Transcript Delerium - Grand Rapids Michigan State University Residency

Alice Emery MD
Hospice of Michigan, Grand Rapids
Ph: 616 322 8461
Mental Health: hallmarks
 Ability with maintain relations with people
 Cooperative/cordial relations with colleagues
 Supportive family relationships. Play role of parent or
spouse
 Ability to engage in useful work
 Focus, problem solving, dependability
 Ability to balance/moderate leisure
activities
 Avoid self-destructive patterns
 Relax and enjoy positive experiences
Mental Health: Supports
1.
2.
3.
4.
5.
Habits
Work/useful engagement
Family and supportive friends
Spirituality/Mission
Body constancy(physical
health)
Mental Health
 Baseline level of mental health for each
person at every stage of life
 Stress/loss can disrupt the baseline/upset
the personality causing adjustment phase
 People with good mental health at baseline,
usually can withstand several stresses or
supports lost at once.
 Adjustment disorder
Mental health for patients
 Calm and Cooperative is the minimum required
Neutral emotion and compliant with staff
Palliative care/hospice referral can result from
inability to maintain calmness or cooperativeness
 Chronic: often with setting of dementia
 Acute
 change in mental status due to environmental
disturbance or discomfort (disordered reaction to
sensory input)
 or Real disturbance in neuronal functioning

Delirium
 Acutely (hrs to days) Decreased
awareness of surroundings and
personal state/impaired
attention/decreased rational thinking
 CONFUSION
 Related to medical illness
 Compare to dementia
 Often Increased purposeless activity
level/ Increased anxiety level
Delirium per DSM-IV
 Disturbance of consciousness (e.g. reduced clarity of awareness of the
environment) with reduced ability to focus, sustain, or shift attention.
 A change in cognition (such as memory deficit, disorientation,
language disturbance) or the development of a perceptual disturbance
that is not better accounted for by a pre-existing, established or
evolving dementia.
 The disturbance develops over a short period of time (usually hours to
days) and tends to fluctuate during the course of the day.
 There is evidence from the history, physical examination, or laboratory
findings that the disturbance is caused by the direct physiologic
consequences of a general medical condition.
Anxiety
 Anxiety is a general sensation of fear, which is not
related to or out of proportion to a real and actual
danger.
 Some anxiety may be 'normal' in the hospice
environment, but requires treatment when anxiety
appears to be disproportionately high, and when it is
associated with other severe signs, such as loss of selfcontrol, or leads to disturbance in family relations
Terminal illness: Plenty to be
anxious about
 The future vs. right now in healthy persons
 Right now I feel pretty good
 In the future I hope to have more money, time etc.
 Right now with Multiple Myeloma (Case)
 My legs both feel uncomfortable
 My hip hurts
 My cancer is damaging my kidneys
 The future with terminal disease
 My hip will shatter
 My legs might have to be amputated
 My kidneys will fail
Agitation
 Agitation is a psychomotor disturbance (excitation)
characterized by a marked increase in purposeless
motor and psychological activity in a patient. It
occurs very frequently in the hospice setting. It may
be isolated, or accompanied by other mental
disorders, such as severe anxiety and delirium
 INCREASED ACTIVITY
 Something is driving it
Agitation
 often accompanied by a loss of control of action and a
disorganization of thought.
 Causes of which are frequently occurring situations in
the setting of terminal illness related to the disease
itself (metabolic disorders, medications, sepsisassociated encephalopathy, pain, and so on) or to
external factors (noise, dislocation)
 Agitation per se may be dangerous in hospital or at
home: Falls, injuries, dehydration, exhaustion
Agitation: phone call
 Pt. agitated: 87 yo has been on hospice 14 days with
Debility related to prior hip fx and pneumonia.
Baseline had been able to speak, answer simple
questions. Yesterday was up and down a lot, last night
did not sleep at all, family exhausted and request med
to make her sleep. (Ativan OK?)
