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.

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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 & 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