Download Delirium - The Coleman Palliative Medicine Training Program

Delirium:
Underrecognized,
Undertreated and Deadly
Coleman Foundation Winter Workshop
February 28, 2013
Andrea Bial, MD
Joanna Martin, MD
Objectives
Learning Objectives
1. Understand how to recognize delirium in the hospice and palliative
setting.
2.
Be able to identify possible factors contributing to patients’ delirium.
3. Incorporate best evidenced-based medicine in treating delirium in
hospice and palliative care settings.
Content Bullets
1. Recognize agitation, confusion, altered level of consciousness,
hallucinations, restlessness and other behaviors associated with delirium in
patients with advanced chronic illness.
2. Understand when to pursue reversible causes of delirium and when to
forgo evaluation and focus on comfort.
3. Be able to use both pharmacological and nonpharmacological
interventions to treat delirium in patients with advanced chronic illness.
Delirium: What’s Going On?
 Pathophysiology not well understood
 Thought to be deficit of acetylcholine (e.g.,
anticholinergic drugs as precipitant) and/or excess of
dopamine (that’s why levodopa can cause & Haldol can
help)
 Other neurotransmitters (GABA, serotonin,
norepinephrine, melatonin, others) and cytokines may
also be involved.
Inouye 2006; Irwin 2013
Delirium: Prevalence
 ~¼ to ½ of advanced cancer patients admitted to the
hospital have delirium.
 85-90% of all patients experience delirium in the hours
or days before death.
 Very common in hospitalized older patients
 33% presenting to ER
 14-24% on admission
 15-53% post op
 70-87% ICU
Inouye 2006;LeGrand 2012; White 2007
Delirium: Prevalence in
Palliative Care
 2013 Literature Review in Palliative Medicine:
 13-42% prevalence at admission to palliative or hospice
units
 26-62% prevalence at some point during hospitalization (in
palliative or hospice unit)
Delirium: Outcomes
 Increased hospitalized mortality (25-75%)
 Increased 1-year mortality (40%)
 Increased LOS (2x)
 Increased hospital complications (incontinence, falls,
pressure sores)
 Increased institutionalization (2-3x)
 Increased healthcare costs (STAT)
Irwin2013
Delirium: Recognition
 Early identification of risk factors can reduce occurrence.
 Early recognition of delirium can reduce duration (and
potentially identify causative/contributing factors).
 FOR LEARNERS:
 Lecture format adequate for knowledge about delirium, but
not to change provider behavior or improve outcomes.
 Need interactive sessions and leaders using clinical
pathways and assessment tools.
Inouye1993, Yanamadala2013
Why is delirium overlooked?
 Fluctuating nature
 Overlaps with dementia
 Lack of formal cognitive assessment
 Under appreciation of clinical consequences
 Not considering the clinical diagnosis important
Types of Delirium
 Hyperactive:
 “Agitated;” repeated (purposeless) limb movements,
restless, trying to get out of bed, hallucinations,….
 Hypoactive
 Quite, withdrawn; may give monosyllabic answers to simple
questions, follow simple commands
 Mixed
Predisposing Risk Factors
UPON ADMISSION
 Serious illness (advanced cancer, sepsis, acute kidney failure,…)
 Cognitive impairment
 Vision impairment
 Elderly
AFTER ADMISSION
 Physical restraints
 ≥3 medications added
 Malnourished
 Urinary catheter placed
Inouye1993;1996;1999
An Ounce of Prevention…
 Yale Delirium Prevention Trial :
 Orientation for cognitive impairment
 Early mobilization
 Prevention of sleep deprivation/fragmentation
 Address vision & hearing impairments
 Preventing dehydration
Inouye 1999
Overlooked
 Inconsistent use of terminology (“confused, altered
mental status agitated, lethargic,…”)
 Objective testing rarely done
 Confused with depression or dementia (see next slide)
 Increase the risk of being overlooked:
 Hypoactive form
 Fluctuating symptoms
 Age ≥80yrs
del Fabbro2006
Identifying Delirium
 Several tools available
 Confusion Assessment Method (CAM)
(94-95% sens/spec)
 Delirium Rating Scale
 Delirium Symptom Interview
 Memorial Delirium Assessment Scale
Casarett2001
CAM
1. Inattentive AND
2. Acute Onset w/ Fluctuating Course AND
3. Disorganized Thinking AND/OR
4. Altered Level of Consciousness
HAVE TO HAVE #1 & #2 AND THEN #3 AND/OR #4 for positive
screen.
HINT: IADL
Inouye1990
CAM: example questions
1. Inattentive: repeat numbers, days of week/months of
the year backwards OR observe staring into space, not
keeping track of conversation, etc.
2. Acute/fluctuating: ask pt about confusion OR observe
variations in attention, speech, thinking, or pyschomotor
activity. (can also ask RN or family)
3. Disorganized thinking: what type of place is this, why
are you here, see or hear anything unusual? OR observe
if pt disoriented or uses illogical ideas/inappropriate
words/rambling conversation.
4. Altered Level of Consciousness: falling asleep during
interview, stuporous/comatose, non-communicative?
Huang2012
Evaluation (after Identification)
 In hospitalized patients:
 History (does pt have dementia? What has been the time
course?)
 Physical Exam (new wounds, neurologic deficits, urinary or
fecal retention, new fx,…?)