 Ask about: Associated symptoms. Review meds, MED
CHANGES, PAIN, BOWELS, URINATION,
HYPOXEMIA,
Fixable causes of agitation or
delirium
 Fecal Impaction
 Urinary retention
 Common in hospice patients who
already have impaired brain function
 Easily overlooked cause of discomfort
 Fixable
Fixable causes of delirium or
agitation:
 Pain: trial of pain med for elderly
 Hypoxemia: oxygen sat/start oxygen
 Infection: UTI
Fixable causes: Medication Effect
Prescribed or illicit drug overdose
or withdrawal (insulin, digoxin,
decadron)
Alcohol: intoxication or withdrawal
Benzodiazepines: adverse reaction
or withdrawal
Paradoxical effect: Benzidiazepine
 5% of people
 Opposite effect of desired calming, relaxing effect
 Can cause physical restlessness, neuroexcitation
 Seizures can be potentiated
 Disinhibition and loss of control.
 Aggression: violent behavior
 Can be mistaken for mania or schizophrenia
 STOP offending agent
 No more benzodiazepines. Use haldol etc
Fixable causes: Medication Effect
 Serotonin syndrome (nvd, fever,
sweating, chills, tremor)
 Neuroleptic malignant syndrome
(muscle rigidity, sweating, fever,
unstable vitals)
 Antipsychotic reaction: akathisia
Agitation due to Toxic Metabolic
Encephalopathy: AGITATED delirium
 What other metabolic causes
 Na+, Ca+, NH4+, unknown factors presumed to be
uncorrectable, high or low glucose
 Circulatory disturbance
 Organ failure
 How to prevent it? Monitoring of electrolytes, good
nursing care.
 Often cannot be prevented, and underlying cause
cannot be treated in hospice setting
Agitated Delirium
 How to evaluate severity?
 Mild: Disordered thinking with paranoia or
hallucinations leading to medication refusal or care
refusal
 Moderate: Distressed affect with psycho-motor
agitation causing safety risk
 Severe: distressed affect, motor agitation, and
aggression/attempts to harm self or others
Toxic-Metabolic Encephalopathy
Management
 Environmental: TV, roommates, level of stimulation
 Special precautions for Veterans
 Safety: restraints or physical limits as needed in
keeping with degree of safety risk
 Medications
Antipsychotics
Typical developed in 1950s beginning with Thorazine
A breakthrough for care of schizophrenia
 with many serious side effects
 Thorazine is very sedating
 Haldol is favorite of Hospice and Palliative care
Atypical Antipsychotics: several types
 Less extrapyramidal motor effects
 Can be sedating (Seroquel due to antihistamine effect)
Agitation due to Toxic Metabolic
Encephalopathy: AGITATED delirium
 Mild: start daily po antipsychotic +/- benzo
 Moderate: po loading dose, then daily antipsychotic
+/- benzodiazepine
 Severe: IM loading doses of Antipsychotic and Benzo
 Followed by scheduled po doses of both.
 For violent resistant patients: Haldol 5mg IM/po now
and 2mg Lorazepam IM/po
 For moderate patients Haldol 1mg tid and titrate
 For mild patients Seroquel or ripserdal low doses
Benzodiazepines
 All benzodiazepines exert, in slightly varying
degrees, 5 major actions: hypnotic, anxiolytic,
anticonvulsant, muscular relaxant and amnesic.
Their main advantages are rapid onset of action
and low toxicity. Few, if any, other drugs can
compete with them in all these respects. Use half
adult doses in elderly.
 Ativan po, sl, IV most often used
 Klonopin po long half life, marketed for seizures
 Valium po, IM rapid onset, long half life
 Xanax po (not preferred)
 Versed IV 1-7mg/hr
Benzodiazepines
 Versed: midazolam: popular in Palliative care
 Rapid onset: watch for resp depression
 Best overall for continuous IV infusion.
