Palliative Care and Delirium Ambereen K. Mehta, MD MPH Assistant Professor Division of General Medicine, Geriatrics, and Palliative Care
Disclosures I have no personal or professional financial relationships or interests with any proprietary entity producing healthcare goods or services.
Objectives Identify the impact of delirium Recognize risk factors, precipitating factors, and causes of delirium Assess patients inside and outside the ICU Manage delirium using non-pharmacological and pharmacological methods Identify and treat delirium at the end of life
DSM V Definition A. Disturbance in attention B. Develops over a short period of time C. Additional disturbance in cognition D. A and C are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal (i.e. coma) E. History, physical examination, or laboratory findings suggest it 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 Saczynski and Inouye. The American Psychiatric Publishing Textbook of Geriatric Psychiatry, 5 th Edition. Ch 7. First ed. 2015
Inouye et al. The Lancet. 2014 Weckmann and Morrison. Evidence-Based Practice of Palliative Medicine. Ch 35. Epidemiology Prevalence General hospital admission 14-24% >65 yo admitted to the hospital 50% Intensive care unit (ICU) 80% Post-op (general surgery) 5-10% Post-op (orthopedic surgery) 42% Near death (hours to days) 88% Palliative care, cancer 47% - incidence
Mortality Admitted with delirium mortality 10-26% Developed during admission mortality 22-76% ICU delirium 2-4 times increased risk of death Present to ER with delirium 70% increased risk of death within 6 months Inouye et al. The Lancet. 2014 Weckmann and Morrison. Evidence-Based Practice of Palliative Medicine. Ch 35.
Case 85 year old woman was admitted to the hospital with fevers, chills, increasing confusion, nausea and vomiting. PMHx: - Hypothyroidism - Diabetes - Rheumatoid arthritis chronic knee pain - Anxiety FamHx: - Mother stroke - Father kidney disease SocHx: - Tobacco never, Alcohol social - Widowed, retired school teacher, loves to dance and read mystery novels - Lives at home with her 2 cats, daughter lives 3 houses away Home Medications: - Synthroid - Metformin - Clonazepam scheduled - Tylenol as needed - Oxycodone as needed - Ativan as needed
Case continued Physical exam Temp 38.3, HR 107, BP 135/90, RR 12 Awake, confused, trying to get out of bed Tachycardic, breathing comfortably, abdomen tender with palpation UA WBC >100,000 UCx E. Coli BCx initially NGTD, then positive for E. Coli
Risks Dementia or cognitive impairment Functional impairment Visual impairment History of alcohol abuse Older age (70 years or more) Higher burden of comorbidities Inouye et al. The Lancet. 2014 Fong et al. The Lancet. 2015
Precipitating Factors Multiple drugs especially psychoactive drugs Physical restraints Bladder catheter Increased serum urea Infection Iatrogenic event Surgery aortic aneurysm, non-cardiac thoracic, neurosurgery Inouye et al. The Lancet. 2014 Fong et al. The Lancet. 2015
Case 85 year old woman was admitted to the hospital with fevers, chills, increasing confusion, nausea and vomiting. PMHx: - Hypothyroidism - Diabetes - Rheumatoid arthritis chronic knee pain - Anxiety FamHx: - Mother stroke - Father kidney disease SocHx: - Tobacco never, Alcohol social - Widowed, retired school teacher, loves to dance and read mystery novels - Lives at home with her 2 cats, daughter lives 3 houses away Home Medications: - Synthroid - Metformin - Clonazepam scheduled - Tylenol as needed - Oxycodone as needed - Ativan as needed
Causes Life Threatening Reversible vs Non Reversible
Reversible Hearing or vision impairment Immobilization Medications Acute neurological diseases Concurrent illness Metabolic derangement Surgery Environment Pain Emotional distress Sustained sleep deprivation Constipation Irreversible Dementia, cognitive impairment Advancing age (>65 yo) History of delirium, stroke, neurological disease, falls, gait disorder Multiple comorbidities Male Chronic renal/liver disease Irwin et al. J Pall Med. 2013
Types of Delirium Type Presentation Associated Diseases Hyperactive Agitation Restlessness Hallucinations Delusions Alcohol withdrawal Intoxication PCP, LSD, amphetamines Hypoactive Lethargy Sedation Decreased responsiveness Hepatic encephalopathy Hypercapnia Older patients Mixed Hyperactive features + Hypoactive features Irwin et al. J Pall Med. 2013
Assessment Identify the patient s baseline Obtain a thorough history Perform a thorough physical exam including mental status exam Identify with patient/family/friends/caregiver whether the change in mental status, behavior, or function acute?
