Dr Holly McGuigan Specialty Doctor in Palliative Medicine Strathcarron Hospice Situation Anne 73 year old lady lung cancer Admitted for symptom control of pain Previously delusional with opioids not keen for same ID: 617497
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Slide1
Delirium in Palliative Care
Dr Holly McGuigan
Specialty Doctor in Palliative Medicine
Strathcarron HospiceSlide2Slide3
Situation
Anne
,
73 year old lady, lung cancerAdmitted for symptom control of pain
“Previously delusional with opioids- not keen for same”“GP reports became more delusional with recent increase in Pregabalin- requesting symptom control admission”Slide4
Background
Metastatic
lung
cancer- recent radiological diagnosisCognitive impairment- subtle, several weeks
Severe depression- 7 yearsSlide5
Assessment
Left shoulder and posterior chest wall pain
Hypoactive
deliriumRight upper limb tremor
Borderline pyrexiaLoose stools Slide6
Medication on Admission
Folic Acid 5mg od
Lansoprazole 30mg od
Sertraline 200mgs odPregabalin 200mg bdMetoclopramide 10mg tidISMN 10mgs bdBisoprolol 2.75mg odDigoxin 125mcg odWarfarin (Target INR 2-3)
Megesterol 160mgs odCo-codamol 8/500 prnChanges on admission: Co-codamol to regular and added PRN Oxycodone 0.5mgSlide7
Investigations
CT- Mild SVD
MRI- Mild SVD
Bloods- Unremarkable
Infection screen- MSSU –ve, stool C+S -ve, nil else localisingSlide8
Over next few days…
Worsening
D
eliriumHyperreflexia
Absence seizuresSlide9
Offending Drugs
Neurological symptoms
Ruled out alternatives
Delirium
Serotonin
SyndromeSlide10
Serotonin Syndrome
Group of
symptoms
U
se of serotonergic drugs
Over-activation
of peripheral and central serotonin receptorsSlide11Slide12
Culprit Drugs
Antidepressants
Some opioids-Tramadol, Fentanyl, Oxycodone
Gabapentin and
Pregabalin
Antiemetics
:
Ondansetron
,
Metoclopramide
,
LevomepromazineSlide13
Why do we miss it?
Diversity of presentation
Lack of awareness
Mistaking it for something
elseSlide14
68%
41%
14%
100
C
onsecutive Admissions
On at least one serotonergic drug on admission
Changes on admission which increased risk of SS
Developed new SS symptoms in next 48 hoursSlide15Slide16
Reduction of Pregabalin
Absence Seizures stopped
Hyperreflexia resolved
Delirium resolvedAble to set goalsWanted to get dressed every daySlide17Slide18
She hasn’t been able to talk about the cancer
No-one’s getting through to her
I can’t bear to see her like thisSlide19Slide20Slide21
holly.mcguigan@nhs.net
@cloudy_lemonade