 Safe and effective IV with rapid titratability
 Can also be used as nasal insufflation
 Buccal Versed also available mostly for status
epilepticus
Other drugs for acute delirium
 Phenobarb IM 60mg
 May only last 4 hrs. need a follow up plan.
Acute mental status change
 Don’t forget the caregivers
 May be overwhelmed
 Lack of sleep
 Lack of understanding
 May need to call in the supporting cast
Acute Behavior problems in
dementia
 Off label use of antipsychotics to manage behavior
problems in dementia patients has become
commonplace despite warnings of side effects,
increased mortality, and general belief that other
means of improving quality of life would be effective
 In good nursing facilities less than 20% of dementia
pts. require scheduled antipsychotics.
 Work on quality of life measures, and periodic dose
reductions are a good thing.
Depression
 Depressed mood is a part of normal loss
 Related to loss, A series of losses
 Major depression
 can be induced/exacerbated by grief
 Can occur for the first time in the setting
of terminal illness or be longstanding
 DECREASED ACTIVITY
Depression
 Hospice interventions: support return to mental
health for patients with mild depression
 Medications are indicated if believed to be a primary
depression rather than normal fluctuation of mood
related to illness
 Difficult to determine if depression is part of illness or
a separate mental illness, since symptoms of
depression are characterized by depressed mood,
anhedonia, and low energy
Depression
 Medications: neuromodulation
 SSRI selective serotonin reuptake inhibitors
 SSRIs are believed to increase the extracellular level of
serotonin by inhibiting its reuptake into the
presynaptic cell, increasing the level of serotonin in
the synaptic cleft to bind to the post synaptic receptor.
They have varying degrees of selectivity for the other
monoamine transporters, with “pure” SSRIs having
only weak affinity for the noradrenaline and dopamine
transporters.
SSRIs
 Most common therapeutic medication for depression
 Also used for anxiety, social phobia, OCD, many other
dysphoric neurotic disorders.
 Effect in mild or moderate depression is similar to
placebo, but in severe depression positive effect begins
in 2-3 weeks with full effect in 4-6wks.
 Side effects: Appetite or sleep disturbance, Possible
suicide potentiation, seizures, arrhythmias
“Pure” SSRIs
 Citalopram: Celexa
 Escitalopram: Lexapro
 Fluoxetine: Prozac
 Fluvoxamine: Luvox
 Paroxetine: Paxil
 Sertraline: Zoloft
 Vilazodone: Viibryd
Other Antidepressants
SNRIs: newer class with similar effects
 Duloxetine: Cymbalta
 Desvenlafaxine: Pristiq
 Venlafaxine: Effexor
Noradrenergic and Specific Serotonin antidepressants:
(NaSSAs) another developing class which block Alpha 2
receptors and certain serotonin receptors .
Sedating, wt. gain.
 Mirtazapine: Remeron
Other antidepressants
NA (norepinephrine) reuptake blockers:
(NRIs)marketed as enhancing concentration and
motivation
 Atomoxatine: Strattera
Na and Da reuptake inhibitors:
 Bupropion: Wellbutrin
Augmenters
Drugs used with another antidepressant
 Trazodone: for sleep
 Buspar: nonsedating anxiolytic
 Psychostimulants: Methylphenidate (Ritalin),
amphetamine (Adderall), modafinil (Provigil)
 Antipsychotics may be added as well such as
risperidone (Risperdal), quetiapine (Seroquel), and
olanzapine (Zyprexa): controversial due to side effects
 Benzodiazepines: for anxiety
Depression
 Complete response in 25% of patients
 Adding augmenters can increase to 30%
 Change the antidepressant
 Still leaving 70% with poor or incomplete partial
response to medication for depression
 Generally each antidepressant takes 4-6 weeks to
evaluate full response
 Positive effects can fade over time
Ketamine for Depression
 Novel use of ketamine: NIH 8/2006 Published use of
weekly Ketamine dosing for resistant depression
 Published use in ED as IV bolus for treatment of acute
suicidality in depression
 Journal Palliative Medicine July 2010 case series in
terminal hospice patients showed a single oral dose of
approx. 30mg gave a measurable elevation of mood
lasting over one week.
