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  1. AMSA PresentationsDepression, Anxiety & DeliriumGU SymptomsAnorexia & FatigueThe Last Days of Life Jeffrey M. Behrens, MD, FACP, CMD Medical Director, VITAS Innovative Hospice of Palm Beach County

  2. Depression, Anxiety & Delirium

  3. Depression

  4. Objectives • Understand how to diagnose depression • Review risk factors for depression • Review risk factors for suicide • Understand management of depression

  5. Definition of depression • Dysphoric mood or loss of interest or pleasure in all or almost all usual activities &m past-times. • Word to describe include: • Depressed • Sad • Blue • Hopeless • Low • Down in the dumps • Irritable

  6. Diagnosis of depression • At least four of the following symptoms have been present nearly every day for a period of at least 2 weeks: • Poor or incresed appetite • Weight gain or loss • Insomnia or hypersomnia • Psychomotor agitation or retardation • Loss of interest or pleasure in usual activities or decreased sexual drive • Loss of energy or fatigue • Feelings of worthlessness, or excessive or inappropriate guilt • Diminished ability to think or concentrate • Recurrent thoughts of death or suicide or actual attempts

  7. Risk Factors • Pain • Progressive physical impairment • Advanced disease

  8. Risk Factors • Advanced age >70 (1 in 6 of people over age 65) • Admission to a nursing home • Psychosocial (isolation, loss of dignity, financial burden, fear of abandonment) • Spiritual pain • Preexisting risk factors (prior psychiatric disease, substance abuse)

  9. Risk Factors • Medications • Benzodiazepines (lorazepam, etc.) • Chemotherapy • Steroids • Beta blockers • Calcium channel blockers • Analgesics

  10. Suicide • Incidence in the elderly is double that in other populations • Discussion of thoughts of suicide may reduce the risk • High risk if recurrent thoughts/plans

  11. Suicide Risk Factors • Depression • Substance abuse • Psychiatric admission within the year • Psychotic disorders • Widowed or divorced • Poor social network • Family discord

  12. Management of Depression • Identify risk factors • Early intervention (improves symptoms, restores function) • Psychotherapeutic interventions (cognitive and behavioral) • Medications

  13. Psychotherapeutic Interventions • Improve patient understanding • Explore religious and spiritual concerns • Create a different perspective • Identify strengths • Re-establish self-worth • Develop new coping strategies • Educate about modifiable factors • Possible use of electroconvulsant therapy. • Review level of care

  14. Pharmacologic Management • Psychostimulants • SSRI’s • Tricyclics • Atypical antidepressants

  15. Psychostimulants • Rapid effect (2-3 days) • Diminishes opioid sedation • Not usually an appetite suppressant • May exacerbate • Tremulousness • Anxiety • Anorexia • Insomnia

  16. Psychostimulates • Methylphenidate (Ritalin) • Modafinil (Provigil) • Dextroamphetamine • Pemoline (Cylert) (no longer available)

  17. SSRI’s (Serotonin Specific Reuptake Inhibitors) • Latency of 2-4 weeks • Highly effective (70%) • Well tolerated • Once daily dosing • Low doses may be effective in advanced illness

  18. SSRI’s • Citalopram (Celexa) • Escitalopram (Lexapro) • Fluoxetine (Prozac) • Paroxetine (Paxil) • Sertraline (Zoloft)

  19. SSRI’s • Side effects (dose related) • Increased intestinal motility-loose stools, nausea & vomiting • Asthenia • Sleep disturbance • Headaches • Sexual dysfunction • Hyponatremia

  20. Tricyclic Antidepressants • Amitriptyline (Elavil) • Desipramine (Norpramin) • Doxepin (Sinequan) • Imipramine (Tofranil) • Nortriptyline (Pamelor)

  21. Tricyclic Antidepressants • Not recommended as first-line therapy • Latency 3-6 weeks • Adverse effects are common (contraindicated in cardiovascular disease) • May be appropriate with • Chronic/neuropathic pain • Weight loss/insomnia • Urinary urgency

  22. Tricyclic Antidepressants • Side effects • Constipation • Dry mouth • Orthostatic hypotension (increased risk of falls)

  23. Atypical Antidepressants • Mirtazapine (Remeron) • Venlafaxine (Effexor) • Duloxetine (Cymbalta) • Bupropion (Wellbutrin) • Trazodone

