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Delirium in Palliative Care & Hospice


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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.

Published in: Health & Medicine
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Delirium in Palliative Care & 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:DeliriumWhat?Why?CausesManagement
  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 is it?DeliriumWHAT?
  5. 5. DeliriumDelirare: to be crazyDe lira: to leave thefurrows
  6. 6. Early Descriptions“they move the face, hunt in “Sick people…lose their judgment empty air, pluck nap from the and talk incoherently…when bedclothes…all these signs are the violence of the fit is abated, bad, in fact deadly” the judgment presently returns…”Hippocrates:400 BCE 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 dementiaTerminal Agitation:A symptom or sign: thrashing, agitation that may occur in the last daysor 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 Less likely to be diagnosed Mixed• Confusion • Confusion• Agitation • Fluctuates • Somnolence• Hallucinations between both • Withdrawn• Myoclonus Hyperactive Hypoactive
  10. 10. Delirium vs. Dementia vs. DepressionFeatures Delirium Dementia DepressionOnset Acute (hours to Insidious (months to Acute or Insidious days) years) (wks to months)Course Fluctuating Progressive May be chronicDuration Hours to weeks Months to years Months to yearsConsciousness Altered Usually clear ClearAttention Impaired Normal except in May be decreased severe dementiaPsychomotor Increased or Often normal May be slowed inchanges decreased severe casesReversibility Usually Irreversible Usually
  11. 11. Dying with Dementia Agitation • 87% Confusion • 83% J. Geriatric Psychiatry 1997
  12. 12. Why bother identify and treat?DeliriumWHY?
  13. 13. Delirium is experienced in up to whatpercentage of terminally ill cancer patients?a) 10%b) 18%c) 40%d) 85%
  14. 14. Up to 85% people experience it at end of life25-40% of hospitalized cancer patientsDelirium is commonWHY TALK ABOUT IT?
  15. 15. Hospital LOSincreases $ Death Nursing home placement from hospital Caregiver burdenDelirium is harmfulWHY TALK ABOUT IT?
  16. 16. Interferes with meaningful communication and interactionDelirium hurts relationshipsWHY TALK ABOUT IT?
  17. 17. >70% seriously ill patients want cognitive awareness89% patients refuse treatments that impair cognition Delirium conflicts with patient goals WHY TALK ABOUT DELIRIUM? JAMA 2000; 284: 2476-2482 • NEJM 2002; 346: 1061-1090
  18. 18. Unlike pain, delirium is seenCreates sense of fear and helplessnessDelirium causes caregiver distressWHY TALK ABOUT IT? Am J Geriatr Psychiatry 2003; 11: 309 - 319
  19. 19. Delirium is commonDelirium is harmfulDelirium hurts relationshipsDelirium conflicts with patient goalsDelirium causes caregiver distressWHY TALK ABOUT IT?
  20. 20. DeliriumWHAT CAUSES IT?
  21. 21. Which is not a risk factor for delirium?a) Ageb) Cognitive impairmentc) Genderd) Opioid usee) 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, trying to get out of bed
  23. 23. What patients are at risk? Environ- mental changePhysical Sensoryfunction Deficits Cognitive statusPatient  oralhabits intake Other Drugs medical problems
  24. 24. rugs, drugs, drugs, dehydration motion, encephalopathy, environmental change ow oxygen, low hearing/seeingnfection, intracerebral event or metastasis etention (urine or stool)ntake changes (malnutrition, dehydration), Immobility remia, under treated pain etabolic diseaseWHAT CAUSES IT?
  25. 25. Which of the following medications cancause delirium?a) Lorazepamb) Hyoscyaminec) Dexamethasoned) All of the abovee) None of the above
  26. 26. Opioids Corticosteroids Benzodiazepines Anticholinergics Diuretics Tricyclics Lithium H2 Blockers NSAIDs Metoclopramide Alcohol/drug use or withdrawalWHAT CAUSES IT?
  27. 27. Diagnosis of exclusionDelirium during the dying process Signs of the dying processMultiple causes, often irreversibleTERMINAL DELIRIUMCAN IMPENDING DEATH CAUSE IT?
