Delirium: Underrecognized - PowerPoint Presentation

Slide1

Delirium: Underrecognized, Undertreated and Deadly

Coleman Foundation Winter Workshop

February 28, 2013

Andrea

Bial

, MD

Joanna Martin, MDSlide2

ObjectivesLearning Objectives

1. 

Understand how to recognize delirium in the hospice and palliative setting.

2.   

Be

able to identify possible factors contributing to patients’ delirium.

3.  

Incorporate best evidenced-based medicine in treating delirium in hospice and palliative care settings.

Content Bullets

1.   

Recognize agitation, confusion, altered level of consciousness, hallucinations, restlessness and other behaviors associated with delirium in patients with advanced chronic illness.

2.   

Understand when to pursue reversible causes of delirium and when to forgo evaluation and focus on comfort.

3. Be

able to use both pharmacological and

nonpharmacological

interventions to treat delirium in patients with advanced

chronic illness.Slide3

Delirium: What’s Going On?Pathophysiology not well understood

Thought to be deficit of acetylcholine (e.g., anticholinergic drugs as precipitant) and/or excess of dopamine (that’s why levodopa can cause & Haldol can help)

Other neurotransmitters (GABA, serotonin, norepinephrine, melatonin, others) and cytokines may also be involved.

Inouye 2006; Irwin 2013Slide4

Delirium: Prevalence~¼ to ½ of advanced cancer patients admitted to the hospital have delirium.

85-90% of all patients experience delirium in the hours or days before death.

Very

common in hospitalized older

patients

33% presenting to ER

14-24% on admission

15-53% post op

70-87% ICU

Inouye 2006;LeGrand 2012; White 2007Slide5

Delirium: Prevalence in Palliative Care

2013 Literature Review in

Palliative Medicine:

13-42% prevalence at admission to palliative or hospice units

26-62% prevalence at some point during hospitalization (in palliative or hospice unit)Slide6

Delirium: Outcomes Increased hospitalized mortality (25-75%)

Increased 1-year mortality (40%)

Increased LOS (2x)

Increased hospital complications (incontinence, falls, pressure sores)

Increased institutionalization (2-3x)

Increased healthcare costs (STAT)

Irwin2013Slide7

Delirium: Recognition Early identification of risk factors can reduce occurrence.

Early recognition of delirium can reduce duration (and potentially identify causative/contributing factors).

FOR LEARNERS:

Lecture format adequate for knowledge about delirium, but not to change provider behavior or improve outcomes.

Need interactive sessions and leaders using clinical pathways and assessment tools.

Inouye1993, Yanamadala2013Slide8

Why is delirium overlooked?Fluctuating natureOverlaps with dementia

Lack of formal cognitive assessment

Under appreciation of clinical consequences

Not considering the clinical diagnosis importantSlide9

Types of DeliriumHyperactive: “Agitated;” repeated (purposeless) limb movements, restless, trying to get out of bed, hallucinations,….

Hypoactive

Quite, withdrawn; may give monosyllabic answers to simple questions, follow simple commands

MixedSlide10

Predisposing Risk Factors

UPON ADMISSION

Serious illness (advanced cancer, sepsis, acute kidney failure,…)

Cognitive impairment

Vision impairment

Elderly

AFTER ADMISSION

Physical restraints

≥3 medications added

Malnourished

Urinary catheter placed

Inouye1993;1996;1999Slide11

An Ounce of Prevention…Yale Delirium Prevention Trial :

Orientation for cognitive impairment

Early mobilization

Prevention of sleep deprivation/fragmentation

Address vision & hearing impairments

Preventing dehydration

Inouye 1999Slide12

OverlookedInconsistent use of terminology (“confused, altered mental status agitated, lethargic,…”)

O

bjective testing rarely done

Confused with depression or dementia (see next slide)

Increase the risk of being overlooked:

Hypoactive form

Fluctuating symptoms

Age ≥80yrs

del Fabbro2006Slide13
Slide14

Identifying DeliriumSeveral tools available

Confusion Assessment Method (CAM) (94-95%

sens

/spec)

Delirium Rating Scale

Delirium Symptom Interview

Memorial Delirium Assessment Scale

Casarett2001Slide15

CAM

I

nattentive

AND

A

cute

Onset w/ Fluctuating Course

AND

D

isorganized

Thinking AND/OR

Altered

L

evel of

Consciousness

HAVE TO HAVE #1 & #2 AND THEN #3 AND/OR #4 for positive screen.

