Presentation Transcript

1. Evaluation and Treatment of Acute Mental Status Change in Hospice and Palliative care

   Alice Emery MD Hospice of Michigan, Grand Rapids Ph: 616 322 8461
2. Mental Health: hallmarks Ability with maintain relations with people Cooperative/cordial relations with colleagues Supportive family relationships. Play role of parent or spouse Ability to engage in useful work Focus, problem solving, dependability Ability to balance/moderate leisure activities Avoid self-destructive patterns Relax and enjoy positive experiences
3. Mental Health: Supports Habits Work/useful engagement Family and supportive friends Spirituality/Mission Body constancy(physical health)
4. Mental Health Baseline level of mental health for each person at every stage of life Stress/loss can disrupt the baseline/upset the personality causing adjustment phase People with good mental health at baseline, usually can withstand several stresses or supports lost at once. Adjustment disorder
5. Mental health for patients Calm and Cooperative is the minimum required Neutral emotion and compliant with staff Palliative care/hospice referral can result from inability to maintain calmness or cooperativeness Chronic: often with setting of dementia Acute change in mental status due to environmental disturbance or discomfort (disordered reaction to sensory input) or Real disturbance in neuronal functioning
6. Delirium Acutely (hrs to days) Decreased awareness of surroundings and personal state/impaired attention/decreased rational thinking CONFUSION Related to medical illness Compare to dementia Often Increased purposeless activity level/ Increased anxiety level
7. Delirium per DSM-IV Disturbance of consciousness (e.g. reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established or evolving dementia. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiologic consequences of a general medical condition.
8. Anxiety Anxiety is a general sensation of fear, which is not related to or out of proportion to a real and actual danger. Some anxiety may be 'normal' in the hospice environment, but requires treatment when anxiety appears to be disproportionately high, and when it is associated with other severe signs, such as loss of self-control, or leads to disturbance in family relations
9. Terminal illness: Plenty to be anxious about The future vs. right now in healthy persons Right now I feel pretty good In the future I hope to have more money, time etc. Right now with Multiple Myeloma (Case) My legs both feel uncomfortable My hip hurts My cancer is damaging my kidneys The future with terminal disease My hip will shatter My legs might have to be amputated My kidneys will fail
10. Agitation Agitation is a psychomotor disturbance (excitation) characterized by a marked increase in purposeless motor and psychological activity in a patient. It occurs very frequently in the hospice setting. It may be isolated, or accompanied by other mental disorders, such as severe anxiety and delirium INCREASED ACTIVITY Something is driving it
11. Agitation often accompanied by a loss of control of action and a disorganization of thought. Causes of which are frequently occurring situations in the setting of terminal illness related to the disease itself (metabolic disorders, medications, sepsis-associated encephalopathy, pain, and so on) or to external factors (noise, dislocation) Agitation per se may be dangerous in hospital or at home: Falls, injuries, dehydration, exhaustion
12. Agitation: phone call Pt. agitated: 87 yo has been on hospice 14 days with Debility related to prior hip fx and pneumonia. Baseline had been able to speak, answer simple questions. Yesterday was up and down a lot, last night did not sleep at all, family exhausted and request med to make her sleep. (Ativan OK?) Ask about: Associated symptoms. Review meds, MED CHANGES, PAIN, BOWELS, URINATION, HYPOXEMIA,
13. Fixable causes of agitation or delirium Fecal Impaction Urinary retention Common in hospice patients who already have impaired brain function Easily overlooked cause of discomfort Fixable
14. Fixable causes of delirium or agitation: Pain: trial of pain med for elderly Hypoxemia: oxygen sat/start oxygen Infection: UTI
15. Fixable causes: Medication Effect Prescribed or illicit drug overdose or withdrawal (insulin, digoxin, decadron) Alcohol: intoxication or withdrawal Benzodiazepines: adverse reaction or withdrawal
16. Paradoxical effect: Benzidiazepine 5% of people Opposite effect of desired calming, relaxing effect Can cause physical restlessness, neuroexcitation Seizures can be potentiated Disinhibition and loss of control. Aggression: violent behavior Can be mistaken for mania or schizophrenia STOP offending agent No more benzodiazepines. Use haldol etc
