Delirium is a disturbance in attention, awareness and cognition that develops over a short period of time and tends to fluctuate. It is common in terminally ill patients, affecting up to 85%. Delirium causes distress for patients and families and conflicts with patient goals of cognitive awareness. It is important to assess for delirium using tools like the Confusion Assessment Method. The first step in managing delirium is to treat any underlying causes, such as infection, dehydration, or medication side effects. Non-pharmacological interventions include reorienting the patient, maintaining their sleep-wake cycle, and engaging family. As a last resort, antipsychotics may be used but they increase the risk of death.
This presentation JoAnne Nowak and I gave for NHPCO last spring addresses the prevention, assessment and treatment of delirium - particularly in hospice and palliative care settings.
Dr. Elizabeth Paulk gives an excellent review of palliative care topics including end of life discussions, hospice, pain management, and family counseling.
Carle General Surgery Grand Rounds presentation on palliative care symptom management, specifically pain, nausea, constipation, and malignant bowel obstruction.
This presentation JoAnne Nowak and I gave for NHPCO last spring addresses the prevention, assessment and treatment of delirium - particularly in hospice and palliative care settings.
Dr. Elizabeth Paulk gives an excellent review of palliative care topics including end of life discussions, hospice, pain management, and family counseling.
Carle General Surgery Grand Rounds presentation on palliative care symptom management, specifically pain, nausea, constipation, and malignant bowel obstruction.
Advance care planning: "Let's get talking"MS Trust
This presentation by Dr Jo Poultney, Dr Sarah MacLaran, and Dr Julia Grant looks at advance care planning and how to support patients to express their preferences about care: what they do and don't want to happen and the people important to them.
It was presented at the MS Trust Annual Conference in November 2014.
Presented at Kansas City University of Osteopathic Medicine 10/27/15 in Lecture Series in Bioethics. See live presentation here: https://www.youtube.com/watch?v=Dr3g3PeVKeo
Ethics at the End of Life and Introduction to Hospice and Palliative Care for Medical Students. Exploration of feeding tubes, code status, when to stop chemo. Discusses cases and the ethical principles and values that are the basis for disagreement in care and what to do when there is a conflict in ethical principles themselves. Also provides an introduction to decisions of last resort including physician aid in dying, palliative sedation and voluntary refusal of nutrition and hydration.
Person centered care models with reference to dementia care, has demonstrated positive outcomes for behavioral disturbance. This presentation will increase awareness and understanding about person-centered care for people with dementia. Discussion includes complex needs of people with dementia, leading to compromised behavioral symptoms; including non-pharmacological approaches, sleep-wake-cycle disturbance, verbal outbursts and aggression. Further discussion encompasses evidence based outcomes with the use of person centered care that focuses on preserving the "personhood" of the individual.
Advance care planning: "Let's get talking"MS Trust
This presentation by Dr Jo Poultney, Dr Sarah MacLaran, and Dr Julia Grant looks at advance care planning and how to support patients to express their preferences about care: what they do and don't want to happen and the people important to them.
It was presented at the MS Trust Annual Conference in November 2014.
Presented at Kansas City University of Osteopathic Medicine 10/27/15 in Lecture Series in Bioethics. See live presentation here: https://www.youtube.com/watch?v=Dr3g3PeVKeo
Ethics at the End of Life and Introduction to Hospice and Palliative Care for Medical Students. Exploration of feeding tubes, code status, when to stop chemo. Discusses cases and the ethical principles and values that are the basis for disagreement in care and what to do when there is a conflict in ethical principles themselves. Also provides an introduction to decisions of last resort including physician aid in dying, palliative sedation and voluntary refusal of nutrition and hydration.
Person centered care models with reference to dementia care, has demonstrated positive outcomes for behavioral disturbance. This presentation will increase awareness and understanding about person-centered care for people with dementia. Discussion includes complex needs of people with dementia, leading to compromised behavioral symptoms; including non-pharmacological approaches, sleep-wake-cycle disturbance, verbal outbursts and aggression. Further discussion encompasses evidence based outcomes with the use of person centered care that focuses on preserving the "personhood" of the individual.
