Palliative Potpourri . Edward (Ted) St. Godard MA MD CCFP Consulting Physician WRHA Palliative Care email@example.com. Robert Pope. “Visitors”. I am funded as an independent contractor by the WRHA. Disclosure . I. Delirium at end-of-life Name it, claim it, tame it.
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Palliative Potpourri Edward (Ted) St. Godard MA MD CCFP Consulting Physician WRHA Palliative Care firstname.lastname@example.org Robert Pope. “Visitors”
At the end of session, participants will Be able to identify the medical condition known as delirium; Appreciate the importance of this recognition; Have an approach to delirium management objectives
Delirium and nurses Agar et al. Palliative Medicine. September, 2011. Nurses are in an optimal position to detect fluctuating symptoms of delirium
Delirium and nurses Agar et al. Palliative Medicine. September, 2011. Silent, unspoken piece of nursing practice, impacting on workload Nurses deal with the unpredictable and fluctuating condition of delirious patients, which may be a signal of impending ‘chaos’
Delirium and nurses Agar et al. Palliative Medicine. September, 2011. Under-detection of delirium relates to a lack of knowledge of the criteria for identifying delirium… failure to relay or communicate detected symptoms at onset…
What is delirium ? • Global cerebral dysfunction • “Brain Failure” • Early signs often mistaken as anger, anxiety, depression, psychosis
Dsm-iv criteria A) Change in consciousness with reduced ability to focus, sustain or shift attention B) Change in cognition (e.g., memory, disorientation, change in language, perceptual disturbance) that is not dementia
Dsm-iv criteria C) Abrupt onset (hours to days) with fluctuation D) Evidence of medical condition judged to be etiologically related to disturbance
Dsm-iv criteria …a disturbance in consciousness with inattention and problems in cognition and/or a disturbance in perception that develop over hours to days with organic causes.
Delirium vs dementia • Dementia • Impaired memory • Impaired judgement • Impaired thinking • Disorientation • Delirium • Impaired memory • Impaired judgement • Impaired thinking • Disorientation
Delirium vs dementia • Dementia • Insidious, progressive • Alert, LOC intact • Minimal • Delirium • Abrupt onset • Decreased LOC • Sleep/wake cycle
Delirium vs dementia • Dementia • Irreversible • Delirium • Reversible? • PREVENTABLE?
Delirium is reversible • In up to 50 % of patients with advanced cancer, delirium can be reversed Kang JH et al. “Comprehensive approaches to managing delirium in patients with advanced cancer.” Cancer Treat Rev (2012)
Reversed vs non-reversed • Lawlor P, Gagnon B, Mancini I, Pereira J, et al. Arch Intern Med 2000
Delirium sub-types • Hypoactive confusion, somnolence, alertness • Hyperactive agitation, hallucinations, aggression • Mixed (>60%) features of both
Delirium sub-types • Lawlor P, Gagnon B, Mancini I, Pereira J, et al. Arch Intern Med 2000
Prevalence/incidence Partridge et al. “The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this?” Int J Ger Psych. October 2012 (online) 80 % in medical intensive care units (ICU) 28 % in patients following hip fracture 22 % in general medical inpatients
Incidence/prevalence • Most frequent neuropsychiatric complication in patients with advanced CA • Up to 85 % of patients delirious prior to death Bruera et al. JPSM 2010; 39;2: 186-196
Incidence/prevalence • ~ 42% patients in PC program delirious on admission • 50% of episodes reversible • “Terminal delirium” in 88 % Lawlor et al. Arch Intern Med 2000; 160:786
Impact • Palliative sedation requests • Delirium/terminal restlessness (55%) • Dyspnea (27%) • Pain (18%) • Nausea/vomiting (4%) Eisenchlas. Current Opinion in Supportive and Palliative Care 2007, 1:207–212
Impact • Palliative sedation requests • Delirium number one reason for requests Fainsinger RL et al. “A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients.” Palliat Med 2000;14:257–65.
