Symptom Control: Agitation and Delirium

1. Symptom Control: Agitation and Delirium AOA OMED Conference San Francisco 2010

2. Acknowledgement We gratefully acknowledge the outstanding work done by: • Scott A. Irwin, MD, PhD • Rosene P. Pirrello, RPh • Jeremy M. Hirst, MD • Gary T. Buckholz, MD • Frank D. Ferris, MD, FAAHPM And the Institute for Palliative Medicine at San Diego Hospice, and AAHPM

3. Objectives • Identify the patient at risk for agitation and delirium • Describe how to relieve suffering and control agitation and delirium

4. Delirium is Change in mental status. Impaired: • Attention • Orientation • Cognition • Consciousness • Reality • Behavior

5. DSM-IV Criteria Delirium 1. Disturbance in consciousness • Attention 2. Change in cognition • Examples: memory, orientation, language 3. Develops over a short period of time 4. Caused by the direct physiological consequences of a general medical condition

6. Delirium Subtypes • Hyperactive: confusion, agitation hallucinations, myoclonus • Hypoactive: confusion, somnolence, withdrawn. More likely to be under diagnosed “If you don’t look for it, you won’t find it” • Mixed

7. Prevalence • Hospitalized elderly: 14-56% • ICU: 70-87% • Advanced Cancer 25-85% or End of Life:

8. Consequences • Six month mortality: up to 25% • Increased mortality: 10-78% • Prolonged hospitalizations • Stress • Discomfort • Reduced quality of life

9. Consequences • Causes a person to be frightened, agitated and upset • Interferes with the assessment and treatment of other symptoms • Increased caregiver burden • Increases the use of restraints • Interferes with meaningful communication and interaction

10. Patients at Risk for Delirium • Decreased oral intake: dehydration, malnutrition • Over age 65 • Male • Low activity level • Constipation/fecal impaction • History of falls • Visual or hearing impairment • Depression • History of previous delirium

11. Causes Delirium has many, many causes – A good number of them are discoverable and reversible – approximately 50%

12. J.O.M.A.C. Mnemonic • J – JUDGEMENT changes • O – ORIENTATION changes • M – MEMORY changes • A – AFFECT changes • C – COGNITIVE changes • Delirium is a state defined by a CHANGE in mental functioning

13. Most Common Causes • Fluid imbalance • Medications (see next slide) • Infections • Hepatic or renal failure • Hypoxia • Hematological disturbances

14. Medication Side Effect (most common) • Opioids • Corticosteroids • Benzodiazepines • Scopolamine • Hydroxyzine • Diphenhydramine • Hyoscyamine • Tricyclic-Antidepressants • H2 Blockers • NSAIDS • Metoclopramide • Alcohol/drug withdrawal

15. Often Under-Recognized In a hospice study of 2700 patients (S.A. Irwin et.al.2008) delirium was recognized in only: • 17.8% of home care patients • 28.3 % of inpatients

16. Why Under-Recognized • Complex presentation • Inconsistent language among professionals about mental status • Preconceived notions • Hypo-active sub-type is quiet • Thought to be normal part of end of life

17. Address Existential Causes • Involve the chaplain • Assess for possible existential crisis or other version of pre-death awareness • Consider prayer, meditation, mantra, ritual

18. Delirium May be Mistaken for Pain • If grimacing and agitation are thought to be pain, assess the cause. If there is no obvious reason for the pain, or the pain is “all over”, it is probably delirium • Frequently, the delirious pt will answer “yes” to the question of pain • An opioid may sedate a delirious pt, leading to the belief that it has helped

19. Delirium May be Mistaken for Anxiety, Depression, or Dementia • Anxiety: apprehension, jitters, etc. but attentive, alert and oriented • Depression: may be restless with decreased concentration but attentive and oriented • Dementia: usually alert, and attentive, decreased cognition over months to years

20. Comparison: Delirium vs Dementia Delirium • Acute onset • Fluctuates • Duration days to weeks • Altered consciousness • Impaired attention • Increased or decreased psychomotor • Can be reversible Dementia • Insidious onset • Progressive • Duration months to years • Clear consciousness • Normal attention except when severe • Normal psychomotor (usually) • Rarely reversible

21. Comparison: Delirium vs. Sundown Syndrome Delirium • Change in alertness • Onset – hours to days • Fluctuates hourly Sundown Syndrome • No change in alertness • Onset – daily, slowly worsening • Fluctuation daily and predictable • Occurs with dementia

22. Treatment

23. Identify Reversible Causes of Delirium Time limited trial to find and reverse the causes such as • Drug side effects • Low oxygen – CHF, COPD, PE • Infection • Retention of urine or feces • Poor intake – malnutrition, dehydration • Organ failure – kidney, liver • Metabolic problems – electrolytes, thyroid, Ca++ 

24. Terminal Delirium • This is delirium during the dying process when there is not a reversible cause and the patient is expected to die in the following hours, days to a week • Frequently there is restlessness, agitation, moaning, and purposeless vocalization. • Signs of active dying process may be present, such as peripheral cooling, abnormal breathing, anuria, etc.

