Delirium at End of Life: The Dying Brain
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1 at End of Life: The Dying Brain Carmen L. Johnson MD, CCFP, ABFP, AAHPM, AAPM, ABAM, ABRPM (Pain Medicine) Medical Director Palliative Care Services, Regina Qu Appelle Health Region
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3 Altered state of consciousness: confusion, distractibility, disorientation disordered thinking and memory defective perception (illusions and hallucinations) prominent hyperactivity, agitation autonomic nervous system over-activity
4 Definition Key Features acute confusion fluctuates during the day
5 GABA (gamma-aminobutyric acid) inhibitory neurotransmitter widely distributed in the neurons of the cortex GABA contributes to: motor control, vision other cortical functions regulates anxiety
6 80 % of brain function is related to GABA GABA production becomes diminished in the delirious brain Disinhibition expression of symptoms and emotions
7 Definition Alternations in Consciousness and Attention cognitive (amnesia) behavioral (agitation) perceptual (hallucinations)
8 Definition sleep wake cycle disturbance delusions emotional lability psychomotor activity disturbance
9 Definition behavior not related to dementia key feature acute nature, not chronic Remember demented patients more susceptible to delirium
10 Types hyperactive hypoactive mixed
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12 Unfortunately, under recognized, misdiagnosed inappropriately treated or untreated symptoms may be mistaken for other psychiatric disorders Those who have recovered from delirium can often remember the horrors of their delirious state
13 Palliative Performance Scale Palliative Prognostic Index (PPI) > 60 0 Oral Intake Severely Reduced (<mouthfuls) 2.5 Moderately Reduced (>mouthfuls) 1.0 Normal 0 Edema Present 1.0 Absent 0 Dyspnea at Rest Present 3.5 Absent 0 Delirium Present 4.0 Absent 0 Maximum possible 15 Score greater than 6 3 weeks survival sensitivity 80% - specificity 85% Score 4 or less 6 weeks survival sensitivity 80% - specificity 77%
14 So, Consider delirium in anyone with: cognitive disturbances, altered attention fluctuating consciousness, acute agitation incidence 80 to 85% last week of life
15 D E L I R I U M (S) Drugs Eyes, ears, and other sensory deficits Low O2 states (e.g. heart attack, stroke, and pulmonary embolism) Infection Retention (of urine or stool) Ictal state Underhydration/undernutrition Metabolic causes (DM, Post-operative state, Sodium abnormalities) Subdural hematoma 15
16 Increased Risk history delirium severe medical problems poor physical functioning infections
17 Increased Risk brain lesions: tumor, parenchymal Drugs: narcotics, anticholinergics, sedatives, corticosteroids electrolyte and metabolic imbalances
18 Increased Risk constipation environmental change sensory deprivation - hearing and vision
19 Differential Diagnosis seizure - may present like confusion post-ictal pain (consider in a demented patient)
20 JS 84-year-old female pulmonary symptoms chest x-ray 2/13-abnormal adenocarcinoma right lung 3/13
21 JS bone scan-no bone mets, 4/13 CT- head, chest, abdomen, pelvis no mets, 5/13
22 JS right lower lobe resection, right upper wedge resection, mediastinal dissection 7/13 tumor encircles pulmonary vein, no obstruction invades mucosa bronchus
23 JS positive 3/9 lymph nodes no post-op complications
24 JS Past Medical History hypertension macular degeneration renal insufficiency pacemaker
25 JS Medications metoprolol 50 mg bid amlodipine 10 mg daily atacand 32/12.5 mg methadone 10 mg bid
26 JS Medications mirtazapine 15 mg q day quetiapine 12.5 mg po bid dimenhydrinate 50 mg q am rabeprazole 20 mg daily
27 JS Medications hydromorphone 4-6 mg q1h prn Vitamin D multivitamin
28 JS Allergies ASA Penicillin V
29 JS Social History lives alone good support-one daughter widow x one year grieving
30 JS Social History non-smoker x 28 years 10 pack year history no alcohol
31 JS March 29, 2014 admitted from home increased confusion x 2 weeks unenhanced CT no brain mets pain in left leg
32 JS reduced oxygen saturation resolved with 2L oxygen chest x-ray no obvious pneumonia? mild CHF KUB marked fecal loading
33 JS Labs WBC elevated Urea 15.1 ( ) Creatinine 166 (60 130) Albumin 33
34 JS U/A suggested UTI treated Nursing Notes 3/29/14 Patient appears anxious, asking a lot of questions and very forgetful, not oriented to time and place.
