offer alternative explanations and
reassure the patient (e.g., speak to the emotion expressed by the patientfear, confusion,
anxietyvs. the patients inaccurate perceptions).
As a rule, the single best environmental intervention is asking supportive family members
or a supportive friend to stay with the patient.

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Common Conditions
Some medical conditions mimic psychiatric illness, especially in the elderly, in patients with
major neurocognitive disorder (dementia), and in patients with other prior cognitive compromise.
These mimics are often the source of the delirium seen in the largest percentage of Western State
Hospitals inappropriate admissions.
Urinary Tract Infection
Confusion, combativeness, and paranoia often onset 48-72 hours before confirmatory
laboratory findings
Delirium is the most common complication of UTI
UTI should always be a first suspect in new-onset delirium
UTI affects both males and females
Following onset of treatment for UTI, delirium and other behavioral symptoms typically
will begin to clear as laboratory values approach normal (48-72 hours)
Pneumonia
Confusion, stupor, and delirium are common consequences, especially in elderly patients,
patients with known brain compromise, and patients with major neurocognitive disorder
(dementia)
Low 02 saturation on room air or with exertion may be predictive of delirium and
confusion
Patients requiring steroids may develop acute and severe psychosis related to these
medications
Confused patients with pneumonia are often physically combative during personal care,
due to sensations of smothering (and the confusion itself)
Cognitive and behavioral symptoms typically clear at around the same pace as the chest
x-ray
Renal Failure & Dialysis
Abnormalities in BUN and CREATININE frequently result in paranoia, which may be
chronic or acute. This is often not treatable due to renal status.
Patients on regular dialysis, especially in later stage disease, will show cognitive,
behavioral and emotional decompensation as time for dialysis approaches.
Delirium is common in renal failure, and can become chronic in dialysis patients.
Encephalopathy, or gradual slowing of brain functions, at times with significant motor
symptoms (tics, myoclonic jerks, other movement disorders), is a relatively common
occurrence in later-stage renal disease and long-term dialysis patients.
End-stage renal patients on long-term dialysis who ask to stop treatment are not
necessarily depressed or suicidal. If they are competent, assessment should consider
length of disease and illness, and realistic prognosis. This is frequently an end-of-life
issue, much as cancer patients refusing chemotherapy, and should be treated as such.
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MOST PSYCHIATRIC HOSPITAL

DO NOT, UNDER ANY
CIRCUMSTANCES, ACCEPT
PATIENTS ON DIALYSIS FOR
TREATMENT.
THIS IS FAR BEYOND
PSYCHIATRIC SCOPE OF CARE,
AND REQUIRES A MED-PSYCH
MODEL.

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Seizure Disorder (Epilepsy)

Important Terminology
Pre-ictal (also spelled pre-ictal). The period of time, usually relatively short, but possibly as
much as 24 hours, prior to onset of seizure activity. EEG abnormalities are often seen, but do not
rise to ictal levels.
Ictal. The period of time during which EEG is abnormal and reflective of seizure activity.
Post-ictal (also spelled post-ictal). The period of time from 5-15 minutes (acute, EEG
normalization occurring) to several hours (post-acute recovery, patient is usually sleeping and
irritable or confused if roused) after a seizure.
Inter-ictal. The period of time between postictal and pre-ictal states.
General Information
Most patients with known epileptic conditions will be under treatment by a neurologist or
PCP, and never referred for behavioral health care. The presence of seizure disorder is not
predictive of mental illness, though incidence of mental illness is higher in patients with
epilepsy. Depression with both functional and organic causation is the most common
issue, and provided that seizures are controlled, these patients can be treated in inpatient
psychiatric.
Patients with untreated or poorly treated seizures often behave in a confused, impulsive,
or disorganized fashion during pre-ictal, ictal, and post-ictal states. They may express
confusion-based delusions, or complain of hallucinations.
Patients with untreated or very poorly treated seizures can develop delirious confusional
states, often termed postepileptic delirium, or postictal delirium.
Patients with true postictal delirium are rare in this age of excellent available treatments,
but patients do stop treatment, or unfortunately, many cannot afford treatment. Patients
with postictal delirium can present significant danger to themselves or others due to
extreme confusion and confusion-related violence.
Violence is typically unprovoked, sudden and extreme, and is usually preceded by rapid
pupillary dilation.
Postictal delirium also can be associated with massive and complex visual hallucinations.
Patients often have visionary experiences, with the most common being fire or visitations
by religious figures, termed religious ecstasy. It is important to remember that while
most auditory hallucinations have a basis in psychosis and psychiatric disorder, roughly
half of all cases of visual hallucinations are related to neurological disorder or substance
abuse, and olfactory, tactile, and gustatory hallucinations are almost always neurological.
Patients with uncontrolled or poorly controlled seizures are not appropriate for inpatient
psychiatric hospitalization, even if the above-described dangerous symptoms are
occurring. This is a life-threatening situation, both due to the behavioral factors and the
risk from the seizures themselves. Locked seizure units are available at many major
medical centers if untreated or very poorly controlled seizures are the known or suspected
cause of the patients problems.