HINT: IADL

Inouye1990Slide16

CAM: example questions

Inattentive: repeat numbers, days of week/months of the year backwards OR observe staring into space, not keeping track of conversation, etc.

Acute/fluctuating: ask

pt

about confusion OR observe variations in attention, speech, thinking, or

pyschomotor

activity. (can also ask RN or family)

Disorganized thinking: what type of place is this, why are you here, see or hear anything unusual? OR observe if

pt

disoriented or uses illogical ideas/inappropriate words/rambling conversation.

Altered Level of Consciousness: falling asleep during interview,

stuporous

/comatose, non-communicative?

Huang2012Slide17

Evaluation (after Identification)

In hospitalized patients:

History (does

pt

have dementia? What has been the time course?)

Physical Exam (new wounds, neurologic deficits, urinary or fecal retention, new

fx

,…?)

Laboratory Tests (if none recent:

wbc

,

cmp

, TSH, B12?)

Radiology Tests (CXR, head CT,….?)

In palliative (Advanced, Chronically ill) patients, is this terminal restlessness?

Inouye2006Slide18
Slide19

Palliative Patients Irwin2013Slide20

Evaluation in Palliative Patients

Need to address Goals of

Care as it will guid

e extent of evaluation.

Easily addressed: constipation, urinary retention, medication side

effect, dehydration

More likely to be reversible in younger patients, those without organ failure, and those w/ less cognitive disturbance.

May be shorter time until death in those w/ irreversible

delrium

.

Leonard2008Slide21

Delirium=SyndromeDelirium is almost always multifactorial

Need to identify potential causes

Evaluation and treatment is always dependent on GOC Slide22

Causes of DeliriumMedications

New drug

Dose too high

In withdrawal (e.g., benzodiazepines

, psych drugs…)

Infection

Dehydration

Metabolic Abnormalities

Irwin2013;LeGrand2012Slide23

Additional Potential Causes of Delirium in CA pts

All of preceding causes, but also…

Primary or Secondary CNS tumors

Toxicity of antineoplastic therapies (chemo,

xrt

,…)

Toxicity of other drugs used in treatment (steroids, anti-nausea drugs, anticonvulsants,…)

Paraneoplastic

neurological syndromes

Caraceni2005Slide24

Treatment: Underlying CauseAdjust medication (if able)

Any medication that has CNS

s.e.

can contribute to delirium (especially those w/ hi anticholinergic activity)

See next slide

Treat infection

Address dehydration (IV fluids,

sq

fluids, oral hydration)

Consider fixing electrolyte abnormalitiesSlide25

Medications as Cause

Antibiotics

Steroids

Benadryl NSAIDS

Benzos

H2

Blockers

Digoxin

Parkinson’s

drugs

GI (

Reglan,

Bentyl

)

Tricyclics

Lithium

Narcotics

Neuroleptics

Any drug with

anticholinergic properties!Slide26

Treatment: NonpharmacologicSafety of room (minimize bed rails or pad, lower bed, mats on floor)

Reorientation (verbal cues, date boards, shades up)

Reduce restraints (“official” and “unofficial”)

Family/friends at bedside

Supply glasses or hearing aids if appropriateSlide27

Treatment: Pharmacologic Caveats

NO MEDICATIONS are currently approved by the FDA for management of delirium

NO published DB, RCT to guide medication management of delirium.

NO consensus: oncology, geriatrics, psychiatry, palliative medicine

Goal is to maximize safetySlide28

Treatment: PharmacologicHaloperidol as first drug of choice

Can be given IV, IM, SC, PO (pill or liquid)

LOW dose to start (0.5mg IV Q6H prn)

BEWARE EPIC!

Can repeat at 30mins if needed

Irwin2013;LeGrand2012Slide29

HaloperidolOld, cheap, decades of useRecent trial: 14 centers/4 countries/119 patients w/ delirium in hospice or palliative care:

Average daily dose: 2.1mg

Most frequent

s.e.

: somnolence (9%) & urinary retention (5%)

1/3 had net benefit (NCI delirium score)

Risks present with ALL antipsychotics

Black box warning on all: increased CV or infectious mx when used in dementia-related psychosis

Crawford2013, Irwin2013Slide30

Other Pharmacologic TreatmentsOther antipsychotics CAN be used

C

onsider side effects: potentially WANT more sedation, or weight gain, or other effect

May use if higher doses needed.