 Laboratory Tests (if none recent: wbc, cmp, TSH, B12?)
 Radiology Tests (CXR, head CT,….?)
 In palliative (Advanced, Chronically ill) patients, is this
terminal restlessness?
Inouye2006
DELIRIUM
Evaluation
Management
History
(dementia?) and
Physical Exam
(head to toe)
FOCAL EXAM:
Do appropriate next
step (e.g.,fevercx)
THEN, review meds&
Order other tests
Treat Findings &
Manage symptoms
NON-AGITATED
PATIENT:
Non-Pharmacologic
treatment
NON-FOCAL EXAM:
Review meds
Order addn’l tests
Treat Findings &
Manage symptoms
AGITATED
PATIENT:
Non-Pharmacologic
& Pharmacologic tx
Palliative Patients
Irwin2013
Evaluation in Palliative Patients
 Need to address Goals of Care as it will guide extent of
evaluation.
 Easily addressed: constipation, urinary retention,
medication side effect, dehydration
 More likely to be reversible in younger patients, those
without organ failure, and those w/ less cognitive
disturbance.
 May be shorter time until death in those w/ irreversible
delrium.
Leonard2008
Delirium=Syndrome
 Delirium is almost always multifactorial
 Need to identify potential causes
 Evaluation and treatment is always dependent on GOC
Causes of Delirium
1. Medications
 New drug
 Dose too high
 In withdrawal (e.g., benzodiazepines, psych drugs…)
2. Infection
3. Dehydration
4. Metabolic Abnormalities
Irwin2013;LeGrand2012
Additional Potential Causes of
Delirium in CA pts
1. All of preceding causes, but also…
2. Primary or Secondary CNS tumors
3. Toxicity of antineoplastic therapies (chemo, xrt,…)
4. Toxicity of other drugs used in treatment (steroids, antinausea drugs, anticonvulsants,…)
5. Paraneoplastic neurological syndromes
Caraceni2005
Treatment: Underlying Cause
1. Adjust medication (if able)
 Any medication that has CNS s.e. can contribute to delirium
(especially those w/ hi anticholinergic activity)
 See next slide
2. Treat infection
3. Address dehydration (IV fluids, sq fluids, oral hydration)
4. Consider fixing electrolyte abnormalities
Medications as Cause
Antibiotics
Steroids
Benadryl
NSAIDS
Benzos
H2 Blockers
Digoxin
Parkinson’s drugs
GI (Reglan, Bentyl)
Tricyclics
Lithium
Narcotics
Neuroleptics
Any drug with anticholinergic properties!
Treatment: Nonpharmacologic
 Safety of room (minimize bed rails or pad, lower bed,
mats on floor)
 Reorientation (verbal cues, date boards, shades up)
 Reduce restraints (“official” and “unofficial”)
 Family/friends at bedside
 Supply glasses or hearing aids if appropriate
Treatment:
Pharmacologic Caveats
 NO MEDICATIONS are currently approved by the FDA for
management of delirium
 NO published DB, RCT to guide medication management
of delirium.
 NO consensus: oncology, geriatrics, psychiatry, palliative
medicine
 Goal is to maximize safety
Treatment: Pharmacologic
 Haloperidol as first drug of choice
 Can be given IV, IM, SC, PO (pill or liquid)
 LOW dose to start (0.5mg IV Q6H prn)
 BEWARE EPIC!
 Can repeat at 30mins if needed
Irwin2013;LeGrand2012
Haloperidol
 Old, cheap, decades of use
 Recent trial: 14 centers/4 countries/119 patients w/
delirium in hospice or palliative care:
 Average daily dose: 2.1mg
 Most frequent s.e.: somnolence (9%) & urinary retention
(5%)
 1/3 had net benefit (NCI delirium score)
 Risks present with ALL antipsychotics
 Black box warning on all: increased CV or infectious mx
when used in dementia-related psychosis
Crawford2013, Irwin2013
Other Pharmacologic Treatments
 Other antipsychotics CAN be used
 Consider side effects: potentially WANT more sedation, or
weight gain, or other effect
 May use if higher doses needed.
 Benzodiazepines
 Can worsen delirium
 Use as first-line only if alcohol/benzo withdrawal or having
seizures
 Can use as second line (in addition to Haldol) if not
achieving adequate response
Delirium in the ICU
 Estimates range from ~20-90% of patients
 10% increase mx for each day of delirium
 Additional risk factors:
 Coma
 Sedatives
 Neurologic diagnosis
Reade2014
Terminal delirium
 Often referred to as “terminal restlessness”
 Characterized by agitation, repeated nonsensical
requests (“I need to sit up”), repetitive movements,
picking at clothes and sheets.
 Occurs in up to 85% of patients in the last weeks of life
 Family/caregiver education is key
 Can use Haldol first line for symptom management
 Consider use of benzodiazepines if Haldol ineffective,
especially in younger patients
Terminal delirium:
Family Support
 The experience of delirium for families can complicate
bereavement
 “Double loss”
 Grief when they lose ability to communicate meaningfully
with patient and again when the patient dies
 Although previous care may have been excellent, if the
delirium goes misdiagnosed or unmanaged, family
members may remember a horrible death "in terrible
pain”
Terminal Delirium:
Family Support, contd.
 Families may be ambivalent about medication use: want
the pt to be comfortable, but fear lack of communication
w/pt or worry that death is hastened.
 Families should be given ample opportunities to ask
questions; information may need to be repeated.
 If suspect death is near, important to ask family if they
want to know prognostic information.
