Delirium: A Waxing & Waning Problem

Terminal Agitation: Managing Symptoms at the End of LifeGregg VandeKieft, MD, MA

Washington State Hospice and Palliative Care Annual Meeting Chelan, WAOctober 12, 20151Speaker BioGregg VandeKieft, MD, MASystem Lead Physician for Palliative Care, Providence Health and Services (PH&S), Renton, WARegional Medical Director for Palliative Care, PH&S Southwest Washington Region, Olympia, WAInpatient and Outpatient Palliative Care, Providence St. Peter Hospital, Olympia, WAFormerly Hospice Medical Director, Providence Sound Home Care and Hospice, Olympia, WAgregg.vandekieft@providence.orgTwitter: @vandekieftg

DisclosuresDr. VandeKieft has no commercial relationships or conflicts of interest to report.

3Learning ObjectivesAt the conclusion of this presentation, participants will be able to:Define delirium and terminal agitationList common causes of terminal agitationDescribe the initial assessment for deliriumRecommend non-pharmacologic interventions and medication management for delirium and terminal agitation4ReflectionDo not go gentle into that good night,Old age should burn and rave at close of day;Rage, rage against the dying of the light.

Dylan Thomas, 1947Do not go gentle into that good night,Old age should burn and rave at close of day;Rage, rage against the dying of the light.

Though wise men at their end know dark is right,Because their words had forked no lightning theyDo not go gentle into that good night.

Good men, the last wave by, crying how brightTheir frail deeds might have danced in a green bay,Rage, rage against the dying of the light.

Wild men who caught and sang the sun in flight,And learn, too late, they grieved it on its way,Do not go gentle into that good night.

Grave men, near death, who see with blinding sightBlind eyes could blaze like meteors and be gay,Rage, rage against the dying of the light.

And you, my father, there on the sad height,Curse, bless, me now with your fierce tears, I pray.Do not go gentle into that good night.Rage, rage against the dying of the light.5Key PointsDelirium is a medical condition, rather than a psychiatric conditionIf possible identify and treat the underlying cause; less practical in the actively dyingUnderlying dementia increases risk of delirium 2-3xTerminal agitation is very common, treatment is often non-pharmacological6DeliriumA transient global disorder of cognitionnot a disease but a syndrome - multiple causes that produce a similar array of symptomsA medical emergency10-25% mortality in patients admitted with deliriumup to 75% mortality in patients who develop delirium during hospitalizationearly diagnosis and treatment correlates to better outcomes7Terminal Agitation or RestlessnessClinical spectrum of unsettling behaviors and cognitive disturbance in the last hours to days of lifeSymptoms include: irritability, anxiety, distress, inattention, hallucinations, paranoiaSigns include: restlessness, fidgeting, grimacing, moaning, attempts to get out of bedIncreased risk with certain medicationsAnticholinergics, opioids, benzodiazepines, steroids, antipsychotics, anticonvulsantsaka, terminal deliriumStudies vary, but incidence 25-85% of people experience terminal restlessness at the end of life.Can be very distressing to the patient and family. Even if the previous care was excellent, if terminal delirium goes misdiagnosed or unmanaged, family members may remember a horrible death and worry that their own death will be the same8Delirium: DSM-5 CriteriaDisturbance in attention and awarenessChange in cognition not better accounted for by an established or evolving dementia.Acute onset (hours to days) and fluctuates over the course of the dayHistory, exam, and/or labs indicate the disturbance is caused by a medical condition, intoxicating substance, medication, or more than one cause.i.e., reduced ability to direct, focus, sustain, and shift attentione.g., memory deficit, disorientation, language disturbance, perceptual disturbance

