Delirium and Nausea. Delirium - definition. Delirium Incidence. Predisposing Risk Factors for Delirium. Impact. Delirium Types 10/14/2016

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1 Delirium - definition Delirium and Nausea Etiologically non-specific global cerebral dysfunction associated with changes in LOC, attention, thinking, perception, memory, psychomotor behavior, emotion and the sleep/wake cycle Delirium Types Delirium Incidence Hypoactive confusion, somnolence, alertness Hyperactive agitation, hallucinations, aggression Mixed (>60%) features of both 20% - 44% on admission to a palliative care unit (common reason for admission) 28% - 45% of patients developed delirium while on the palliative care unit 68% - 90% prior to death 50% of episodes reversible Terminal delirium in 88% Lawlor et al. Arch Intern Med 2000; 160:786 Impact Predisposing Risk Factors for Delirium 73/99 patients (74%) remembered delirious episode Of these, 81% recalled experience as distressing Family stress > patients recalled stress Functional and psycho-social factors: Advanced age Sensory deficit (poor vision/hearing) Functional disability Chronic physical illness Substance abuse Disease state factors: Pre-existing dementia Depression Neurological impairment Dehydration Multiple medication use Hui et al. JPSM 99;2:

2 Mnemonics Drugs, including any new medications, increased dosages, drug interactions, over-the-counter drugs, alcohol, etc Electrolyte disturbances, especially dehydration, and thyroid problems DELIRIUM I WATCH DEATH Lack of drugs, such as when long-term sedatives (including alcohol and sleeping pills) are stopped, or when pain drugs are not being given adequately Infection, commonly urinary or respiratory tract infection Reduced sensory input, which happens when vision or hearing are poor Intracranial (referring to processes within the skull) such as a brain infection, hemorrhage, stroke, or tumor (rare) Urinary problems or intestinal problems, such as inability to urinate or constipation Myocardial (heart) and lungs, e.g. heart attack, problems with heart rhythm (arrhythmia), worsening of heart failure or chronic obstructive lung disease. There are many various acronyms for DELIRIUM these are just two INFECTIONS, (UTI, Pneumonia, Meningitis) WITHDRAWAL, (Benzo/Alcohol) ACUTE METABOLIC DISORDER, (Lytes/Liver/Kidney) TRAUMA, (Head injury/ Post op) CNS, (Stroke/Haemorrhage) HYPOXIA, (Anemia/CCF/Pulmonary Embolism) Symptomatology: Delirium v. Dementia Acute onset DELIRIUM More rapid changes in severity, cycling of symptoms DEMENTIA Usually slower progression Symptom severity more steady DEFICIENCIES, (B12/Folic Acid/Thiamine) ENDOCRINOPATHIES, (Thyroid/Parathyroid/Hypoglycemia/Adrenal) ACUTE VASCULAR PROBLEMS, (Shock/Vasculitis/Hypertensive Encephalopathy) TOXINS, (Substance Abuse/Anticholinergics/narcotics/Alcohol) HEAVY METALS, (Arsenic/ Lead / Mercury) Altered level of consciousness Reversible Hallucinations may occur Fully conscious Irreversible Hallucinations are generally rare A Step-Wise Approach to Drug Treatment of Delirium Management Of Delirium Establish diagnosis of delirium Establish goals of therapy Is it distressing for patient or family?? Prioritize according to patient s overall symptom management needs Identify risk factors for delirium Are they practically reversible? What is patient s tolerance for likely diagnostic and treatment options? Are there competing risks/benefits for other symptom management needs and the risk of delirium? 1. Environmental Quite, private setting: single room if possible Low lighting, calendar, clock, familiar objects Minimal room changes with unnecessary distractions 2. Fix the Fixable if possible and appropriate 3. Help family navigate complex choices and non-choices, dictated by how the patient would guide care if that were possible 4. Effective sedation with frank discussion of anticipated course If delirium irreversible, goal of care is sedation Sedation does not hasten the dying process Will facilitate meaningful visiting Encourage communication, even though patient not interactive 2

3 Drug Treatment for Delirium: Medication Classes 1 st Generation ( Typical ) Antipsychotics Haloperidol (Haldol ), Loxapine, Chlorpromazine, Methotrimeprazine (Nozinan ) 2 nd Generation ( Atypical ) Antipsychotics Olanzapine (Zyprexa ), Risperidone (Risperdal ), Quetiapine (Seroquel ) Benzodiazepines Lorazepam (Ativan ), Clonazepam, Midazolam Treatment - Pharmacological Mild restlessness haloperidol Delirium and Agitation in Terminal Illness Haloperidol, methotrimeprazine Sometimes chlorpromazine in more severe cases of delirium with aggression if haloperidol or methotrimeprazine not effective End Of Life Delirium/Restlessness Symptoms may appear or existing symptoms may worsen as patient deteriorates Benzodiazepenes are most likely to be used, if avoiding sedation is no longer an issue Lorazepam sc/sl q4h regularly Midazolam iv/sc by continuous infusion Nausea & Vomiting Nausea & Vomiting - definition Incidence Of Nausea & Vomiting In Terminal Cancer Patients Nausea - an unpleasant feeling of the need to vomit Vomiting - the expulsion of gastric contents through the mouth, caused by forceful and sustained contraction of the abdominal muscles and diaphragm Nausea: % Vomiting: 30 % 3