Michelle Peck | Legal Nurse | Nurse Practitioner | Health Care | Geriatric | Consultant | Speaker | Educator | Researcher
During your journey through this slide deck of the geriatric populations 3 D’s, you will experience: the difference between geriatric dementia, geriatric delirium and geriatric depression; the global impact of dementia and the importance of a quality diagnosis; and the dementia assessment, management and treatment options.
The links in this slide deck lead you to expert geriatric teaching tools and videos that you will value and love.
According to the World Alzheimer Report if dementia care were a country, it would be the world’s 18th largest economy. The worldwide costs of dementia exceeded 1% of global GDP in 2010, at US$604 billion. If dementia were a company, it would be the world’s largest by annual revenue exceeding Wal-Mart (US$414 billion) and Exxon Mobil (US$311 billion). Geriatric populations are increasing and Alzheimer’s in the USA will ALMOST TRIPLE BY 2050. Let’s stay informed!
Learn it-Live it-Love it-Your path for a more informed life!
Michelle Peck | Legal Nurse | Nurse Practitioner | Health Care | Geriatric | Consultant | Speaker | Educator | Researcher
This is a presentation I gave to help members of the Genesee Valley Nurses Association understand important differences among delirium, dementia, and depression. Tuesday, November 27, 2012.
Doctor’s Hospice is a hospice agency with three locations in Louisiana specializing in home health services for patients with life-limiting illnesses. Doctor’s Hospice...helping others find peace in troubled times.
Its all about forensic psychiatry aspects of India not very frequently discussed and so a little attempt from me. Its not exhaustive and many more aspects regularly updated should be tallied.
important points regarding ICU psychosis, role of dexmedetomidine in it's treatment, mortality associated with delirium, symptomatic and definitive management
Explores impact of disturbed sleep on symptom management in patients with concurrent serious illness and at the end of life. Presented during Hospice and Palliative Medicine Fellowship at the University of Kansas 2014
Hospice care and palliative care: Is there a difference between the two, and if so, what?
Many people still think that palliative care means hospice care. But today, hospice is only a small part of palliative care.
The goal of palliative care is to prevent or treat the symptoms and side effects of a disease; and it should be part of the picture from the first day a serious illness is diagnosed.
Dr. Jim Meadows, Director of Hospice and Palliative Care at Tennessee Oncology, will discuss this important topic. How does a family and a health care team best work together to guide a patient through a terminal illness? How does everyone continue to support quality, patient-centered, end-of-life care?
A lecture given at a Primary Care Conference in Massachusetts - on the important role primary care physicians could play in ensuring good palliative care for patients, communication, hospice, myths & realities
hii guys this is my ongoing presentation from my speciality class i hope u guys lije that please so i hope it is been useful for u in ur specialities by getting little help with that
The word delirium means “out of one’s furrow” which refers to the dramatic behavior changes that the person may experience. Some have called delirium "brain failure” because it may represent a variety of caused such as heart failure does in cardiac health.
Delirium is an outcome of a general medical condition, head injury and drug intoxication or withdrawal.
Homeopathic Doctor - Dr. Anita Salunke homeopathic clinic for DimentiaShewta shetty
Homeopathic Doctor Anita Salunke practices in Chembur, Mumbai, India in her homeopathic clinic Mindheal. Find more information about homeopathic treatment at Mindheal. Welcome to safe, sure and effective homeopathic treatment Dimentia
These are the slides I presented at RWJ School of Medicine Grand Rounds, University Day when new faculty were inducted into the Master Educator's Guild.
In this talk about integrative medicine, I outline the need to teach clinicians - doctors, nurses, holistic healers, psychologists, naturopaths, etc. - about deep healing. We are taught to deconstruct the human into anatomic parts, cells, physiology in order to cure. But to heal, we need to help a person reintegrate all those parts - and rediscover themselves - as a person with family, hopes, dreams, beliefs, culture, tradition, hobbies.
We seek healthcare not for the experience of healthcare, but because the process helps us live more fully, and enjoy the things we love. This reintegration can happen at any stage of life and illness. It is holism. It is deep healing.
Building on the lecture I gave (and uploaded) "Palliative Care: what every primary care doctor should know" I built this talk. It is geared for 1st year medical students who are learning anatomy, physiology, and perhaps some pharmacology and pathophysiology.
