Delirium (in palliative care and hospice)


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Presentation given by me and Dr. Novack about assessing and managing delirium in patients receiving palliative care and hospice care.
Original presentation was shared with NHPCO - this is a version of the slides provided there.

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  • 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)
  • Predisposing conditions:DementiaElderly manMetastatic lung cancerImmobilityPoor oral intakePoly-pharmacyPossible precipitating factors:Drug side effect?Hypoxemia?Infection?Constipation?Urinary retention?Metabolic disorder?Brain metastases?Emotional distress?
  • 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
  • EnvironmentBodyMind/heartSoul/spiritAvoid poly-pharmacy
  • a
  • 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.
  • SightsLight/dark cycles, visual cues, familiar facesSoundsReduce ambient noise, music therapy, familiar voicesSmells (and taste)AromatherapyHome cookingTouch
  • 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.
  • Delirium (in palliative care and hospice)

    1. 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
    2. 2. Overview: Delirium What? Why? Causes Management
    3. 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
    4. 4. WHAT? Delirium What is it?
    5. 5. Delirium Delirare: to be crazy De lira: to leave the furrows
    6. 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. 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. 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. 9. Clinical Subtypes: Delirium • Confusion • Agitation • Hallucinations • Myoclonus Hyperactive • Fluctuates between both Mixed • Confusion • Somnolence • Withdrawn Hypoactive Less likely to be diagnosed
    10. 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
    11. 11. Dying with Dementia Agitation • 87% Confusion • 83% J. Geriatric Psychiatry 1997
    12. 12. WHY? Delirium Why bother identify and treat?
    13. 13. Delirium is experienced in up to what percentage of terminally ill cancer patients? a) 10% b) 18% c) 40% d) 85%
    14. 14. WHY TALK ABOUT IT? Delirium is common Up to 85% people experience it at end of life 25-40% of hospitalized cancer patients
    15. 15. WHY TALK ABOUT IT? Delirium is harmful Hospital LOS $ Death Nursing home placement from hospital Caregiver burden increases
    16. 16. WHY TALK ABOUT IT? Delirium hurts relationships Interferes with meaningful communication and interaction
    17. 17. WHY TALK ABOUT DELIRIUM? Delirium conflicts with patient goals >70% seriously ill patients want cognitive awareness 89% patients refuse treatments that impair cognition JAMA 2000; 284: 2476-2482 • NEJM 2002; 346: 1061-1090
    18. 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. 19. WHY TALK ABOUT IT? Delirium is common Delirium is harmful Delirium hurts relationships Delirium conflicts with patient goals Delirium causes caregiver distress
    20. 20. WHAT CAUSES IT? Delirium
    21. 21. Which is not a risk factor for delirium? a) Age b) Cognitive impairment c) Gender d) Opioid use e) Constipation
    22. 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. 23. What patients are at risk? Patient habits Cognitive status Physical function Sensory Deficits Environ- mental change  oral intake Drugs Other medical problems
    24. 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. 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
    26. 26. WHAT CAUSES IT? Opioids Corticosteroids Benzodiazepines Anticholinergics Diuretics Tricyclics Lithium H2 Blockers NSAIDs Metoclopramide Alcohol/drug use or withdrawal
    27. 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. 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. 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. 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. 31. 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
    32. 32. 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.
    33. 33. 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
    34. 34. 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
    35. 35. Next steps: managing delirium weighing benefits & burdens • Lab tests • Treating underlying cause(s) • Treating agitation
    36. 36. 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
    37. 37. MANAGEMENT Delirium
    38. 38. MANAGING DELIRIUM An ounce of prevention is worth a pound of cure.
    39. 39. Prevention Protocol: Delirium • Orient • Stimulate • Mobilize • Sleep (non-pharmacologic) • Create restful night-time environment • See • Hear • Eat/drink (based on goals of care) NEJM 1999; 340: 669-676
    40. 40. Hospice approach to prevention Know the risk factors Develop a prevention/intervention plan of care • Healthy sleep • Treat symptoms • Movement • Avoid poly-pharmacy • Orient to place & time • Light – day-night cycle • Familiar people • Address faith • Legacy • Relationships • Communicate • Engage healthy relationships Emotional Existential PhysicalEnvironment
    41. 41. RECOGNIZING AND NAMING First step in the management of delirium Once it’s happened
    42. 42. Delirium is reversible in what percentage of cases? a) ~ 50% b) ~ 25% c) ~ 10% d) ~ 1%
    43. 43. 50% Delirium can be reversed Lawlor et al. Arch Intern Med 2000;160:786-94
    44. 44. PALLIATIVE EMERGENCY When is delirium a
    45. 45. 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
    46. 46. 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
    47. 47. Assessing severity of agitation Uncooperative, intense stare Motor restlessness Mood lability, loud speech Irritability, intimidation Aggressive, hostile Adapted from Scott Irwin, San Diego Hospice
    48. 48. 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
    49. 49. STEP 1: TREAT UNDERLYING CAUSE Delirium Management
    50. 50. 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.
    51. 51. 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
    52. 52. 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
    53. 53. 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
    54. 54. AGITATION WITH DEMENTIA Treat the pain Address sleep-wake cycle Create familiar environment Facilitate range of motion & exercise
    55. 55. Sleep-wake cycle: normalize Melatonin 3-7mg in the evening, with sunset.
    56. 56. STEP 2: NON-PHARMACOLOGIC APPROACH Delirium Management
    57. 57. 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
    58. 58. 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
    59. 59. 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.
    60. 60. 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
    61. 61. Existential Causes of DELIRIUM Johann Rudolf Schnellberg after Fuseli's “Head of a damned Soul from Dante’s Inferno” (1775)
    62. 62. STEP 3: PHARMACOLOGIC APPROACH Delirium Management
    63. 63. Hypoactive delirium • Day-night cycle can be critical • Methylphenidate 5mg qam and qnoon – Watch for anxiety, symptomatic palpitations Management STEP3: PHARMACOLOGIC
    64. 64. MANAGING DELIRIUM If all else fails, use antipsychotics
    65. 65. 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!
    66. 66. 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
    67. 67. 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
    68. 68. Profiles of antipsychotics Adapted from Muscarinic
    69. 69. 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)
    70. 70. 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
    71. 71. 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.
    72. 72. Inadequate or no response: Reassess cause again, depending on goals of care. Consider sedation if needed. benzodiazepines, barbiturates or propofol This is palliative sedation!
    73. 73. 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
    74. 74. 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.
    75. 75. 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
    76. 76. 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.
    77. 77. 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?
    78. 78. 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
    79. 79. 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
    80. 80. 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.
    81. 81. Tending to delirium takes a community family & friends hospice caregivers nursing home caregivers chaplain volunteers
    82. 82. SUMMARY
    83. 83. RECOGNIZING DELIRIUM is a sign not a diagnosis
    84. 84. RECOGNIZING DELIRIUM Know the difference delirium vs dementia vs depression
    85. 85. RECOGNIZING DELIRIUM Terminal delirium Diagnosis of exclusion Should not be presumed
    86. 86. CONFRONTING DELIRIUM Prevent it • know the risks Recognize it • assess often Reverse it • reverse the reversible Treat it • non-pharmacologic • antipsychotic • sedatives
    87. 87. THANK YOU
    88. 88. 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