Delirium in Palliative Care. Case Studies 2015
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1 Delirium in Palliative Care Case Studies 2015
2 Case 1 - Alex 35 yo M with metastatic melanoma Decreased LOC, unilateral hearing loss and bilateral vision loss, back pain, lower extremity weakness,? confusion/hallucinations Meds: morphine SR 30mg po q12h and morphine 5-10m po q1hr prn Awaiting acceptance into clinical trial
3 Case 1 Exam: Cooperative, drowsy Volume status N Cardioresp, abdo benign Neuro: pupils N, bilateral visual loss, left SNHL, strength 4/5 bilat LE, impaired joint position sense, normal pain and temp Labs: WBC 9.2, Hb 129, Plt 320 Na 134, K 4.2, Ca 2.2, Cr 76 LFTs N, urine N
4 Case 1 - Alex You would explain his neurologic findings as? a. Delirium b. Depression c. Dementia d. CNS pathology (metastasis, leptomeningeal disease, vascular disease)
5 Case 1 - Alex If his goals of care are to continue with active therapy, would you investigate his symptoms/signs further? a. Yes b. No
6 Case 1 - Alex From a palliative care perspective, how would you treat his present symptoms? (as many responses as appropriate) a. Steroid b. Haldol c. Benzodiazepine d. Rotate his morphine to another opioid
7 Case 2 George 82 yo M with prostate CA metastatic to bone Decreased LOC, paranoia, hallucinations, psychomotor agitation low urine output, cough Finished palliative RT to left hip 2 weeks ago Meds: Fentanyl patch 50mcg/hr, hydromorphone 2-4mg po q1hr prn, fluconazole 100mg po daily, citalopram 20mg po daily, lorazepam 1mg SL qhs bowel routine, dexamethasone 4mg po daily, clarithromycin 500mg q12hr Family has been giving more HM as he appears to have increased pain all over
8 Case 2 Exam: General: agitated, shouting, picking, trying to get out of bed Volume: JVP flat, dry mouth, dry skin Resp: bibasilar crackles Abdo benign Skin: grade 1 skin breakdown on coccyx Neuro: not cooperative, miosis, no obvious lateralizing signs Labs: WBC 14, Hb 104, Plt 250 Na 132, K 4.5, Ca 2.72 (corr), Cr 80, LFTs: WNL Urine cloudy, +nitrates, +leuks, +blood
9 Case 2 What are the clinical criteria for a diagnosis of delirium in this gentleman? a. Altered alertness/conscious b. Paranoia c. Underlying medical condition d. Hallucinations/delusions e. Changed cognition f. Agitation g. Pain all over
10 Case 2 What type of delirium does this gentleman have? (more than one response is possible) a. Hyopactive/hypoalert b. Mixed c. Hyperactive/hyperalert d. Potentially reversible e. Irreversible f. Irreversible by goals of care determination
11 Case 2 How would you treat his pain? (more than one response possible) a. Continue giving as many hydromorphone BTA as necessary b. Rotate to another opioid c. Rotate to another opioid & give Haldol d. Decrease or stop his dexamethasone e. Decrease or stop his lorazepam f. Decrease or stop his citalopram g. Decrease or stop his fluconazole h. Stop his clarithromycin
12 Case 2 What are some of the reversible factors contributing to his delirium? (more than one response possible) a. UTI b. Respiratory infection c. Fentanyl d. Hydromorphone e. Dexamethasone f. Lorazepam g. Fluconazole h. Oxygen deficiency i. Citalopram j. Dehydration k. Hypercalcemia
13 Case 3 65Y man, diagnosed with advanced gastric cancer 2 months ago, extensive intra-abdominal metastasis living at home, home care nurses are visiting and has Level of care M2 designation in place. On morphine LA 60mg po q12h & 10mg q1h prn Maxeran and laxatives; until recently symptoms well controlled Today became very confused: Occasionally agitated, tries to get out of bed, seems to pick at the air at times and complains of increasing pain, pain all over and moaning, groaning with unusual jerking motions of his upper limbs according to his wife
14 Case 3 Cachectic Unable to complete formal cognitive screening test Mucosa dry Feels febrile (temp 37.6 C) Moderate pedal edema Chest examination is essentially normal Soft abdomen with normal bowel sounds