Benzodiazepines

C

an worsen delirium

Use as first-line only if alcohol/

benzo

withdrawal or having seizures

Can use as second line (in addition to Haldol) if not achieving adequate responseSlide31

Delirium in the ICUEstimates range from ~20-90% of patients

10% increase mx for each day of delirium

Additional risk factors:

Coma

Sedatives

Neurologic diagnosis

Reade2014Slide32
Slide33

Terminal deliriumOften referred to as “terminal restlessness”

Characterized by agitation, repeated nonsensical requests (“I need to sit up”), repetitive movements, picking at clothes and sheets.

Occurs in up to 85% of patients in the last weeks of life

Family/caregiver education is key

Can use H

aldol

first line for symptom management

Consider use of benzodiazepines if

H

aldol ineffective,

especially in younger patientsSlide34

Terminal delirium: Family Support

The experience of delirium for families can complicate

bereavement

“

Double loss”

Grief when they lose ability to communicate meaningfully with patient and again when the patient dies

Although previous care may have been excellent, if the delirium goes misdiagnosed or unmanaged, family members may remember a horrible death "in terrible pain”Slide35

Terminal Delirium: Family Support, contd.

Families may be ambivalent about medication use: want the

pt

to be comfortable, but fear lack of communication w/

pt

or worry that death is hastened.

Families should be given ample opportunities to ask questions; information may need to be repeated.

If suspect death is near, important to ask family if they want to know prognostic information.

Brajtman2005Slide36

Patient AB105yo W in hospice w/ dementia and COPD.

Takes Xanax 0.25mg QHS (for years).

Called by RN:

pt

had a night of agitation: was up all night, convinced her son was being held hostage. When son was called to talk to her to reassure her he was ok, she was sure he was being forced to say he was fine.

CG couldn’t give her any more Xanax (

pt

refused) and family didn’t want to give her Haldol since last time she got it, “She was knocked out.”Slide37

Patient AB: QuestionsIs this patient delirious?Is this patient having terminal restlessness?

What do you recommend for the future?

Increase bedtime Xanax

Repeat bedtime Xanax dose at start of agitation

Use Haldol anyway

Have son come over and sit w/ patientSlide38

Patient ABWhat do you do?

Increase bedtime

Xanax to 0.5mg.

Repeat bedtime Xanax dose at start of

agitation.

Use Haldol

anyway, starting at lower dose than before and use at start of agitation.

Have son come over and sit w/

patient.

1., 2., 4.

1., 3.

None of the aboveSlide39

Patient case #1Mr. S is an 80 year old NH resident with history of end stage dementia admitted to hospice with history of aspiration pneumonia. Mr. S is usually calm, nonverbal and can sit in the dayroom in his wheelchair. The NH calls you that he

has become quite

agitated and won’t let the CNA give him his bath today.Slide40

Patient case #1 cont. . .NH reports patient usually calm and often sits in day room, pleasantly confused at baseline.

Exam: VSS with no BM since hospice admission one week ago, patient lying in bed, agitated and moaning, lung exam stable, abdomen distended with bowel sounds; rectal vault filled with stool

Meds reviewed: HCTZ, Nifedipine, prevacid, roxanol 5mg q4hrs prnSlide41

Is this patient delirious?Acute onset and fluctuating course YES

Inattention YES

Disorganized thinking NO

Altered level of consciousness YESSlide42

Patient case #1Patient is impacted

Fleets enema performed with good results

Patient straight cathed to check post void residual which was <100cc

Meds reviewed: HCTZ, nifedipine and roxanol can cause constipation

Meds adjusted

Bowel regimen: senna dailySlide43

Patient case #1Patient much more comfortable by the next day

He returns to baseline within a few days

Hospice team provides a lot of oversight to nursing home care; patient requires close medication monitoring and has ongoing issues with constipationSlide44

Patient case #2Patient is a 50 year old man with metastatic lung cancer admitted to hospice one month ago. Patient is steadily declining and using ativan now multiple times a day for anxiety. His wife contacts you that he is pacing, agitated and combative. At baseline he is usually anxious but can be reassured. Slide45

Case 2 continued. . . On exam, he is confused, hyperalert and report seeing ants walking on the ceiling. He is unable to follow your other questions. His exam is remarkable for cachexia and hypoxia. SOB is controlled. Bowels are moving and patient urinating regularly.