Diagnosis is clinical9EpidemiologyEstimated incidence in hospital40% of hospitalized patients >65 yrs old10-20% of elderly patients at time of admission50% of patients after hip fracture40% of patients in ICU20% of patients on general medical wardAdvanced cancer patients 30-50% of on admission to hospital or hospice80-90% of these patients experience delirium in their final hours to days of lifecan be effectively treated in 30-75% of cases10Risk factorsAge >60Men > womenMajor medical illness or major surgeryPre-existing brain pathologydementia, stroke, tumorPsychiatric illness, including depressionPolypharmacySubstance abuseRisk greater with increased burden of disease and/or patient vulnerability11Clinical Features of DeliriumAcute onset hours to daysFluctuating levels of consciousnessDecreased ability to maintain attentionEmotional labilityAgitation or hypersomnolenceAltered cognitive functionDay/night reversals common12Delirium vs. DementiaDelirium acute onset, cognitive changes fluctuatealertness and attention wax and wane, speech confused and disorganizedDementiagradual onset, chronic but stable memory deficits and executive function disturbanceintact alertness and attention, but deficits in speech and thought processes13Characteristic Cognitive DeficitsSpeech disturbanceslurred, mumbling, incoherent, disorganizedLanguage impairmentsword finding difficultyMemory dysfunctionshort-term memory impaired; disoriented to persons, place, timePerceptual disturbancedelusions, hallucinations, misrepresentations14Clinical Case: Rose76 year old woman with non-small cell lung cancer, metastatic to pelvis and spines/p chemo and radiation, now on hospiceno known psychiatric issues or dementianeighbors called police after she wandered into their house confused she became combative with the policeParamedics bring her to ER for evaluation

15Delirium in Oncology PatientsDirect effects of cancer on CNSmetastatic diseasehigher circulating cytokine levelsIndirect effects of cancercancer related organ dysfunction - e.g., liverparaneoplastic syndromesinfections, electrolyte disturbanceExogenous factorschemotherapy, radiation therapyopioids, polypharmacy16Differential DiagnosisBrain metastasisdelirium not typically initial manifestation, butMedication reaction or interactionvery common review med list, timing of medications relative to onset of symptomseliminate all meds that are not essentialAlcohol or drug withdrawalconsider EtOH if onset 24-48 hrs after hospital admithas patient missed regular psychotropics or opioids?Intracranial bleedconsider unwitnessed fall, especially for debilitated or thrombocytopenic patients17Types of deliriumHyperactive deliriumagitated, may be combativee.g., alcohol withdrawalHypoactive deliriumhypersomnolent, unable to maintain attention when awakee.g., hepatic encephalopathy, hypercapneaMixed has features of bothfluctuations more pronounceddaytime sedation, nocturnal agitationBoth types can cause substantial suffering for the patient and family many who survive and recall their delirium episode describe it as the worst nightmare of their life18AssessmentPitfalls in diagnosisHyperactive: misinterpreted as primary psychiatric issue, medical workup is delayedHypoactive: not a problem patient so delirium not recognized as quicklyClinical diagnosisno single diagnostic testTargeted workup based on differential diagnosisthorough history is essentialreview chart for new symptoms and/or behavioral changesreview medication list, lab work, diagnostic imagingUp to 70% of hospitalists and 30% of nursing staff will initially miss delirium19Confusion Assessment MethodFeature 1: Acute onset, fluctuating courseFeature 2: InattentionFeature 3: Disorganized thinkingFeature 4: Altered level of consciousness

CAM + for delirium if1 and 2 pluseither 3 or 4Feature 1: Acute Onset and Fluctuating CourseThis feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions: Is there evidence of an acute change in mental status from the patients baseline? Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?Feature 2: InattentionThis feature is shown by a positive response to the following question: Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?Feature 3: Disorganized thinkingThis feature is shown by a positive response to the following question: Was the patients thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?Feature 4: Altered Level of consciousnessThis feature is shown by any answer other than alert to the following question:Overall, how would you rate this patients level of consciousness? (alert [normal]), vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])20