 Mechanism? (not opioid receptor or just NMDA effect)
 Side effects? (acute hallucinations/disassociative state)
Case 1
 64 yo woman with COPD and depressive symptoms
developing over several months.
 Low mood, low energy, hypersomnia, decreased
appetite with unintentional weight loss, hopelessness,
and excessive feelings of guilt, especially regarding
feeling like a burden on her roommate, who was also
her close friend and primary caregiver. She was
preoccupied with thoughts of wanting to die. She did
not plan or intend to end her life, stating “I'm too
chicken to die.”
Case 1
 She had stopped socializing and reading and was
letting bills pile up
 Anxious with daily panic attacks
 Irritable with roommate and the dog
 Fidgety
 Focused on pain and dyspnea
 No cognitive impairment
Case 1
 Informed consent and psychiatric baseline testing
done with
 Hamilton depression scale
 Hospital Anxiety and Depression Scale
 Brief Psychiatric Rating Scale
 Young Mania rating scale
 Mini mental status exam
 Treated with 0.5mg/kg oral ketamine
 Depression and anxiety decreased within hours.
Case 1
 no longer had suicidal thoughts: expressed hope for the future
 no longer felt irritable
 became much more engaging, desiring to talk about television shows
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and soap operas.
Her appetite had improved dramatically
anxiety and irritability she displayed prior to ketamine dosing were
absent
She paid and filed away her entire pile of bills.
Her caregiver reported that S.B. was much more alert and no longer
“nodded off” throughout the day.
Her pain and shortness of breath improved.
trouble sitting still, “I want to get out and do things now.”
She had become less preoccupied with feeling like a burden
begun to read books again,
she started to call her friends and initiated planning social gatherings
Case 1
 Symptoms returned (but not as severely) after a month
and by that time she had developed some confusion
and was on more pain medications
 Repeat dosing did not bring improvement
 Case illustrates one personal result of ketamine
therapy for depression
Case 2
 70 yo man with prostate ca metastatic to liver, bone,
and lung and had been bedbound for 8 months.
 Prognosis days to weeks
 Depression developing over 3 months
 depressed mood, significantly decreased energy, lack
of appetite with unintentional weight loss, poor sleep
with early morning awakening, and ruminative
thoughts of wanting to be dead. He denied a suicidal
plan or intent, explaining “even if I wanted to, I could
not do anything in this state.” He described significant
anhedonia, which contrasted with his prior zest for life
Case 2
 he no longer wanted friends to visit, stopped watching
movies and reading, and had to force himself to eat.
Furthermore, he experienced excessive guilt about
feeling like “a burden” to his wife, who was his primary
caregiver
 Excessive worry and daily panic attacks
 No cognitive impairments
 Treated with 0.5mg/kg oral ketamine
 Noted improvements within hours
Case 2
 Within 60 minutes of dosing, he reported an improvement in his
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anxiety and pain, and his wife observed that he looked “more calm and
peaceful.”
By day 3, he started to request his favorite foods, and his humor was
noted to improve.
On day 4, his wife observed “a big difference” explaining he “was more
chipper.” He watched an entire movie “without dozing” for the first
time in months.
His mood continued to dramatically improve over the following week.
He began to watch, enjoy, and discuss several movies a day with his
wife. His appetite increased and he continued to request his favorite
foods.
he began to have friends visit again and savored their time together.
Around day 13, his physical health worsened to the point that he could
no longer participate with assessments. His wife articulated that his
focus on death qualitatively shifted from wanting to die to “accepting
death.” He peacefully died at home within the following 2 weeks.
Could end of life depression be
more treatable than we think?