Jalna Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
Delirium
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• Withdrawn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, trying 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, decubiti
• 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
Notas del editor
B- is the correct answer
Disturbance in consciousness with reduced ability to focus, sustain, or shift attention
A change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established or evolving dementia
Develops over a short period of time (usually hours to days) and tends to fluctuate over the course of the day
There 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 - 2482
89% 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 confusion
38% witnessed these symptoms daily
Sense of fear and helplessness
May 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 - 319
Most 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 scale
Fear 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:
Dementia
Elderly man
Metastatic lung cancer
Immobility
Poor oral intake
Poly-pharmacy
Possible 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 sat
Treatments of underlying cause(s)?
Antibiotics, oxygen, bladder catheter, other
Treatments of agitated behavior?
Antipsychotics, sedative hypnotics
Change in setting of care
TARGETED RISK FACTOR AND ELIGIBLE PATIENTS STANDARDIZED INTERVENTION PROTOCOLS
TARGETED OUTCOME
FOR REASSESSMENT
Cognitive impairment*
All patients, protocol once daily; patients with
base-line MMSE score of <20 or orientation
score of <8, protocol three times daily
Orientation 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 score
Sleep deprivation
All patients; need for protocol assessed
once daily
Non-pharmacologic sleep protocol: at bedtime, warm drink (milk or
herbal tea), relaxation tapes or music, and back massage
Sleep-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 of
sedative drug for sleep†
Immobility
All 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 rest
Early-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 score
Visual impairment
Patients with <20/70 visual acuity on
binocular near-vision testing
Vision 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 use
Early correction of vision,
«48 hr after admission
Hearing impairment
Patients hearing «6 of 12 whispers on
Whisper Test
Hearing protocol: portable amplifying devices, earwax disimpaction,
and special communication techniques, with daily reinforcement
of these adaptations
Change in Whisper Test score
Dehydration
Patients with ratio of blood urea nitrogen to
creatinine»18, screened for protocol by
geriatric nurse-specialist
Dehydration 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
Environment
Body
Mind/heart
Soul/spirit
Avoid poly-pharmacy
a
If patient does not fully respond to treatment
Reevaluate diagnosis/presumed cause
Inquire about adherence to medication
Consider dosage adjustment
Titrate before rotate - just like with pain!
Consider a different medication
Refer to a specialist
BMJ 2011;343:d4065 doi: 10.1136/bmj.d4065
Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial
Bettina S Husebo postdoctoral fellow, Clive Ballard professor, Reidun Sandvik registered nurse, Odd Bjarte Nilsen statistician, Dag Aarsland professor
Abstract
Objective To determine whether a systematic approach to the treatment
of pain can reduce agitation in people with moderate to severe dementia
living in nursing homes.
Design Cluster randomised controlled trial.
Setting 60 clusters (single independent nursing home units) in 18 nursing
homes within five municipalities of western Norway.
Participants 352 residents with moderate to severe dementia and
clinically significant behavioural disturbances randomised to a stepwise
protocol for the treatment of pain for eight weeks with additional follow-up
four weeks after the end of treatment (33 clusters; n=175) or to usual
treatment (control, 27 clusters; n=177).
Intervention Participants in the intervention group received individual
daily treatment of pain for eight weeks according to the stepwise protocol,
with paracetamol (acetaminophen), morphine, buprenorphine transdermal
patch, or pregabaline. The control group received usual treatment and
care.
Main outcome measures Primary outcome measure was agitation
(scores on Cohen-Mansfield agitation inventory). Secondary outcome
measures were aggression (scores on neuropsychiatric inventory-nursing
home version), pain (scores on
mobilisation-observation-behaviour-intensity-dementia-2), activities of
daily living, and cognition (mini-mental state examination).
Results Agitation was significantly reduced in the intervention group
compared with control group after eight weeks (repeated measures
analysis of covariance adjusting for baseline score, P<0.001): the
average reduction in scores for agitation was 17% (treatment effect
estimate −7.0, 95% confidence interval −3.7 to −10.3). Treatment of pain
was also significantly beneficial for the overall severity of neuropsychiatric
symptoms (−9.0, −5.5 to −12.6) and pain (−1.3, −0.8 to −1.7), but the
groups 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=70
Improvement 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.