1. Geriatrics for Hospice and Palliative Care Providers Heather Herrington, MD Division of Geriatrics, Gerontology and Palliative Care University of Alabama at Birmingham

2. A little bit about me… …and tell me about you… …and what are we doing today?

3. Question: An 88yo woman has dementia and metastatic lung cancer. She was recently discharged from the hospital to home hospice. Her daughter has noticed increased agitation and confusion over the past couple of days. What is the best first step?

4. What do you think?? a. The patient needs a sedating medicine such as lorazepam (Ativan) b. The patient needs an antipsychotic medicine such as haloperidol (Haldol) c. The patient should be checked for fecal impaction and/or urinary retention d. The patient should be checked for dehydration or liver dysfunction e. The patient needs a pain medicine such as morphine

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6. HOLD THAT THOUGHT… lets talk about a patient

7. Which of the following best describes what is going on with Mrs. Lloyd?  She has worsening of her dementia  She is having a psychotic episode  She has a potentially reversible delirium  She is dying and has terminal delirium  She has a severe depression

8. Answer:  c. She has a potentially reversible delirium Why is this the best answer?

9. What is delirium? a potentially reversible condition with many possible causes or contributors…  Why is this not dementia? http://www.youtube.com/watch?v=9QUR zexhWP4 http://www.youtube.com/watch?v=9QUR zexhWP4

10. Delirium vs dementia  Delirium  Acute change  Fluctuating course with inattention  Presumed to be reversible  Dementia  Chronic  Progressive- worsens over time  Not reversible in most cases

11. How do we define or describe delirium?

12.  Disturbance of consciousness  Change in cognition or perceptual disturbance that is not better accounted for by a dementia  Disturbance develops over a short period of time and fluctuates during the day  Result of a general medical condition, medication side effect, substance intoxication or withdrawal, or multiple etiologies  DSM

13. Confusion Assessment Method (CAM)  Acute onset and fluctuating course  Inattention  Disorganized thinking  Altered level of consciousness  Inouye, Annals of Internal Medicine, 1990

14. What are some of Mrs. Lloyd’s underlying risk factors for delirium?

15. Understanding delirium  Generally multifactorial in origin  Predisposing risk factors- these increase a person’s vulnerability to delirium  Precipitating risk factors- these may be avoided

16. Predisposing risk factors  Advanced age  Cognitive impairment  ADL dependence  Sensory impairments  Multimorbidity

17. Precipitating risk factors  Infections  Catheters or other restraints  Constipation/impaction; urinary retention  Uncontrolled pain  Psychoactive medications  Recent hospitalization or other care transition  Metabolic derangements  Withdrawal or intoxications  Acute cardiac, neurologic, pulmonary events

18. Mrs. Lloyd continues to be agitated and confused. How would you want to evaluate her delirium?

19.  Mrs. Lloyd’s daughter reveals that Mrs. Lloyd has not had a BM since before she left the hospital. The daughter also notes that Mrs. Lloyd has only urinated one time today.  A rectal exam reveals hard stool in the rectal vault. After disimpaction, a small, firm mass is noted in the lower pelvis (the distended bladder); a foley catheter is inserted with 1 liter of urine return.  Mrs. Lloyd’s other symptoms of mild dyspnea and back pain are treated with prn low-dose opioids.

20. What should Mrs. Lloyd’s daughter know about delirium?

21. What medications might be contributing to Mrs. Lloyd’s delirium? Are any of her medicines on the Beers list?

22. Case resolution  After fecal disimpaction, placement of a foley catheter and discontinuing contributing medications including Tylenol PM (Benadryl/diphenhydramine), lorazepam, ranitidine and promethazine, Mrs. Lloyd is back to her baseline mental status.  Roxanol (morphine concentrate) is helping with dyspnea, but it is used sparingly because it can make her more confused.  The foley catheter is removed and she is able to void afterwards. Mrs. Lloyd’s daughter is very pleased with the care she has received.

23. Other thoughts….

24. Are delirious patients always agitated?

25. Hypoactive and Hyperactive Delirium  HYPOactive  More common  Patients are somnolent with decreased function  Less often recognized  HYPERactive  More often recognized  Patients are agitated, and if severe they may have hallucinations or be physically aggressive  Mixed delirium - hypoactive and hyperactive

26. Do people remember delirium?  “The impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers”  74% of patients remembered the delirium episode; 81% reported the experience as distressing  Delirium distress score was higher in family caregivers than in patients  Delirium distress score was low in nurses and palliative care specialists  Bruera et al. Cancer. 2009.

27. Mrs. Lloyd could have had terminal delirium, but we don’t think so… Why not? Why is it important to differentiate between potentially reversible delirium and terminal delirium in this patient?

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