Palliative Potpourri

1. Palliative Potpourri Edward (Ted) St. Godard MA MD CCFP Consulting Physician WRHA Palliative Care tstgodard@wrha.mb.ca Robert Pope. “Visitors”

2. I am funded as an independent contractor by the WRHA Disclosure

3. I. Delirium at end-of-lifeName it, claim it, tame it

4. At the end of session, participants will Be able to identify the medical condition known as delirium; Appreciate the importance of this recognition; Have an approach to delirium management objectives

7. Delirium and nurses Agar et al. Palliative Medicine. September, 2011. Nurses are in an optimal position to detect fluctuating symptoms of delirium

8. Delirium and nurses Agar et al. Palliative Medicine. September, 2011. Silent, unspoken piece of nursing practice, impacting on workload Nurses deal with the unpredictable and fluctuating condition of delirious patients, which may be a signal of impending ‘chaos’

9. Delirium and nurses Agar et al. Palliative Medicine. September, 2011. Under-detection of delirium relates to a lack of knowledge of the criteria for identifying delirium… failure to relay or communicate detected symptoms at onset…

10. What is delirium ? • Global cerebral dysfunction • “Brain Failure” • Early signs often mistaken as anger, anxiety, depression, psychosis

11. Dsm-iv criteria A) Change in consciousness with reduced ability to focus, sustain or shift attention B) Change in cognition (e.g., memory, disorientation, change in language, perceptual disturbance) that is not dementia

12. Dsm-iv criteria C) Abrupt onset (hours to days) with fluctuation D) Evidence of medical condition judged to be etiologically related to disturbance

13. Dsm-iv criteria …a disturbance in consciousness with inattention and problems in cognition and/or a disturbance in perception that develop over hours to days with organic causes.

14. Delirium vs dementia • Dementia • Impaired memory • Impaired judgement • Impaired thinking • Disorientation • Delirium • Impaired memory • Impaired judgement • Impaired thinking • Disorientation

15. Delirium vs dementia • Dementia • Insidious, progressive • Alert, LOC intact • Minimal  • Delirium • Abrupt onset • Decreased LOC • Sleep/wake cycle 

16. Delirium vs dementia • Dementia • Irreversible • Delirium • Reversible? • PREVENTABLE?

17. Delirium is reversible • In up to 50 % of patients with advanced cancer, delirium can be reversed Kang JH et al. “Comprehensive approaches to managing delirium in patients with advanced cancer.” Cancer Treat Rev (2012)

18. Reversed vs non-reversed • Lawlor P, Gagnon B, Mancini I, Pereira J, et al. Arch Intern Med 2000

19. Delirium sub-types • Hypoactive confusion, somnolence,  alertness • Hyperactive agitation, hallucinations, aggression • Mixed (>60%) features of both

20. Delirium sub-types • Lawlor P, Gagnon B, Mancini I, Pereira J, et al. Arch Intern Med 2000

21. Prevalence/incidence Partridge et al. “The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this?” Int J Ger Psych. October 2012 (online) 80 % in medical intensive care units (ICU) 28 % in patients following hip fracture 22 % in general medical inpatients

22. Incidence/prevalence • Most frequent neuropsychiatric complication in patients with advanced CA • Up to 85 % of patients delirious prior to death Bruera et al. JPSM 2010; 39;2: 186-196

23. Incidence/prevalence • ~ 42% patients in PC program delirious on admission • 50% of episodes reversible • “Terminal delirium” in 88 % Lawlor et al. Arch Intern Med 2000; 160:786

24. Impact • Palliative sedation requests • Delirium/terminal restlessness (55%) • Dyspnea (27%) • Pain (18%) • Nausea/vomiting (4%) Eisenchlas. Current Opinion in Supportive and Palliative Care 2007, 1:207–212

25. Impact • Palliative sedation requests • Delirium number one reason for requests Fainsinger RL et al. “A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients.” Palliat Med 2000;14:257–65.

