1. LOUTH & MEATH SPECIALIST PALLIATIVE CARE SERVICES RECOGNITION AND MANAGEMENT DELIRIUM DR AISLING O’GORMAN Consultant in Palliative Medicine

2. 2 DELIRIUM The entity formally known as …. –Confusion & agitation- Organic psychosis –Acute confusional state- Opioid toxicity –Cognitive impairment / failure –Acute brain syndrome- ITU encephalopathy

3. 3 DELIRIUM An aetiologically non-specific, global, cerebral dysfunction characterised by concurrent disturbance of level of consciousness, attention, thinking, perception, memory, psychomotor behaviour, emotion and the sleep-wake cycle.

4. Delirium = Brain Failure Confused ????

5. 5 DELIRIUM An aetiologically non-specific, global, cerebral dysfunction characterised by concurrent disturbance of level of consciousness, attention, thinking, perception, memory, psychomotor behaviour, emotion and the sleep-wake cycle.

6. Delirium Subtypes Hyperactive Hypoactive Mixed Hypoactive HyperactiveMixed

7. Delirium – What’s it to YOU ??? Delirious patients Stop eating Stop drinking fluids Stop taking important medications May fall and injure themselves Are often placed in restraints and suffer complications such as aspiration and decubitus

8. Morbidity: –Associated with prolonged hospitalisation –More hospital-acquired complications e.g. falls & pressure sores –Increased risk of long term cognitive decline –More likely to require admission to long term care –Loss of independent living

9. Delirium Is Deadly !!! Mortality rates: –10% - 65% - With appropriate management, may be reversible in up to 50% But

10. 10 DELIRIUM Prevalence: –10% - 35% of hospitalised patients Elderly Patients –30% of hospitalised elderly Cancer Patients –25% - 40% of cancer patients –Up to 85% of cancer patients with advanced disease

11. 11 Risk FactorAssessment for Delirium Age 65 yrs or older Cognitive impairment (past or present) Current hip fracture Severe illness

12. Mental Health Problems among elderly in hospitals 50% cognitive impairment 27% delirium 8-32% depressive illness 6% hallucinations 8% delusions 21% apathy 9% agitation/aggression Goldberg et al; Age Ageing 2011 Sep 1

13. Elderly patients with mental health problems in hospital –47%Incontinent –49% Assistance with feeding required –44%Major assistance to transfer Goldberg et al; Age Ageing 2011 Sep 1

14. Delirium – Differential Diagnosis Dementia Depression Mania Psychosis

15. 15 DELIRIUMDEMENTIA Acute.Chronic. Often remitting & Usually progressive reversible.& irreversible. Mental clouding. Brain damage. ( info not taken in)(info not retained) Poor concentration Impaired short term memory Disorientation Living in past Misinterpretations Hallucinations Delusions

16. 16 DELIRIUMDEMENTIA Speech rambling &Speech incoherent.stereotypes & limited. Often diurnal Constant variation.(in later stages). Often aware &Unaware & anxious.Unconcerned (in later stages).

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19. Pathophysiology of Delirium ↓ Acetylcholine ↑ Dopamine ↑ Noradrenaline ↑ Serotonin ↓ Histamine Gaba Cytokines- IL-1, IL-2,6; TNF; IF

20. Recognising Delirium - Indicators Recent changes or fluctuations in behaviour –Cognitive function –Perception –Physical function –Social behaviour

21. Clinical Features Acute onset Fluctuating course Inattention Disorganised thinking Altered consciousness Cognitive deficit Perceptual disturbance Psychomotor disturbance Altered sleep-wake cycle Emotional disturbance

22. 22 ESSENTIAL CRITERIA FOR DIAGNOSING DELIRIUM Disturbance of consciousness / impaired attention. Change in cognition Acute / subacute onset & fluctuating course Evidence of general medical condition judged to be aetiologically related to the disturbance. DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS IV

23. Consciousness Level of consciousness = awake/alertness Content of consciousness = awareness HypoalertHyperalert

24. Attention Inability to direct, focus and sustain attention –Distractable –Neglect –Perseveration Linked to arousal/ consciousness Serial 7’s Count down 20-1 ‘WORLD’–‘DLROW’ Digit span forward & backwards Registration of new information does not occur –> immediate & short term memory loss

25. Change in Cognition Disorganised thinking –Memory deficit –Disorientation –Language disturbance –Perceptual disturbance

26. Bedside Tests Cognitive Tests - –MMSE –SOMCT Tests to Differentiate Delirium from Dementia –DRSR-98 –MDAS Tests for Delirium –Cognitive Test for Delirium –DRS – R-98 –CAM – Confusion Assessment Method –NUDESC

27. Management of Delirium SOLVE THE PROBLEM !!!! Treat the underlying causes Environmental interventions Antipsychotics –Haloperidol, risperidone, quetiapine, olanzapine,

28. 28 CAUSES OF DELIRIUM Drug Toxicity Infection Surgery Metabolic encephalopathy Electrolyte Direct CNS Causes Hypoxia Environmental Paraneoplastic Haematological Elimination disorder

