Delirium in Palliative Care Dr Holly McGuigan Specialty Doctor in Palliative Medicine Strathcarron Hospice Introductions

What we’re doing at the moment…/ Why I’m talking to you about this…

Situation Anne, 73 year old lady, lung cancer Admitted for symptom control of pain “Previously delusional with opioids- not keen for same” “GP reports became more delusional with recent increase in Pregabalin- requesting symptom control admission” Presents to hospice for symptom control of pain. Limited scope to titrate drugs in community as any change to analgesia seems to precipitate a delirium Delirum at home following titration of prebabalin from 200mg bd to 250mg bd prior to admission so back down to 200mg Attributed to opioid toxicity ?As oxy was added Hisotry from community- even small doses oxycodone worsen delirium Won’t tolerate increase in pregabalin due to delirium

Background Metastatic lung cancer- recent radiological diagnosis Cognitive impairment- subtle, several weeks Severe depression- 7 years

Assessment Left shoulder and posterior chest wall pain Hypoactive delirium Right upper limb tremor Borderline pyrexia Loose stools

Medication on Admission Folic Acid 5mg od Lansoprazole 30mg od Sertraline 200mgs od Pregabalin 200mg bd Metoclopramide 10mg tid ISMN 10mgs bd Bisoprolol 2.75mg od Digoxin 125mcg od Warfarin (Target INR 2-3) Megesterol 160mgs od Co-codamol 8/500 prn Increase 8/500 co-codamol from PRN to regular Started on 0.5mg oxycodone PRN Changes on admission: Co-codamol to regular and added PRN Oxycodone 0.5mg

Investigations CT- Mild SVD MRI- Mild SVD Bloods- Unremarkable Infection screen- MSSU –ve, stool C+S -ve, nil else localising Assess for potentially reversible causes of delirium- including brain imaging, blood tests and screening for infection

Over next few days… Worsening Delirium Hyperreflexia Absence seizures S +S not consistant

Neurological symptoms Offending Drugs Serotonin Syndrome Neurological symptoms Delirium Ruled out alternatives

Serotonin Syndrome Group of symptoms Use of serotonergic drugs Over-activation of peripheral and central serotonin receptors Group of Symptoms precipitated by the use of serotonergic drugs and Overactivation of peripheral and central serotonin receptors

Any drug combination which leads to an increase in serotonin can cause serotonin toxicity Spectrum of illness ranging from barely noticeable symptoms such as tremor, through to life-threatening acute illness Not all of these features are present in all cases Mild cases may go unrecognised Tremor, akathisia and diarrhoea are early features Agitation, hypervigilance and pressured speech may occur Renal failure and disseminated intravascular coagulation may occur Mortality for severe serotonin syndrome is estimated between 2 and 12 % Triad of Autonomic hyperactivity Neuromuscular abnormality Mental status changes It is underdiagnosed due to: the diversity of presentation, evolving diagnostic criteria, a lack of awareness amongst prescribers and mistaking of the symptoms for features of an alternative diagnosis Continuing or increasing the offending drug can cause progression to severe illness

Culprit Drugs Antidepressants Some opioids-Tramadol, Fentanyl, Oxycodone Gabapentin and Pregabalin Antiemetics: Ondansetron, Metoclopramide, Levomepromazine One drug or multiple drugs in combo…

Why do we miss it? Diversity of presentation Lack of awareness Mistaking it for something else

100 Consecutive Admissions 68% 41% 14% Retrospective review of 100 consecutive patient admissions Of the 100 patients audited, 68 were taking at least one drug implicated in SS On admission 41% had changes made to their medication which increased their risk of SS At 48 hours 14% of patients displayed new symptoms suggestive of SS On at least one serotonergic drug on admission Changes on admission which increased risk of SS Developed new SS symptoms in next 48 hours

Reduction of Pregabalin Absence Seizures stopped Hyperreflexia resolved Delirium resolved Able to set goals Wanted to get dressed every day Recalled being distress and work towards spending time with family in conservatory of hospice Had a good spell over a couple of weeks

Any drug combination which leads to an increase in serotonin can cause serotonin toxicity Spectrum of illness ranging from barely noticeable symptoms such as tremor, through to life-threatening acute illness Not all of these features are present in all cases Mild cases may go unrecognised Tremor, akathisia and diarrhoea are early features Agitation, hypervigilance and pressured speech may occur Renal failure and disseminated intravascular coagulation may occur Mortality for severe serotonin syndrome is estimated between 2 and 12 % Triad of Autonomic hyperactivity Neuromuscular abnormality Mental status changes It is underdiagnosed due to: the diversity of presentation, evolving diagnostic criteria, a lack of awareness amongst prescribers and mistaking of the symptoms for features of an alternative diagnosis Continuing or increasing the offending drug can cause progression to severe illness

No-one’s getting through to her I can’t bear to see her like this She hasn’t been able to talk about the cancer Husband unable to sit with her as too upset to see frailty Unable to plan funeral/get affairs in order ‘no-one’s getting through to her’- daughter

The Experiences of caregivers of patients with delirium, and their role in its management in palliative care settings: an integrative literature review; Finucane et al (2017); Psycho-Oncology 26: 291-300

holly.mcguigan@nhs.net @cloudy_lemonade