Assessment & Management of Cognitive Impairment

1. Hospice & Palliative Care: 2012 Update for the Specialist Team Assessment & Management of Cognitive Impairment Brenda Matti – Orozco, MD St. Luke’s – Roosevelt Hospital Center, NY November 27, 2012

2. Hospice & Palliative Care: 2012 Update for the Specialist Team Objectives • Recognize and differentiate delirium from dementia and depression • Apply principles of assessment and management of delirium • Identify and manage other conditions associated with cognitive impairment: • Terminal delirium • Behavioral disturbances • Psychosis • Agitation

3. Hospice & Palliative Care: 2012 Update for the Specialist Team Definition • Cognitive impairment • Delirium • Acute confusional state • Encephalopathy • Organic brain syndrome • Terminal restlessness • Terminal agitation • ICU psychosis

4. Hospice & Palliative Care: 2012 Update for the Specialist Team

5. Hospice & Palliative Care: 2012 Update for the Specialist Team DSM-IV TR • Disturbance of consciousness • Reduced clarity of awareness of environment • Reduced ability to focus, sustain or shift attention • Change in cognition • Memory deficit, disorientation • Language or perceptual disturbance • Short period of time & fluctuating course • Evidence of an underlying medical condition

6. Hospice & Palliative Care: 2012 Update for the Specialist Team Epidemiology & Prevalence • GIP Hospice patients with cancer ~ 90% • Median survival ~ 10 days • Etiology • 42% dehydration • 29% liver failure • 25% medication • Home hospice patients 50% Morita, J Pain Symptom Manage 2001 Nowels, J Pall Med 2002;

7. Hospice & Palliative Care: 2012 Update for the Specialist Team Predisposing Factors for Delirium • Demographic characteristics • Age of 65 years or older • Male sex • Cognitive status • Dementia • Cognitive impairment • History of delirium • Depression • Functional status • Functional dependence • Immobility • Low level of activity • History of falls • Sensory impairment • Visual impairment • Hearing impairment • Decreased oral intake • Dehydration • Malnutrition • Drugs • Treatment with multiple psychoactive drugs • Polypharmacy • Alcohol abuse • Coexisting medical conditions • Severe illness • Multiple coexisting conditions • Chronic renal or hepatic disease • History of stroke • Neurologic disease • Metabolic derangements • Fracture or trauma • Terminal illness • Infection with human immunodeficiency virus Inouye S. NEJM 2006;354:1157-1165.

8. Hospice & Palliative Care: 2012 Update for the Specialist Team Precipitating Factors for Delirium • Drugs • Sedative hypnotics • Narcotics • Anticholinergic drugs • Treatment with multiple drugs • Alcohol or drug withdrawal • Primary neurologic diseases • Stroke, particularly nondominant hemispheric • Intracranial bleeding • Meningitis or encephalitis • Intercurrent illnesses • Infections • Iatrogenic complications • Severe acute illness • Hypoxia • Shock • Fever or hypothermia • Anemia • Intercurrent illnesses • Dehydration • Poor nutritional status • Low serum albumin level • Metabolic derangements • Surgery • Orthopedic surgery • Cardiac surgery • Non-cardiac surgery • Environmental • Admission to an intensive care unit • Use of physical restraints • Use of bladder catheter • Use of multiple procedures • Pain • Emotional stress • Prolonged sleep deprivation

9. Hospice & Palliative Care: 2012 Update for the Specialist Team

10. Hospice & Palliative Care: 2012 Update for the Specialist Team Medications Causing Delirium • Anti-cholinergics • Diphenhydramine • Atropine • Scopolamine • TCAs • Anti-inflammatories • Benzodiazepines • Cardiovascular • Digoxin • Anti-HTN • Diuretics • Ranitidine • Lithium • Opioid

11. Hospice & Palliative Care: 2012 Update for the Specialist Team Impact of Delirium • Shortens life expectancy • Increases SNF placement (73% vs 30%) • Distressing to patient and family • Difficult pain management • Increases hospital LOS and cost • Complications

12. Hospice & Palliative Care: 2012 Update for the Specialist Team Delirium & Depression • Often co-morbid and symptoms commonly overlap • 100 patients admitted to in-patient hospice • 34% delirium • 30% subsyndromal delirium (SSD) • 37% major depressive disorder (MDD) • 54% patients with delirium had core features of MDD (38% SSD)

