Download Delerium at End of Life

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. Orientation
3. Cognition
4. Consciousness
5. Reality
6. 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withdrawn.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:
14-56%

ICU:
70-87%

Advanced Cancer
or End of Life:
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 – JUDGEMENT changes
 O – 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
TricyclicAntidepressants
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 predeath 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. Fluctuates
3. Duration days to
weeks
4. Altered consciousness
5. Impaired attention
6. Increased or
decreased
psychomotor
7. Can be reversible
Dementia
1. Insidious onset
2. Progressive
3. Duration months to
years
4. Clear consciousness
5. Normal attention
except when severe
6. Normal psychomotor
(usually)
7. Rarely reversible
Delirium
 Change in alertness

Onset – hours to
days
Sundown Syndrome
 No change in
alertness
 Onset – daily, slowly
worsening

Fluctuates hourly

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
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 antipsychotic 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
