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The EPEC-O Project Education in Palliative and End-of-life Care - Oncology

TM. The EPEC-O Project Education in Palliative and End-of-life Care - Oncology. The EPEC TM -O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

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The EPEC-O Project Education in Palliative and End-of-life Care - Oncology

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  1. TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPECTM-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

  2. EPEC– Oncology Education in Palliative and End-of-life Care – Oncology Module 3g: Symptoms – Delirium

  3. Delirium • A disturbance of consciousness • A change in cognition • Acute onset, fluctuating course APA Practice guideline. Am J Psychiatry. 1999.

  4. Associated changes • Day-night reversal • Emotional state • Nonspecific neurological abnormalities • Decline in functional ability

  5. Types • Hyperactive • Associated behavioral disturbances • Hallucinations • Delusional beliefs • Hypoactive • Quiet • Mistaken for depression or fatigue • Mixed – waxing and waning

  6. Prevalence • 80 – 85% of terminally ill patients

  7. Prognosis • Increased risk of • Complications • Protracted hospitalizations • Protracted postoperative recovery • 25% delirious patients die <6 months • In elderly delirious, risk of dying during a hospital admission is 22 – 76%

  8. Key points • Pathophysiology • Assessment • Management

  9. Infection Withdrawal Acute metabolic Trauma CNS pathology Hypoxia Deficiencies Endocrinopathies Acute vascular Toxins or drugs Heavy metals Causes of delirium . . .

  10. . . . Causes of delirium • Don’t forget: • Constipation, fecal impaction • Urinary retention

  11. Neurophysiology • Multiple cortical, subcortical levels affected • Several neurotransmitters involved • Changes in regional cerebral perfusion

  12. Assessment • Clinical history, physical examination, serial observations • Folstein Mini-Mental State exam • Review of medication regimen • Thorough medical and laboratory work-up to elucidate underlying cause

  13. Delirium vs. dementia

  14. Management • Treat underlying causes • Nonpharmacologic • Pharmacologic • Consult psychiatrist for assistance

  15. Treat underlying causes • Medications • Anticholinergics • Analgesics • Ensure adequate hydration • Many other causes

  16. Non-pharmacologic management • Environmental factors • Materials (calendars, clocks) to reorient • Adequate soft lighting • Identify all individuals • Limit number of different individuals • Limit stimulation • Sitters for safety

  17. Pharmacologic management • Antipsychotics • Haloperidol (nonsedating) • Chlorpromazine (sedating) • Risperidone (nonsedating) • Olanzapine (sedating) • Quetiapine (sedating)

  18. Day-night reversal • Use a sedating antipsychotic • Chlorpromazine • Olanzapine • Quetiapine

  19. Managing adverse effects • Dystonic reactions • Diphenhydramine • Akathisia, parkinsonian reactions • Benztropine • TardiveDyskinesia • Stop medications • Consult psychiatry

  20. Benzodiazepines • Delirium due to alcohol withdrawal • For all other causes, not first-line therapy • More likely cause disinhibition, particularly in elderly • Low dose with antipsychotic medications may be synergistic

  21. Reassess regularly • Monitor carefully • If negligible or partial response • Re-evaluate diagnosis • Inquire about adherence to medication • Consider dosage adjustment • Consider a different medication • Refer to a specialist

  22. Terminal delirium • Delirium during the dying process • Signs of the dying process • Agitation, restlessness • Moaning, groaning • Multiple causes, irreversible • Lorazepam or midazolam to settle • Sedating antipsychotics Breitbart W, Strout D. ClinGeriatr Med. 2000.

  23. Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience.

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