13. Hospice & Palliative Care: 2012 Update for the Specialist Team

14. Hospice & Palliative Care: 2012 Update for the Specialist Team Delirium & Dementia • Age & cognitive impairment: strongest risk factors for delirium

16. Hospice & Palliative Care: 2012 Update for the Specialist Team Table 2. Bedside Delirium Instruments

17. Hospice & Palliative Care: 2012 Update for the Specialist Team Bedside Delirium Instruments • Likelihood ratio (LR) > 5 for diagnosing delirium • GAR, MDAS, CAM, DRS-R-98 • CAC, DOSS • Least useful: MMSE • Time-efficient, < 5 mins: CAM Wong CL, et al. JAMA. 2010;304(7):779 – 786.

18. Hospice & Palliative Care: 2012 Update for the Specialist Team Confusion Assessment Method

19. Hospice & Palliative Care: 2012 Update for the Specialist Team Screening Recommendations • SQiD (Single Question in Delirium) • “Do you think patient has been more confused lately?” • 80% sensitive and 71% specific in hospitalized oncology patients • Basic cognitive tests • Verbal trails (alternate alphabet and numbers to 10) • Day of week or months of year backwards • Clock drawing • Count backwards from 20 to 1 (dementia patients)

20. Hospice & Palliative Care: 2012 Update for the Specialist Team

21. Hospice & Palliative Care: 2012 Update for the Specialist Team Delirium Types Attentional & Perceptual Disturbances Affective Disturbance Posterior Parietal/Prefrontal & Related Subcortical Circuits Temporal/Limbic/Paralimbic/ Orbitofrontal Cortex & Related Subcortical Circuits Occipital Perez DL, et al. J NeurolNeurophysiol S1.doi:10.4172/2155-9562.S1-003

22. Hospice & Palliative Care: 2012 Update for the Specialist Team Table 4. Delirium Types

23. Hospice & Palliative Care: 2012 Update for the Specialist Team

24. Hospice & Palliative Care: 2012 Update for the Specialist Team Approach to Evaluation

26. Hospice & Palliative Care: 2012 Update for the Specialist Team Other Delirium Interventions • Opioid rotation • PCA for pain control • Methylphenidate for hypoactive delirium • Hydration • Music therapy • Warm milk • Massage therapy

27. Hospice & Palliative Care: 2012 Update for the Specialist Team Pharmacologic Treatment • No FDA-approved medication for delirium • No published double-blind, randomized, placebo controlled trials • Anti-psychotics: treatment of choice • Off label use Weckmann M. AAHPM Intensive Board Review Course 2012.

28. Hospice & Palliative Care: 2012 Update for the Specialist Team Risk of Death & Antipsychotics • Dementia: increased risk • Black Box warning since 2004 • Across all antipsychotics • Relative Risk = 1.6 – 1.7 • Absolute Risk = 3.5% vs 2.3% with placebo • Number Needed to Harm = 83 • Number Needed to Treat = 5 – 14 • For every 9 – 25 persons helped: 1 death • Delirium: no evidence of increased risk Schneider LS, et al. JAMA.2005;294:1934 – 1943; Jeste DV, et al. Neuropsychopharma.2008 Apr;33(5):957 – 970; Elie M, et al. Int Psychogeriatr.2009 Jun;21(3):588 – 592.

29. Hospice & Palliative Care: 2012 Update for the Specialist Team Antipsychotic Side Effects

30. Common Antipsychotics Hospice & Palliative Care: 2012 Update for the Specialist Team TYPICAL ATYPICAL Risperidone (Risperdal) Ziprasidone (Geodon) Olanzapine (Zyprexa) Quetiapine (Seroquel) Clozapine (Clozaril) Aripiprazole (Abilify) • Chlorpromazine (Thorazine) • Thioridazine (Melleril) • Prochlorperazine (Compazine) • Haloperidol (Haldol) • Fluphenazine (Prolixin) • Perphenazine (Trilafon)

31. Hospice & Palliative Care: 2012 Update for the Specialist Team Antipsychotic Comparison • Typical antipsychotics • Greater evidence base • Cheaper • Multiple routes of administration • Efficacy: Haloperidol (Haldol) equal to • Olanzapine (Zyprexa) • Risperidone (Risperdal) • Aripiprazole (Abilify)