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Complex Partial Seizures

This type of seizure is also called partial complexolder terminology would be psychomotor
seizures or temporal lobe epilepsy. Complex partial seizures usually begin between late
childhood and the early thirties, though they can onset following brain trauma at any age.
Though they are much less recognized and understood by most people in comparison to
generalized seizure activity, this type of seizure occurs in 65% of epilepsy patients. This type of
seizure is also more likely to be referred to a behavioral health professional for treatment, either
in error or because practitioners, family member, or patients themselves do not understand the
scope of symptoms likely to be seen.

A small percentage of patients with complex partial seizures develop inter-ictal psychotic
states. This most often occurs when seizures are poorly controlledoften because they
are difficult to measure and recognizeor just following sudden forced normalization,
or rapidly-induced seizure control. Inter-ictal psychosis does not typically respond well or
completely to antipsychotics, but resolves as seizure control improves. Seizure units are
the best option of inter-ictal psychosis is the known or suspected condition.

Patients who experience hallucinations only during pre-ictal, ictal, or post-ictal states do
not necessarily have psychiatric disorder, and in fact, most do not. Seizure-related
hallucinations are typically unusually complex compared to the simplistic types of
hallucinations experienced by psychiatric patients, eliciting appropriate reactions and
emotions.

Patients in complex partial ictal states can engage in simple activities such as standing,
walking, pacing, and driving. Most of the time, activities are repetitive and simplistic or
overlearned rather than complex.

Patients in ictal states can respond verbally with simplistic or telegraphic answers, often
accurately. They often report a sense of depersonalization or dissociation, or being
trapped in concrete, or made of concrete, seeing the world but unable to interact with it.

Many patients experience abdominal sensations prior to seizure, and may make
confusional complaints of snakes or other animals in their stomach.

Ictal sex, or complete sexual acts while in an ictal state, while popular in movies and
literature, is exceedingly rare. Rudimentary sexual activities such as disrobing,
masturbation, scratching of the perineum, and pelvic thrusting are the typical expressions
of ictal eroticism/disinhibited sexual activity. When occurring exclusively in the pre-ictal,
ictal, or post-ictal period, this does not constitute psychiatric disorder, though it may be
understandably distressing to the patient, the patients family, and the hospital
environment.

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Ictal violence, again, while popular in the movies and literature, is exceedingly rare.
Violent acts during ictal states are typically confused, uncoordinated, and without specific
target (e.g., directed at whatever is in the environment, without any discernable goal).
Most ictal violence can be termed resistive violence, and occurs when the patient battles
against restraints placed on them during the seizure, to protect them from physical harm.
The remainder of ictal violence, estimated to occur in only .1% of patients, involves
random kicking, hitting, shoving, pushing, and more typically, screaming. In other words,
it is violent, but not necessarily aggressive.