  28. 28. Case: Paul – is he at risk for delirium?Predisposing factors Possible precipitating factorsDementiaAge Drug side effects?Metastatic lung cancer Hypoxemia?Immobility Infection?Poor oral intake Constipation?Poly-pharmacy 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 MethodFeature 1: Acute Onset Obtained from a family member or nurse:and Fluctuating Course • 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: • Was the patient’s thinking disorganized or incoherent, suchDisorganized thinking as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?Feature 4: Altered • Overall, how would you rate this patient’s level ofLevel of consciousness 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 deliriumweighing benefits & burdens• Lab tests• Treating underlying cause(s)• Treating agitation
  36. 36. Paul’s follow up Goals of care: Peaceful death at home • DNH • no needlesticks Treated the treatable Treated the delirium • Disimpaction, daily bowel • Haloperidol 0.5-1mg SL qHS regimen and q8hrs prn • Treated UTI w/ liquid • Calmer environment antibiotics • Improved communication • Weaned lorazepam • Encouraged safe movementIn 2-3 days, Paul was back to baseline
  37. 37. DeliriumMANAGEMENT
  38. 38. An ounce of prevention is worth a pound of cure.MANAGING DELIRIUM
  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• Communicate • Address faith• Engage healthy • Legacy relationships • Relationships Emotional Existential Environment Physical• Orient to place & time • Healthy sleep• Light – day-night cycle • Treat symptoms• Familiar people • Movement • Avoid poly-pharmacy
  41. 41. Once it’s happenedFirst step in the management of deliriumRECOGNIZING AND NAMING
  42. 42. Delirium is reversible in what percentage ofcases?a) ~ 50%b) ~ 25%c) ~ 10%d) ~ 1%
  43. 43. 50%Delirium can be reversedLawlor et al. Arch Intern Med 2000;160:786-94
  44. 44. When is delirium aPALLIATIVE EMERGENCY
  45. 45. Step 1: Treat underlying causesStep 2: Non-pharmacologicalStep 3: PharmacologicalMonitor: GIP or continuous careAddress family, caregivers and otherpsychosocial impacts of deliriumDeliriumMANAGEMENT
  46. 46. Which of the following are appropriateinterventions for delirium?a) Music during turns/personal careb) Minimize ambient sound (alarms, bells, voice)c) Aromatherapy such as Lavender or Melissa with bed bathd) Spiritual interventions such as prayer, ritual, meditatione) Cognitive behavioral therapy for PTSDf) Engaging family or familiar people in careg) All of the above
  47. 47. Assessing severity of agitation Aggressive, hostile Irritability, intimidation Mood lability, loud speech Motor restlessness Uncooperative, intense stare Adapted from Scott Irwin, San Diego Hospice
  48. 48. Hierarchy of interventions for agitated delirium Seclusion Emergency and/or medicine restraint Voluntary medication Verbal intervention Check for needs, Step 1: Treat underlying causes non-pharmacologic Step 2: Non-pharmacological Step 3: Pharmacological Address family, caregivers and other psychosocial impacts of delirium Adapted from Scott Irwin, San Diego Hospice
  49. 49. Delirium ManagementSTEP 1: TREAT UNDERLYING CAUSE
  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 diseaseSTEP1: TREAT CAUSE Management
  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 seizuresAnti-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 deliriumSTEP1: TREAT CAUSE Management
  54. 54. Treat the painAddress sleep-wake cycleCreate familiar environmentFacilitate range of motion & exerciseAGITATION WITH DEMENTIA
  55. 55. Sleep-wake cycle: normalizeMelatonin 3-7mg in the evening, with sunset.
  56. 56. Delirium ManagementSTEP 2: NON-PHARMACOLOGIC APPROACH
  57. 57. NON-PHARMACOLOGIC APPROACH• Engage social work • Engage chaplaincy & psychology • Acknowledge• Consider past faith, legacy, regret trauma, Ψ history Emotional Existential Environment Physical• Engage • Nurses, aides, and aides, housekeeping doctors , family. • Exquisite care of the• Consider the 5 body senses
  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.STEP2: NON-PHARM Management
  59. 59. Case 3: Mr. U65 year old retired engineer with metastatic lungcancer to bone.HPI: Severe pain, principally in area of leg requiringcomplex pain management. Now he is experiencingincreased confusion, agitation, restlessness at night.Past Medical History: Generally healthy until diagnosis.Social History: Married to a non-Catholic woman. Has 2grown daughters. Raised Catholic but has not been tochurch 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. ExistentialCauses ofDELIRIUMJohann RudolfSchnellberg afterFuselis “Head ofa damned Soulfrom Dante’sInferno” (1775)
