AOA OMED Conference San Francisco 2010

We gratefully acknowledge the outstanding work done by:  Scott A. Irwin, MD, PhD   Rosene P. Pirrello, RPh Jeremy M. Hirst, MD  Gary T. Buckholz, MD  Frank D. Ferris, MD, FAAHPM And the Institute for Palliative Medicine at San Diego Hospice, and AAHPM

  Identify the patient at risk for agitation and delirium Describe how to relieve suffering and control agitation and delirium

Change in mental status. Impaired: 1.

Attention 2.

3.

Orientation Cognition 4.

5.

6.

Consciousness Reality Behavior

1. Disturbance in consciousness  Attention 2. Change in cognition  Examples: memory, orientation, language 3. Develops over a short period of time 4. Caused by the direct physiological consequences of a general medical condition

   Hyperactive: confusion, agitation hallucinations, myoclonus Hypoactive: confusion, somnolence, withdrawn. More likely to be under diagnosed “If you don’t look for it, you won’t find it” Mixed

 Hospitalized elderly:  ICU:  Advanced Cancer or End of Life: 14-56% 70-87% 25-85%

      Six month mortality: up to 25% Increased mortality: 10-78% Prolonged hospitalizations Stress Discomfort Reduced quality of life

     Causes a person to be frightened, agitated and upset Interferes with the assessment and treatment of other symptoms Increased caregiver burden Increases the use of restraints Interferes with meaningful communication and interaction

         Decreased oral intake: dehydration, malnutrition Over age 65 Male Low activity level Constipation/fecal impaction History of falls Visual or hearing impairment Depression History of previous delirium

Delirium has many, many causes – A good number of them are discoverable and reversible – approximately 50%

     

J O

– JUDGEMENT changes – ORIENTATION changes

M

– MEMORY changes

A

– AFFECT changes

C

– COGNITIVE changes Delirium is a state defined by a CHANGE in mental functioning

      Fluid imbalance Medications (see next slide) Infections Hepatic or renal failure Hypoxia Hematological disturbances

         Opioids Corticosteroids Benzodiazepines Scopolamine Hydroxyzine Diphenhydramine Hyoscyamine Tricyclic Antidepressants H2 Blockers    NSAIDS Metoclopramide Alcohol/drug withdrawal

In a hospice study of 2700 patients (S.A. Irwin et.al.2008) delirium was recognized in only:   17.8% of home care patients 28.3 % of inpatients

     Complex presentation Inconsistent language among professionals about mental status Preconceived notions Hypo-active sub-type is quiet Thought to be normal part of end of life

   Involve the chaplain Assess for possible existential crisis or other version of pre death awareness Consider prayer, meditation, mantra, ritual Physical Social, Emotional Spirit

   If grimacing and agitation are thought to be pain, assess the cause. If there is no obvious reason for the pain, or the pain is “all over”, it is probably delirium Frequently, the delirious pt will answer “yes” to the question of pain An opioid may sedate a delirious pt, leading to the belief that it has helped

   Anxiety: apprehension, jitters, etc. but attentive, alert and oriented Depression: may be restless with decreased concentration but attentive and oriented Dementia: usually alert, and attentive, decreased cognition over months to years

Delirium 1.

Acute onset 2.

3.

Fluctuates Duration days to weeks 4.

5.

6.

7.

Altered consciousness Impaired attention Increased or decreased psychomotor Can be reversible Dementia 1.

Insidious onset 2.

3.

Progressive Duration months to years 4.

5.

6.

7.

Clear consciousness Normal attention except when severe Normal psychomotor (usually) Rarely reversible

Delirium  Change in alertness  Onset – hours to days  Fluctuates hourly Sundown Syndrome   No change in alertness Onset – daily, slowly worsening  Fluctuation daily and predictable  Occurs with dementia

Time limited trial to find and reverse the causes such as  Drug side effects   Low oxygen – CHF, COPD, PE Infection     Retention of urine or feces Poor intake – malnutrition, dehydration Organ failure – kidney, liver Metabolic problems – electrolytes, thyroid, Ca++

   This is delirium during the dying process when there is not a reversible cause and the patient is expected to die in the following hours, days to a week Frequently there is restlessness, agitation, moaning, and purposeless vocalization.

