Delirium in Palliative care. Presentation to Volunteers 2016 David Falk

Transcription

1 Delirium in Palliative care Presentation to Volunteers 2016 David Falk

2 Delirium What is delirium?

3 Case Study - Delirium 60+ year old PQ presents to hospice very somnolent. She was admitted with her adult daughter who states her mother has had previously well until 2-3 days ago when she starting showing increasing confusion, bizzare behaviour, and seeing bugs on the wall. She was diagnosed with breast cancer a few years ago but declined any active therapy other than Clodronate. As a result, she has fungating wounds to her right breast and bone metastases from DI done about two months ago. PQ is able to engage in meaningful conversation sometimes but especially in the evenings and nights, she wants to get out of bed for no reason, talks nonsense, and becomes paranoid with some of the nursing care.

4 What is Delirium? Delirium is a serious disturbance in mental abilities that results in confused thinking and reduced awareness of your environment. The start of delirium is usually rapid within hours or a few days. Because symptoms of delirium and dementia can be similar, input from a family member or caregiver may be important for a doctor to make an accurate diagnosis.

5 Some symptoms of delirium Reduced awareness of the environment This may result in: An inability to stay focused on a topic or to switch topics Getting stuck on an idea rather than responding to questions or conversation Being easily distracted by unimportant things Being withdrawn, with little or no activity or little response to the environment

6 Some symptoms of delirium Poor thinking skills (cognitive impairment) This may appear as: Poor memory, particularly of recent events Disorientation, for example, not knowing where you are or who you are Difficulty speaking or recalling words Rambling or nonsense speech Trouble understanding speech Difficulty reading or writing

7 Some symptoms of delirium Behavior changes This may include: Seeing things that don't exist (hallucinations) Restlessness, agitation or combative behavior Calling out, moaning or making other sounds Being quiet and withdrawn especially in older adults Slowed movement or lethargy Disturbed sleep habits Reversal of night-day sleep-wake cycle

8 Some symptoms of delirium Emotional disturbances This may appear as: Anxiety, fear or paranoia Depression Irritability or anger A sense of feeling elated (euphoria) Apathy Rapid and unpredictable

9 Differences between delirium & dementia Onset. The onset of delirium occurs within a short time, while dementia usually begins with relatively minor symptoms that gradually worsen over time. Attention. The ability to stay focused or maintain attention is significantly impaired with delirium. A person in the early stages of dementia remains generally alert. Fluctuation. The appearance of delirium symptoms can fluctuate significantly and frequently throughout the day. While people with dementia have better and worse times of day, their memory and thinking skills stay at a fairly constant level during the course of a day.

10 Causes Delirium occurs when the normal sending and receiving of signals in the brain become impaired. This impairment is most likely caused by a combination of factors that make the brain vulnerable and trigger a malfunction in brain activity.

11 Causes Delirium may have a single cause or more than one cause, such as a medical condition and medication toxicity. Sometimes no cause can be identified. Possible causes include:

12 Frequent Etiologies

13 Some Causes Certain medications or drug toxicity Alcohol or drug abuse or withdrawal A medical condition Metabolic imbalances, such as low sodium or low calcium Severe, chronic or terminal illness Fever and acute infection, particularly in children Exposure to a toxin Malnutrition or dehydration Sleep deprivation or severe emotional distress Pain Surgery or other medical procedures that include anesthesia

14 Common Reversible EOL C-onstipation H-hypercalcemia, hypoglycemia, hypokalemia I- nfection M-edications B-ladder outlet obstruction O-2 deficiency P-ain

15 Risk Factors Any condition that results in a hospital stay Brain disorders Older age Previous delirium episodes Visual or hearing impairment Multiple medical problems End of life

16 Preventing or Minimizing Delirium Always ask yourself, Could this be delirium? Studies show that early detection means early minimizing of delirium, shorter duration of delirium, & less distress

17 Preventing or Minimizing Delirium Promote good sleep habits To promote good sleep habits: Provide a calm, quiet environment Keep inside lighting appropriate for the time of day Plan for uninterrupted periods of sleep at night Help the person keep a regular daytime schedule Encourage self-care and activity during the day

18 Preventing or Minimizing Delirium Promote calmness and orientation To help the person remain calm and well-oriented: Provide a clock and calendar and refer to them regularly throughout the day Communicate simply about any change in activity, such as time for lunch or time for bed Keep familiar and favorite objects and pictures around, but avoid a cluttered environment Approach the person calmly Identify yourself or other people regularly Avoid arguments Use comfort measures, such as reassuring touch, when appropriate Keep noise levels and other distractions to a minimum

19 Preventing or Minimizing Delirium Prevent complicating problems Help prevent medical problems by: Giving the person the proper medication on a regular schedule Providing plenty of fluids and a healthy diet Encouraging regular physical activity Getting treatment for potential problems, such as infection or metabolic imbalances, early Avoid frequent room changes, invasive procedures, poor lighting, lack of natural light, loud noises

20 Preventing or Minimizing Delirium Caring for the caregiver Providing regular care for a person with delirium can be scary and exhausting. Take care of family/nursing staff/yourself, too. Ask for educational materials or other resources from a health care provider to share with family. Share caregiving with family and friends who are familiar the person so everyone get a break.

21 Treatment of Delirium Maximize the preventing/minimizing factors Identify reversible illnesses (CHIMBOP) Review present medications & minimize them or rotate them to something else Avoid alcohol If a medication has been withdrawn, it or it s equivalent needs to be re-introduced Hydrate Share information with family/friends about delirium

22 Treatment of Delirium Use particular medications to control behaviour only if necessary: Neuroleptics -e.g. Haldol, olanzepine, seroquil, Benzodiazepines e.g. Ativan, Versed

23 Case Study continued PQ is investigated for reversible factors using CHIMBOP. Medications were changed & behaviour control was attempted with Haldol and low dose Versed unsuccessfully. Both husband and daughter were not too sure what PQ s desire would be in a case like this. She had been so independent with her husband going to work each day and her daughter continuing with her EMS job. They both appeared to be reluctant in seeing PQ die in a few days so bloodwork was done. It showed marked hypercalcemia.

24 Case Study continued The hypercalcemia was treated and the delirium resolved over the next 4-5 days. When talking with PQ after it s resolution, she stated she could not remember most of those days so we had to fill her in on some of the activities. One day I asked her if she could remember any sensation and if it was scary. She denied it being scary but she did state she lived a vivid dream where her guardian angels were all around her and physically restrained her from going over a precipice. She then added. This experience has taken away the existential fear I have held for years from my abusive past. I am much more at peace with myself than I have ever been.

25 EOL Questions?