1. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. Education in Palliative and End-of-life Care - Oncology The Project EPEC-O TM

2. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 3g Symptoms – Delirium Module 3g Symptoms – Delirium EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

3. Delirium l A disturbance of consciousness l A change in cognition l Acute onset, fluctuating course l A disturbance of consciousness l A change in cognition l Acute onset, fluctuating course APA Practice guideline. Am J Psychiatry, 1999.

4. Associated changes l Day-night reversal l Emotional states l Non-specific neurological abnormalities l Decline in functional ability l Day-night reversal l Emotional states l Non-specific neurological abnormalities l Decline in functional ability

5. Types l Hyperactive Associated behavioral disturbances Hallucinations Delusional beliefs l Hypoactive Quiet Mistaken for depression or fatigue l Mixed – waxing and waning l Hyperactive Associated behavioral disturbances Hallucinations Delusional beliefs l Hypoactive Quiet Mistaken for depression or fatigue l Mixed – waxing and waning

6. Prevalence l 80 – 85 % of terminally ill patients

7. Prognosis l Increased risk of Complications Protracted hospitalizations Protracted postoperative recovery l 25 % delirious patients die < 6 months l In elderly, risk of dying during a hospital admission is 22 – 76 % l Increased risk of Complications Protracted hospitalizations Protracted postoperative recovery l 25 % delirious patients die < 6 months l In elderly, risk of dying during a hospital admission is 22 – 76 %

8. Key points 1.Pathophysiology 2.Assessment 3.Management 1.Pathophysiology 2.Assessment 3.Management

9. Causes of delirium... l Infection l Withdrawal l Acute metabolic l Trauma l CNS pathology l Hypoxia l Infection l Withdrawal l Acute metabolic l Trauma l CNS pathology l Hypoxia l Deficiencies l Endocrinopathies l Acute vascular l Toxins or drugs l Heavy metals

10. ... Causes of delirium l Don’t forget Constipation, fecal impaction Urinary retention l Don’t forget Constipation, fecal impaction Urinary retention

11. Neurophysiology l Multiple cortical, subcortical levels affected l Several neurotransmitters involved l Changes in regional cerebral perfusion l Multiple cortical, subcortical levels affected l Several neurotransmitters involved l Changes in regional cerebral perfusion

12. Assessment l Clinical history, physical examination, serial observations l Folstein Mini-Mental State exam l Review of medication regimen l Thorough medical and laboratory work-up to elucidate underlying cause l Clinical history, physical examination, serial observations l Folstein Mini-Mental State exam l Review of medication regimen l Thorough medical and laboratory work-up to elucidate underlying cause

13. Delirium vs. dementia DeliriumDementia Change in alertness YesNo Onset Hours to days Gradual FluctuationYesNo

14. Management l Treat underlying causes l Non-pharmacological l Pharmacological l Consult psychiatrist for assistance l Treat underlying causes l Non-pharmacological l Pharmacological l Consult psychiatrist for assistance

15. Treat underlying causes l Medications AnticholinergicsAnalgesics l Ensure adequate hydration l Many other causes l Medications AnticholinergicsAnalgesics l Ensure adequate hydration l Many other causes

16. Non-pharmacological management l Environmental factors Materials (like calendars, clocks) to reorient Adequate soft lighting Identify all individuals Limit number of different individuals Limit stimulation Sitters for safety l Environmental factors Materials (like calendars, clocks) to reorient Adequate soft lighting Identify all individuals Limit number of different individuals Limit stimulation Sitters for safety

17. Pharmacological management l Antipsychotics Haloperidol (non-sedating) Chlorpromazine (sedating) Risperidone (non-sedating) Olanzapine (sedating) Quetiapine (sedating) l Antipsychotics Haloperidol (non-sedating) Chlorpromazine (sedating) Risperidone (non-sedating) Olanzapine (sedating) Quetiapine (sedating)

18. Day-night reversal l Use a sedating antipsychotic ChlorpromazineOlanzapineQuetiapine ChlorpromazineOlanzapineQuetiapine

19. Managing adverse effects l Dystonic reactions Diphenhydramine l Akathisia, parkinsonian reactions Benztropine l Tardive Dyskinesia Stop medications Consult psychiatry l Dystonic reactions Diphenhydramine l Akathisia, parkinsonian reactions Benztropine l Tardive Dyskinesia Stop medications Consult psychiatry

20. Benzodiazepines l Delirium due to alcohol withdrawal l For all other causes, not first line therapy More likely cause disinhibition, particularly in elderly l Low dose with antipsychotic medications may be synergistic l Delirium due to alcohol withdrawal l For all other causes, not first line therapy More likely cause disinhibition, particularly in elderly l Low dose with antipsychotic medications may be synergistic

21. Reassess regularly l Monitor carefully l If negligible or partial response Reevaluate diagnosis Inquire about adherence to medication Consider dosage adjustment Consider a different medication Refer to a specialist l Monitor carefully l If negligible or partial response Reevaluate diagnosis Inquire about adherence to medication Consider dosage adjustment Consider a different medication Refer to a specialist

22. Terminal delirium l Delirium during the dying process Signs of the dying process Agitation, restlessness Moaning, groaning l Multiple causes, irreversible l Lorazepam or midazolam to settle l Sedating antipsychotics l Delirium during the dying process Signs of the dying process Agitation, restlessness Moaning, groaning l Multiple causes, irreversible l Lorazepam or midazolam to settle l Sedating antipsychotics Breitbart W, Strout D. Clin Geriatr Med, 2000.

23. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience