Home Care and Hospice Association of New Jersey Annual Conference 2017

Transcription

1 Home Care and Hospice Association of New Jersey Annual Conference 2017 I D E N T I F I C A T I O N A N D M A N A G E M E N T O F D E L I R I U M E L I Z A B E T H M A G E R - O C O N N O R A C H P N DR A R N O L D S C H A M MD Objectives By the end of the presentation the learner will be able to: Define delirium and its risk factors Recognize subtypes of delirium Identify appropriate non-pharmacologic as well as pharmacologic interventions to prevent and manage delirium 1

2 Incidence of Delirium -Occurs in 6-56 % of hospitalized patients -Diagnosed in 15-53% of older postoperative adults % of ICU patients Delirium is identified in % of cancer patients upon hospitalization Occurs in up to 88% of patients in the last week of life Siddiqi,N.2006 Implications for our patients Labeled as confused or agitated Patients are frightened and distressed Increased pain Fall risk, injuries Family distress, caregiver fatigue Potential institutionalization 2

3 Delirium defined DSM V A. Disturbance in attention(reduced ability to direct focus, sustain or shift attention) and awareness (reduced orientation to the environment) B. The disturbance develops over a period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day. C. An additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception). Delirium Defined, DSM V D. The disturbances in Criteria A and C are no better explained by a preexisting, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma. E. There is evidence from the history, physical examination or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e. due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies. DSM-5 3

4 Delirium subtypes Hypoactive Hyperactive Mixed Delirium Delirium is under recognized and therefore under treated. Distress is experienced by patients, spouses/caregivers and staff Patients with hypoactive delirium are often misdiagnosed or perceived to be in less distress than agitated patients with hyperactive delirium. Breitbart,W,

5 Subtypes of Delirium Misconceptions: Hypoactive Delirium is thought to be very rare, but in fact accounts for an average of 50% of delirium cases. Hypoactive Delirium was incorrectly thought not to cause morbidity and therefore did not require pharmacologic intervention (neuroleptics and antipsychotics). Brietbart,W 2016 Confusion Assessment Method Delirium = (1 and 2) and (3 or 4) 5

6 CAM Feature 1 Acute onset fluctuating course: Is there evidence of an acute change in mental status from the patient s baseline? Did the abnormal behavior fluctuate during the day, tend to come and go, increase or decrease in severity? Feature 2 Inattention: Did the patient have difficulty focusing attention, for example, being easily distractable or having difficulty keeping track of what was said? CAM Feature 3 Disorganize thinking: Was the patient s thinking disorganized or incoherent, such as rambling or irrelevant conversation unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Feature 4 Altered level of consciousness: Shown by any answer other than alert to the following question-overall, how would you rate this patient s level of consciousness? Inouye,SK

7 Risk factors for Delirium Advancing Age Dementia ADL impairment High medical comorbidity Sensory impairment Delirium:Prevention Identify at risk population and intervene to prevent delirium *Multifactorial intervention: Cognitive impairment interventions Sleep depravation interventions Immobility Visual and hearing impairment Dehydration Reduced incidence of delirium in those over age 70 by 1/3 Inouye,SK

8 Delirium Prevention Cognitive Impairment: Orientation protocol tid; therapeutic activities Sleep deprivation: non-pharmacologic sleep protocol; warm milk, relaxation tapes, massage. Unit wide noise reduction strategies; schedule adjustments to allow sleep Immobility: early mobilization protocol, ambulation or ROM exercises tid; minimal use of immobilizing equipment Prevention Visual and Hearing Impairment: Visual aides, adaptive equipment, portable amplifying devices, earwax removal. Dehydration protocol: early recognition of dehydration and volume depletion 8

9 Delirium Prevention So keep in mind.. Promote normal sleep patterns Identify high risk medications Monitor for dehydration Maintain fluid and electrolyte balance Control pain Re-orientation Medications Estimated 12-39% of delirious episodes in the elderly are due to medication issues! Antidepressants Narcotics Anticholinergics Steroids Sedative Hypnotics Catic,AG

10 Goals of treatment for delirium Pre-terminal Patient Identify the underlying etiology, look for reversible condition End of Life Care: Aim to control symptoms during an irreversible process Diagnostic work up consistent with goals of care: Minimally invasive in our terminally ill population Treatments are effective, minimally burdensome or distressing Delirium : Evaluation Review prescription and OTC medications Exclude infection and other medical causes Labs: CBC, electrolytes, LFTs, renal function tests, serum albumin, serum calcium, glucose, UA Consider- oxygen saturation, CXR, EKG 10

11 Management of Delirium Treat the primary process (when reasonable) Avoid other causes of delirium/ optimize the environment Manage behavioral problems Counsel and support patient and family Brajtman,S 2005 Have you met this patient? 87 year old gentleman on hospice with COPD, steroid and oxygen dependent. H/O frequent hospitalizations for pneumonia. At baseline alert and oriented. Daughter calls one morning and reports father up very 2 hours, confused, calling out he needs to get to the bus.. What do we need to know? 11

12 The end of the story.. Urinary retention secondary to Benadryl in setting of BPH Foley placed drained 1.5 l of urine Patient sleeps through the day, more relaxed! Slowly returns to baseline mental status. Consider d/c foley in 24 hours Pharmacologic Management of delirium Delirium is a highly distressing experience, especially when accompanied by the presence of delusions and hallucinations Hypoactive delirium is as distressing as hyperactive delirium Treat with antipsychotics because of association with significant suffering in patients, spouses/caregivers and staff Brietbart,W

13 Delirium: Medications Benzodiazepines: Lorazepam, Xanax -Alone can aggravate delirium -Generally avoid in the older population, used in terminal delirium or in addition to antipsychotic -Indicated for sedative/alcohol withdrawal Delirium: Medications Cochrane Review Recommendations: Antipsychotics To Treat Delirium -Haldol and atypical antipsychotics such as Olanzapine and Risperdal are effective in managing symptoms of delirium. -The extrapyramidal side effects of the atypical antipsychotics did not differ significantly from haloperidol when doses of haloperidol were less then 4-5 mg/24 hr. Lonergan, E et al

14 Delirium Medications Haldol : mg po or IV a 4 hr prn Chlorpromazine: mg, po q 4 8 hr prn Olanzapine : mg po daily; dissolving tablet, IV, or IM Quetiapine: mg po BID Risperidone: mg po or IV q 4 hours prn Delirium, Ann Int Med 2011 Delirium: Side Effects of Antipsychotics Anticholinergic Dry mouth Constipation Cardiovascular (BP, QT interval) Antihistaminic Sedation, Weight Gain Dopamine Blocking Extrapyramidal side effects Hyperprolactinemia Neuroleptic Malignant Syndrome 14

15 Delirium :Side Effects of Atypical Antipsychotics Metabolic Syndrome Hyperglycemia (Olanzapine, Clozapine) Hyperlipidemia Weight Gain QT Interval Prolongation Acute care- monitor EKG Consider interactions with other agents that prolong QT Conclusion Delirium is a common and frightening symptom to patients, family members and staff Delirium is often treatable if recognized Delirium is a poor prognostic sign, increasing mortality in both short and long term Close and Long

16 Delirium Case Study #1 87 year old Mrs Jones fell going to the bathroom at night. She was able to call her son who came right over and took her to the ER. Work up demonstrates a fractured radius, cast and sling applied and patient returns home. Appointment to follow up with orthopedics. Two days later you are called by the son to visit Mrs Jones. He arrived there to find she had not eaten that day. She is normally an energetic, meticulous person, now her clothing is soiled. She can t remember what day it is.. reports vaguely that she would like to nap. Delirium case study Knowing this patient you are aware she has been independent and managing alone until this accident Do we diagnose Delirium? What is our plan? 16

17 Delirium Case Study Mrs Jones does have delirium Acute process, disorganized, inattentive You review Mrs Jones medical history and provide a physical exam.. You learn that Mrs Jones was prescribed Percocet 5/325 mg for her pain. She cannot recall her last dose but explains she does have pain and self administered several doses. Son explains he is overwhelmed between work and family. Delirium Case Study Plan for Mrs Jones Son advised to contact agencies and arrange 24 hour help for his mother. Explain this might be temporary but she cannot be home alone at this time Recommend that Percocet be held for severe pain only one tab. Tylenol on a routine schedule. Recommend that arm be elevated, ice applied. 17

18 Delirium Case Study #2 Mrs Roberts is a 82 year old with non insulin dependent diabetes, HTN, PVD. She fell in her home and c/o left rib pain. When pain interfered with rest her daughter gave her ibuprofen 400 mg every 8 hours. On the third day labs were drawn routinely by the endocrinologist. The MD called concerned the following day as Mrs Roberts with no h/o renal disease had a BUN/creatinine of 80/2.8. He recommended to hospitalize for hydration and f/u Dlirium Case Study #2 At the hospital MD consults with daughter, mother still has pain and ibuprofen now stopped. After reviewing labs and x-ray, will order pain medication for the night so she can rest. 4 am daughter receives a call from the hospital that Mrs Roberts is attempting OOB, pulling out foley catheter, calling for the police. 18

19 Delirium Case Study#2 MD had prescribed a Fentanyl patch which was removed. Mrs Roberts mentation cleared in 4 hours and she recalled being frightened and feeling alone. References American Psychiatric Association (2013).Diagnostic and statistical manual of mental disorders: DSM-5.Washington, D.C.: American Psychiatric Association. Brajtman S. Helping the Family Through the Experience of Terminal Restlessness. JHPN. Vol 7 No 2 Mar/Apr 2005 Breitbart W, Alici Y. Agitation and Delirium at the end of life, We couldn t manage him : JAMA.2008:300(24) Breitbart W, Gibson C, Trembly A. The delirium experience, delirium recall and delirium related distress in hospitalized patients with cancer, their spouses/caregivers and their nurses. Psychosomatics.2002;43(3): Breitbart, William Delirium in Cancer Patients. Psychopharmacology in Cancer Care: An Update for Clinicians of all Disciplines. Memorial Sloan Kettering Cancer Center. New York. Oct 29,2016 Lecture 19

20 References Catic AG. Identification and Management of In-Hospital Drug Induced Delirium in Older Patients Drugs & Aging 2011; 28(9): Close JF, Long C. Delirium: Opportunity for Comfort in Palliative Care. JHPN. Vol 14 No 6 Aug Cohen CL. Refractory Delirium in a Hospice Patient. JHPN. Vol 17 No 2 Apr 2015 Delirium. Ann Int Med. 2011;154(11) ITC6-1 Fick DM. Hodo DM. Lawrence f. Inouye S. Recognizing Delirium Superimposed on Dementia, Assessing Nurses Knowledge Using Case Vignettes. J Geron Nurs 2007 Feb;33(2): Gagnon P. Allard P. Gagnon B. Merette C. Tardif F. Delirium prevention in terminal cancer: assessment of a multicomponent intervention Psycho-Oncology. 21: (2012) References LeGrand S. Delirium in Palliative Medicine: A Review. J Pain Sym Mgt Vol 44 No Lonergan E. Britton AM. Luxenberg J. Antipsychotics for delirium (Review). The Cochrane Collaboration. John Wiley & Sons, Ltd.2009 Reston JT. Schoelles KM. In-Facility Delirium Prevention Program as a Patient Safety Strategy: A Systematic Review. Ann Int Med. 2013: Szarpa KL. Kerr CW. Wright ST. Luczkiewicz DL. Hang PC. Ball LS. The Prodrome to Delirium A Grounded Theory Study. JHPN. Vol 15 No 6 Aug Communicate with presentors: Elizabeth Mager OConnor mageel@valleyhealth.com Dr A Scham: schama@valleyhealth.com 20