Dementia
Dysphasia
Delirium
CONFUSION
Limbic encephalitis
Terminal restlessness
Deafness
DSM IV
Disturbance of consciousness
reduced ability to focus, sustain or shift attention
A change in cognition or the development of a perceptual disturbance that is not due to a pre-existing dementia Develops over a short period of time and tends to fluctuate Evidence that disturbance is caused by the direct physiological consequences of a general medical condition, substance intoxication or withdrawal.
The get out clause
Clarifying confusion
Delirium
Multi-factorial syndrome characterised by acute onset of cognitive dysfunction, fluctuating course and deficits in attention Most common neuropsychiatric complication in advanced cancer
26-44% admissions to hospice/hospital 80% advanced cancer patients experience terminal delirium in the last few days of life
Interferes with adequate clinical evaluation Impedes patient participation in decision making
And yet....
Delirium generally under-researched Limited research on delirium in palliative care setting
Ambiguous terminology Failure to use validated diagnostic tools
Moreover.....
Major reason for admission to palliative care units Failure to recognise / misdiagnosis
Associated with worse outcomes
AND......
Up to 50% cases potentially reversible
Types of delirium
Hypoactive
M
Hypoactive
Mixed
Delirium recognition
1. Recognition of cognitive deficits
MMSE, AMTS etc
Delirium
CONFUSION ASSESSMENT METHOD (CAM) SHORTENED VERSION WORKSHEET Patient: Staff: Date:
BOX 1
I. ACUTE ONSET AND FLUCTUATING COURSE a) Is there evidence of an acute change in mental status from the patients baseline? b) Did the (abnormal) behaviour fluctuate during the day, that is tend to come and go or increase and decrease in severity? No _Yes___ No Yes___
II. INATTENTION Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? No_ Yes___ ______________________________________________________________________
BOX 2
III. DISORGANIZED THINKING Was the patient s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? No Yes_ IV. ALTERED LEVEL OF CONSCIOUSNESS Overall, how would you rate the patients level of consciousness? Alert (normal) or
Vigilant (hyper alert) __Lethargic (drowsy, easily aroused) __Stupor (difficult to arouse) __Coma (unrousable) Do any checks appear? (any level of consciousness other than normal) ________________________________________________________________________ If all Yess in Box 1 are checked and at least one Yes in Box 2 is checked a diagnosis of delirium is suggested.
No _Yes__
Adapted from Inouye SK et al, Clarifying Confusion: The Confusion Assessment Method. A New Method for Detection of Delirium. Ann Intern Med. 1990; 113:941-8.
MDAS
1. 2. 3. 4. Disorientation (5 place, 5 time) Reduced level of consciousness Short term memory impairment (Recall of 3 words) Impaired digit span 3,4, then 5 forwards 3, then 4 backwards 5. Reduced ability to maintain and shift attention (during interview) 6. Disorganised thinking (during interview) 7. Perceptual disturbance 8. Delusions 9. Decreased or increased psychomotor activity 10. Sleep-wake cycle disturbance
Scored /30 (>13 predictive of delirium)
Why it matters
Agitated delirium
Stress of family
Overload of team
Sedation
After Centeno et al Palliative Care 2004
Delirium is under-recognised
Only 20-50% of cases recorded as delirium in records Failure to recognize associated with poor management (Young, Age and Ageing 2003) Use of cognitive screening tests can improve recognition (Jitapunkul 1991, Anthony Psychol Med 1982, O`Keeffe
JAGS 2005, Young, Age and Ageing 2003)
Delirium is an independent predictor of poor prognosis for short term survival (Lawlor,
Arch Int Med 2000)
Misdiagnosis of delirium
Stress
Failure to identify and treat cause
Worsening of delirium
Death
High
Vulnerability
Low
Mild
Insult
After Inouye
Age > 75 Dementia (2/3 cases) Severe illness Physical frailty Cachexia
Organ failure
Precipitants of delirium
prospective study General Medical in-patients >70yrs n=87
J Laurila EDA 2009
=245%!!!
Delirium is multi-factorial
Delirium is multi-factorial
Inflammatory theory
peripheral stimulus causing intracerebral inflammatory response involving cytokines etc
Cholinergic theory
Ach delirium Evidence that:
Severe illness / trauma Ach Hypoxia/hypoglycaemia Ach Thiamine deficiency Ach Serum Anti Cholinergic Activity in delirium Anticholinergic drugs cause delirium
Opiates
Opiods implicated in 21-76% cases (Zimmerman,
Am J Hospice Pall Med, 2011)
Often required for adequate analgesia Beware misdiagnosis of delirium for pain
Consider
Cessation Dose reduction Opiod switching Adequate hydration
(Leonard, J Psychosomatic Research 2008; Lawlor, Arch Int Med 2000)
Anticholinergic drugs
Often used in end of life symptom control:
Scopolamine / hyoscine patches Ipratropium Urinary anticholinergics H1 antagonists e.g. Hydroxyzine H2 antagonists e.g. Ranitidine Anti-emetics e.g. Promethazine Anti-diarrhoeals e.g. Loperamide
Benzodiazepines
Frequently used in palliative care Often inappropriately prescribed for agitation (Agar, Pall Med 2008)
Precipitate or worsen delirium (Breitbart, Am J Psych 1996)
Management
Identify and, if appropriate treat cause(s) Drug review Assess patients priorities
Maintaining cognitive function Patient / staff / carer safety Reducing distress
Dehydration
IV or SC fluids
Raised ICP
steroids
Hypercalcaemia
Bisphosphonates
Hyponatraemia
Fluid restriction / demeclocycline
Hypoxia
Oxygen therapy
Managing symptoms
Antipsychotics:
Limited good research evidence, but widespread expert opinion Haloperidol (best evidence and most experience)
Low dose, oral/im/iv/sc Effective in reducing hallucinations, delusions and disorganised thinking Also effective as an anti-emetic
Atypical antipsychotics
Less evidence, no more effective than haloperidol
Other drugs
Methylphenidate hydrochloride
Trialled in cancer patients with hypoactive delirium of unidentified cause (Gagnon Rev Psychiatr Neurosci 2005)
Rivastigmine does not decrease duration of delirium in RCT of ICU patients with delirium and may increase mortality (Eijk, Lancet 2010)
Terminal delirium
Symptom management should be targeted and individualised
Distressing Terminal restlessness not responding to antipsychotics, may need benzodiazepines
Non-pharmacological management
HELP interventions
Cognitive impairment Vision/hearing impairment Reality orientation Therapeutic activities Vision/hearing aids Adaptive equipment
Immobilisation
Psychoactive medication use
HELP Intervention
Cognitive decline Physical decline 8% 14% 45%
Control
26% 33% 56%
p
<0.05 <0.05 0.03
Reference
38%
Inouye NEJM 1999 Rubin JAGS 2006 Caplan Int Med J 2007 Vidan JAGS 2009
Costs
Rizzo Med care 2001 Rubin JAGS 2006 Caplan Int Med J 2007
11.4 4.7
Non-pharmacological management
Communication
Carers and family Team
Environment
Avoid restraint Familiar objects Lighting Space to wander & sit
Recognise delirium
Manage symptoms
Drug review
Non-pharmacological
Pharmacological
Infections
Haloperidol
Delirium
Everybody's problem