http://www.hospitalelderlifeprogram.org/delirium-instruments/

Clinical Case (cont.)In ERRose undergoes lab tests, receives IV fluids, electrolytes, meds, becomes marginally orienteda mental health professional is consulted, determines she is able to make her own health care decisions and cannot be hospitalized against her wishes she refuses admission and is discharged home against medical advicethe following day, her hospice nurse finds her covered with feces, rambling incoherentlyCommon Reversible Clinical Causes of DeliriumElectrolyte disordershypercalcemia, hyponatremia, hyperkalemiaDrug reactions, interactions, or toxicity benzodiazepenes, opioids, anticholinergics, steroids, digoxin, Parkinsons meds, H2-blockers, alcoholInfectionHypoxemiaHyper- or hypoglycemiaHypotensionHepatic or renal encephalopathyMost cases are multifactorial25Causes of Terminal AgitationBiochemical abnormalities as organs failHypercalcemia especially common in cancerOpioid or other drug toxicityDrug interactionsPainFever, with or without infectionSpiritual or existential distressUnresolved psychosocial issuesIn metastatic cancer, also think about brain metsConundrum: does the patient need more aggressive pain management, or is the agitation due to opioid toxicity?26

Obtain historyInterview patient when possibledelirium covers a wide range of presentations, some patients can provide significant historyIf possible, talk to family or caregivers who know patients baselineReview records carefullyTypical tests of cognitive function (e.g., MMSE) not very helpful in deliriumuse tests that measure attention e.g., serial 7s, spell world backward, or list months in reverseClock drawing test can be helpful often results in half the clock being drawn and then the patient becomes distracted28Targeted workupFor all studies, ask: Will it alter treatment?how does test fit within broader context of illness trajectory and treatment goals?Brain mets: cranial CT or MRIInfection: CBC, UA, cultures, x-raysElectrolyte abnormalities: chem panelLiver failure: hepatic panel, ammoniaRenal failure: BUN/Cr, monitor I/OsRespiratory failure: O2 sat, ABGsClinical Case (cont.)Rose is brought back to ER, remains disoriented, admitted Hospice GIP statuswork-up showed UTI, possible pneumonia started on IV antibioticsrequired 1:1 sitter due to behavioral outburstsresponded well to p.r.n. haloperidol but no SNF would take her while she needed 1:1 or was receiving haloperidolrisperidone added, good response, transferred to SNF, did well until she died 6 weeks laterTreatmentIdentify and treat underlying cause, if ableOften not practical during actively dying phaseWhen etiology uncertain, treat symptomsEnvironmental therapyFacilitate a quiet, peaceful settingProvide cues: family photos, calendar, clockAddress psychosocial issues, spiritual or existential concernsInvolve family, staff, spiritual care, music thanatology

Anticipatory element: Educate family about natural trajectory at the end of life including decreased ability to communicate, the possibility of terminal delirium, that it is usually reversible with management, and that hospice/palliative care staff have the expertise to help. Have appropriate medications available, advise families/facility staff that even if theyre not needed now they may be in the future and that staff will walk them through when/how to administer.If death is imminent, dont pursue an elaborate evaluation of the cause focus on treating symptoms and supporting the family/facility staff31Treatment (cont.)Pharmacologic debridementReview med profile, look for potential offending agents, eliminate all unnecessary medsPharmacotherapy if non-pharmacologic interventions unsuccessfulTarget patients who are severely agitatedBehavior interferes with essential interventions or poses a safety hazard to self, family, staffAvoid restraints! Usually worsens agitation32Medical ManagmentBenzodiazepenesgenerally avoid - can paradoxically worsen symptomshelpful for alcohol withdrawal, anxietyConventional antipsychoticshaloperidol 1st line in hospital or home, but usually not an option in nursing homesIV or oral onset of action 5-20 min for IV routeAtypical antipsychoticshelpful for maintenance use, especially olanzapine or risperidoneSchedule antipsychotics and taper gradually. High risk of recurrence, even up to 1 month later

33Key PointsDelirium is a medical condition, rather than a psychiatric conditionIf possible identify and treat the underlying cause; less practical in the actively dyingUnderlying dementia increases risk of delirium 2-3xTerminal agitation is very common, treatment is often non-pharmacological34Questions?