In this talk, I do not explicitly address hospice care - as that was provided in an online chapter for students at UMass. I will later upload another slide set on that topic.
I hope you enjoy it.
FYI- the link to the youtube video: http://www.youtube.com/watch?v=XHtHXGhTIC4
Link to PDF of the slide show: https://files.me.com/s.mak/8fzat6
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
The Importance of Community Nursing Care.pdfAD Healthcare
NDIS and Community 24/7 Nursing Care is a specific type of support that may be provided under the NDIS for individuals with complex medical needs who require ongoing nursing care in a community setting, such as their home or a supported accommodation facility.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
1. Delirium:
Recognizing, Assessing and Managing Terminal Restlessness
Suzana Makowski, MD MMM
Associate Director of Palliative Care in the Cancer Center
UMass Memorial Healthcare, Worcester, MA
JoAnne Nowak, MD
Medical Director, Merrimack Valley Hospice, Lawrence, MA
Special thanks to Jennifer Reidy, MD who helped prepare the content
3. Which symptom is necessary for the diagnosis of delirium?
a) impairment of only short term memory
b) impairment of attention
c) agitation or restlessness
d) delusions or hallucinations
6. Early Descriptions
“they move the face, hunt in
empty air, pluck nap from the
bedclothes…all these signs are
bad, in fact deadly”
Hippocrates:400 BCE
“Sick people…lose their judgment
and talk incoherently…when
the violence of the fit is abated,
the judgment presently
returns…”
Celsus: 1st Century BCE
7. Delirium
• Synonyms: acute confusional state, organic
brain syndrome, encephalopathy, terminal
agitation, terminal restlessness
• Often mistaken for depression, anxiety, or
dementia
Terminal Agitation:
A symptom or sign: thrashing, agitation that may occur in the last days
or hours of life.
May be caused by:
• pain • anxiety • dyspnea • delirium
8. DSM-IV Criteria: Delirium
• Disturbance of consciousness affecting attention
• Change in cognition
• Develops over a short period of time, and may
fluctuate
• Caused by physiologic consequence of a general
medical condition
9. Clinical Subtypes: Delirium
• Confusion
• Agitation
• Hallucinations
• Myoclonus
Hyperactive
• Fluctuates
between both
Mixed
• Confusion
• Somnolence
• Withdrawn
Hypoactive
Less likely to
be diagnosed
10. Delirium vs. Dementia vs. Depression
Features Delirium Dementia Depression
Onset Acute (hours to
days)
Insidious (months to
years)
Acute or Insidious
(wks to months)
Course Fluctuating Progressive May be chronic
Duration Hours to weeks Months to years Months to years
Consciousness Altered Usually clear Clear
Attention Impaired Normal except in
severe dementia
May be decreased
Psychomotor
changes
Increased or
decreased
Often normal May be slowed in
severe cases
Reversibility Usually Irreversible Usually
18. WHY TALK ABOUT IT?
Delirium causes caregiver distress
Unlike pain, delirium is seen
Creates sense of fear and helplessness
Am J Geriatr Psychiatry 2003; 11: 309 - 319
19. WHY TALK ABOUT IT?
Delirium is common
Delirium is harmful
Delirium hurts relationships
Delirium conflicts with patient goals
Delirium causes caregiver distress
21. Which is not a risk factor for delirium?
a) Age
b) Cognitive impairment
c) Gender
d) Opioid use
e) Constipation
22. Case: Paul
• Paul is 72 years
old, with Alzheimer’s
disease and lung cancer.
• Retired dentist, active
and “in charge”
• Now
agitated, combative, tryi
ng to get out of bed
23. What patients are at risk?
Patient
habits
Cognitive
status
Physical
function
Sensory
Deficits
Environ-
mental
change
oral
intake
Drugs
Other
medical
problems
24. WHAT CAUSES IT?
rugs, drugs, drugs, dehydration
motion, encephalopathy, environmental change
ow oxygen, low hearing/seeing
nfection, intracerebral event or metastasis
etention (urine or stool)
ntake changes (malnutrition, dehydration), Immobility
remia, under treated pain
etabolic disease
25. Which of the following medications can
cause delirium?
a) Lorazepam
b) Hyoscyamine
c) Dexamethasone
d) All of the above
e) None of the above
27. TERMINAL DELIRIUM
CAN IMPENDING DEATH CAUSE IT?
