Alice Emery MD Hospice of Michigan, Grand Rapids Ph: 616 322 8461
46
Evaluation and Treatment of Acute Mental Status Change in Hospice and Palliative care Alice Emery MD Hospice of Michigan, Grand Rapids Ph: 616 322 8461
Alice Emery MD Hospice of Michigan, Grand Rapids Ph: 616 322 8461
Alice Emery MD Hospice of Michigan, Grand Rapids Ph: 616 322
8461
Slide 2
Mental Health: hallmarks Ability with maintain relations with
people Cooperative/cordial relations with colleagues Supportive
family relationships. Play role of parent or spouse Ability to
engage in useful work Focus, problem solving, dependability Ability
to balance/moderate leisure activities Avoid self-destructive
patterns Relax and enjoy positive experiences
Slide 3
Mental Health: Supports 1. Habits 2. Work/useful engagement 3.
Family and supportive friends 4. Spirituality/Mission 5. Body
constancy(physical health)
Slide 4
Mental Health Baseline level of mental health for each person
at every stage of life Stress/loss can disrupt the baseline/upset
the personality causing adjustment phase People with good mental
health at baseline, usually can withstand several stresses or
supports lost at once. Adjustment disorder
Slide 5
Mental health for patients Calm and Cooperative is the minimum
required Neutral emotion and compliant with staff Palliative
care/hospice referral can result from inability to maintain
calmness or cooperativeness Chronic: often with setting of dementia
Acute change in mental status due to environmental disturbance or
discomfort (disordered reaction to sensory input) or Real
disturbance in neuronal functioning
Slide 6
Delirium Acutely (hrs to days) Decreased awareness of
surroundings and personal state/impaired attention/decreased
rational thinking CONFUSION Related to medical illness Compare to
dementia Often Increased purposeless activity level/ Increased
anxiety level
Slide 7
Delirium per DSM-IV Disturbance of consciousness (e.g. reduced
clarity of awareness of the environment) with reduced ability to
focus, sustain, or shift attention. A change in cognition (such as
memory deficit, disorientation, language disturbance) or the
development of a perceptual disturbance that is not better
accounted for by a pre-existing, established or evolving dementia.
The disturbance develops over a short period of time (usually hours
to days) and tends to fluctuate during the course of the day. There
is evidence from the history, physical examination, or laboratory
findings that the disturbance is caused by the direct physiologic
consequences of a general medical condition.
Slide 8
Anxiety Anxiety is a general sensation of fear, which is not
related to or out of proportion to a real and actual danger. Some
anxiety may be 'normal' in the hospice environment, but requires
treatment when anxiety appears to be disproportionately high, and
when it is associated with other severe signs, such as loss of
self- control, or leads to disturbance in family relations
Slide 9
Terminal illness: Plenty to be anxious about The future vs.
right now in healthy persons Right now I feel pretty good In the
future I hope to have more money, time etc. Right now with Multiple
Myeloma (Case) My legs both feel uncomfortable My hip hurts My
cancer is damaging my kidneys The future with terminal disease My
hip will shatter My legs might have to be amputated My kidneys will
fail
Slide 10
Agitation Agitation is a psychomotor disturbance (excitation)
characterized by a marked increase in purposeless motor and
psychological activity in a patient. It occurs very frequently in
the hospice setting. It may be isolated, or accompanied by other
mental disorders, such as severe anxiety and delirium INCREASED
ACTIVITY Something is driving it
Slide 11
Agitation often accompanied by a loss of control of action and
a disorganization of thought. Causes of which are frequently
occurring situations in the setting of terminal illness related to
the disease itself (metabolic disorders, medications, sepsis-
associated encephalopathy, pain, and so on) or to external factors
(noise, dislocation) Agitation per se may be dangerous in hospital
or at home: Falls, injuries, dehydration, exhaustion
Slide 12
Agitation: phone call Pt. agitated: 87 yo has been on hospice
14 days with Debility related to prior hip fx and pneumonia.