35 JS Nurses Notes: 3/30/14 Writer left room briefly after telling patient writer was going to get her pyjamas. Shortly after writer heard patient yelling. When asked what was wrong the patient stated I don t know why I did that. Visibly agitated. No recollection of events of yesterday or this afternoon. Restless at night. Posey alarm set. Evaluated for pain, meds given and settled.
36 JS Nurses Notes: 3/31/14 Ate full breakfast. Pleasantly confused. Weepy at times. I don t even know what time it is! Reoriented, patient pleasant. Disimpacted for large amount hard stool.
37 JS Nurses Notes: 3/31/14 21:30 haloperidol 5 mg agitation not effective hydromorphone 6 mg and quetiapine patient aware of her confusion (not seen in dementia patients)
38 JS Nurses notes: 3/4/14 more agitation not controlled - frequent haloperidol constant fidgeting asks, Why can t I settle? frustrated with self wants to help the girls get out of the washroom.
39 JS Nurses Notes: 4/4/14 ambulating independently O2 saturations good - no supplementary O2 wandering constantly nursing wants her transferred to an Alzheimer s unit
40 JS Nurses Notes: 4/4/14 methotrimeprazine started hs, prn auditory hallucinations
41 JS Nurses Notes: 5/4/14 constant motion washing dishes seeks social interaction
42 JS Nurses Notes: 5/4/14 ate entire lunch while stating she wasn t hungry agitation worsens towards evening pain not an issue
43 JS Progress: 11/4/14 delirium continues repeat u/a negative for infection Delirium may take 1 2 weeks to clear after infection
44 JS Progress: 11/4/14 risperidone started q hs, prn patient agitated, became physically aggressive with others
45 JS Nursing Notes: 12/4/14 pacing and increased confusion start methotrimeprazine at hs Progress :13/4/14 haloperidol d/c methotrimeprazine scheduled
46 JS Nursing Notes: 14/4/14 still wandering methotrimeprazine increased patient slept well
47 JS Nurses Notes: 16/4/14 nurse withheld morning antipsychotic patient alert, pleasantly confused not agitated 3 hours later significant agitation, difficult to settle patient left order not to hold antipsychotics
48 JS Nurses Notes: 16/4/14 Night Shift swearing at staff increasing agitation kicking, pulling hair methotrimeprazine s/q ineffective
49 JS Nurses Notes: 17/4/14 midazolam given to settle effective clonazepam started po/pr
50 JS Nurses Notes: 19/4/14 phenobarbital added stirred with cares settled
51 JS Nurses Notes: 20/4/14 unresponsive to cares palliative sedation continued JS died peacefully - 25/4/14
52 Delirium is a Medical Emergency! needs aggressive treatment patient suffering staff safety may need to be treated with scheduled meds
53 Early Delirium Screening Questions visual seeing things perceptions someone in the room with you tactile itching, touch
54 Early Delirium Patient with excellent MOCCA, MMSE may still have delirium! 36 year old female pink hippopotamus in the room
55 How May a Patient Present? confusion agitation perplexing uncontrolled pain
56 How May a Patient Present? Perplexing Uncontrolled Pain patient peaceful until we touch him grimaces, stiff, cries out, furrowed brow, frightened pain medications don t seem effective
57 Perplexing uncontrolled pain likely delirium generalized whole body pain patient can t localize pain
58 Perplexing Uncontrolled Pain primitive reflexes protect oneself brain cannot understand the signals from body misinterprets stimulation as danger
59 Perplexing Uncontrolled Pain often settles with scheduled anti-psychotic patient may become more alert
60 Medications Anti-psychotics Haloperidol (Haldol) least sedating most anti-dopaminergic
61 Medications Anti-psychotics Methotrimeprazine (Nozinan) more sedating less anti-dopaminergic more postural bp drops Chlorpromazine (Largactil) same as methotrimeprazine
62 Take home messages Delirium is very, very common Acute confusion Fluctuates Affects consciousness, attention
63 Take home messages Under-recognized, misdiagnosed Inappropriately treated, untreated Significant morbidity and mortality Important to treat patient suffering
64 Take home messages Medical palliative emergency! Aggressive treatment Scheduled and prn medications
65 References Geriatric Palliative Care, Morrison, et al. Oxford University Press, 2003 Palliative Medicine, Walsh et al., Saunders 2009 Pallium Project, Pereira et al Stedman s Medical Dictionary 27 th edition. Lippincott, 2000
66 Delirium (s) References * Adapted from: Saint Louis University Geriatrics Evaluation Mnemonics Screening Tools (SLU GEMS). Developed or compiled by: Faculty from Saint Louis University Geriatrics Division and St. Louis Veterans Affairs GRECC 66
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