Diagnosis of exclusion
Delirium during the dying process
Signs of the dying process
Multiple causes, often irreversible
28. Case: Paul – is he at risk for delirium?
Predisposing factors
Dementia
Age
Metastatic lung cancer
Immobility
Poor oral intake
Poly-pharmacy
Possible precipitating factors
Drug side effects?
Hypoxemia?
Infection?
Constipation?
Urinary retention?
Metabolic disorder?
Brain metastases?
Emotional distress?
29. General Assessment: Delirium
• Hospice diagnosis, co-morbidities
• Onset of mental status change
• Oral intake, urine output, bowel movements
• Recent medication history
• Review of systems:
fever, N/V, pain, dyspnea, cough, edema, dec
ubiti
• Alcohol or illicit drug use
• Falls, safety
• Emotional, spiritual distress
30. Assessment: Paul
• Metastatic non-small cell lung cancer
• Severe Alzheimer’s disease
• More restless, combative in last 3 days
• Hand-fed small, pureed meals & thickened
liquids but minimal in 3 days
• Small amount dark urine, no BM in 1 week
31.
32. Assessment Tools: Delirium
• Confusion Assessment Method (CAM)
– 94-100% sensitive, 90-95% specific
– 10-15 minutes by trained interviewer
• SQiD (single question in delirium)
– “Do you think Paul has been more confused
lately?”
– 80% sensitive and 71% specific in oncology patient
33. Confusion Assessment Method
Feature 1: Acute Onset
and Fluctuating Course
Obtained from a family member or nurse:
• Is there evidence of an acute change in mental status from
the patient’s baseline?
• Did the (abnormal) behavior fluctuate during the day, that is,
tend to come and go, or increase and decrease in severity?
Feature 2: Inattention • Did the patient have difficulty focusing attention, for
example, being easily distractible, or having difficulty
keeping track of what was being said?
Feature 3:
Disorganized thinking
• Was the patient’s thinking disorganized or incoherent, such
as rambling or irrelevant conversation, unclear or illogical
flow of ideas, or unpredictable switching from subject to
subject?
Feature 4: Altered
Level of consciousness
• Overall, how would you rate this patient’s level of
consciousness?
alert [normal]),
vigilant [hyperalert],
lethargic [drowsy, easily aroused],
stupor [difficult to arouse], or
coma [unarousable])
The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.
34. Diagnostic Approach to Delirium
• Delirium is a clinical, bedside diagnosis
• Careful, gentle approach to patient
• Appearance, vital signs
• Focused exam based on history
• Consider rectal exam, catheter
35. Paul’s assessment: Delirium
• Lethargic, frail, elderly man lying in hospital bed;
fidgeting of arms, legs; slow but persistent
attempts to sit up or slide between side rails;
quiet but anxious expression
• CAM: all features present
• Afebrile, BP 105/62, HR 95, RR 24
• Positive findings:
– MM dry;
– Foley catheter w/cloudy, dark urine;
– abd distended but soft,
– quiet BS; rectal +stool;
– decubitus stable w/o infection
37. Paul’s follow up
Treated the treatable
• Disimpaction, daily bowel
regimen
• Treated UTI w/ liquid
antibiotics
• Weaned lorazepam
Treated the delirium
• Haloperidol 0.5-1mg SL qHS
and q8hrs prn
• Calmer environment
• Improved communication
• Encouraged safe movement
Goals of care: Peaceful death at home • DNH • no needlesticks
In 2-3 days, Paul was back to baseline
46. MANAGEMENT
Delirium
Monitor: GIP or continuous care
Address family, caregivers and other
psychosocial impacts of delirium
Step 1: Treat underlying causes
Step 2: Non-pharmacological
Step 3: Pharmacological
47. Which of the following are appropriate
interventions for delirium?
