4/3/2014. Disclosures Delirious about End-of-Life Delirium? Objectives. Case 1. Yes ma am, that s delirium. What are we talking about?

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1 Disclosures Delirious about End-of-Life Delirium? No financial or other conflicts of interest There will be off-label discussion TNMHO Convention San Antonio, Texas April 2014 Presenter: Robert A. Friedman, MD FAAFP FAAHPM Chief Medical Officer Hospice Austin President Central Texas Palliative Care Associates Objectives 1. Recognize End-of-Life Delirium 2. Determine and work-up potential causes, as appropriate 3. Describe treatment options 4. Compare medication options 5. Develop a Plan of Care Case 1 81 y.o. male with Stage 4 NSCLC Metastatic to liver Former smoker, has COPD PPS 30%, but decreased intake Develops rather rapid onset of agitation and confusion Is disoriented, paranoid, a little combative, wants to climb out of bed, but is unsteady Family denies that patient has had recent constipation and States that he is voiding regularly Hasn t slept much in the last 24 hours What are we talking about? Delirium occurs in 22-83% of patients nearing end of life Delirium in end-of-life is frequently missed and significantly under-diagnosed by physicians What is confusion? Delirium, dementia, psychosis, obtundation, cognitive decline during the few weeks before death Distinguish delirium from other causes of confusion Use a validated assessment tool Confusion Assessment Method Delirium Rating Scale Delirium Symptom Interview Memorial Delirium Assessment Scale Yes ma am, that s delirium Presentation Acute change in level of arousal Onset is over hours to days Fluctuating course Altered LOC Cognitive impairments Disorganized thought processes Incoherent slow or rapid speech Disturbance of memory, orientation and attention Emotional lability Perceptual disturbances, delusions and hallucinations Restlessness/agitation Lethargy Altered sleep/wake cycle Course Can last hours to weeks, if reversible 1

2 Case 1 In case you re confused or forgot 81 y.o. male with Stage 4 NSCLC Metastatic to liver Former smoker, has COPD PPS 30%, but decreased intake Develops rather rapid onset of agitation and confusion Is disoriented, paranoid, a little combative, wants to climb out of be, but is unsteady Family denies that patient has had recent constipation and Family states that he is voiding regularly Hasn t slept much in the last 24 hours What do you do, what do you do? 1. I don t know, I m confused 2. Consider potential cause(s) of delirium 3. Start lorazepam 1 mg q1hr prn until calm 4. Start lorazepam 1 mg q4hrs prn until calm 5. Start haloperidol 1 mg q1hr prn until calm 6. Start haloperidol 1 mg q4hrs prn until calm 7. Start thorazine mg q4hrs prn until calm 8. Educate family on terminal restlessness, begin above treatment and tell them to call back if the treatment isn t working 9. Start Crisis Care 10. Admit to Inpatient Unit 11. Other Types of delirium Hyperactive: vigilance and/or agitation Hypoactive: lethargy, somnolence or coma Mixed: fluctuation between hyperactive and hypoactive state What transpired Started on haloperidol 1 mg q4hrs prn agitation DRE is negative Foley placed and results in 2 liters of urine output over several minutes Patient calms down over 2 hours, but required a second dose of 1 mg of haloperidol 1 hour after the first dose, remains confused, but is fairly cooperative Kept on Haloperidol 2 mg q4hrs ATC, may hold if sedated or sleeping Intake is now minimal, mainly sips Patient dies the next day Risk factors for delirium Increasing age General debility Advanced disease Dementia/cognitive impairment Change in environment Impaired renal function Depression Pain/other symptoms Sleep deprivation Assess for reversible causes- In advanced terminal illnesses Drug toxicity Antichoinergics: anti-secretion drugs, anti-emetics, antihistamines, TCAs Sedative hypnotics Opioids Infection Hypotension Hypoxia Hypoglycemia CNS pathology Hypercalcemia Elevated ammonia Alcohol-sedative drug withdrawal Sleep deprivation Potential easily reversible causes Pain Constipation Urinary retention 2

3 Case 2 78 y.o. female admitted to hospice with dx of Alzheimer s Dementia Also has HTN and Hypothyroidism FAST 7d PPS 40%, still able to feed self, but appetite is fair and she lost 10% of her body weight over the 6 months prior to admission to hospice. BMI now 18.9 She is developing contractures of both arms and legs in spite of passive ROM therapy at PCH and has a Stage 2 pressure ulcer over her sacrum Flash forward-6 weeks She suddenly stops eating, smiling or making eye contact, and appears more lethargic What do you do? Order CBC, Urinalysis, and CXR Send to local ER for evaluation Review/discuss current goals of care with patient s medical decision maker Educate the family that this is normal disease progression and recommend supportive care Start on antibiotics pending lab results to cover for possible infection (UTI or pneumonia) Discuss option of placing a PEG tube for nutritional purposes Perform a DRE and palpate her bladder Other Formulating the work-up Consider first: Goals of care Disease trajectory What new diagnosis does this patient have? Urinary tract infection Pneumonia Poorly controlled hypothyroidism Sepsis from pressure ulcer Not sure Some other diagnosis-specify Case 2-What have we here? Hypoactive delirium Discussion with MPOA/family Patient has a DNR and Advance Directives MPOA states that patient would not want further hospitalizations, work-ups or treatments The saga of Case 2 continues Next step Thoughtful discussion/reality check on consequences Your responsibilities? Supportive care Anticipate needs 3