29. Delirium - Causes –Medications Chemotherapy Steroids Radiotherapy Opioids Benzodiazepines Anticholinergics Antiemetics Withdrawal

30. 30 MANAGEMENT OF DELIRIUM Assess patient: –Determine cause –? Potentially reversible factors –Check list –History (NB collateral) –Examination –Review medication –Blood tests

31. 31 MANAGEMENT OF DELIRIUM Environmental Interventions: –Supportive measures –Keep to a routine –Quiet & well lit room –Orientate patient frequently –Separate past & present –Explanations to patient –Identify & respond to mood –Avoid unnecessary confrontation –Avoid restraints –Courtesy & respect –Presence of family member/close friend

32. 32 MANAGEMENT OF DELIRIUM Communicate with family: –Clear explanation of goals of management & possible outcomes.

33. 33 MEDICAL MANAGEMENT OF DELIRIUM There are 3 distinct clinical entities: –Hyperactive: Agitated –Mixed: Hypoactive – Hyperactive –Hypoactive – Hypoalert, withdrawn, confused

34. 34 MEDICAL MANAGEMENT OF DELIRIUM Haloperidol: –Highly potent dopamine blocking agent –Half life: 20 hours –Minimal anticholinergic V/E –Less sedating than phenothiazines –Administration: Po, iv, im, sc –Dose: 1-2 mg po/sc q 6 hrly Elderly 0.5 – 1mg bd 1 mg q 1 hrly prn Titrate as needed Higher doses may be required initially, if severely agitated Rarely exceed 20mg / 24 hours

35. 35 MEDICAL MANAGEMENT OF DELIRIUM Olanzapine Fewer Extrapyramidal V/E Dose 2.5mg stat, prn Available in Velotab preparation V/E – Drowsiness & Weight Gain, ACH Risperidone Dose 500mcg bd & prn Increase by 500mcg bd on alt days Median maintenance dose – 1mg/day Quetiapine Dose 12.5 – 25mg bd NEW ATYPICAL ANTIPSYCHOTICS

36. 36 MEDICAL MANAGEMENT OF DELIRIUM Methotrimeprazine: –Widely used in terminal stages –V/E: sedating postural hypotension –Dose: 6.25mg – 12.5 mg sc/po q 8-12h Higher doses in terminal stages: –12.5 mg – 25 mg sc/po q 4 – 8 hrly –Up to 300 mg / 24 hours via syringe driver reported

37. 37 MEDICAL MANAGEMENT OF DELIRIUM Chlorpromazine: –Useful oral alternative when some sedation is desirable –Dose: 25mg po q 8 hrly Midazolam: –Rapid onset & short half life –Administration: iv, im, sc –Dose:2.5 mg – 10 mg stat followed by 20mg – 100 mg / 24 hours Phenobarbitone: –Pre terminal agitation –Used with midazolam –Dose:200 mg – 800 mg / 24 hours

38. 38 Delirium and Suffering in the Dying Patient Suffering caused by delirium is hard to assess, even retrospectively. Interferes with meaningful contact Distressing to families Visions and visitation on the deathbed: -Pathologic? -Supernatural?

39. 39 Delirium at End of Life Treatment Overview Primary Goals: - Maximizing Patient Comfort -Minimizing Patient (Family) Distress Tx Underlying Cause ( When Possible & Appropriate ) Usually involves Medication: -Benzodiazepines -Neuroleptics May Require Heavy Sedation

40. 40 TERMINAL DELIRIUM Delirium occuring in last days of life Cause – multifactorial, unknown Investigations – limited Focus – Patient comfort NB General measures Haloperidol 10 – 30mg/24hrs Methotrimeprazine 50 – 200mg/24hrs Phenobarbitone 800 – 1600mg/24hrs +/- Midazolam 10 – 100mg/24 hrs

41. 41 CONCLUSION Prevention / Minimise Risk Early Diagnosis Early Treatment Careful Systematic Approach Correct Reversible Causes NB General Measures

42. References Inuoye S. Delirium in Older Persons. NEJM. 2006; 354:1157-65 Centeno C, Sanz A,Bruera E. Delirium in advanced cancer patients. Palliat Med. 2004; 18: 184-94 Lawlor P et al. Occurrence, Causes and outcome of delirium in patients with advanced cancer. Arch Intern Med; 160: 786-94 Caraceni A, Simonetti F. Palliating delirium in patients with cancer. The Lancet. 2009: 10; 164-72 Lonergan E et al. Antipsychotics for delirium. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD005594

43. References Grover S, Matoo SK, Gupta N. Usefulness of atypical antipsychotics and choline esterase inhibitors in delirium: a review. Pharmacopsychiatry. 2011 Mar; 44(2): 43-54 Grover S, Kumar V, Chakrabarti S. Comparative efficacy study of haloperidol, olanzapine and risperidone in delirium. J Psychosom Res. 2011. Oct;71(4): 277-81 Delirium: diagnosis, prevention and management. NICE clinical guideline 103.