a) Music during turns/personal care
b) Minimize ambient sound (alarms, bells, voice)
c) Aromatherapy such as Lavender or Melissa with bed bath
d) Spiritual interventions such as prayer, ritual, meditation
e) Cognitive behavioral therapy for PTSD
f) Engaging family or familiar people in care
g) All of the above
48. Assessing severity of agitation
Uncooperative, intense stare
Motor restlessness
Mood lability, loud
speech
Irritability, intimidation
Aggressive, hostile
Adapted from Scott Irwin, San Diego Hospice
49. Hierarchy of interventions for agitated delirium
Check for needs,
non-pharmacologic
Verbal intervention
Voluntary
medication
Emergency
medicine
Seclusion
and/or
restraint
Adapted from Scott Irwin, San Diego Hospice
Step 1: Treat underlying causes
Step 2: Non-pharmacological
Step 3: Pharmacological
Address family, caregivers and other
psychosocial impacts of delirium
51. Case 2: Rosie’s distress
• 88 yo great-grandmother with end-stage
pulmonary fibrosis, renal insufficiency.
• “CMO” and morphine drip was started to treat
her dyspnea – then sent home with hospice.
Please help! She is
moaning, agitated, in pain
even when we touch her
lightly. Other times, we can’t
wake her up.
52. rugs, drugs, drugs, dehydration
motion, encephalopathy, environmental change
ow oxygen, low hearing/seeing
nfection, intracerebral event or metastasis
etention (urine or stool)
ntake changes (malnutrition, dehydration), Immobility
remia, under treated pain
etabolic disease
ManagementSTEP1: TREAT CAUSE
53. Opioid neurotoxicity: important cause
• Morphine metabolized in the liver to
– Morphine 6-glucoronide
– Morphine 3-glucoronide
• Builds up disproportionately in renal failure
• Neuro-agitation:
– Increased RR, agitation, myoclonus, and
sometimes seizures
Anti-psychotics may worsen opioid neurotoxicity:
benzodiazepines and phenobarbitol are treatments of choice
54. Rosie’s distress: treat underlying cause
Attempt to reverse morphine neurotoxicity
• Stop morphine
• Start lorazepam or phenobarbitol
• Consider IV/SQ fluids depending on goals of care
PRN SL oxycodone or IV fentanyl if needed for pain or
dyspnea or schedule methadone
Oxygen for hypoxemia-induced delirium
ManagementSTEP1: TREAT CAUSE
55. AGITATION WITH DEMENTIA
Treat the pain
Address sleep-wake cycle
Create familiar environment
Facilitate range of motion & exercise
58. NON-PHARMACOLOGIC APPROACH
•Nurses, aides, and
doctors
•Exquisite care of the
body
•Engage
aides, housekeeping
, family.
•Consider the 5
senses
•Engage chaplaincy
•Acknowledge
faith, legacy, regret
•Engage social work
& psychology
•Consider past
trauma, Ψ history
Emotional Existential
PhysicalEnvironment
59. Physical environment & body
Sight
• Light/dark cycles, visual cues, familiar faces
Sound
• Reduce ambient noise, music therapy, familiar voices
Smell
• Cleanliness, aromatherapy, home cooking
Touch
• Massage, physical therapy, movement
Taste
• Drink if thirsty – but hydrating drinks. Eat if hungry – and assure good bowels.
ManagementSTEP2: NON-PHARM
60. Case 3: Mr. U
65 year old retired engineer with metastatic lung
cancer to bone.
HPI: Severe pain, principally in area of leg requiring
complex pain management. Now he is experiencing
increased confusion, agitation, restlessness at night.
Past Medical History: Generally healthy until diagnosis.
Social History: Married to a non-Catholic woman. Has 2
grown daughters. Raised Catholic but has not been to
church much since his marriage.
61. Case 3: Mr. U’s agitation
• Physical: under treated pain
• Emotional: sadness at losing his family
• Existential:
– Fear of afterlife
– Unresolved conflicts
– Never married in the Church
Created non-judgmental ritual, presence
Witnessing by hospice team and family
67. But they increase death!
Increased risk by 1.6 – 1.7 RR
absolute increase from 2.3% to 3.5% during intervention
Risk / benefit and goals of care
Time
Management
STEP3: PHARMACOLOGIC
Antipsychotics are the mainstay of pharmacologic treatment
Black Box Warning!