Signs of active dying process may be present, such as peripheral cooling, abnormal breathing, anuria, etc.

Provide support and orientation:  Communicate clearly, concisely, and calmly  Give repeated verbal reminders of the day, time and location   Provide clear signposts to patient’s location, including clock and date Have familiar objects from the patient’s home nearby

Provide an unambiguous environment:    Try to avoid frequent change in bed location Avoid using medical jargon in front of the patient Avoid extremes of bright lighting and darkness   Control excess noise Keep room temperature between 70-75 degrees.

Maintaining competence:  Identify and correct sensory impairments. Ensure patients have their glasses, hearing aid and dentures  Use an interpreter as needed  Encourage self care and participation in treatment

  Have patient/caregiver give feedback on treatments of symptoms Maintain activity levels; and arrange treatments to allow for maximum periods of un-interrupted sleep.

Hyperactive delirium  Haloperidol (Haldol) is drug of choice for symptom of agitation (or other symptom causing suffering)   Haloperidol is a butyrophenone derivative with antipsychotic properties that has been considered particularly effective in the management of hyperactivity, agitation, and mania. Haloperidol is an effective neuroleptic and also possesses antiemetic properties

   Haldol is NOT for use in alcohol or benzodiazepine withdrawal Check to see if the patient has Parkinson’s Disease prior to initiating it There may be a slightly increased risk of serious side effects (e.g., pneumonia and heart failure) when used in older adults with dementia.

Second generation medications such as  chlorpromazine (thorazine)   olanzapine (zyprexa) quetiapine (seroquel)  risperidone (risperdol) may be needed if haldol alone is not effective

Hypoactive delirium  Medication for hypoactive delirium is not usually needed Mixed delirium  Medication as per hyperactive delirium with less during hypoactive part of the day

Terminal delirium  Sedation is the main treatment and  Benzodiazepines are more important (examples of benzodiazepines are ativan, xanax, librium, valium)

   If there is not adequate relief of suffering, try further non-pharmacologic comfort measures. Treat agitation like a breakthrough symptom (pain) and use PRN medication If the pharmacologic treatment is not effective in relieving suffering, the physician should be notified for further orders.

  Observe for medication side effect Note the varying degree of sedation and extra-pyramidal symptoms that different drugs have

Drug

Haloperidol Thorazine Risperdal Zyprexa Seroquel

Sedation

1+ 3+ 1+ 2+ 2-3+ *EPS: Extra-pyramidal Symptoms (Parkinsonian-like)

EPS*

4+ 2+ 2+ 1+ 0

EPS are movement disorders that can occur as a result of taking haldol (or other anti psychotic drugs). Examples:  Tardive dyskinesia -involuntary, irregular muscle movements, usually in the face      Muscular lead-pipe rigidity Bradykinesia – slow movement Akinesia – inability to initiate movement Resting tremor Postural instability

Indicated for  Delirium due to alcohol and benzodiazepine withdrawal  Anxiety    Primal fear (e.g., feeling of suffocation) Sedation therapy (use with haldol for delirium) Seizure disorder

  Like all drugs in this chemical family, (i.e. benzodiazepines), lorazepam enhances the action of the inhibitory neurotransmitter GABA by acting at the GABAA receptor.

It has anxiolytic, sedative and hypnotic properties

   Respiratory depression, especially if opioids are present May worsen delirium Over sedation when treating delirium

CMS Nursing Home surveys include audit and review of    F-329 Unnecessary drugs used F-330 Antipsychotics received when appropriate F-331 Antipsychotics dose reduction Documentation needs to focus on the symptoms causing suffering, and the interventions, both non-pharmacologic and pharmacologic that have been used to help relieve symptoms

     Provide support and orientation Provide an unambiguous environment Help the patient maintain competence, function and activities as much as he is able Observe for medication side effects Address safety issues and implement fall prevention strategies, especially for patients with agitation

   Order appropriate laboratory and diagnostic studies to assess for reversible causes Include non-pharmacologic interventions in the Plan of Care Prescribe pharmacologic treatment for the suffering and symptoms of delirium if indicated

     Anna is a 78 yr female, primary diagnosis non-small cell lung carcinoma Right lobectomy two years ago Maintained on continuous O2 @1.5 L/min Lives at home alone Usually alert and oriented