25. Non-pharmacologic Management of Delirium Provide support and orientation: • Communicate clearly, concisely, and calmly • Give repeated verbal reminders of the day, time and location • Provide clear signposts to patient’s location, including clock and date • Have familiar objects from the patient’s home nearby

26. Non-pharmacologic Management of Delirium Provide an unambiguous environment: • Try to avoid frequent change in bed location • Avoid using medical jargon in front of the patient • Avoid extremes of bright lighting and darkness • Control excess noise • Keep room temperature between 70-75 degrees.

27. Non-pharmacologic Management of Delirium Maintaining competence: • Identify and correct sensory impairments. Ensure patients have their glasses, hearing aid and dentures • Use an interpreter as needed • Encourage self care and participation in treatment

28. Non-pharmacologic Management of Delirium • Have patient/caregiver give feedback on treatments of symptoms • Maintain activity levels; and arrange treatments to allow for maximum periods of un-interrupted sleep.

29. Pharmacologic Management of Delirium

30. Pharmacologic Management of Delirium Hyperactive delirium • Haloperidol (Haldol) is drug of choice for symptom of agitation (or other symptom causing suffering) • Haloperidol is a butyrophenone derivative with antipsychotic properties that has been considered particularly effective in the management of hyperactivity, agitation, and mania. • Haloperidol is an effective neuroleptic and also possesses antiemetic properties

31. Haloperidol (Haldol) • Haldol is NOT for use in alcohol or benzodiazepine withdrawal • Check to see if the patient has Parkinson’s Disease prior to initiating it • There may be a slightly increased risk of serious side effects (e.g., pneumonia and heart failure) when used in older adults with dementia.

32. Haloperidol (Haldol) Second generation medications such as • chlorpromazine (thorazine) • olanzapine (zyprexa) • quetiapine (seroquel) • risperidone (risperdol) may be needed if haldol alone is not effective

33. Pharmacologic Management of Delirium Hypoactive delirium • Medication for hypoactive delirium is not usually needed Mixed delirium • Medication as per hyperactive delirium with less during hypoactive part of the day

34. Pharmacologic Management of Delirium Terminal delirium • Sedation is the main treatment and • Benzodiazepines are more important (examples of benzodiazepines are ativan, xanax, librium, valium)

35. Reassessment • If there is not adequate relief of suffering, try further non-pharmacologic comfort measures. • Treat agitation like a breakthrough symptom (pain) and use PRN medication • If the pharmacologic treatment is not effective in relieving suffering, the physician should be notified for further orders.

36. Medication Side Effects • Observe for medication side effect • Note the varying degree of sedation and extra-pyramidal symptoms that different drugs have

37. Medication Side Effects *EPS: Extra-pyramidal Symptoms (Parkinsonian-like)

38. Extra-pyramidal Symptoms (EPS) EPS are movement disorders that can occur as a result of taking haldol (or other anti-psychotic drugs). Examples: • Tardive dyskinesia -involuntary, irregular muscle movements, usually in the face • Muscular lead-pipe rigidity • Bradykinesia – slow movement • Akinesia – inability to initiate movement • Resting tremor • Postural instability

39. Lorezapam (Ativan) Indicated for • Delirium due to alcohol and benzodiazepine withdrawal • Anxiety • Primal fear (e.g., feeling of suffocation) • Sedation therapy (use with haldol for delirium) • Seizure disorder

40. Lorazepam (Ativan) • Like all drugs in this chemical family, (i.e. benzodiazepines), lorazepam enhances the action of the inhibitory neurotransmitter GABA by acting at the GABAA receptor. • It has anxiolytic, sedative and hypnotic properties

41. Toxicity with Ativan • Respiratory depression, especially if opioids are present • May worsen delirium • Over sedation when treating delirium

42. Nursing Home Quality of Care – F tags CMS Nursing Home surveys include audit and review of • F-329 Unnecessary drugs used • F-330 Antipsychotics received when appropriate • F-331 Antipsychotics dose reduction Documentation needs to focus on the symptoms causing suffering, and the interventions, both non-pharmacologic and pharmacologic that have been used to help relieve symptoms

43. Nursing Implications • Provide support and orientation • Provide an unambiguous environment • Help the patient maintain competence, function and activities as much as he is able • Observe for medication side effects • Address safety issues and implement fall prevention strategies, especially for patients with agitation

44. Goal: Early Diagnosis, Assessment and Treatment • Order appropriate laboratory and diagnostic studies to assess for reversible causes • Include non-pharmacologic interventions in the Plan of Care • Prescribe pharmacologic treatment for the suffering and symptoms of delirium if indicated

45. Case Study • Anna is a 78 yr female, primary diagnosis non-small cell lung carcinoma • Right lobectomy two years ago • Maintained on continuous O2 @1.5 L/min • Lives at home alone • Usually alert and oriented

46. Film clip