68. Treat like other breakthrough symptoms:
Schedule medicine based on t ½
Breakthrough medicines based on Cmax
Consider selection of antipsychotic based on profile
Management
STEP3: PHARMACOLOGIC
69. Pharmacology of Anti-psychotics
Drug Cmax T ½
Chlorpromazine
25mg SQ/IV/PR q3 hours prn
up to 2g/day
1-4 hours 16-30 hours
Quetiapine
25-100mg PO q1 hour prn
up to 1200 mg/day
1-2 hours 6-7 hours
Risperidone
0.25-1mg PO q1 hour
up to 6mg/d
1-1.5 hours 3-24 hours
Olanzapine
5-10mg PO q4 hours prn
up to 30mg/day
4-6 hours 20-70 hours
Haloperidol
0.5 – 2 mg q1 hr prn
30 min – 1 hour 4-6 hours
71. Chlorpromazine vs. Haloperidol
Antipsychotic Agent Chlorpromazine Haloperidol
Sedation +++ +
EPS ++ ++++
Anticholinergic ++ +
Orthostatic
Hypotension
+++ +
++++ = very high incidence, +++ = high incidence, ++ = moderate incidence, + = low incidence
Drug Facts and Comparisons (Oct 2003)
72. More on Anti-psychotics
Length of
use
Sed Sed - EPS
3-7 Days
Haloperidol
0.5-2 mg q1 hour prn
IM, IV, SC
PO (tab/sol)
SCI
Chlorpromazine
12.5-25 mg q 3
hours prn up to 3
grams/day
IM, IV, PR
SCI?
PO - erratic
>7 Days
Risperidone
(Risperdal)
PO: tab,sol,odt
IM: long acting
Olanzapine
(Zyprexa)
PO: tab,odt
IM: intermittent
Quetiapine
(Seroquel)
PO: tab
Ziprasidone
(Geodon)
PO: cap
IM: intermittent
73. Choose based on level of behavior
If more hyperactive, consider atypical antipsychotics
If more hypoactive, consider haloperidol
Titrate medication if initial dose is not effective.
Consider switching medication if:
Lengthy treatment anticipated
Lack of response despite increase dose.
74. Inadequate or no response:
Reassess cause again, depending on goals of care.
Consider sedation if needed.
benzodiazepines, barbiturates or propofol
This is palliative sedation!
75. Agitated delirium - severe
For imminent risk of harm to self or others due to agitation,
mix in following order:
Lorazepam 1-2mg
Haloperidol 2-
5mg
Diphenhydramine
50-100mg
76. Agitated delirium – severe
(alternatives)
• Chlorpromazine 50-100mg SQ/PR up to 2g/day
– Increase dose by 25-50mg q1-4 hours until controlled
– Likely to not need diphenhydramine
– Consider lorazepam along side
• Olanzapine 5-10mg IM q4 hours up to 30mg/day
• Phenobarbitol 20-40mg starting dose q3 hours prn
– especially useful for brain mets.
77. Hierarchy of interventions for agitated delirium
Check for
needs, non-
pharmacologic
Verbal intervention
Voluntary
medication
Emergency
medicine
Seclusion
and/or
restraint
Adapted from Scott Irwin, San Diego Hospice
Step 1: Treat underlying causes
Step 2: Non-pharmacological
Step 3: Pharmacological
Address family, caregivers and other
psychosocial impacts of delirium
78. Case 4: Philip’s struggle
63 yo retired photographer with end-stage CHF, in
the context of drug abuse history. He was an
active duty veteran.
He was estranged from his family and no longer
active in his Jewish faith.
Severe dyspnea. Now over 2 weeks becoming
increasingly confused multiple times each day.
Sometimes confusion is agitated, sometimes
somnolent.
79. Philip’s struggle
“Philip has terminal agitation, and I think he
needs more …?”
– Is it terminal agitation, or something else?
– How can you find out?
Based on what we’ve talked about this far:
What would your next step be?