17. Fixable causes: Medication Effect Serotonin syndrome (nvd, fever, sweating, chills, tremor) Neuroleptic malignant syndrome (muscle rigidity, sweating, fever, unstable vitals) Antipsychotic reaction: akathisia
18. Agitation due to Toxic Metabolic Encephalopathy: AGITATED delirium What other metabolic causes Na+, Ca+, NH4+, unknown factors presumed to be uncorrectable, high or low glucose Circulatory disturbance Organ failure How to prevent it? Monitoring of electrolytes, good nursing care. Often cannot be prevented, and underlying cause cannot be treated in hospice setting
19. Agitated Delirium How to evaluate severity? Mild: Disordered thinking with paranoia or hallucinations leading to medication refusal or care refusal Moderate: Distressed affect with psycho-motor agitation causing safety risk Severe: distressed affect, motor agitation, and aggression/attempts to harm self or others
20. Toxic-Metabolic Encephalopathy Management Environmental: TV, roommates, level of stimulation Special precautions for Veterans Safety: restraints or physical limits as needed in keeping with degree of safety risk Medications
21. Antipsychotics Typical developed in 1950s beginning with Thorazine A breakthrough for care of schizophrenia with many serious side effects Thorazine is very sedating Haldol is favorite of Hospice and Palliative care Atypical Antipsychotics: several types Less extrapyramidal motor effects Can be sedating (Seroquel due to antihistamine effect)
22. Agitation due to Toxic Metabolic Encephalopathy: AGITATED delirium Mild: start daily po antipsychotic +/- benzo Moderate: po loading dose, then daily antipsychotic +/- benzodiazepine Severe: IM loading doses of Antipsychotic and Benzo Followed by scheduled po doses of both. For violent resistant patients: Haldol 5mg IM/po now and 2mg Lorazepam IM/po For moderate patients Haldol 1mg tid and titrate For mild patients Seroquel or ripserdal low doses
23. Benzodiazepines All benzodiazepines exert, in slightly varying degrees, 5 major actions: hypnotic, anxiolytic, anticonvulsant, muscular relaxant and amnesic. Their main advantages are rapid onset of action and low toxicity. Few, if any, other drugs can compete with them in all these respects. Use half adult doses in elderly. Ativan po, sl, IV most often used Klonopin po long half life, marketed for seizures Valium po, IM rapid onset, long half life Xanax po (not preferred) Versed IV 1-7mg/hr
24. Benzodiazepines Versed: midazolam: popular in Palliative care Rapid onset: watch for resp depression Best overall for continuous IV infusion. Safe and effective IV with rapid titratability Can also be used as nasal insufflation Buccal Versed also available mostly for status epilepticus
25. Other drugs for acute delirium Phenobarb IM 60mg May only last 4 hrs. need a follow up plan.
26. Acute mental status change Don’t forget the caregivers May be overwhelmed Lack of sleep Lack of understanding May need to call in the supporting cast
27. Acute Behavior problems in dementia Off label use of antipsychotics to manage behavior problems in dementia patients has become commonplace despite warnings of side effects, increased mortality, and general belief that other means of improving quality of life would be effective In good nursing facilities less than 20% of dementia pts. require scheduled antipsychotics. Work on quality of life measures, and periodic dose reductions are a good thing.
28. Depression Depressed mood is a part of normal loss Related to loss, A series of losses Major depression can be induced/exacerbated by grief Can occur for the first time in the setting of terminal illness or be longstanding DECREASED ACTIVITY
29. Depression Hospice interventions: support return to mental health for patients with mild depression Medications are indicated if believed to be a primary depression rather than normal fluctuation of mood related to illness Difficult to determine if depression is part of illness or a separate mental illness, since symptoms of depression are characterized by depressed mood, anhedonia, and low energy
30. Depression Medications: neuromodulation SSRI selective serotonin reuptake inhibitors SSRIs are believed to increase the extracellular level of serotonin by inhibiting its reuptake into the presynaptic cell, increasing the level of serotonin in the synaptic cleft to bind to the post synaptic receptor. They have varying degrees of selectivity for the other monoamine transporters, with “pure” SSRIs having only weak affinity for the noradrenaline and dopamine transporters.
