Delirium. Preconference SHPCA Clinical Day Saskatoon, SK May 13, 2014
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1 Preconference SHPCA Clinical Day 2014 Saskatoon, SK May 13, 2014 Carmen L. Johnson MD, CCFP, ABFP, AAHPM, AAPM, ABAM, ABRPM (Pain Medicine) Medical Director Palliative Care Services, Regina Qu Appelle Health Region
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3 Definition Altered state of consciousness, consisting of confusion, distractibility, disorientation, disordered thinking and memory, defective perception (illusions and hallucinations), prominent hyperactivity, agitation and autonomic nervous system over-activity.
4 Definition Key Features acute confusion fluctuates during the day
5 Definition Alternations in Consciousness and Attention cognitive (amnesia) behavioral (agitation) perceptual (hallucinations)
6 Definition sleep wake cycle disturbance delusions emotional lability psychomotor activity disturbance
7 Definition behavior not related to dementia key feature acute nature, not chronic demented patients more susceptible to delirium
8 Types hyperactive hypoactive mixed
9 Unfortunately, under recognized, misdiagnosed inappropriately treated or untreated symptoms may be mistaken for other psychiatric disorders
10 So, consider delirium in anyone with cognitive disturbances, altered attention, fluctuating consciousness, acute agitation incidence 80 to 85% last week of life
11 Increased Risk history delirium severe medical problems poor physical functioning infections
12 Increased Risk brain lesions-tumor, parenchymal drugs-narcotics, anticholinergics, sedatives, corticosteroids electrolyte and metabolic imbalances
13 Increased Risk constipation environmental change sensory deprivation - hearing and vision
14 Differential Diagnosis seizure - may present like confusion post-ictal pain (consider in a demented patient)
15 84-year-old female pulmonary symptoms chest x-ray 2/13-abnormal adenocarcinoma right lung 3/13
16 bone scan-no bone mets, 4/13 CT- head, chest, abdomen, pelvis no mets, 5/13
17 right lower lobe resection, right upper wedge resection, mediastinal dissection 7/13 tumor encircles pulmonary vein, no obstruction invades mucosa bronchus
18 positive 3/9 lymph nodes no post-op complications
19 Past Medical History hypertension macular degeneration renal insufficiency pacemaker
20 Medications metoprolol 50 mg bid amlodipine 10 mg daily atacand 32/12.5 mg methadone 10 mg bid
21 Medications mirtazapine 15 mg q day quetiapine 12.5 mg po bid dimenhydrinate 50 mg q am rabeprazole 20 mg daily
22 Medications hydromorphone 4-6 mg q1h prn Vitamin D multivitamin
23 Allergies ASA Penicillin V
24 Social History lives alone good support-one daughter widow x one year grieving
25 Social History non-smoker x 28 years 10 pack year history no alcohol
26 March 29, 2014 admitted from home increased confusion x 2 weeks unenhanced CT no brain mets pain in left leg
27 reduced oxygen saturation resolved with 2L oxygen chest x-ray no obvious pneumonia? mild CHF KUB marked fecal loading
28 Labs WBC elevated Urea 15.1 ( ) Creatinine 166 (60 130) Albumin 33
29 U/A suggested UTI treated Nursing Notes 3/29/14 Patient appears anxious, asking a lot of questions and very forgetful, not oriented to time and place.
30 Nurses Notes: 3/30/14 Writer left room briefly after telling patient writer was going to get her pyjamas. Shortly after writer heard patient yelling. When asked what was wrong the patient stated I don t know why I did that. Visibly agitated. No recollection of events of yesterday or this afternoon. Restless at night. Posey alarm set. Evaluated for pain, meds given and settled.
31 Nurses Notes: 3/31/14 Ate full breakfast. Pleasantly confused. Weepy at times. I don t even know what time it is! Reoriented, patient pleasant. Disimpacted for large amount hard stool.