4 Case 3 39 y.o. female with clear cell ovarian cancer diagnosed on 4/7/2010 Declined further disease-directed therapy and was admitted to hospice in 12/2012. At that time she has metastatic disease to the peritoneum and pleura Oncology records from 2/2012 show CA 125 of 2397 and Ca++ of 12.4, with normal albumin at 3.9 Takes 2.5 methadone q12hrs for pain and 20 mg liquid morphine q1hr prn pain, which is adequate She is a very private person This morning mother reports: Over the last 3 days has had increasing confusion, with restlessness, agitation and dyspnea. Patient can t get comfortable On-call nurse reports: Received 20 mg morphine this morning x2, but suffered emesis immediately after on both occasions Received promethazine 25 mg pr x 1 this morning Appears to be having some hallucinations, (visual and auditory) She is extremely cachectic and her abdomen is extremely distended So you order labs which show: CBC and Urinalysis normal Random BS 95 mg/dl Calcium 10.3 and the rest of the chem panel is normal except for Alk Phos 520 Albumin 1.7 and protein 4.9 What do you do? Haloperidol 1 mg PO/SC q4hrs prn nausea and confusion Reassure the patient and family that this is normal disease progression and offer comfort/supportive treatment Start Levofloxacin 500 mg qday for altered mental status changes due to possible UTI Give IV saline and zoledronate 4 mg slow IV push Order a new bone scan Case 3 epilogue? Her corrected calcium level is 12.1 mg/dl (Ca corrected = Ca serum + 0.8(4-Albumin serum ) She is admitted to the hospice IPU After 2L of IV saline and zoledronate 4 mg slowly IV push, her sensorium clears She is discharged home Routine Chem panel scheduled again in 4 weeks 4

5 Rewind of Case 3 Oncologist is contact this morning and asks that patient be admitted to the hospice IPU On-call RN assesses patient Patient extremely restless, appears in severe pain, and concurs that patient should be transported to the IPU You are the receiving physician and you have one Oncology note from 12/2012 in addition to the a hospice nursing clinical summary from time of admission to hospice, in addition to periodic updates to this summary What you know- Nurse reports Over the last 3 days has had increasing confusion, is restlessness, agitation and dyspnea. Patient can t get comfortable Received 20 mg morphine this morning x2, but suffered emesis immediately after on both occasions Received promethazine 25 mg pr x 1 this morning Appears to be having some hallucinations, (visual and auditory) She is extremely cachectic and her abdomen is extremely distended What would you like to know Recent intake? How long has her abdomen been extremely distended? Goals of care? Other? So what happened next? Medications for EOL Delirirum Benzodizepines Useful for alcohol-sedative drug withdrawal or anticholinergic excess Can cause paradoxical worsening of delirium Can be used as an adjunct to neuroleptics when severe agitation not controlled with neuroleptics alone Neuroleptics First-line pharmacological choice for symptom managment Haloperidol Best studied and agent of choice for most patients Has a favorable side-effect profile, but has potential side effects with higher doses and prolonged use Can be given PO/PR/SC/IV, starting doses 0.5 mg to 1 mg, can titrate hourly. Can be scheduled in divided doses. Medications for EOL Deliriumcontinued Other neuroleptics-thorazine Older typical neuroleptic May have higher incidence of EPS, sedation, and hypotension Some advocate its use in dying patients when sedation is desired Atypical neuroleptics Olanzapine, quetiapine, risperidone Scant evidence for use with delirium Not first line Associated with fewer drug-induced movement disorders?agents of choice with NMDs These meds are given daily to TID depending on the medication and should only be titrated over days to a week May not work as fast as conventional antipsychotics Quetiapine is the most sedating of this group 5

6 Non-pharmacologic management Always use Reduce or increase sensory stimulation as needed Bed sitters Frequent reorientation Time permitting: CAM Delirium in terminally ill patients Is a reliable indicator of death within days to weeks End-of-life restlessness: may include Skin mottling and cool extremities Mouth breathing with hyper-extended neck Respiratory pattern changes such as Cheyne-Stokes, shallow breathing Calling out or speaking to deceased families or friends Other EOL phenomenon Periods of deepening somnolence References 1. William Breitbart; Yesne Alici. Agitation and Delirium at the End of Life: We Couldn t Manage Him. JAMA. 2008;300(24): Diagnosis and Treatment of Terminal Delirium, 2 nd ed. EPERC Fast Facts and Concepts # Pharmacologic Management of Delirium; Update on Newer Agents, 2 nd ed. EPERC Fast Facts and Concepts # Joel S. Policzer, Jason Sobel. Management of Selected Nonpain Symptoms of Life- Limiting Illness. AAHPM UNIPAC 4, third edition, Robert Friedman. Palliative Management of Common Non-pain Symptomspresentations; Watson, Lucas, Hoy, and Back. Oxford Handbook of Palliative Care. New York, USA: Oxford University Press, Inc; Woodruff. Palliative Medicine. Victoria, Australia: Oxford University Press, 4 th ed, reprinted in American Psychiatric Association, Diagnostic and Statistical Manual, 4th ed, APA Press, Washington, DC Questions????????? 6