Meds: ativan (7 doses in past 24 hrs), decadron 4mg, MS Contin 30 bid and roxanol 5mg prnSlide46

Is this patient delirious?Acute onset and fluctuating course YES

Inattention YES

Disorganized thinking YES

Altered level of consciousness YESSlide47

Patient case #2Decision made to decrease dose of ativan back to bid and start haldol 0.5 mg bid and q4 hrs prn; give decadron in AM

Patient calms down enough to wear oxygen and wife able to manage sx

No need for opioid rotation

Ends up using haldol 1mg q4hrs ATC

Much calmer and comfortable until death one month laterSlide48

Patient case #2Decision made to decrease dose of ativan back to bid and start haldol 0.5 mg bid and q4 hrs prn; give decadron in AM

Patient calms down enough to wear oxygen and wife able to manage sx

No need for opioid rotation

Ends up using haldol 1mg q4hrs ATC

Much calmer and comfortable until death one month laterSlide49

Patient Case #3Patient is a 65 year old woman with stage IV breast cancer in home hospice

Family calls to report that patient more confused in past two days and sleeping moreSlide50

Case #3 continued. . . On exam: VSS, patient is sleepy and able to answer some questions but has trouble tracking conversation and is tangential, no focal neuro deficits noted, exam otherwise unchanged

Meds: fentanyl patch and roxanol prn; sennaSlide51

Is this patient delirious?Acute onset and fluctuating course YES

Inattention YES

Disorganized thinking YES

Altered level of consciousness YESSlide52

Patient case #3 continued. . .Patient with chronic severe pain so opioids not changed

Delirium likely due to final days of life

Family educated - KEY

Patient had some periods of lucidity over next several days and died

a week laterSlide53

Take Home PointsBe able to recognize signs and symptoms of delirium as early as

possible; remember hypoactive is the most common form and often not found unless looked for.

Assess for easily reversible causes of delirium and understand when evaluation is not indicated due to terminal restlessness/near EOL.

Be comfortable in using both pharmacological and

nonpharmacological

measures to treat delirium.

Provide information to family.Slide54

Works Cited

BrajtmanS

. Helping the family through the experience of terminal restlessness.

JHosPallNurs

2005;7:73.

CaraceniA

et al in Doyle D et al, eds. Oxford textbook of palliative medicine. OxfordUnivPress2005pp708-712

Cassarett

D et al. Diagnosis and management of delirium at end of life. Ann Intern Med 2001;135:32

Crawford GB et al.

Pharmacovigilance

in hospice/palliative care: net effect of haloperidol in delirium. J Pall Med. 2013;16:1335-1341.

Del

Fabbro

E et al. Symptom control in palliative care—part III: dyspnea and delirium. J Pall Med. 2006;9:422-433

.

Hosie

A et al. Delirium prevalence, incidence and implications for screening. Pall Med 2013;27:486.

Huang LW et al. Identifying indicators of important diagnostic features of delirium. JAGS 2012;60:1044-1050.

Irwin SA et al. Clarifying delirium management: practical, evidence based, expert recommendations for clinical practice. J Pall Med. 2013;16:423-435.

InouyeSK

et al. Clarifying Confusion: the confusion assessment model. AnnIntMed1990;113:941-948.

Inouye SK et al. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. 1993;119:474-481.

Inouye SK et al. Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA1996;275:852-857

Inouye SK et al. A multicomponent intervention to prevent delirium in hospitalized older patients. NEJM 1999;340:669.

Inouye SK. Delirium in older persons. NEJM 2006;354:1157.

LeGrand

SB. Delirium in palliative medicine: a review.

JPainSymMan

2012;44:583-594

.

LeonardM

et al. Reversibility of

dellirium

in terminally ill patients & predictors of mortality. PallMed2008;22:848.

Reade MC, et al. Sedation and delirium in the ICU. NEJM 2014;370:444

Von

Gunten

CF et al. New versus old neuroleptics: efficacy versus marketing. J Pall Med 2013;16:1509-1514

.

White C et al. First do no harm…terminal restlessness or drug-induced delirium. J Pall Med 2007;10:345-351.

Yanamadala

M et al. Educational intervention to improve recognition of delirium: a systematic review. JAGS 2013;61:1983-1993.