LOUTH & MEATH SPECIALIST PALLIATIVE CARE SERVICES

RECOGNITIONAND

MANAGEMENT

DELIRIUM

DR AISLING O’GORMANConsultant in Palliative Medicine

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DELIRIUM The entity formally known as ….

– Confusion & agitation - Organic psychosis

– Acute confusional state - Opioid toxicity– Cognitive impairment / failure– Acute brain syndrome - ITU encephalopathy

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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.

Delirium = Brain Failure

Confused ????

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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.

Delirium Subtypes

Hyperactive Hypoactive Mixed

Hypoactive HyperactiveMixed

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

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 !!!

Mortality rates:– 10% - 65%

- With appropriate management, may be reversible in up to 50%

But

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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

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Risk FactorAssessment for Delirium

Age 65 yrs or older Cognitive impairment (past or present) Current hip fracture Severe illness

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

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

Delirium – Differential Diagnosis

Dementia Depression Mania Psychosis

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DELIRIUM DEMENTIAAcute. Chronic.Often remitting & Usually progressive reversible. & irreversible.Mental clouding. Brain damage.(info not taken in) (info not retained)

Poor concentrationImpaired short term memoryDisorientationLiving in pastMisinterpretationsHallucinationsDelusions

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DELIRIUM DEMENTIA

Speech rambling & Speechincoherent. stereotypes &

limited.

Often diurnal Constantvariation. (in later stages).

Often aware & Unaware &anxious. Unconcerned

(in later stages).

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Pathophysiology of Delirium

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

Recognising Delirium - Indicators

Recent changes or fluctuations in behaviour– Cognitive function– Perception– Physical function– Social behaviour

Clinical Features

Acute onset Fluctuating course Inattention Disorganised

thinking Altered

consciousness Cognitive deficit

Perceptual disturbance

Psychomotor disturbance

Altered sleep-wake cycle

Emotional disturbance

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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

Consciousness

Level of consciousness = awake/alertness

Content of consciousness = awareness

Hypoalert Hyperalert

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

Change in Cognition

Disorganised thinking– Memory deficit– Disorientation– Language disturbance– Perceptual disturbance

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

Management of Delirium

SOLVE THE PROBLEM !!!! Treat the underlying causes Environmental interventions Antipsychotics

– Haloperidol, risperidone, quetiapine, olanzapine,

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CAUSES OF DELIRIUM

Drug Toxicity

Infection

Surgery

Metabolic

encephalopathy

Electrolyte

Direct CNS Causes

Hypoxia

Environmental

Paraneoplastic

Haematological

Elimination disorder

Delirium - Causes

– Medications• Chemotherapy• Steroids• Radiotherapy• Opioids• Benzodiazepines• Anticholinergics• Antiemetics• Withdrawal

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MANAGEMENT OF DELIRIUM

Assess patient:

– Determine cause– ? Potentially reversible factors– Check list– History (NB collateral)– Examination– Review medication– Blood tests

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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

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MANAGEMENT OF DELIRIUM

Communicate with family:

– Clear explanation of goals of management & possible outcomes.

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MEDICAL MANAGEMENT OF DELIRIUM

There are 3 distinct clinical entities:

– Hyperactive: Agitated– Mixed: Hypoactive – Hyperactive – Hypoactive – Hypoalert, withdrawn,

confused

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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

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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

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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

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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

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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?

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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

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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

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CONCLUSION

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

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

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.