31. SSRIs Most common therapeutic medication for depression Also used for anxiety, social phobia, OCD, many other dysphoric neurotic disorders. Effect in mild or moderate depression is similar to placebo, but in severe depression positive effect begins in 2-3 weeks with full effect in 4-6wks. Side effects: Appetite or sleep disturbance, Possible suicide potentiation, seizures, arrhythmias
32. “Pure” SSRIs Citalopram: Celexa Escitalopram: Lexapro Fluoxetine: Prozac Fluvoxamine: Luvox Paroxetine: Paxil Sertraline: Zoloft Vilazodone: Viibryd
33. Other Antidepressants SNRIs: newer class with similar effects Duloxetine: Cymbalta Desvenlafaxine: Pristiq Venlafaxine: Effexor Noradrenergic and Specific Serotonin antidepressants: (NaSSAs) another developing class which block Alpha 2 receptors and certain serotonin receptors . Sedating, wt. gain. Mirtazapine: Remeron
34. Other antidepressants NA (norepinephrine) reuptake blockers: (NRIs)marketed as enhancing concentration and motivation Atomoxatine: Strattera Na and Da reuptake inhibitors: Bupropion: Wellbutrin
35. Augmenters Drugs used with another antidepressant Trazodone: for sleep Buspar: nonsedating anxiolytic Psychostimulants: Methylphenidate (Ritalin), amphetamine (Adderall), modafinil (Provigil) Antipsychotics may be added as well such as risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa): controversial due to side effects Benzodiazepines: for anxiety
36. Depression Complete response in 25% of patients Adding augmenters can increase to 30% Change the antidepressant Still leaving 70% with poor or incomplete partial response to medication for depression Generally each antidepressant takes 4-6 weeks to evaluate full response Positive effects can fade over time
37. Ketamine for Depression Novel use of ketamine: NIH 8/2006 Published use of weekly Ketamine dosing for resistant depression Published use in ED as IV bolus for treatment of acute suicidality in depression Journal Palliative Medicine July 2010 case series in terminal hospice patients showed a single oral dose of approx. 30mg gave a measurable elevation of mood lasting over one week. Mechanism? (not opioid receptor or just NMDA effect) Side effects? (acute hallucinations/disassociative state)
38. Case 1 64 yo woman with COPD and depressive symptoms developing over several months. Low mood, low energy, hypersomnia, decreased appetite with unintentional weight loss, hopelessness, and excessive feelings of guilt, especially regarding feeling like a burden on her roommate, who was also her close friend and primary caregiver. She was preoccupied with thoughts of wanting to die. She did not plan or intend to end her life, stating “I'm too chicken to die.”
39. Case 1 She had stopped socializing and reading and was letting bills pile up Anxious with daily panic attacks Irritable with roommate and the dog Fidgety Focused on pain and dyspnea No cognitive impairment
40. Case 1 Informed consent and psychiatric baseline testing done with Hamilton depression scale Hospital Anxiety and Depression Scale Brief Psychiatric Rating Scale Young Mania rating scale Mini mental status exam Treated with 0.5mg/kg oral ketamine Depression and anxiety decreased within hours.
41. Case 1 no longer had suicidal thoughts: expressed hope for the future no longer felt irritable became much more engaging, desiring to talk about television shows and soap operas. Her appetite had improved dramatically anxiety and irritability she displayed prior to ketamine dosing were absent She paid and filed away her entire pile of bills. Her caregiver reported that S.B. was much more alert and no longer “nodded off” throughout the day. Her pain and shortness of breath improved. trouble sitting still, “I want to get out and do things now.” She had become less preoccupied with feeling like a burden begun to read books again, she started to call her friends and initiated planning social gatherings
42. Case 1 Symptoms returned (but not as severely) after a month and by that time she had developed some confusion and was on more pain medications Repeat dosing did not bring improvement Case illustrates one personal result of ketamine therapy for depression
43. Case 2 70 yo man with prostate ca metastatic to liver, bone, and lung and had been bedbound for 8 months. Prognosis days to weeks Depression developing over 3 months depressed mood, significantly decreased energy, lack of appetite with unintentional weight loss, poor sleep with early morning awakening, and ruminative thoughts of wanting to be dead. He denied a suicidal plan or intent, explaining “even if I wanted to, I could not do anything in this state.” He described significant anhedonia, which contrasted with his prior zest for life
44. Case 2 he no longer wanted friends to visit, stopped watching movies and reading, and had to force himself to eat. Furthermore, he experienced excessive guilt about feeling like “a burden” to his wife, who was his primary caregiver Excessive worry and daily panic attacks No cognitive impairments Treated with 0.5mg/kg oral ketamine Noted improvements within hours
45. Case 2 Within 60 minutes of dosing, he reported an improvement in his anxiety and pain, and his wife observed that he looked “more calm and peaceful.” By day 3, he started to request his favorite foods, and his humor was noted to improve. On day 4, his wife observed “a big difference” explaining he “was more chipper.” He watched an entire movie “without dozing” for the first time in months. His mood continued to dramatically improve over the following week. He began to watch, enjoy, and discuss several movies a day with his wife. His appetite increased and he continued to request his favorite foods. he began to have friends visit again and savored their time together. Around day 13, his physical health worsened to the point that he could no longer participate with assessments. His wife articulated that his focus on death qualitatively shifted from wanting to die to “accepting death.” He peacefully died at home within the following 2 weeks.
46. Could end of life depression be more treatable than we think?