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

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

3. 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

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

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

6. 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

7. 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

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

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

10. 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

11. 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

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

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

14. 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

16. 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

17. 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

18. 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

19. 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:

21.
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