Dementia, Delirium, Depression, and Anxiety at End of Life

1. Dementia, Delirium, Depression, and Anxiety at End of Life Dr. Mike Marschke Horizon Hospice

2. Objectives • To understand how mental status changes like dementia and delirium impact care at the end of life • To understand some of the main psychiatric problems that can occur at this time • To learn how to manage these problems effectively

3. Dementia A symptom complex with declining mental functioning with many causes: • Alzheimer’s dementia – 50-60%, pathologic diagnosis and also diagnosis of exclusion • Vascular, multi-infarct – 10-20%, step-wise decline • Pseudodementia – from depression • Others – tumors, AIDS, alcohol, syphilis, hypothyroid, B12 deficiency, hydrocephalus, Parkinsons, vasculitis (<10% are potentially reversible)

4. End-stage Dementia Prognosis < 6 mos: • Severe dementia with need for total assistance in ADLs (dressing, bathing, continence), unable to walk, only able to speak a few words • Comorbid conditions – aspiration pneumonia, urosepsis, decubiti, sepsis • *Unable to maintain caloric intake with weight loss of 10% or more in 6 months (and no feeding tubes)

5. Complications from dementia • Delusions in up to 50%, most with paranoia • Hallucinations in up to 25% • Depression, social isolation may also occur • Aggressive behavior in 20-40% (may be related to above problems, misinterpretation) • Dangerous behavior – driving, creating fires, getting lost, unsafe use of firearms, neglect • Sundowning – nocturnal episodes of confusion with agitation, restlessness

6. Treatment of complications • Hallucinations, delusions, agitation, sun-downing may be improved with anti-psychotics like haloperidol, risperdal, mellaril… • If any signs of depression, may be beneficial to treat • Anxiety may respond to benzodiazepines • Behavioral mod – re-inforce good behavior, DON’T fight aggressive behavior • Familiarity (change in environments make things worse) • Safety – key locks, knobs off stoves, take away car keys/cigarettes/firearms…, lights, watch stairs • Avoid restraints, use human contact/music/pets/ distraction

7. Artificial Nutrition in Dementia • Many excellent reviews demonstrate no improvement in quality of life and quantity of life with G-tubes. • 5% morbidity and mortality with the procedure itself • No decrease in aspiration with them • Risk of infection • Can keep patient comfortable without it

8. Other EOL care needs for dementia • In bedbound, watch out for and prevent decubiti • Feeding instructions to prevent aspiration – head up, chin tucked, thick consistency foods like pudding/jello/ice cream… • Caregiver stress – difficult care, poor sleep, education to prevent aggressive behavior, early bereavement losing loved one before they are gone, need for support/respite

9. Delirium • An acute disorder of awareness, attention, and cognition • Usually presents with fluctuating levels of consciousness • Usually treatable with quick resolution • Occurs in 15-50% of hospitalized elderly, with an associated increase in mortality, in nursing home placement, in costs and complications • Risks increase with advanced age, more medical problems, change in environment • Beware of previous traumatic experiences (Concentration camp, sexual abuse..) • Not uncommon in the final hours of life

10. Causes of Delirium • Infections (even simple UTIs) • Medications, alcohol, withdrawal • Hypoxia • Metabolic abnormalities (low/hi Na, low K, hi Ca, low/hi glucose, hypothyroid, renal/liver failure) • Head injury, subdural hematoma • Stroke, seizure • MI,CHF • Fecal impaction; urinary retention

11. Management of Delirium • Assure safety – try to avoid restraints • Re-assuring voice, don’t fight them, play along, re-orient, bring in familiar things/people • Companionship • Reduce excessive stimulation/needle sticks • Get back home • Look for treatable causes

12. Medical management of delirium • If needed, anti-psychotics tend to be most effective: - haloperidol 0.5-1mg po/iv/sc q1hr until settled - chlorpromazine, thioridazine 10- 25mg po/iv q4hr, more sedating - atypicals like risperidol 0.5-1mg, olanzepine 2.5-7.5mg q6hrs have less extra-pyramidal effects • Benzodiazepines may work with agitation/anxiety