4 Assessing Nausea & Vomiting Onset: when did it first start; is this new Provocation: identify triggers may have multiple, e.g. odors, eating, pain, anxiety, anticipation, medication, etc Quality: persistent nausea; cramping/ spasmodic; content of emesis; nausea +/- vomiting OR vomiting +/- nausea Relief: relieving factors effective medications & nonpharmacological interventions; relief with vomiting or not Severity: 0-10 (getting worse or improving; what is acceptable) Timing: pattern; for how long and how often Understanding of the symptom and what is its impact Principles of Treating Nausea & Vomiting Treat underlying causes e.g., hypercalcemia, urosepsis, constipation, uremia, intracranial pressure, bowel obstruction, dehydration, medication adverse effects, reduced intestinal motility Treat disease specific issues, i.e. match medication to etiology: anticipate need (prior to meals, treatment, etc.) use adequate, regular doses +/- PRN aim at receptor involved combinations if necessary anticipate need for alternate routes Value; what is the patient s goal for this symptom Nausea Vomiting Central Nervous System Cerebral High CNS Increased Intracranial Pressure Integrative Vomiting Center (IVC) [Emesis Center] Chemorecptor Trigger Zone (CTZ) Psychological (fear, anxiety, pain) Anticipatory nausea / vomiting to sights, smells, etc. Treatments Benzodiazepines Cannabinoids Relaxation Therapy Vestibular GI Tract - Vagal The IVC is stimulated by all of the pathways which in turn initiates N & V Central Nervous System Gastro-Intestinal Tract/ Vagal Increased Intracranial Pressure (brain metastases, infectious meningitis, cerebral edema, bleeding) Headache +/- cranial nerve signs, (diurnal). Vomiting often without nausea. Treatments Gastric irritation (ASA, NSAIDs, steroids, antibiotics, blood, ETOH, stress, radiotherapy) Obstruction (partial or complete) Constipation Gastric stasis Mass effect (GI, GU, hepaticdistention, carcinomatosis) Anatomic / Structural Epigastric pain, fullness, acid reflux, early satiety, flatulence, hiccup, intermittent nausea relieved with vomiting. Altered bowel habit, pain may occur with oral intake. Vomitus may be large volume and fecal smelling. 4

5 Gastro-Intestinal Tract/ Vagal Gastro-Intestinal Tract/ Obstruction Treatment (non-obstruction) Dopamine Receptors Gastrokinetic Metoclopramide (Maxeran) Domperidone Phenothiazine Serotonin Receptors Ondansetron (Zofran) Metoclopramide (Nozinan) Octreotide Treatment (obstruction) Haloperidol Octreotide Avoid prokinetics and serotonin agonists NPO NG tube for suction Consideration of surgical interventions Chemorecptor Trigger Zone (CTZ)/ Chemical Chemorecptor Trigger Zone (CTZ)/ Chemical Drugs (opioids, digoxin, steroids, antibiotics, anticonvulsants, cytotoxics) Biochemical (hypercalcaemia, uremia, organ failure) Toxins (tumour factors, infection, drug metabolites, radiation) Symptoms of drug toxicity or underlying disease plus nausea as the prominent symptom. Nausea usually not relieved by vomiting. Treatments Dopamine Receptors Gastrokinetic Metoclopramide Domperidone Phenothiazine Methrotrimeprazine Haloperidol (Haldol) Prochlorperazine (Stemitil) Chlorperazine Neurokinin Receptors Aprecipitant Serotonin Receptors Ondansetron Metoclopramide Benzodiazepines Cannabinoids Relaxation Therapy Vestibular Motion sickness Cerebellar tumour Nausea +/- vomiting with movement. Treatment H1 Antagonist Dimenhydrinate (Gravol) Anticholinergic Scopolamine Atropine Integrative Vomiting Centre (IVC)/ Emesis Centre Treatment Histamine Receptors Dimenhydrinate Anticholinergic Scopolamine Atropine Serotonin Receptors Olanzapine Ondansetron Cannabinoid Receptors THC Neurokinin Receptors Aprecipitant The IVC is stimulated by any and all of the pathways which in turn initiates N & V 5

6 Principles of Treating Nausea & Vomiting - Non-pharmacological Modifications to diet (consult Dietitian if needed) food modification restricted intake small frequent meals sips of fluid (sports drinks, broth, popsicles, water) cool and bland food avoiding lying flat after eating avoid alcohol & tobacco avoid spicy, acidic, salty, hard, crunchy foods Principles of Treating Nausea & Vomiting - Non-pharmacological Modifications to environment e.g. control smells and noise, air fresheners/deodorizers Good oral hygiene, especially after vomiting Relaxation, visualization, distraction Psychosocial support and anxiety reduction: social worker, counsellor, spiritual health practitioner Acupressure for chemotherapy-induced acute nausea but not for delayed symptoms Urgent Blood (bright red or black); coffee ground emesis Severe cramping, acute abdominal pain Dizziness, weakness, confusion, excessive thirst, dark urine Projectile vomiting Fever No improvement with interventions 6