80. Philip’s medications
MSContin and Roxinol for dyspnea
Oxygen
Lorazepam q4 hours prn for anxiety
Furosemide qDay for edema
Metoprolol bid for CHF
Lisinopril for CHF
81. Addressing Philip’s DELIRIUM
Step 1: reverse the reversible
Opioids rotated
Benzos weaned
Assessment for UTI –
negative
Poor
hydration/nutrition –
not reversed due to
goals of care
Oxygen increased
Step 2: Non-pharmacologic
Social worker addressed
PTSD
Chaplain was involved
Step 3: Psychopharm
Hyperactive periods less
intense BUT
Mental status continued
to wax and wane
Haloperidol was started
82. Philip’s
struggle
With these interventions, he awoke
with more alertness for a brief a
few days.
Later he showed signs of active
dying:
Mottling of hands and feet
Irregular breathing patterns
He died peacefully 7 days later. http://upload.wikimedia.org/wikipedia/commons/a/ab/USAF_photographer.jpg
83. Tending to delirium
takes a community
family &
friends
hospice
caregivers
nursing home
caregivers
chaplain
volunteers
88. CONFRONTING DELIRIUM
Prevent it • know the risks
Recognize it • assess often
Reverse it • reverse the reversible
Treat it • non-pharmacologic • antipsychotic • sedatives
90. Which are you most likely to use today?
a) Recognize the difference between agitation and delirium
b) Use specific tools for assessment (CAM, SQiD)
c) Engage all members of the IDT earlier
d) Remember the non-pharmacologic interventions
e) Know my pharmacology
Editor's Notes
B- is the correct answer
Disturbance in consciousness with reduced ability to focus, sustain, or shift attentionA change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established or evolving dementiaDevelops over a short period of time (usually hours to days) and tends to fluctuate over the course of the dayThere is evidence from the history, physical exam, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition
d
Greater than > 70 % of seriously ill patients rate mental awareness as important JAMA 2000; 284: 2476 - 248289% of seriously ill patients would not choose a treatment if the outcome is cognitive impairment; the more risk the less inclined to treatment NEJM 2002; 346: 1061 - 1090
76% witnessed delirium or confusion38% witnessed these symptoms dailySense of fear and helplessnessMay contribute to caregiver risk for Major Depressive Disorder and quality of life impairments (in aggregate with prevalence and frequency of other distressing events) Am J Geriatr Psychiatry 2003; 11: 309 - 319Most caregiver measures center on the consequence of care provision for the caregiver’s well being and function. This study measured the impact of caregiver exposure to distress of their loved ones. Delirium the second most prevalent symptom after severe pain (80%)Sense of helplessness (between 1 = somewhat and 2 = very) 1.22 on scaleFear 0.79 (0= none 1 = somewhat)
c
Causes of Delirium Acronym (adapted from Capital Health)D Drugs, drugs, drugs, dehydration, depression E Electrolyte, endocrine dysfunction (thyroid, adrenal), ETOH (alcohol) and/or drug use, abuse or withdrawal L Liver failure I Infection (urinary tract infection, pneumonia, sepsis) R Respiratory problems (hypoxia), retention of urine or stool (constipation) I Increased intracranial pressure; U Uremia (renal failure), under treated pain M Metabolic disease, metastasis to brain, medication errors/omissions, malnutrition (thiamine, folate or B12 deficiency)
What are the benefits and burdens of:Labs, tests to search for reversible causes of delirium?CBC, lytes, BUN/creat, calcium, glucose, UA, O2 satTreatments of underlying cause(s)?Antibiotics, oxygen, bladder catheter, otherTreatments of agitated behavior?Antipsychotics, sedative hypnoticsChange in setting of care
TARGETED RISK FACTOR AND ELIGIBLE PATIENTS STANDARDIZED INTERVENTION PROTOCOLSTARGETED OUTCOMEFOR REASSESSMENTCognitive impairment*All patients, protocol once daily; patients with base-line MMSE score of <20 or orientation score of <8, protocol three times dailyOrientation protocol: board with names of care-team members and day’s schedule; communication to reorient to surroundings Therapeutic-activities protocol: cognitively stimulating activities three times daily (e.g., discussion of current events, structured reminiscence, or word games)Change in orientation scoreSleep deprivationAll patients; need for protocol assessedonce dailyNon-pharmacologic sleep protocol: at bedtime, warm drink (milk or herbal tea), relaxation tapes or music, and back massageSleep-enhancement