15 Case 3 What are the essential features of Delirium?
16 What are the essential features? Reversible confusion Sudden onset - in hours and days Fluctuating course Memory deficit Delusions and agitation Reduced level of consciousness Altered sense and reduced concentration Wake up at night Disordered attention and cognition Disturbed psychomotor behavior
17 Case 3 What are possible causes?
18 Delirium Assessment 65Y What are possible causes? Disease progression: tumor spread to vital organs / Brain Constipation Urinary retention Metabolic: hyper ca, Na, or hypo Na; dehydration, renal insufficiency Infection: Bladder, lung, abcess Medication: opioids, benzos, neuroleptics and anticholinergics Hypoxia, CHF Mass lesion CNS
19 Case 3 Would you consider requesting investigations at this point?
20 Case 3 Yes, Goals of Care Designation (GCD) = M2 More than 50% reversible What investigations would you consider?
21 Investigations to consider O2 saturation CBC, lytes, Creatinine, Ca & albumin Consider source of infection If in a rural setting if mobile lab is not available, may need to bring to ER
22 Case 3 Management- What would you suggest at this time? After discussion, family requests reversal of delirium as he was mobile and was enjoying gardening 3 days ago. Today extremely agitated
23 Case 3 Management- What would you suggest at this time? WBC 10 x 10 x 9 /L Creatinine 185 umol/l BUN 13 mmol/l Calcium 2.55 mmol/l Albumin 23 g/l Sodium 127 mmol/l Rest of the blood work was normal What is corrected calcium?
24 Case 3 What is your treatment plan at this point?
25 Case 3 What is your treatment plan at this point? Spouse needs help Mini mental (modified or MMSE) Haloperidol s/c for agitation Review medications Opioid rotation If UTI or aspiration pneumonia antibiotic If dehydrated, start clysis
26 Case 3 Delirium resolves with the use of haloperidol and another 6 weeks later, presents with jaundice & enlarged liver, profoundly cachectic in delirium. Blood work now shows raised corrected calcium. Haloperidol use not helping.
27 Case 3 How would you manage at this point?
28 Case 3 How would you manage at this point? Irreversible hepatic failure Hypercalcemia: IV Bisphoshonates Opioids & Neuroleptics regular & prn dose Hydration by clysis Re-check Calcium and albumin next day Provide family support Communicate with staff Reassess goals of care
29 Case 3 Despite all your interventions, remains extremely agitated, totally incoherent. Family members are very distressed and beg you to do something to relieve his suffering. How would you manage at this point?
30 Case 3 Discuss with family the irreversible nature of the delirium & warn them he will be sedated to some degree If Haloperidol does not worsen the agitation/restlessness, titrate upwards to effect If this does not work, add a benzodiazepine & titrate to effect Use the Richmond Agitation Sedation Scale (RASS) to obtain a score of -1 to -2 If he does not settle on this, change to methotrimprazine &/or deeply sedate using midazolam/phenobarbital/propofol (RASS of -4 to -5)
31 Delirium: References Delirium acute confusional states in Palliative Medicine: A. Caraceni, L. Grassi, Oxford University Press, 2003 Delirium in patients with advanced cancer: P.G. Lawlor, E.D. Bruera, Hematol Ocol Clin N Am 16: , 2002 Delirium: R.C. Packard, The Neurologist, 7: , 2001 Delirium in advanced cancer patients: C. Centeno, A. Sanz, E.D. Bruera Palliative Medicine 18: , 2004 Clarifying Delirium Management: S. Irwin, R Pirrello, J Hirst, G Buckholz, F Ferris JPallMed 16:4:
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