Tools for Assessment Mini Cog Identifies patients who are high risk for developing delirium Not for patients with delirium or cognitive impairment Confusion Assessment Method (CAM) Sensitivity 94-100%, Specificity 90-95% 5 minutes to administer Sands et al, Palliat Med. 2010.
ICU Assessment Tools Confusion Assessment Method for the ICU (CAM-ICU) Uses nonverbal assessments (ventilated patients), have to be arousable with verbal stimuli Takes 1-2 minutes Sensitivity 75.5%, Specificity 95.8% Diagnosis if: 1. Mental status acutely changes or fluctuates 2. Auditory or visual tests for inattention 3. Disorganized thinking OR 4. Altered level of consciousness http://www.icudelirium.org/delirium.html Fast Facts #160. Screening for ICU Delirium. Gusmao-Flores et al. Crit Care. 2012
Delirium vs Dementia Often coexist Leading risk factor for delirium pre-existing dementia or cognitive impairment Independent risk factor long term cognitive decline and dementia delirium Delirium onset sudden, hours-days Dementia onset progressive, months-years Delirium attention fluctuating, reduced Dementia attention normal until advanced stage Fong et al. The Lancet. 2015
Management First steps Ensure and maintain patient s safety Protect airway, prevent aspiration, maintain hydration, maintain nutrition, prevent skin breakdown, prevent falls Avoid restraints and bed alarms Identify the cause(s) First look for medical emergencies (hypoxia, hypoglycemia, hypercarbia) Treat reversible causes Manage symptoms Irwin et al. J Pall Med. 2013
Non-pharmacological Management First line approach Stop or decrease anticholinergic, psychoactive drugs Reorientation techniques family photos, calendar, clocks Relaxing techniques tea, music, massage Quiet environment 53% decrease with earplugs at night in ICU Hearing aids, eyeglasses Family, familiar nurses, sitters PT, OT Safety (remove dangerous items, increased surveillance, floor mats, padding, remove IV lines/foley catheters) Weckmann and Morrison. Evidence-Based Practice of Palliative Medicine. Ch 35.
Pharmacological Management Hyperactive Antipsychotics 1 st generation Drug Dose Administration Adverse Effects Haldol* 0.5-1 mg PO or IV every 6 hours Max dose: 100 mg/day Extrapyramidal side effects (EPS) (IV less than oral) >4.5 mg/day Chlorpromazine (Thorazine) 25-50 mg PO every 6 hours Max dose: 2000 mg/day Dry mouth, sedation, confusion, falls, hypotension Antipsychotics 2 nd generation Olanzapine (Zyprexa) 5 mg PO (disintegrating tab) daily Max dose: 20 mg/day Sedation, confusion, Hypotension Quetiapine* (Seroquel) 25 mg PO every 6 hours Max dose: 300-400 mg/day Most sedating, Least EPS, Orthostasis Risperidone (Risperdal) 1-2 mg PO nightly Least sedating, No orthostasis Weckmann and Morrison. Evidence-Based Practice of Palliative Medicine. Ch 35.
Pharmacological Management Benzodiazepines Avoid Paradoxical worsening of delirium Use if delirium due to drug withdrawal, anticholinergic excess 0.5-2 mg PO/IV/SQ q1h prn Melatonin/Ramelteon (melatonin analog) Helps regulate sleep-wake cycle Can be used to prevent onset in at-risk patients 5-10 mg PO nightly Weckmann and Morrison. Evidence-Based Practice of Palliative Medicine. Ch 35. Foster et al. Syst Rev. 2016
Case continued Treatment for bacteremia with sepsis of urinary source: IV antibiotics, pressors Delirium treatment Haldol 0.5 mg IV q6h initially as needed, then changed to scheduled Moved to a window bed Minimized night time interruptions (rescheduled medications and vitals)
Case continued She continued to decline and family chose to pursue comfort measures with admission to hospice Agitation, confusion continued despite haloperidol (Haldol) increased to 2 mg IV q4h sch Changed to chlorpromazine (Thorazine) scheduled with improvement She died 3 days after admission to hospice
Delirium at the end of life No common definition of terminal delirium Similar causes at end of life as others Aggressive management of other symptoms may improve delirium Medications used for symptom control at end of life may be the cause - opioids, scopolamine, metoclopramide
Take home points Use a brief screening tool like CAM First implement non-pharmacological methods (e.g. sitters, hearing/vision aids, ear plugs, sleep hygiene, etc.) Antipsychotics are appropriate for hyperactive delirium Benzodiazepines may make symptoms worse (except in select circumstances) Identify goals of care and consider sedating medications for terminal delirium