protocol: unit-wide noise-reduction strategies (e.g., silent pill crushers, vibrating beepers, and quiet hallways) and schedule adjustments to allow sleep (e.g., rescheduling of medications and procedures)Change in rate of use ofsedative drug for sleep†ImmobilityAll patients; ambulation whenever possible, and range-of-motion exercises when patients chronically non-ambulatory, bed or wheelchair bound, immobilized (e.g., because of an extremity fracture or deep venous thrombosis), or when prescribed bed restEarly-mobilization protocol: ambulation or active range-of-motion exercises three times daily; minimal use of immobilizing equipment (e.g., bladder catheters or physical restraints)Change in Activities of Daily Living scoreVisual impairmentPatients with <20/70 visual acuity on binocular near-vision testingVision protocol: visual aids (e.g., glasses or magnifying lenses) and adaptive equipment (e.g., large illuminated telephone keypads, large-print books, and fluorescent tape on call bell), with daily reinforcement of their useEarly correction of vision, «48 hr after admissionHearing impairmentPatients hearing «6 of 12 whispers onWhisper TestHearing protocol: portable amplifying devices, earwax disimpaction, and special communication techniques, with daily reinforcement of these adaptationsChange in Whisper Test scoreDehydrationPatients with ratio of blood urea nitrogen to creatinine»18, screened for protocol by geriatric nurse-specialistDehydration protocol: early recognition of dehydration and volume repletion (i.e., encouragement of oral intake of fluids)Change in ratio of blood urea nitrogen to creatinine
If patient does not fully respond to treatmentReevaluatediagnosis/presumed causeInquire about adherence to medicationConsider dosage adjustment Titrate before rotate - just like with pain!Consider a different medicationRefer to a specialist
BMJ 2011;343:d4065 doi: 10.1136/bmj.d4065Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trialBettina S Husebo postdoctoral fellow, Clive Ballard professor, Reidun Sandvik registered nurse, Odd Bjarte Nilsen statistician, Dag Aarsland professor AbstractObjective To determine whether a systematic approach to the treatmentof pain can reduce agitation in people with moderate to severe dementialiving in nursing homes.Design Cluster randomised controlled trial.Setting 60 clusters (single independent nursing home units) in 18 nursinghomes within five municipalities of western Norway.Participants 352 residents with moderate to severe dementia andclinically significant behavioural disturbances randomised to a stepwiseprotocol for the treatment of pain for eight weeks with additional follow-upfour weeks after the end of treatment (33 clusters; n=175) or to usualtreatment (control, 27 clusters; n=177).Intervention Participants in the intervention group received individualdaily treatment of pain for eight weeks according to the stepwise protocol,with paracetamol (acetaminophen), morphine, buprenorphine transdermalpatch, or pregabaline. The control group received usual treatment andcare.Main outcome measures Primary outcome measure was agitation(scores on Cohen-Mansfield agitation inventory). Secondary outcomemeasures were aggression (scores on neuropsychiatric inventory-nursinghome version), pain (scores onmobilisation-observation-behaviour-intensity-dementia-2), activities ofdaily living, and cognition (mini-mental state examination).Results Agitation was significantly reduced in the intervention groupcompared with control group after eight weeks (repeated measuresanalysis of covariance adjusting for baseline score, P<0.001): theaverage reduction in scores for agitation was 17% (treatment effectestimate −7.0, 95% confidence interval −3.7 to −10.3). Treatment of painwas also significantly beneficial for the overall severity of neuropsychiatricsymptoms (−9.0, −5.5 to −12.6) and pain (−1.3, −0.8 to −1.7), but thegroups did not differ significantly for activities of daily living or cognition.
Aromatherapy massage RCT showed short-term benefit in anxiety in patients with cancer related anxiety.Lavandula augustifolia (Lavender) aromatherapy - agitation in elderly patients with dementia. Cross-over randomized study. N=70Improvement in Agitation (p<0.0005), irritability (p<0.001), physical aggression, physical behavior non-aggressive, and verbally agitated behavior (p<0.001).Other studies showed cutaneous application of oil for effect, given decrease in olfactory function in elderly.