Sources used to create this informational sheet include the following:

Kaufman, David (1990). Clinical Neurology for Psychiatrists, 3rd Edition.
Philadelphia: Harcourt Brace Jovanovich.
Niedermeyer, Ernst (1990). The Epilepsies: Diagnosis and Management.
Baltimore: Urban & Schwarzenberg

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End-Stage Organ Failure

Patients with end-stage organ failure, or any end-stage medical illness, may not be appropriate
for inpatient psychiatric admission, if the problematic behavior or symptoms arise exclusively
from the illness itself, and will not be responsive to psychiatric intervention. This is especially
true if the symptoms constitute end-of-life agitation, which will be addressed in the final section.
Cardiac Disease
Patients with end-stage cardiac disease are frequently short of breath, delirious, confused,
and combative. Refer back to guidelines and suggestions for delirium.
Major neurocognitive disorder (dementia) is often present.
Lucid patients with end-stage cardiac disease often state a wish to die due to marked life
limitations. With respect to treatment refusals for their condition, this may represent a
competence to choose/stage of terminal illness issue, typically not appropriate for an
inpatient setting.
Pulmonary Disease
Patients with end-stage lung disease frequently show psychosis, prolonged panic, and
increasing delirium, stupor, and cognitive deficits. Refer back to guidelines and
suggestions for delirium, and review information on pneumonia.

Lucid patients with end-stage pulmonary disease often express a wish to die, or for the
sensations to stop at any cost. If they refuse treatment, this may be a competence to
choose/stage of terminal illness issue, typically not appropriate for an inpatient
psychiatric setting.

Hepatic Disease
Patients with end-stage liver disease often show marked delirium, intermittent coma,
severe combativeness when awake, and movement disorder (asterixis, or flapping of the
wrists/hands usually accompanied by short, arrhythmic losses of voluntary muscle
contractions and associated short, quick lapses of posture). See information on delirium.
Even when awake, these patients can be evaluated with the Glasgow Coma Scale. Any
patient who can be rated on this scale is questionable at best for inpatient psychiatric
admission, but patients moderate or below on the scale are definitely inappropriate, and
cannot benefit from the type of treatment available in an inpatient psychiatric setting.

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End Of Life Agitation

End of life agitation, or confusional and delirious states that occur as a patient approaches death,
is a particularly sensitive issue for both physicians and families. Many families and medical
professionals prefer not to discuss or address these issues, and even many nursing facilities fail to
recognize the difference between evolving behavioral and psychiatric disorders and the onset of
end of life agitation. Referrals for inpatient care may be based in denial, lack of knowledge, or
uncertainty about the patients status. This is perhaps one of the most important distinctions to be
made in considering patients who could be in terminal phases of illness, for the following
reasons:

Most inpatient psychiatric facilities cannot by policy, accreditation, or scope of care, offer
hospice care. Palliative care is limited to oral medications (e.g., we cannot do intravenous
or intramuscular injections or infusions to manage pain).
Most inpatient psychiatric facilities cannot honor DNR requests without re-initiating
them at the new facility.
Most inpatient psychiatric facilities cannot honor advanced directives (such as refusal of
feeding tubes) under any circumstances.
Patients with end of life agitation, with or without pre-existing mental illness, cannot
benefit from inpatient psychiatric care.

Determining what constitutes end of life is also difficult, especially in non-cancer illnesses.
There is much misinformation even among treating professionals about what constitutes terminal
illness, but as a state provider, state statute is likely the safest definition to consider. From
Michies Kentucky Revised Statues, Certified Version, Volume 12, Chapters 309-341:
Terminal condition means a condition caused by injury, disease, or illness, which to a
reasonable degree of medical probability, as determined solely by the patients attending
physician and one (1) other physician, is incurable and irreversible and will result in
death within a relatively short time, and where the application of life-prolonging
treatment would serve only to artificially prolong the dying process.
With this in mind, we move on to the next reliable source, which are the federal/VA guidelines
for hospice eligibility, to gain an understanding of parameters in harder-to-track illnesses. The
following VA guidelines are adapted from Medical Guidelines for Determining Prognosis in
Selected Non-Cancer Diseases, 2nd ed., National Hospice Organization, Arlington, VA, 1996:

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Estimating Prognosis in Non-Cancer Diseases