  24. Mirtazapine (Remeron) • Attractive choice in the elderly • Increased appetite and weight gain • Increased somnolence at lower doses • Lack of cardiotoxicity • Low risk for drug to drug interactions

  25. Mirtazapine (Remeron) • Adverse effects • Dry mouth • Constipation • Dizziness • Abnormal dreams • headache

  26. Norepinephrine and Dopamine Reuptake Blockers • Bupropion (Wellbutrin) • Advantages in elderly patients due to lack of sedative effects, cardiotoxicity, and sexual dysfunction • Side effects • Agitation, headache, dizziness, tremor, insomnia, anorexia, nausea • Seizures have been reported with doses greater than 400 mg/day

  27. Serotonin 2 Antagonists/Serotonin Reuptake Inhibitors • Trazodone • Very sedating at low doses (<100mg) • Increased orthostatic hypotension • Adjunct to analgesics

  28. Summary • Depression is……. • Challenging…difficult to treat • Overwhelming to patients, families, and caregivers • A reason for placement in LTCF • Easily misdiagnosed • An opportunity to improve the quality of life for the patient and/or caregiver

  29. Anxiety

  30. Objectives • Understand how to diagnose anxiety • Review risk factors for anxiety • Understand management of anxiety

  31. Diagnosis of Anxiety • Psychological reactions • Insomnia • Irritability • Inability to concentrate • Poor coping skills • Symptoms and physical features • Anorexia • Nausea • Hyperventilation • Palpitations • Sweating.

  32. Risk Factors • Changes in life situations • Direct or indirect effects of terminal illness • Exacerbation of preexisting conditions.

  33. Pharmacologic Treatment of Anxiety • Benzodiazepines • Lorazepam (Ativan) • Temazepam (Restoril) • Oxazepam (Serax) • Diazepam (Valium) • Barbiturates • Pentobarbital • Thioridazine (Mellaril) • Haloperidol (Haldol).

  34. Delirium & Terminal agitation

  35. Objectives • Define Delirium and Terminal Agitation • Describe the Causes for Delirium and Terminal Agitation • Identify the key factors for assessment of Delirium and Terminal Agitation • Explain the goals and interventions for treatment of Delirium and Terminal Agitation • Discuss patient and family education regarding Delirium and Terminal Agitation

  36. Delirium & Terminal Agitation • Must be differentiated from anxiety and dementia • Impacts cognitive skills • Acute process • Waxes and wanes, usually worse at night • Must assess over 24 hour related to erratic symptoms seen over day • Occasional incoherent word usage, but not verbal loss • Hallucinations • Hyperawareness, and possible emotional liability • May show apathy, fear, or rage • Treatment must include psychosocial support and calm environment

  37. Common Causes of Delirium & Terminal Agitation • Drugs, especially psychotropics • Electrolyte or glucose abnormality • Liver failure • I schemia or hypoxia • Renal failure • I mpaction of stool • Urinary tract or other infection • Mestastases to the brain

  38. Step 1: Assessment • Maintain a high index of suspicion for delirium. It may be life threatening; proper assessment is essential. • Use a screening tool to assess cognition even in patients who do not appear confused. Do not rely solely on orientation questions.

  39. Step 1: Assessment (cont.) • Ask specifically about hallucinations (usually visual and tactile) and paranoid ideation. • Examine and look for signs of infection, opioid toxicity (myoclonus, hyperalgesia), dehydration, uremia, hepatic encephalopathy, etc. • Order investigation when appropriate, e.g., CBC, electrolytes, ionized calcium, urea, and creatinine, urinalysis, CXR, O2 sats, etc.

  40. Step 2 : Treating the Underlying Cause if Appropriate • Opioid toxicity: Change to another opioid. • Sepsis: Start antibiotics if appropriate, considering the goals of care. • Drugs: Stop, wean, or decrease possible offending drugs, e.g., tricyclic antidepressants, benzodiazepines

  41. Step 2 : Treating the Underlying Cause if Appropriate (cont.) • Dehydration: Consider Hypodermocyclis with normal saline (if the site leaks or swelling is uncomfortable, give 150 u hyaluronidase into the SC site before infusion; usually unnecessary); reassess daily. If IV line is already established, hydration can be given IV.

  42. Step 2 (cont.) • Hypercalcemia: Treat for dehydration. Consider Calcitonin, saline + furosemide, IV Biphosphonates (Alendronate, Pamidronate) • Hypoxia: Treat underlying cause and administer O2. • Urosepsis: If possible remove indwelling urinary catheter and treat infection with appropriate antibiotics

  43. Medications Used to Manage Delirium & Terminal Agitation in Patient with Advanced Disease • Generic Name Approximate Daily Dose Route • Neuroleptics • Haloperidol 0.5-5 mg every 2-12 h po, IV, SC, IM • Thioridazine 10-75 mg every 4-8 h po • Chlorpromazine 12.5-50 mg every 4-12 h po, IV, IM • Methotrimeprazine 12.5-50 mg every 4-8 h IV, SC, po • Molindone 10-50 mg every 8-12 h po • Drioerudol 0.625-2.5 mg every 4-8 h IV, IM • Atypical Neuroleptics • Olanzapine 2.5-20 mg every 12-24 h po • Risperidone 1-3 mg every 12-24 h po • Quetiapine 25-200 mg every 12-24 h po

  44. Medications for Delirium & Terminal Agitation (cont.) • Generic Name Approximate Daily Dose Route • Benzodiazephines • Lorazepam 0.5-2.20 mg every 1-4 h po, IV, IM • Midazolam 30-100 mg every 24 h IV, SC • Anesthetics • Propofol 10-70 mg every h IV Up to 200-400 mg/h

  45. Step 3Treatment for Moderate to Severe Agitated Delirium • For Moderate Delirium • Haloperidol (Haldol) 1 to 2 mg PO or SC hourly as needed to calm a crisis; then q 6 to 12 h PO or by infusion If more sedation is needed consider: • Thioridazine (Mellaril), or 25-50 mg PO hr until calm, then q 6 to 12 h • Chlorpromazine (Thorazine) 25-50 mg PO, PR, or IV hr until calm: then q 6 to 12 h or by infusion • For Severe Agitated Delirium: Reassess for reversible causes and if necessary, consider the addition of benzodiazepines or a high dose of a sedating phenothiazine, even though they may cause more clouding of the sensorium.

  46. Step 3 (cont.) • Lorazepam (Ativan) 1-2 mg hourly, PO, SL, or IV • Midazolam (Versed) 0.4 to 4 mg/h continuous, SC{ a mean dose of 2.9 mg/h (70 mg/d) was effective in 22 of 23 patients in one series} • Chlorpromazine (Thorazine) 100 mg every hour IV, PO, PR • Some patients are held by a combination of: • Haloperidol (Haldol) 5 to 20 mg/d and midazolam (Versed) 10 to 100 mg/d via continuous subcutaneous infusion • In rare cases, when none of the above methods work during the final hours of life, consider therapeutic sedation with: • Phenobarbital 130 mg SC hourly until calm and then subcutaneous infusion (600 to 1200 mg/d) • When all else fails, consider: • Thiopental (20 to 200 mg/h) or methohexiatal sodium (Brevital Sodium) continuous IV infusion titrated to unconsciousness

  47. Step 4 Psychological Supports for the Restless Patient • Provide information in accord with individual wishes. • Permit expression of emotion. • Clarify concerns and problems. • Involve patient in decision making. • Provide continuity of care from named staff. • Provide group discussion for information and support. • Provide music therapy. • Provide art therapy. • Teach relaxation techniques. • Provide aromatherapy. • Arrange for a change of scenery.

  48. Step 5: Family and Staff Education • Confusion and agitation are often expression of brain dysfunction. Misinterpretation of symptoms as pain can result in excessive use of opioids, resulting in aggravation of the agitation. • Most patients have limited or no recollection of their symptoms after the episode subsides.

  49. Step 5 (cont.) • The treatment goal is comfort, not prolongation of life. • Delirium may be superimposed on preexisting dementia unrecognized by family or healthcare professionals. • Urinary retention and constipation in cognitively impaired patients can be misdiagnosed as agitated delirium or “crescendo” pain.

  50. Summary • Delirium &Terminal agitation is multifactorial. • Must be recognized early and differentiated from anxiety or dementia • Reversible causes, if any, should be corrected • Rapid & efficient therapy should be initiated as soon as possible