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RECOGNITION AND MANAGEMENT

RECOGNITION AND MANAGEMENT. DELIRIUM. DR AISLING O’GORMAN Consultant in Palliative Medicine. DELIRIUM. The entity formally known as …. Confusion & agitation - Organic psychosis Acute confusional state - Opioid toxicity Cognitive impairment / failure

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RECOGNITION AND MANAGEMENT

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  1. RECOGNITIONAND MANAGEMENT DELIRIUM DR AISLING O’GORMAN Consultant in Palliative Medicine

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

  3. 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. 3

  4. Confused ???? Delirium = Brain Failure

  5. 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. 5

  6. Delirium Subtypes • Hyperactive • Hypoactive • Mixed Hypoactive Mixed Hyperactive

  7. 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

  8. 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

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

  10. 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 10

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

  12. 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

  13. 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

  14. Delirium – Differential Diagnosis • Dementia • Depression • Mania • Psychosis

  15. DELIRIUMDEMENTIAAcute. 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

  16. DELIRIUMDEMENTIASpeech rambling & Speechincoherent. stereotypes & limited.Often diurnal Constantvariation. (in later stages).Often aware & Unaware &anxious. Unconcerned (in later stages). 16

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

  18. Recognising Delirium - Indicators • Recent changes or fluctuations in behaviour • Cognitive function • Perception • Physical function • Social behaviour

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

  20. 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

  21. Consciousness • Level of consciousness = awake/alertness • Content of consciousness = awareness Hypoalert Hyperalert

  22. 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 Attention Registration of new information does not occur –> immediate & short term memory loss

  23. Change in Cognition • Disorganised thinking • Memory deficit • Disorientation • Language disturbance • Perceptual disturbance

  24. 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

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

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

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

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

  29. 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 MANAGEMENT OF DELIRIUM

  30. MANAGEMENT OF DELIRIUM • Communicate with family: • Clear explanation of goals of management & possible outcomes.

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

  32. 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 MEDICAL MANAGEMENT OF DELIRIUM

  33. 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 MEDICAL MANAGEMENT OF DELIRIUM • NEW ATYPICAL ANTIPSYCHOTICS 35

  34. 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 MEDICAL MANAGEMENT OF DELIRIUM

  35. 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

  36. 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? 38

  37. 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

  38. 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

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

  40. 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

  41. 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.

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