The following are guidelines for consideration of hospice care (and referral for Medicare hospice
benefit) in that fulfilling the criteria for any of the categories supports that the patient has a
prognosis less than 6 months. Other criteria may apply:
General
Meet all:
1. life-limiting condition;
2. treatment goals are for comfort rather than cure;
3. in the past 6 months the patient has either documented terminal disease-related decline in
nutritional status (weight loss > 10%) or clinical progression of disease (repeated
emergency room or inpatient admissions, or functional status decline).
Congestive Heart Failure
Meet on optimal treatment:
1. Class IV failure or ejection fraction < 20%;
2. syncope, cardiac arrest, cardiogenic stroke, symptomatic arrhythmia.
COPD
Meet some:
1. Dyspnea at rest unresponsive to bronchodilators.
2. Forced Expiratory Volume (FEV1) after bronchodilator less than 30% of predicted.
3. Dyspnea limits walking to a few steps.
4. Resting pCO2 > 50.
5. O2 saturation < 88% or pO2 < 55 on supplemental oxygen.
6. Cor pulmonale.
7. Weight loss > 10% of body weight, resting tachycardia > 100.
Renal failure
Chronic renal failure with creatinine > 8.0, off dialysis.
Cirrhosis/liver failure
With clinical judgment:
1. Spend most time in bed
2. INR > 1.5
3. albumin < 2.5 g/dL.
4. Comorbidity: encephalopathy, spontaneous bacterial peritonitis, refractory ascites,
recurrent variceal bleeding, hepatorenal syndrome, wasting.

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Major Neurocognitive Disorder (Dementia)

Meet all:
1. Speech limited to 6 words
2. bed-bound
3. incontinent
4. unable to ambulate, dress, and bathe without assistance.
5. Comorbidity in prior year: pyelonephritis, pressure ulcer, sepsis, fever after antibiotics,
difficulty feeding with aspiration pneumonia, or weight loss > 10%.
HIV Disease
Meet some:
1. CD4+ count below 25 cells/uL; viral load > 100,000/mL;
2. declining functional status;
3. certain opportunistic infections;
4. albumin < 2.5 g/dL.
Strokes/Coma
Acute phase
Meet any:
1. Coma or persistent vegetative state 3 days after stroke.
2. Any 4 of the following on day 3 of coma: no verbal response, abnormal
brain stem response, no response to pain, serum creatinine > 1.5, age > 70.
3. Dysphagia preventing adequate intake in a patient who is not a candidate
for artificial nutrition.
Chronic phase
Meet some:
1.
2.
3.
4.
5.

Poor functional status;

Major neurocognitive disorder (dementia)
dependent in ambulation, dressing, bathing, and toileting;
weight loss > 10%, albumin < 2.5 g/dL.
Complications: aspiration pneumonia, pyelonephritis, sepsis, stage 3 or 4
decubitus, fever after antibiotic.

ALS
Rapid progression of ALS with decline in one: ventilatory capacity, swallowing, or functional
status.

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Understanding the Dying Process

"Gone From My Sight: The Dying Experience" is a resource developed by a long-term
hospice nurse, which describes in greater than usual detail the various physical stages of death
and dying. Per websites citing her pamphlet, to obtain a copy, contact her at the following
address: Barbara Karnes, R.N., P.O. Box 335, Stillwell, Kansas, 60085, 1995.

One to three months prior to death

Withdrawal from world and people

Decreased food intake

Increased sleep

Going inside self

Less Communication

One to Two Weeks Prior to Death

Disorientation

Agitation

Talking with Unseen

Confusion

Picking at Clothes

Physical Changes
o Decreased blood pressure
o Pulse increase or decrease
o Color changes; pale, bluish

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o
o
o
o
o
o
o

Increased perspiration
Respiration irregularities
Congestion
Sleeping but responding
Complaints of body tired and heavy
Not eating, taking little fluids
Body temperature hot/cold

End of Life Agitation-4

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Days or Hours

Intensification of 1-2 week signs

Surge of energy

Decrease in blood pressure

Eyes glassy, tearing, half open

Irregular breathing, stop/start

Restlessness or no activity

Purplish knees, feet, hands, blotchy

Pulse weak and hard to fine

Decreased urine output

May wet or stool the bed

Fish out of water breathing

Cannot be awakened

Minutes

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