recognition and management
DESCRIPTION
RECOGNITION AND MANAGEMENT. DELIRIUM. DR AISLING O’GORMAN Consultant in Palliative Medicine. DELIRIUM. The entity formally known as …. Confusion & agitation- Organic psychosis Acute confusional state- Opioid toxicity Cognitive impairment / failure - PowerPoint PPT PresentationTRANSCRIPT
LOUTH & MEATH SPECIALIST PALLIATIVE CARE SERVICES
RECOGNITIONAND
MANAGEMENT
DELIRIUM
DR AISLING O’GORMANConsultant in Palliative Medicine
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DELIRIUM The entity formally known as ….
– Confusion & agitation - Organic psychosis
– Acute confusional state - Opioid toxicity– Cognitive impairment / failure– Acute brain syndrome - ITU encephalopathy
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DELIRIUM
An aetiologically non-specific, global, cerebral dysfunction characterised by concurrent disturbance of level of consciousness, attention, thinking, perception, memory, psychomotor behaviour, emotion and the sleep-wake cycle.
Delirium = Brain Failure
Confused ????
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DELIRIUM
An aetiologically non-specific, global, cerebral dysfunction characterised by concurrent disturbance of level of consciousness, attention, thinking, perception, memory, psychomotor behaviour, emotion and the sleep-wake cycle.
Delirium Subtypes
Hyperactive Hypoactive Mixed
Hypoactive HyperactiveMixed
Delirium – What’s it to YOU ???
Delirious patients
Stop eating Stop drinking fluids Stop taking important medications May fall and injure themselves Are often placed in restraints and suffer
complications such as aspiration and decubitus
Morbidity:– Associated with prolonged hospitalisation– More hospital-acquired complications e.g.
falls & pressure sores– Increased risk of long term cognitive
decline– More likely to require admission to long
term care– Loss of independent living
Delirium Is Deadly !!!
Mortality rates:– 10% - 65%
- With appropriate management, may be reversible in up to 50%
But
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DELIRIUM Prevalence:
– 10% - 35% of hospitalised patients
Elderly Patients– 30% of hospitalised elderly
Cancer Patients– 25% - 40% of cancer patients– Up to 85% of cancer patients with
advanced disease
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Risk FactorAssessment for Delirium
Age 65 yrs or older Cognitive impairment (past or present) Current hip fracture Severe illness
Mental Health Problems among elderly in hospitals 50% cognitive impairment 27% delirium 8-32% depressive illness 6% hallucinations 8% delusions 21% apathy 9% agitation/aggression
Goldberg et al; Age Ageing 2011 Sep 1
Elderly patients with mental health problems in hospital– 47% Incontinent– 49% Assistance with feeding required– 44% Major assistance to transfer
Goldberg et al; Age Ageing 2011 Sep 1
Delirium – Differential Diagnosis
Dementia Depression Mania Psychosis
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DELIRIUM DEMENTIAAcute. Chronic.Often remitting & Usually progressive reversible. & irreversible.Mental clouding. Brain damage.(info not taken in) (info not retained)
Poor concentrationImpaired short term memoryDisorientationLiving in pastMisinterpretationsHallucinationsDelusions
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DELIRIUM DEMENTIA
Speech rambling & Speechincoherent. stereotypes &
limited.
Often diurnal Constantvariation. (in later stages).
Often aware & Unaware &anxious. Unconcerned
(in later stages).
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Pathophysiology of Delirium
↓ Acetylcholine ↑ Dopamine ↑ Noradrenaline ↑ Serotonin ↓ Histamine Gaba Cytokines- IL-1, IL-2,6; TNF; IF
Recognising Delirium - Indicators
Recent changes or fluctuations in behaviour– Cognitive function– Perception– Physical function– Social behaviour
Clinical Features
Acute onset Fluctuating course Inattention Disorganised
thinking Altered
consciousness Cognitive deficit
Perceptual disturbance
Psychomotor disturbance
Altered sleep-wake cycle
Emotional disturbance
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ESSENTIAL CRITERIA FOR DIAGNOSING DELIRIUM
Disturbance of consciousness / impaired attention.
Change in cognition Acute / subacute onset & fluctuating course Evidence of general medical condition judged
to be aetiologically related to the disturbance.
DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS IV
Consciousness
Level of consciousness = awake/alertness
Content of consciousness = awareness
Hypoalert Hyperalert
Attention
Inability to direct, focus and sustain attention – Distractable– Neglect– Perseveration
Linked to arousal/ consciousness
Serial 7’s Count down 20-1 ‘WORLD’–‘DLROW’ Digit span forward &
backwards
Registration of new information does not occur –> immediate & short term memory loss
Change in Cognition
Disorganised thinking– Memory deficit– Disorientation– Language disturbance– Perceptual disturbance
Bedside Tests
Cognitive Tests - – MMSE– SOMCT
Tests to Differentiate Delirium from Dementia– DRSR-98– MDAS
Tests for Delirium– Cognitive Test for Delirium– DRS – R-98– CAM – Confusion Assessment Method– NUDESC
Management of Delirium
SOLVE THE PROBLEM !!!! Treat the underlying causes Environmental interventions Antipsychotics
– Haloperidol, risperidone, quetiapine, olanzapine,
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CAUSES OF DELIRIUM
Drug Toxicity
Infection
Surgery
Metabolic
encephalopathy
Electrolyte
Direct CNS Causes
Hypoxia
Environmental
Paraneoplastic
Haematological
Elimination disorder
Delirium - Causes
– Medications• Chemotherapy• Steroids• Radiotherapy• Opioids• Benzodiazepines• Anticholinergics• Antiemetics• Withdrawal
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MANAGEMENT OF DELIRIUM
Assess patient:
– Determine cause– ? Potentially reversible factors– Check list– History (NB collateral)– Examination– Review medication– Blood tests
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MANAGEMENT OF DELIRIUM
Environmental Interventions:
– Supportive measures– Keep to a routine– Quiet & well lit room– Orientate patient
frequently– Separate past & present– Explanations to patient
– Identify & respond to mood
– Avoid unnecessary confrontation
– Avoid restraints– Courtesy & respect– Presence of family
member/close friend
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MANAGEMENT OF DELIRIUM
Communicate with family:
– Clear explanation of goals of management & possible outcomes.
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MEDICAL MANAGEMENT OF DELIRIUM
There are 3 distinct clinical entities:
– Hyperactive: Agitated– Mixed: Hypoactive – Hyperactive – Hypoactive – Hypoalert, withdrawn,
confused
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MEDICAL MANAGEMENT OF DELIRIUM
Haloperidol:– Highly potent dopamine
blocking agent– Half life: 20 hours– Minimal anticholinergic
V/E– Less sedating than
phenothiazines– Administration:
• Po, iv, im, sc
– Dose:• 1-2 mg po/sc q 6 hrly• Elderly 0.5 – 1mg bd• 1 mg q 1 hrly prn• Titrate as needed• Higher doses may be
required initially, if severely agitated
• Rarely exceed 20mg / 24 hours
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MEDICAL MANAGEMENT OF DELIRIUM
Olanzapine• Fewer Extrapyramidal
V/E• Dose 2.5mg stat, prn • Available in Velotab
preparation• V/E – Drowsiness &
Weight Gain, ACH
Risperidone• Dose 500mcg bd &
prn • Increase by 500mcg
bd on alt days• Median maintenance
dose – 1mg/day
Quetiapine• Dose 12.5 – 25mg bd
NEW ATYPICAL ANTIPSYCHOTICS
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MEDICAL MANAGEMENT OF DELIRIUM
Methotrimeprazine:
– Widely used in terminal stages
– V/E: • sedating • postural hypotension
– Dose:• 6.25mg – 12.5 mg
sc/po q 8-12h• Higher doses in
terminal stages:– 12.5 mg – 25 mg
sc/po q 4 – 8 hrly– Up to 300 mg / 24
hours via syringe driver reported
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MEDICAL MANAGEMENT OF DELIRIUM
Chlorpromazine:– Useful oral alternative when some sedation is
desirable– Dose: 25mg po q 8 hrly
Midazolam:– Rapid onset & short half life– Administration: iv, im, sc– Dose: 2.5 mg – 10 mg stat followed by
20mg – 100 mg / 24 hours Phenobarbitone:
– Pre terminal agitation– Used with midazolam– Dose: 200 mg – 800 mg / 24 hours
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Delirium and Suffering in the Dying Patient
Suffering caused by delirium is hard to assess, even retrospectively.
Interferes with meaningful contact Distressing to families Visions and visitation on the deathbed:
-Pathologic?-Supernatural?
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Delirium at End of Life
Treatment Overview Primary Goals:
-Maximizing Patient Comfort-Minimizing Patient (Family) Distress
Tx Underlying Cause (When Possible & Appropriate) Usually involves Medication:
-Benzodiazepines-Neuroleptics
May Require Heavy Sedation
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TERMINAL DELIRIUM
Delirium occuring in last days of life Cause – multifactorial, unknown Investigations – limited Focus – Patient comfort NB General measures Haloperidol 10 – 30mg/24hrs Methotrimeprazine 50 – 200mg/24hrs Phenobarbitone 800 – 1600mg/24hrs +/- Midazolam 10 – 100mg/24 hrs
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CONCLUSION
Prevention / Minimise Risk Early Diagnosis Early Treatment Careful Systematic Approach Correct Reversible Causes NB General Measures
References
Inuoye S. Delirium in Older Persons. NEJM. 2006; 354:1157-65
Centeno C, Sanz A,Bruera E. Delirium in advanced cancer patients. Palliat Med. 2004; 18: 184-94
Lawlor P et al. Occurrence, Causes and outcome of delirium in patients with advanced cancer. Arch Intern Med; 160: 786-94
Caraceni A, Simonetti F. Palliating delirium in patients with cancer. The Lancet. 2009: 10; 164-72
Lonergan E et al. Antipsychotics for delirium. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD005594
References
Grover S, Matoo SK, Gupta N. Usefulness of atypical antipsychotics and choline esterase inhibitors in delirium: a review. Pharmacopsychiatry. 2011 Mar; 44(2): 43-54
Grover S, Kumar V, Chakrabarti S. Comparative efficacy study of haloperidol, olanzapine and risperidone in delirium. J Psychosom Res. 2011. Oct;71(4): 277-81
Delirium: diagnosis, prevention and management. NICE clinical guideline 103.