32. Pharmacotherapy Hospice & Palliative Care: 2012 Update for the Specialist Team ANTIPSYCHOTICS SEDATIVES Lorazepam 0.5-1 mg PO/IV/SQ q 4hr Diprivan (Propofol) 10 mg IV bolus (then 10 mg/hr) Midazolam 1-2 mg IV q 1hr • Haloperidol 0.5-1mg q 30 mins • Chlorpromazine 25-50 mg PO/PR TID-QID • Olanzapine 2-5 mg PO/SL daily • Risperidone 0.5 mg PO/SL BID • Quetiapine 50-100 mg PO BID

33. Hospice & Palliative Care: 2012 Update for the Specialist Team Terminal Delirium • Common reason for terminal sedation • Treatment recommendations: • Antipsychotic at higher doses • High dose benzodiazepines: if antipsychotic ineffective • Sedative agent: if sedation is desired • Phenobarbital • Diprivan

34. Hospice & Palliative Care: 2012 Update for the Specialist Team Behavioral Disturbances • Disruptive physical or verbal behaviors • Approach: • Remove aggravating factors • Consider pain, hunger, thirst, medical illness • Remember not to teach • Distraction strategy

35. Hospice & Palliative Care: 2012 Update for the Specialist Team Psychosis • Don’t argue; reassure • Identify the symptoms • Visual • Tactile • Delusions • Misperceptions • Consider aggravating medications or illness

36. Hospice & Palliative Care: 2012 Update for the Specialist Team Agitation as an Emergency ALWAYS Usually From Treatment of Behavioral Emergencies. The Expert Consensus Guideline Series, 2001.

37. Hospice & Palliative Care: 2012 Update for the Specialist Team Hierarchy of Interventions RARELY Sometimes Usually From Treatment of Behavioral Emergencies. The Expert Consensus Guideline Series, 2001.

38. Hospice & Palliative Care: 2012 Update for the Specialist Team Antipsychotic Pharmacokinetics P L A S M A C O N C SC/ IM = 30 min Cmax PO/ PR = 60 min For all = 24 hrs Half-life (t1/2) Time From Treatment of Behavioral Emergencies. The Expert Consensus Guideline Series, 2001.

39. Hospice & Palliative Care: 2012 Update for the Specialist Team Moderate Agitation • Haloperidol 1-2 mg SQ/ PO • Increase dose by 1 mg q Cmax until controlled • Alternatives • Chlorpromazine 50-100 mg SQ up to 2 g/day • Increase dose by 50 mg q Cmax until controlled • SQ can burn, infusing 1 mg dexamethasone q 24hr can help • Risperidone 0.25-1 mg PO q 1hr up to 6 mg/day • Olanzapine 5-10 mg PO q 1hr up to 30 mg/day • Quetiapine 25-100 mg PO q 1 hr up to 1200 mg/day

40. Hospice & Palliative Care: 2012 Update for the Specialist Team Severe Agitation • Imminent risk of harm to self or others due to agitation • Haloperidol 2-5 mg x 1 • + Diphenhydramine 50-100 mg • + Lorazepam 1-2 mg • Mix very slowly in order in same syringe: • Lorazepam  Haloperidol  Diphenhydramine

41. Hospice & Palliative Care: 2012 Update for the Specialist Team Severe Agitation • Alternatives • Chlorpromazine 50-100 mg SQ up to 2 g/day • Olanzapine 5-10 mg IM up to 30 mg/day • Ziprasidone 10-20 mg IM up to 40 mg/day

42. Hospice & Palliative Care: 2012 Update for the Specialist Team Dementia Related Agitation • Antipsychotics may no longer be first line • Consider behavioral/ non-pharmacologic techniques first • Some evidence for: • Beta-blockers • Propranolol 10 mg daily to 160 mg TID • Gabapentin • 100-300 mg q 1hr up to 3600 mg/day • Trazodone • 25-50 mg q1hr up to 300 mg/day • Anticholinesterase inhibitors • High dose SSRIs

43. Hospice & Palliative Care: 2012 Update for the Specialist Team Drug Treatment for Agitation • Antipsychotics most commonly used • Treat agitation like another breakthrough symptom such as pain • Start with prn dosing and dose on the Cmax • Calculate scheduled dose based on needed prn amount in previous 24 hrs • Use time limited trials

44. Hospice & Palliative Care: 2012 Update for the Specialist Team

45. Hospice & Palliative Care: 2012 Update for the Specialist Team