Brajtman2005
Patient AB
 105yo W in hospice w/ dementia and COPD.
 Takes Xanax 0.25mg QHS (for years).
 Called by RN: pt had a night of agitation: was up all
night, convinced her son was being held hostage. When
son was called to talk to her to reassure her he was ok,
she was sure he was being forced to say he was fine.
 CG couldn’t give her any more Xanax (pt refused) and
family didn’t want to give her Haldol since last time she
got it, “She was knocked out.”
Patient AB: Questions
 Is this patient delirious?
 Is this patient having terminal restlessness?
 What do you recommend for the future?
 Increase bedtime Xanax
 Repeat bedtime Xanax dose at start of agitation
 Use Haldol anyway
 Have son come over and sit w/ patient
Patient AB
 What do you do?
1. Increase bedtime Xanax to 0.5mg.
2. Repeat bedtime Xanax dose at start of agitation.
3. Use Haldol anyway, starting at lower dose than before and
use at start of agitation.
4. Have son come over and sit w/ patient.
5. 1., 2., 4.
6. 1., 3.
7. None of the above
Patient case #1
 Mr. S is an 80 year old NH resident with history of end
stage dementia admitted to hospice with history of
aspiration pneumonia. Mr. S is usually calm, nonverbal
and can sit in the dayroom in his wheelchair. The NH
calls you that he has become quite agitated and won’t
let the CNA give him his bath today.
Patient case #1 cont. . .
 NH reports patient usually calm and often
sits in day room, pleasantly confused at
baseline.
 Exam: VSS with no BM since hospice
admission one week ago, patient lying in
bed, agitated and moaning, lung exam
stable, abdomen distended with bowel
sounds; rectal vault filled with stool
 Meds reviewed: HCTZ, Nifedipine,
prevacid, roxanol 5mg q4hrs prn
Is this patient delirious?
Acute onset and fluctuating course
YES
Inattention
YES
Disorganized thinking
NO
Altered level of consciousness YES
Patient case #1
 Patient is impacted
 Fleets enema performed with good
results
 Patient straight cathed to check post
void residual which was <100cc
 Meds reviewed: HCTZ, nifedipine and
roxanol can cause constipation
 Meds adjusted
 Bowel regimen: senna daily
Patient case #1
Patient much more comfortable by
the next day
He returns to baseline within a few
days
Hospice team provides a lot of
oversight to nursing home care;
patient requires close medication
monitoring and has ongoing issues
with constipation
Patient case #2
 Patient is a 50 year old man with metastatic lung cancer
admitted to hospice one month ago. Patient is steadily
declining and using ativan now multiple times a day for
anxiety. His wife contacts you that he is pacing,
agitated and combative. At baseline he is usually
anxious but can be reassured.
Case 2 continued. . .
 On exam, he is confused, hyperalert and report seeing
ants walking on the ceiling. He is unable to follow your
other questions. His exam is remarkable for cachexia
and hypoxia. SOB is controlled. Bowels are moving and
patient urinating regularly.
 Meds: ativan (7 doses in past 24 hrs), decadron 4mg,
MS Contin 30 bid and roxanol 5mg prn
Is this patient delirious?
Acute onset and fluctuating course
YES
Inattention
Disorganized thinking
YES
YES
Altered level of consciousness
YES
Patient case #2
 Decision made to decrease dose of
ativan back to bid and start haldol 0.5
mg bid and q4 hrs prn; give decadron
in AM
 Patient calms down enough to wear
oxygen and wife able to manage sx
 No need for opioid rotation
 Ends up using haldol 1mg q4hrs ATC
 Much calmer and comfortable until
death one month later
Patient case #2
 Decision made to decrease dose of
ativan back to bid and start haldol 0.5
mg bid and q4 hrs prn; give decadron
in AM
 Patient calms down enough to wear
oxygen and wife able to manage sx
 No need for opioid rotation
 Ends up using haldol 1mg q4hrs ATC
 Much calmer and comfortable until
death one month later
Patient Case #3
 Patient is a 65 year old woman with stage IV breast
cancer in home hospice
 Family calls to report that patient more confused in past
two days and sleeping more
Case #3 continued. . .
 On exam: VSS, patient is sleepy and able to answer
some questions but has trouble tracking conversation
and is tangential, no focal neuro deficits noted, exam
otherwise unchanged
 Meds: fentanyl patch and roxanol prn; senna
Is this patient delirious?
Acute onset and fluctuating course
YES
Inattention
Disorganized thinking
YES
YES
Altered level of consciousness
YES
Patient case #3 continued. . .
 Patient with chronic severe pain so opioids not changed
 Delirium likely due to final days of life
 Family educated - KEY
 Patient had some periods of lucidity over next several
days and died a week later
Take Home Points
1. Be able to recognize signs and symptoms of delirium as
early as possible; remember hypoactive is the most
common form and often not found unless looked for.
2. Assess for easily reversible causes of delirium and
understand when evaluation is not indicated due to
terminal restlessness/near EOL.
3. Be comfortable in using both pharmacological and
nonpharmacological measures to treat delirium. Provide
information to family.
Works Cited

