AOA OMED ConferenceSan 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, FAAHPMAnd 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. Attention2. Orientation3. Cognition4. Consciousness5. Reality6. Behavior

1. Disturbance in consciousness Attention2. Change in cognition Examples: memory, orientation,

language3. Develops over a short period of time4. 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Hypoactive: confusion, somnolence, withdrawn.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: 14-56%

ICU: 70-87%

Advanced Cancer 25-85% or End of Life:

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 – JUDGEMENT changes O – ORIENTATION changes M – MEMORY changes A – AFFECT changes C – COGNITIVE changes Delirium is a state defined by a

CHANGECHANGE 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

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

Delirium1. Acute onset2. Fluctuates3. Duration days to

weeks4. Altered

consciousness5. Impaired attention6. Increased or

decreased psychomotor

7. Can be reversible

Dementia1. Insidious onset2. Progressive3. Duration months to

years4. Clear consciousness5. Normal attention

except when severe6. Normal psychomotor

(usually)7. 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 neededMixed 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 Sedation EPS*

Haloperidol 1+ 4+

Thorazine 3+ 2+

Risperdal 1+ 2+

Zyprexa 2+ 1+

Seroquel 2-3+ 0

*EPS: Extra-pyramidal Symptoms (Parkinsonian-like)

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