32 Nurses Notes: 3/31/14 21:30 haloperidol 5 mg agitation not effective hydromorphone 6 mg and quetiapine patient aware of her confusion (not seen in dementia patients)
33 Nurses notes: 3/4/14 more agitation not controlled - frequent haloperidol constant fidgeting asks, Why can t I settle? frustrated with self wants to help the girls get out of the washroom.
34 Nurses Notes: 4/4/14 ambulating independently O2 saturations good - no supplementary O2 wandering constantly nursing wants her transferred to an Alzheimer s unit
35 Nurses Notes: 4/4/14 methotrimeprazine started hs, prn auditory hallucinations
36 Nurses Notes: 5/4/14 constant motion washing dishes seeks social interaction
37 Nurses Notes: 5/4/14 ate entire lunch while stating she wasn t hungry agitation worsens towards evening pain not an issue
38 Progress: 11/4/14 delirium continues repeat u/a negative for infection Delirium may take 1 2 weeks to clear after infection
39 Progress: 11/4/14 risperidone started q hs, prn patient agitated, became physically aggressive with others
40 Nursing Notes: 12/4/14 pacing and increased confusion start methotrimeprazine at hs Progress :13/4/14 haloperidol d/c methotrimeprazine scheduled
41 Nursing Notes: 14/4/14 still wandering methotrimeprazine increased patient slept well
42 Nurses Notes: 16/4/14 nurse withheld morning antipsychotic patient alert, pleasantly confused not agitated 3 hours later significant agitation, difficult to settle patient left order not to hold antipsychotics
43 Nurses Notes: 16/4/14 Night Shift swearing at staff increasing agitation kicking, pulling hair methotrimeprazine s/q ineffective
44 Nurses Notes: 17/4/14 midazolam given to settle effective clonazepam started po/pr
45 Nurses Notes: 19/4/14 phenobarbital added stirred with cares settled
46 Nurses Notes: 20/4/14 unresponsive to cares palliative sedation continued died peacefully - 25/4/14
47 Delirium is a Medical Emergency! needs aggressive treatment patient suffering staff safety may need to be treated with scheduled meds
48 Early Delirium Screening Questions visual seeing things perceptions someone in the room with you tactile itching, touch
49 Early Delirium Patient with excellent MOCCA, MMSE may still have delirium! 36 year old female pink hippopotamus in the room
50 Delirium Three Types hypoactive hyperactive mixed
51 How May a Patient Present? confusion agitation perplexing uncontrolled pain
52 How May a Patient Present? Perplexing Uncontrolled Pain patient peaceful until we touch him grimaces, stiff, cries out, furrowed brow, frightened pain medications don t seem effective
53 Perplexing uncontrolled pain likely delirium generalized whole body pain patient can t localize pain
54 Perplexing Uncontrolled Pain primitive reflexes protect oneself brain cannot understand the signals from body misinterprets stimulation as danger
55 Perplexing Uncontrolled Pain often settles with scheduled anti-psychotic patient may become more alert
56 Medications Anti-psychotics Haloperidol (Haldol) least sedating most anti-dopaminergic
57 Medications Anti-psychotics Methotrimeprazine (Nozinan) more sedating less anti-dopaminergic more postural bp drops Chlorpromazine (Largactil) same as methotrimeprazine
58 Medications Atypical Anti-psychotics Risperidone (Risperdal) 4 x more potent than haloperidol similar effect to haloperidol
59 Medications Atypical Anti-psychotics Quetiapine (Seroquel) reduced role in delirium need doses 200 mg or above for anti-psychotic benefits best option for Parkinson s patients
60 Medications Atypical Anti-psychotics Olanzapine not covered by Saskatchewan Drug Plan wafer formulation
61 References Geriatric Palliative Care, Morrison, et al. Oxford University Press, 2003 Palliative Medicine, Walsh et al., Saunders 2009 Pallium Project, Pereira et al Stedman s Medical Dictionary 27 th edition. Lippincott, 2000
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