Terminal Restlessness Dr. Christopher Churchill St. Cloud VA Health Care System EC&R Service Line Director & Medical Director Hospice & Palliative Care March 31, 2016 Learning Objectives Different Terminology Most Common Signs and Symptoms Most Common Types Multiple Etiologies Non Clinical Outcomes Definition: general medical disorder affecting the brain Approximately > 80% of all terminally ill patients will develop delirium prior to their death Very important symptom to detect and manage High prevalence and frequency Distress it causes patients and families Terminal Restlessness Spectrum of behaviors and symptoms seen in the last few days of life Can overlap with but does not fit the diagnostic criteria of delirium Ensure reversible causes are addressed Clinical signs and symptoms Acute or subacute onset (hours days) Fluctuating course Short term duration if cause is reversible Impaired consciousness with a reduced environmental awareness Inability to focus, sustain, or shift attention Hallucinations and delusions are common Clinical signs and symptoms continued. Global cognitive impairment Sundowning Lbil Labile mood 1
Hyperactive Restlessness Agitation Hypervigilance Delusions Hallucinations More recognizable Hypoactive Confusion Somnolence Delusions and hallucinations present in > 50% cases Less noticeable Accounts for up to 86% of HPC patients with delirium Misdiagnosed as depression or fatigue Mixed Subtype with alternating features of hyperactive and hypoactive delirium Multiple neurotransmitters involved Dopamine excess Acetylcholine and GABA deficiency Elevated levels l of cytokines Due to the advanced illness state in this patient population, multiple etiologies may be responsible Multiple etiologies Pain Urinary retention Constipation i Dehydration Infection Electrolyte imbalances Drug/alcohol withdrawal Medication side effects Anticholinergic drugs Anti emetics, antihistamines, TCAs, TCA s scopolamine, etc. Opioids Sedative hypnotics H2 blockers and metoclopramide Corticosteroids NSAIDS 2
Blood loss anemia Immobilization Environment Unfamiliar Social isolation Vision and/or hearing impairment Cardiac or Pulmonary disease Renal failure Hepatic failure CNS dysfunction Central lesion (e.g.. Metastatic brain disease) Seizure CVA Non Pharmacologic Treatment Identify reversible causes Environment Safety Minimize i i risk ik of injury (especially for agitated patients) Familiar objects (clocks, calendars, etc.) Photographs Familiar music Windows with outside views Provide education to family and/or caregivers Pharmacotherapy Determine goals of care Attempt to reverse the delirium Restores meaningful cognitive connection to family Initiate palliative sedation Irreversible delirium without agitation May only require comfort measures Anxiolytic Not first line therapy for underlying delirium Try to avoid as they can cause paradoxical worsening of delirium and agitation Lorazepam (Ativan) 0.5 1 mg PO/SL/SQ/IV q4h PRN May be indicated when sedation is indicated Alcohol and/or substance withdrawal Neuroleptic malignant syndrome Second line agent for delirium in patient s with Parkinson s Disease Short term adjunct for agitated delirium 3
Typical Neuroleptics Haloperidol (Haldol) 0.5 1.0 mg PO/SL/SQ/PR/IV q4 12h ATC or PRN Chlorpromazine (Thorazine) 12.5 50 50 mg PO/SL/PR/IM q4 8h ATC or PRN Atypical Neuroleptics Olanzapine (Zyprexa) 2.5 5 mg PO Daily Quetiapine (Seroquel) 25 mg BID Risperidone id (Risperdal) 0.25 1 mg PO BID Key Points Start at the lower end of the dosage range Frequent assessments of response to treatment and potential side effects are needed Consider palliative sedation if symptoms not controlled with optimal doses of antipsychotics Clinical Outcomes Prolonged hospitalizations Functional and cognitive decline Institutionalization Higher mortality 1 and 6 month mortality 14 and 22%, respectively Protracted delirium (6 months) increased 1 year mortality References American Academy of Hospice and Palliative Medicine (http://www.aahpm.org). Cole MG, Primeau FJ. Prognosis of delirium in elderly hospital patients. CMAJ 1993; 149:41. Fainsinger R, MacEachern T, Hanson J, et al: Symptom control during the last week of life on a palliative care unit. J Palliat Care. 1991; 7:5 11. Ferrell BR, Coyle N:, Confusion, Agitation, and Restlessness. Oxford Textbook of Palliative Nursing. New York: Oxford University Press, 2010, pp. 449 468. Goals of Care Conversations, Train the Trainer Session, February 18 19, 2015: Department of Veterans Affairs, Employee Education System, and National Center for Ethics in Health Care. References Kiely DK, Marcantonio ER, Inouye SK, et al. Persistent delirium predicts greater mortality. J Am Geriatr Soc 2009; 57:55. Palliative Care Consultant: Guidelines for Effective Management of Symptoms, GEMS. 3 rd Ed., 2008. HospiScript, LLC. Shuster JL: Confusion, agitation, and delirium at the end of life. Journal of Palliative Medicine. 1998; 1:177 186. Stiefel F, Fainsinger R, Bruera E: Acute confusional states in patients with advanced cancer. J Pain Symptom Manage. 1992; 7:94 98. UNIPAC Series: Hospice and Palliative Care Training for Physicians (Self Study); AAHPM. 4
Christopher.Churchill@va.gov 5