BrajtmanS. Helping the family through the experience of terminal restlessness. JHosPallNurs 2005;7:73.

CaraceniA et al in Doyle D et al, eds. Oxford textbook of palliative medicine. OxfordUnivPress2005pp708-712

Cassarett D et al. Diagnosis and management of delirium at end of life. Ann Intern Med 2001;135:32

Crawford GB et al. Pharmacovigilance in hospice/palliative care: net effect of haloperidol in delirium. J Pall Med.
2013;16:1335-1341.

Del Fabbro E et al. Symptom control in palliative care—part III: dyspnea and delirium. J Pall Med. 2006;9:422433.

Hosie A et al. Delirium prevalence, incidence and implications for screening. Pall Med 2013;27:486.

Huang LW et al. Identifying indicators of important diagnostic features of delirium. JAGS 2012;60:1044-1050.

Irwin SA et al. Clarifying delirium management: practical, evidence based, expert recommendations for clinical
practice. J Pall Med. 2013;16:423-435.

InouyeSK et al. Clarifying Confusion: the confusion assessment model. AnnIntMed1990;113:941-948.

Inouye SK et al. A predictive model for delirium in hospitalized elderly medical patients based on admission
characteristics. 1993;119:474-481.

Inouye SK et al. Precipitating factors for delirium in hospitalized elderly persons: predictive model and
interrelationship with baseline vulnerability. JAMA1996;275:852-857

Inouye SK et al. A multicomponent intervention to prevent delirium in hospitalized older patients. NEJM
1999;340:669.

Inouye SK. Delirium in older persons. NEJM 2006;354:1157.

LeGrand SB. Delirium in palliative medicine: a review. JPainSymMan 2012;44:583-594.

LeonardM et al. Reversibility of dellirium in terminally ill patients & predictors of mortality. PallMed2008;22:848.

Reade MC, et al. Sedation and delirium in the ICU. NEJM 2014;370:444

Von Gunten CF et al. New versus old neuroleptics: efficacy versus marketing. J Pall Med 2013;16:1509-1514.

White C et al. First do no harm…terminal restlessness or drug-induced delirium. J Pall Med 2007;10:345-351.

Yanamadala M et al. Educational intervention to improve recognition of delirium: a systematic review. JAGS
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