13. Depression at End of Life • 25-75% of patients will experience it • Most have an intense sadness, maybe with anxiety, about their illness but tends to resolve in days to weeks • Persistent symptoms of depression are not normal at the end of life • Depression is often viewed with shame or a sign of weakness and may be hidden

14. Risk factors for depression • Pain or other uncontrolled symptoms • Physical impairment • Advanced disease • Medications like steroids, benzodiazepines • Spiritual suffering • Family history of depression or alcohol abuse • History of alcohol/substance abuse • Women experience it twice as much as men

15. Signs of Major Depression • May be hard to determine in advanced disease – the somatic symptoms of fatigue, decreased appetite, decreased libido, sleep disturbances may all be related to the underlying disease • Dysphoria – sad, flat affect, distraught • Anhedonia – lack of anything pleasurable • Feelings of worthlessness, hopelessness, helplessness, guilt, and despair • “Do you feel depressed most of the time?” is a sensitive question to ask • Watch out for it in pain not responding as expected • Watch out for it with requests to end life early

16. Suicide • Women attempt it twice as much, but men are 4x more likely to succeed • White men over 85 are at highest risk to do it • All patients with depressive symptoms should be assessed for it • Talking about it can decrease risks • High risk of attempt if thoughts are recurring or if have thought out the plan ONE OTHER POTENTIAL HOSPICE EMERGENCY: • If risk high – DON’T leave patient alone, immediately consult a psychiatrist – may need in-patient care or involvement of authorities

17. Management of depression • Psychotherapy – behavioral, cognitive, and other supportive approaches by psychologists, licensed social workers, chaplains, even bereavement counselors may help • New coping strategies like meditation, relaxation, guided imagery, hypnosis may help • Medications

18. Pharmacological management of depression • Tricyclic antidepressants (Elavil, desimpramine, Nortriptyline…) – take 4-6 weeks, need to titrate slowly to avoid cardiac failure, can cause sedation, dry mouth, constipation • SSRIs or other newer agents (Prozac, Zoloft, Paxel, Effexor…) – work in 1-2 weeks, less side effects, may cause insomnia, anxiety, confusion • Psychostimulants (Ritalin, dextro-amphetamine…) – work within 1-2 days, increase energy and well-being, can improve opioid sedation, may cause anxiety, tremors, insomnia, anorexia

19. Anxiety • May be a normal response to the situation – fears, uncertainty, reaction to physical condition, social or spiritual needs • Usually with 1 or more of the following signs – agitation, restless, sweating, tachycardia, hyperventilation, insomnia, excessive worry, tension • Look for signs of depression, delirium, alcohol/drug abuse, caffeine abuse • About 5% are affected by agoraphobia

20. Related anxiety conditions • Panic attacks – acute onset of palpitations, sweating, hot, shaking, chest pain, nausea, dizzy, derealization, fear, numbness; usually short lived • Phobias – fears with avoidance, feelings of being trapped, exposed • Post-traumatic Stress Syndrome – in response to severe trauma, get more intense fear, terror, dreams, feelings of helplessness, detachment that can occur later on

21. Management of Anxiety • Counseling or supportive therapy • Medications: - Benzodiazepines – valium – longer half-life so may accumulate, ativan (0.5-2mg PO/SL/IV q4-6hrs), xanax – shorter half-life so more withdrawal effects - SSRIs, Remeron, Serzone are anti-depressants that may work for general anxiety or panic attacks

22. Summary • A change in mental or emotional status of the patient is not uncommon with a life-threatening illness • Need to be aware of conditions that may be normal reactions or have causes that are potentially reversible, but at the end of life, may need to focus on acute management of these conditions • Need compassionate, supportive care for patient and caregiver, always addressing safety