26. Impact • “We’d rather see dad dead than like this.” • “S/he would be horrified by this.”

27. impact • 73/99 patients (74%) remembered delirious episode • Of these, 81 % recalled experience as distressing • Family stress > patients’ recalled stress Bruera et al. JPSM 2010; 39;2: 186-196

28. impact • Interferes with Sx assessment and Tx • Increases morbidity and mortality • Hinders communication within families Bruera et al. JPSM 2010; 39;2: 186-196

29. Sx difficulty and distress D/D Pain Dyspnea Delirium

30. Sx difficulty and distress Ax/TxChallenges Worsening Delirium

31. pathophysiology • Delirium mediated by failure in central cholinergic transmission? • Acetylcholine final common neurotransmitter pathway leading to delirium? White et. al. “First Do no Harm…” JPM. 10 (2); 2007: 345-351

32. pathophysiology • Relative acetylcholine deficiency and dopamine excess could mediate the characteristic symptoms of delirium • Delirium can be evoked by dopamine agonists and anticholinergic medications Moyer. American Journal of Hospice and Palliative Medicine 28(1), 2011. 44- 51 Kang JH et al. Comprehensive approaches to managing delirium in patients with advanced cancer. Cancer Treat Rev (2012)

33. pathophysiology • Dopamine/acetylcholine inverse relationship • Haloperidol first line treatment for delirium • Haloperidol D2 antagonist: • ? Haloperidol increase levels acetylcholine? White et. al. “First Do no Harm…” JPM. 10 (2); 2007: 345-351 Kang JH et al. Comprehensive approaches to managing delirium in patients with advanced cancer. Cancer Treat Rev (2012)

34. pathophysiology • Sometimes successfully treated with dopamine receptor antagonists and possibly by cholinesterase inhibitors • High serum anticholinergic activity in patients with delirium Moyer. American Journal of Hospice and Palliative Medicine 28(1), 2011. 44- 51

35. pathophysiology • Υ-aminobutyric acid (GABA)-ergic benzodiazepines seem to cause delirium • Neuroinflammatory processes drives up-regulation of GABA receptors • GABA receptor versus microglial activation versus apoptosis C.G. Hughes et al. “Future Directions in Delirium Management and Research.” Best Practice & Research Clinical Anaesthesiology. 26 (2012) 395–405

36. causes • Precipitating • Predisposing

37. causes • Predisposing factors: • Prevalence increases with age • Male > female • Visual impairment • Depression White et. al. “First Do no Harm…” JPM. 10 (2); 2007: 345-351

38. causes • Predisposing factors: • Functional dependence • Immobility • Hip fracture • Dehydration • Alcoholism • Stroke • Severity of physical illness White et. al. “First Do no Harm…” JPM. 10 (2); 2007: 345-351

39. Who’s predisposed? All of our patients!

40. Fragile? Frail?

41. Fragile? Frail? HANDLE WITH CARE

42. Fragile patients • Inverse relationship between the preexisting vulnerability of the patient, and the severity of the insult necessary to precipitate delirium

43. Fragile patients • Most patients nearing EOL have multiple predisposing factors • Most of these are beyond our control

44. causes • Precipitating • Predisposing

45. Decrease predisposition? • Impractical, given our patient population (frail, usually old) • Imperative to minimize precipitating factors

46. precipitators • ‘lyte derangements (dehyd’n, hypo/hypernatremia) • Infx (UTI, resp., skin/soft tissue [sacral ulcers]) • Metabolic (hyper/hypoglycemia, hypercalcemia, uremia) • Low perfusion, hypoxia • Withdrawal

47. drugs • Anti-cholinergics (Gravol, TCAs, anti-secretories); • BZDs • Opioids • Steroids • Cipro, lasix (?) ranitidine, and on and on….

48. drugs • Drug withdrawal: • EtOH, Bzd, opioid, “street drugs”

49. Prevention? • Prophylactic haldol • Prophylactic olanzepine • Prohylactic cholinesterase inhib.s Gagnon et al. Psycho‐Oncology 21: 187–194 (2012)

50. Prevention? • Maintain sensorium: hearing aids, eye glasses • Orientation (clocks, calendars, conversation) Gagnon et al. Psycho‐Oncology 21: 187–194 (2012)