DELIRIUM RECOGNITION AND MANAGEMENT DR AISLING OGORMAN Consultant

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

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

DELIRIUM n 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. 3

Confused ? ? Delirium = Brain Failure

DELIRIUM n 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. 5

Delirium Subtypes Hyperactive n Hypoactive n Mixed n Hypoactive Mixed Hyperactive

Delirium – What’s it to YOU ? ? ? Delirious patients n n n 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

n 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

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

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

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

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

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

Delirium – Differential Diagnosis Dementia n Depression n Mania n Psychosis n

DELIRIUM DEMENTIA 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 15

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

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

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

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

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

Consciousness n Level of consciousness = awake/alertness n Content of consciousness = awareness Hypoalert Hyperalert

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

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

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

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

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

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

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

MANAGEMENT OF DELIRIUM n 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 31

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

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

MEDICAL MANAGEMENT OF DELIRIUM n 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 – 1 mg bd 1 mg q 1 hrly prn Titrate as needed Higher doses may be required initially, if severely agitated • Rarely exceed 20 mg / 24 hours 34

MEDICAL MANAGEMENT OF DELIRIUM n. NEW n ATYPICAL ANTIPSYCHOTICS Olanzapine • Fewer Extrapyramidal V/E • Dose 2. 5 mg stat, prn • Available in Velotab preparation • V/E – Drowsiness & Weight Gain, ACH n Risperidone • Dose 500 mcg bd & prn • Increase by 500 mcg bd on alt days • Median maintenance dose – 1 mg/day n Quetiapine • Dose 12. 5 – 25 mg bd 35

MEDICAL MANAGEMENT OF DELIRIUM n Methotrimeprazine: – Dose: – Widely used in terminal stages – V/E: • sedating • postural hypotension • 6. 25 mg – 12. 5 mg sc/po q 8 -12 h • 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 36

MEDICAL MANAGEMENT OF DELIRIUM n Chlorpromazine: – Useful oral alternative when some sedation is desirable – Dose: 25 mg po q 8 hrly n Midazolam: – Rapid onset & short half life – Administration: iv, im, sc – Dose: 2. 5 mg – 10 mg stat followed by 20 mg – 100 mg / 24 hours n Phenobarbitone: – Pre terminal agitation – Used with midazolam – Dose: 200 mg – 800 mg / 24 hours 37

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

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

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

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

References n Inuoye S. Delirium in Older Persons. NEJM. 2006; 354: 1157 -65 n Centeno C, Sanz A, Bruera E. Delirium in advanced cancer patients. Palliat Med. 2004; 18: 184 -94 n Lawlor P et al. Occurrence, Causes and outcome of delirium in patients with advanced cancer. Arch Intern Med; 160: 786 -94 n Caraceni A, Simonetti F. Palliating delirium in patients with cancer. The Lancet. 2009: 10; 164 -72 n Lonergan E et al. Antipsychotics for delirium. Cochrane Database Syst Rev. 2007 Apr 18; (2): CD 005594

References n 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 n 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 n Delirium: diagnosis, prevention and management. NICE clinical guideline 103.