Impact • “We’d rather see dad dead than like this.” • “S/he would be horrified by this.”
impact • 73/99 patients (74%) remembered delirious episode • Of these, 81 % recalled experience as distressing • Family stress > patients’ recalled stress Bruera et al. JPSM 2010; 39;2: 186-196
impact • Interferes with Sx assessment and Tx • Increases morbidity and mortality • Hinders communication within families Bruera et al. JPSM 2010; 39;2: 186-196
Sx difficulty and distress D/D Pain Dyspnea Delirium
Sx difficulty and distress Ax/TxChallenges Worsening Delirium
pathophysiology • Delirium mediated by failure in central cholinergic transmission? • Acetylcholine final common neurotransmitter pathway leading to delirium? White et. al. “First Do no Harm…” JPM. 10 (2); 2007: 345-351
pathophysiology • Relative acetylcholine deficiency and dopamine excess could mediate the characteristic symptoms of delirium • Delirium can be evoked by dopamine agonists and anticholinergic medications Moyer. American Journal of Hospice and Palliative Medicine 28(1), 2011. 44- 51 Kang JH et al. Comprehensive approaches to managing delirium in patients with advanced cancer. Cancer Treat Rev (2012)
pathophysiology • Dopamine/acetylcholine inverse relationship • Haloperidol first line treatment for delirium • Haloperidol D2 antagonist: • ? Haloperidol increase levels acetylcholine? White et. al. “First Do no Harm…” JPM. 10 (2); 2007: 345-351 Kang JH et al. Comprehensive approaches to managing delirium in patients with advanced cancer. Cancer Treat Rev (2012)
pathophysiology • Sometimes successfully treated with dopamine receptor antagonists and possibly by cholinesterase inhibitors • High serum anticholinergic activity in patients with delirium Moyer. American Journal of Hospice and Palliative Medicine 28(1), 2011. 44- 51
pathophysiology • Υ-aminobutyric acid (GABA)-ergic benzodiazepines seem to cause delirium • Neuroinflammatory processes drives up-regulation of GABA receptors • GABA receptor versus microglial activation versus apoptosis C.G. Hughes et al. “Future Directions in Delirium Management and Research.” Best Practice & Research Clinical Anaesthesiology. 26 (2012) 395–405
causes • Precipitating • Predisposing
causes • Predisposing factors: • Prevalence increases with age • Male > female • Visual impairment • Depression White et. al. “First Do no Harm…” JPM. 10 (2); 2007: 345-351
causes • Predisposing factors: • Functional dependence • Immobility • Hip fracture • Dehydration • Alcoholism • Stroke • Severity of physical illness White et. al. “First Do no Harm…” JPM. 10 (2); 2007: 345-351
Who’s predisposed? All of our patients!
Fragile? Frail? HANDLE WITH CARE
Fragile patients • Inverse relationship between the preexisting vulnerability of the patient, and the severity of the insult necessary to precipitate delirium
Fragile patients • Most patients nearing EOL have multiple predisposing factors • Most of these are beyond our control
causes • Precipitating • Predisposing
Decrease predisposition? • Impractical, given our patient population (frail, usually old) • Imperative to minimize precipitating factors
precipitators • ‘lyte derangements (dehyd’n, hypo/hypernatremia) • Infx (UTI, resp., skin/soft tissue [sacral ulcers]) • Metabolic (hyper/hypoglycemia, hypercalcemia, uremia) • Low perfusion, hypoxia • Withdrawal
drugs • Anti-cholinergics (Gravol, TCAs, anti-secretories); • BZDs • Opioids • Steroids • Cipro, lasix (?) ranitidine, and on and on….
drugs • Drug withdrawal: • EtOH, Bzd, opioid, “street drugs”
Prevention? • Prophylactic haldol • Prophylactic olanzepine • Prohylactic cholinesterase inhib.s Gagnon et al. Psycho‐Oncology 21: 187–194 (2012)
Prevention? • Maintain sensorium: hearing aids, eye glasses • Orientation (clocks, calendars, conversation) Gagnon et al. Psycho‐Oncology 21: 187–194 (2012)