Baseline had been able to speak, answer simple questions. Yesterday
was up and down a lot, last night did not sleep at all, family
exhausted and request med to make her sleep. (Ativan OK?) Ask
about: Associated symptoms. Review meds, MED CHANGES, PAIN, BOWELS,
URINATION, HYPOXEMIA,
Slide 13
Fixable causes of agitation or delirium Fecal Impaction Urinary
retention Common in hospice patients who already have impaired
brain function Easily overlooked cause of discomfort Fixable
Slide 14
Fixable causes of delirium or agitation: Pain: trial of pain
med for elderly Hypoxemia: oxygen sat/start oxygen Infection:
UTI
Slide 15
Fixable causes: Medication Effect Prescribed or illicit drug
overdose or withdrawal (insulin, digoxin, decadron) Alcohol:
intoxication or withdrawal Benzodiazepines: adverse reaction or
withdrawal
Slide 16
Paradoxical effect: Benzidiazepine 5% of people Opposite effect
of desired calming, relaxing effect Can cause physical
restlessness, neuroexcitation Seizures can be potentiated
Disinhibition and loss of control. Aggression: violent behavior Can
be mistaken for mania or schizophrenia STOP offending agent No more
benzodiazepines. Use haldol etc
Agitation due to Toxic Metabolic Encephalopathy: AGITATED
delirium What other metabolic causes Na+, Ca+, NH4+, unknown
factors presumed to be uncorrectable, high or low glucose
Circulatory disturbance Organ failure How to prevent it? Monitoring
of electrolytes, good nursing care. Often cannot be prevented, and
underlying cause cannot be treated in hospice setting
Slide 19
Agitated Delirium How to evaluate severity? Mild: Disordered
thinking with paranoia or hallucinations leading to medication
refusal or care refusal Moderate: Distressed affect with
psycho-motor agitation causing safety risk Severe: distressed
affect, motor agitation, and aggression/attempts to harm self or
others
Slide 20
Toxic-Metabolic Encephalopathy Management Environmental: TV,
roommates, level of stimulation Special precautions for Veterans
Safety: restraints or physical limits as needed in keeping with
degree of safety risk Medications
Slide 21
Antipsychotics Typical developed in 1950s beginning with
Thorazine A breakthrough for care of schizophrenia with many
serious side effects Thorazine is very sedating Haldol is favorite
of Hospice and Palliative care Atypical Antipsychotics: several
types Less extrapyramidal motor effects Can be sedating (Seroquel
due to antihistamine effect)
Slide 22
Agitation due to Toxic Metabolic Encephalopathy: AGITATED
delirium Mild: start daily po antipsychotic +/- benzo Moderate: po
loading dose, then daily antipsychotic +/- benzodiazepine Severe:
IM loading doses of Antipsychotic and Benzo Followed by scheduled
po doses of both. For violent resistant patients: Haldol 5mg IM/po
now and 2mg Lorazepam IM/po For moderate patients Haldol 1mg tid
and titrate For mild patients Seroquel or ripserdal low doses
Slide 23
Benzodiazepines All benzodiazepines exert, in slightly varying
degrees, 5 major actions: hypnotic, anxiolytic, anticonvulsant,
muscular relaxant and amnesic. Their main advantages are rapid
onset of action and low toxicity. Few, if any, other drugs can
compete with them in all these respects. Use half adult doses in
elderly. Ativan po, sl, IV most often used Klonopin po long half
life, marketed for seizures Valium po, IM rapid onset, long half
life Xanax po (not preferred) Versed IV 1-7mg/hr
Slide 24
Benzodiazepines Versed: midazolam: popular in Palliative care
Rapid onset: watch for resp depression Best overall for continuous
IV infusion. Safe and effective IV with rapid titratability Can
also be used as nasal insufflation Buccal Versed also available
mostly for status epilepticus
Slide 25
Other drugs for acute delirium Phenobarb IM 60mg May only last
4 hrs. need a follow up plan.
Slide 26
Acute mental status change Dont forget the caregivers May be
overwhelmed Lack of sleep Lack of understanding May need to call in
the supporting cast
Slide 27
Acute Behavior problems in dementia Off label use of
antipsychotics to manage behavior problems in dementia patients has
become commonplace despite warnings of side effects, increased
mortality, and general belief that other means of improving quality
of life would be effective In good nursing facilities less than 20%
of dementia pts. require scheduled antipsychotics. Work on quality
of life measures, and periodic dose reductions are a good
thing.
Slide 28
Depression Depressed mood is a part of normal loss Related to
loss, A series of losses Major depression can be
induced/exacerbated by grief Can occur for the first time in the
setting of terminal illness or be longstanding DECREASED
ACTIVITY
Slide 29
Depression Hospice interventions: support return to mental
health for patients with mild depression Medications are indicated
if believed to be a primary depression rather than normal
fluctuation of mood related to illness Difficult to determine if
depression is part of illness or a separate mental illness, since
symptoms of depression are characterized by depressed mood,
anhedonia, and low energy
Slide 30
Depression Medications: neuromodulation SSRI selective
serotonin reuptake inhibitors SSRIs are believed to increase the
extracellular level of serotonin by inhibiting its reuptake into
the presynaptic cell, increasing the level of serotonin in the
synaptic cleft to bind to the post synaptic receptor. They have
varying degrees of selectivity for the other monoamine
transporters, with pure SSRIs having only weak affinity for the
noradrenaline and dopamine transporters.