  62. 62. Delirium ManagementSTEP 3: PHARMACOLOGIC APPROACH
  63. 63. Hypoactive delirium • Day-night cycle can be critical • Methylphenidate 5mg qam and qnoon – Watch for anxiety, symptomatic palpitationsSTEP3: PHARMACOLOGIC Management
  64. 64. If all else fails, use antipsychoticsMANAGING DELIRIUM
  65. 65. Antipsychotics are the mainstay of pharmacologic treatment Black Box Warning! 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 TimeSTEP3: PHARMACOLOGIC Management
  66. 66. Treat like other breakthrough symptoms: Schedule medicine based on t ½ Breakthrough medicines based on Cmax Consider selection of antipsychotic based on profileSTEP3: PHARMACOLOGIC Management
  67. 67. Pharmacology of Anti-psychoticsDrug Cmax T½Chlorpromazine 1-4 hours 16-30 hours25mg SQ/IV/PR q3 hours prnup to 2g/dayQuetiapine 1-2 hours 6-7 hours25-100mg PO q1 hour prnup to 1200 mg/dayRisperidone 1-1.5 hours 3-24 hours0.25-1mg PO q1 hourup to 6mg/dOlanzapine 4-6 hours 20-70 hours5-10mg PO q4 hours prnup to 30mg/dayHaloperidol 30 min – 1 hour 4-6 hours0.5 – 2 mg q1 hr prn
  68. 68. Profiles of antipsychotics MuscarinicAdapted from
  69. 69. Chlorpromazine vs. HaloperidolAntipsychotic Agent Chlorpromazine HaloperidolSedation +++ +EPS ++ ++++Anticholinergic ++ +OrthostaticHypotension +++ +++++ = very high incidence, +++ = high incidence, ++ = moderate incidence, + = low incidenceDrug Facts and Comparisons (Oct 2003)
  70. 70. More on Anti-psychoticsLength of  Sed  Sed - EPSuse Haloperidol Chlorpromazine 3-7 Days 0.5-2 mg q1 hour prn 12.5-25 mg q 3 IM, IV, SC hours prn up to 3 PO (tab/sol) grams/day SCI IM, IV, PR SCI? PO - erratic Risperidone Olanzapine Quetiapine >7 Days (Risperdal) (Zyprexa) (Seroquel) PO: tab,sol,odt PO: tab,odt PO: tab IM: long acting IM: intermittent Ziprasidone (Geodon) PO: cap IM: intermittent
  71. 71. Choose based on level of behavior If more hyperactive, consider atypical antipsychotics If more hypoactive, consider haloperidolTitrate 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 - severeFor imminent risk of harm to self or others due to agitation,mix in following order: Haloperidol 2- DiphenhydramineLorazepam 1-2mg 5mg 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 Seclusion Emergency and/or medicine restraint Voluntary medication Verbal intervention Check for Step 1: Treat underlying causes needs, non- Step 2: Non-pharmacological pharmacologic Step 3: Pharmacological Address family, caregivers and other psychosocial impacts of delirium Adapted from Scott Irwin, San Diego Hospice
  76. 76. Case 4: Philip’s struggle63 yo retired photographer with end-stage CHF, inthe context of drug abuse history. He was anactive duty veteran.He was estranged from his family and no longeractive in his Jewish faith.Severe dyspnea. Now over 2 weeks becomingincreasingly confused multiple times each day.Sometimes confusion is agitated, sometimessomnolent.
  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 medicationsMSContin and Roxinol for dyspneaOxygenLorazepam q4 hours prn for anxietyFurosemide qDay for edemaMetoprolol bid for CHFLisinopril for CHF
  79. 79. Addressing Philip’s DELIRIUMStep 1: reverse the reversibleOpioids rotated Step 2: Non-pharmacologicBenzos weaned Social worker addressed Step 3: PsychopharmAssessment for UTI – PTSDnegative Chaplain was involved Hyperactive periods lessPoor intense BUThydration/nutrition –not reversed due to Mental status continuedgoals of care to wax and waneOxygen increased Haloperidol was started
  80. 80. Philip’s struggleWith these interventions, he awokewith more alertness for a brief afew days.Later he showed signs of activedying: Mottling of hands and feet Irregular breathing patternsHe died peacefully 7 days later.
  81. 81. Tending to delirium takes a community volunteers family & friends hospicechaplain caregivers nursing home caregivers
  82. 82. SUMMARY
  83. 83. is a sign not a diagnosisRECOGNIZING DELIRIUM
  84. 84. Know the differencedelirium vs dementia vs depressionRECOGNIZING DELIRIUM
  85. 85. Terminal deliriumDiagnosis of exclusionShould not be presumedRECOGNIZING DELIRIUM
  86. 86. Prevent it • know the risksRecognize it • assess oftenReverse it • reverse the reversibleTreat it • non-pharmacologic • antipsychotic • sedativesCONFRONTING DELIRIUM
  87. 87. THANK YOU
  88. 88. Which are you most likely to use today?a) Recognize the difference between agitation and deliriumb) Use specific tools for assessment (CAM, SQiD)c) Engage all members of the IDT earlierd) Remember the non-pharmacologic interventionse) Know my pharmacology