Slide 31
SSRIs Most common therapeutic medication for depression Also
used for anxiety, social phobia, OCD, many other dysphoric neurotic
disorders. Effect in mild or moderate depression is similar to
placebo, but in severe depression positive effect begins in 2-3
weeks with full effect in 4-6wks. Side effects: Appetite or sleep
disturbance, Possible suicide potentiation, seizures,
arrhythmias
Other Antidepressants SNRIs: newer class with similar effects
Duloxetine: Cymbalta Desvenlafaxine: Pristiq Venlafaxine: Effexor
Noradrenergic and Specific Serotonin antidepressants: (NaSSAs)
another developing class which block Alpha 2 receptors and certain
serotonin receptors. Sedating, wt. gain. Mirtazapine: Remeron
Slide 34
Other antidepressants NA (norepinephrine) reuptake blockers:
(NRIs)marketed as enhancing concentration and motivation
Atomoxatine: Strattera Na and Da reuptake inhibitors: Bupropion:
Wellbutrin
Slide 35
Augmenters Drugs used with another antidepressant Trazodone:
for sleep Buspar: nonsedating anxiolytic Psychostimulants:
Methylphenidate (Ritalin), amphetamine (Adderall), modafinil
(Provigil) Antipsychotics may be added as well such as risperidone
(Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa):
controversial due to side effects Benzodiazepines: for anxiety
Slide 36
Depression Complete response in 25% of patients Adding
augmenters can increase to 30% Change the antidepressant Still
leaving 70% with poor or incomplete partial response to medication
for depression Generally each antidepressant takes 4-6 weeks to
evaluate full response Positive effects can fade over time
Slide 37
Ketamine for Depression Novel use of ketamine: NIH 8/2006
Published use of weekly Ketamine dosing for resistant depression
Published use in ED as IV bolus for treatment of acute suicidality
in depression Journal Palliative Medicine July 2010 case series in
terminal hospice patients showed a single oral dose of approx. 30mg
gave a measurable elevation of mood lasting over one week.
Mechanism? (not opioid receptor or just NMDA effect) Side effects?
(acute hallucinations/disassociative state)
Slide 38
Case 1 64 yo woman with COPD and depressive symptoms developing
over several months. Low mood, low energy, hypersomnia, decreased
appetite with unintentional weight loss, hopelessness, and
excessive feelings of guilt, especially regarding feeling like a
burden on her roommate, who was also her close friend and primary
caregiver. She was preoccupied with thoughts of wanting to die. She
did not plan or intend to end her life, stating I'm too chicken to
die.
Slide 39
Case 1 She had stopped socializing and reading and was letting
bills pile up Anxious with daily panic attacks Irritable with
roommate and the dog Fidgety Focused on pain and dyspnea No
cognitive impairment
Slide 40
Case 1 Informed consent and psychiatric baseline testing done
with Hamilton depression scale Hospital Anxiety and Depression
Scale Brief Psychiatric Rating Scale Young Mania rating scale Mini
mental status exam Treated with 0.5mg/kg oral ketamine Depression
and anxiety decreased within hours.
Slide 41
Case 1 no longer had suicidal thoughts: expressed hope for the
future no longer felt irritable became much more engaging, desiring
to talk about television shows and soap operas. Her appetite had
improved dramatically anxiety and irritability she displayed prior
to ketamine dosing were absent She paid and filed away her entire
pile of bills. Her caregiver reported that S.B. was much more alert
and no longer nodded off throughout the day. Her pain and shortness
of breath improved. trouble sitting still, I want to get out and do
things now. She had become less preoccupied with feeling like a
burden begun to read books again, she started to call her friends
and initiated planning social gatherings
Slide 42
Case 1 Symptoms returned (but not as severely) after a month
and by that time she had developed some confusion and was on more
pain medications Repeat dosing did not bring improvement Case
illustrates one personal result of ketamine therapy for
depression
Slide 43
Case 2 70 yo man with prostate ca metastatic to liver, bone,
and lung and had been bedbound for 8 months. Prognosis days to
weeks Depression developing over 3 months depressed mood,
significantly decreased energy, lack of appetite with unintentional
weight loss, poor sleep with early morning awakening, and
ruminative thoughts of wanting to be dead. He denied a suicidal
plan or intent, explaining even if I wanted to, I could not do
anything in this state. He described significant anhedonia, which
contrasted with his prior zest for life
Slide 44
Case 2 he no longer wanted friends to visit, stopped watching
movies and reading, and had to force himself to eat. Furthermore,
he experienced excessive guilt about feeling like a burden to his
wife, who was his primary caregiver Excessive worry and daily panic
attacks No cognitive impairments Treated with 0.5mg/kg oral
ketamine Noted improvements within hours
Slide 45
Case 2 Within 60 minutes of dosing, he reported an improvement
in his anxiety and pain, and his wife observed that he looked more
calm and peaceful. By day 3, he started to request his favorite
foods, and his humor was noted to improve. On day 4, his wife
observed a big difference explaining he was more chipper. He
watched an entire movie without dozing for the first time in
months. His mood continued to dramatically improve over the
following week. He began to watch, enjoy, and discuss several
movies a day with his wife. His appetite increased and he continued
to request his favorite foods. he began to have friends visit again
and savored their time together. Around day 13, his physical health
worsened to the point that he could no longer participate with
assessments. His wife articulated that his focus on death
qualitatively shifted from wanting to die to accepting death. He
peacefully died at home within the following 2 weeks.
Slide 46
Could end of life depression be more treatable than we
think?