Transcript WHAT YOU CAN DO

MEDICAL MIMICS OF
PSYCHIATRIC DISORDER
SUSAN R. REDMOND-VAUGHT, PH.D.
DELIRIUM
A CLINICAL STATE CHARACTERIZED BY AN
ACUTE, FLUCTUATING CHANGE IN MENTAL
STATUS, WITH INATTENTION AND ALTERED
LEVELS OF CONSCIOUSNESS.
Primary Source: Merck Manual of Geriatrics, 3rd Edition; www.merck.com
DELIRIUM (CONTINUED)
“THE HALLMARK OF DELIRIUM IS ACUTE COGNITIVE DYSFUNCTION WITH IMPAIRED
ATTENTIVENESS, WHICH DEVELOPS SUDDENLY OR OVER A SHORT TIME (USUALLY HOURS
TO DAYS).”
AN INDIVIDUAL WITH DELIRIUM HAS SEVERE VARIATIONS IN THEIR MENTAL STATUS, WITH
VARYING LEVELS OF INATTENTION AND ALTERED LEVELS OF CONSCIOUSNESS.
OTHER SYMPTOMS INCLUDE:
• CHANGES IN ORIENTATION, MEMORY, AND ABSTRACT THINKING
• PSYCHOMOTOR ACTIVITY, OR LEVEL OF AROUSAL, MAY BE VARIABLY ABNORMAL
• HALLUCINATIONS,
• DELUSIONS,
• TREMORS
• ABNORMALITIES IN THE INDIVIDUAL’S SLEEP-WAKE CYCLE
DELIRIUM (CONTINUED)
• IN SOME FRAIL, ELDERLY INDIVIDUALS, DELIRIUM PRECEDES THE APPEARANCE OF ANOTHER
ILLNESS AND IS THE ONLY MANIFESTATION OF THAT ILLNESS
• DELIRIUM MAY PERSIST FOR MANY WEEKS OR MONTHS
• INFREQUENTLY IT NEVER CLEARLY RESOLVES, OR IT SHIFTS INTO TO CHRONIC COGNITIVE
DYSFUNCTION
COMMON CAUSES OF DELIRIUM
• DRUG USE
• ELECTROLYTE AND PHYSIOLOGIC ABNORMALITIES
• LACK OF DRUGS (WITHDRAWAL)
• INFECTION
• REDUCED SENSORY INPUT
• INTRACRANIAL PROBLEMS
• URINARY RETENTION AND FECAL IMPACTION
• MYOCARDIAL PROBLEMS
DELIRIUM VS. MAJOR NEUROCOGNITIVE DISORDER
(DEMENTIA)
“Delirium and dementia are the most common causes of mental (cognitive)
dysfunction—the inability to acquire, retain, and use knowledge normally.
Although delirium and dementia may occur together, they are quite
different. Delirium begins suddenly, causes fluctuations in mental function,
and is usually reversible. Dementia begins gradually, is slowly progressive,
and is usually irreversible. Also, the two disorders affect mental function
differently. Delirium affects mainly attention. Dementia affects mainly
memory. Both delirium and dementia may occur at any age but are much
more common among older people because of age-related changes in the
brain.”
http://www.merckmanuals.com/home/brain_spinal_cord_and_nerve_disorders/delirium
_and_dementia/overview_of_delirium_and_dementia.html
Comparing Delirium and Dementia
Feature
Delirium
Dementia
Development
Sudden, sometimes with a definite beginning point
Slow, with an uncertain beginning point
Cause
Almost always another condition, such as an
infection, dehydration, or use or stopping of
certain drugs
Inability to pay attention
Usually a brain disorder, such as Alzheimer
disease, vascular dementia, or Lewy body
dementia
Loss of memory, especially for recent events
Effect at night
Level of alertness (consciousness)
Almost always worse
Impaired to varying degrees, can vary from being
hyperalert to sluggish
Often worse
Normal until late stages
Orientation to surroundings
Effect on language
Varies
Slowed speech, often with incoherent and
inappropriate language
Impaired
Sometimes difficulty finding the right word
Memory
Varies
Lost, especially for recent events
Progression
Slowly progresses, gradually but eventually
greatly impairing all mental functions
Duration
Causes variations in mental function—people are
alert one moment and sluggish and drowsy the
next
Days to weeks, sometimes longer
Need for treatment
Effect of treatment
Immediate
Usually reverses the losses
Needed but less urgently
May slow progression but cannot reverse or
cure the disorder
Main early symptom
Almost always permanent
CEREBROVASCULAR ACCIDENT
(CVA, STROKE)
“A STROKE OCCURS WHEN AN ARTERY TO THE BRAIN BECOMES
BLOCKED OR RUPTURES, RESULTING IN DEATH OF AN AREA OF
BRAIN TISSUE DUE TO LOSS OF ITS BLOOD SUPPLY (CEREBRAL
INFARCTION) AND CAUSING SUDDEN SYMPTOMS.”
http://www.merckmanuals.com/home/brain_spinal_cord_and_nerve_disorders/stroke_cva
/overview_of_stroke.html?qt=cva&alt=sh
CVA BASICS
• STROKES CAN HAPPEN TO PEOPLE OF ANY AGE. MOST STROKES ARE ISCHEMIC (USUALLY
DUE TO BLOCKAGE OF AN ARTERY OR VESSEL), BUT SOME ARE HEMORRHAGIC (DUE TO
RUPTURE OF AN ARTERY OR VESSEL).
• TRANSIENT ISCHEMIC ATTACKS RESEMBLE ISCHEMIC STROKES EXCEPT THAT NO PERMANENT
BRAIN DAMAGE OCCURS AND THE SYMPTOMS TYPICALLY RESOLVE WITHIN 1 HOUR.
• SYMPTOMS OCCUR SUDDENLY AND CAN INCLUDE MUSCLE WEAKNESS, PARALYSIS,
ABNORMAL OR LOST SENSATION ON ONE SIDE OF THE BODY, DIFFICULTY SPEAKING,
CONFUSION, PROBLEMS WITH VISION, DIZZINESS, LOSS OF BALANCE AND COORDINATION,
AND, IN ONE TYPE, A SUDDEN, SEVERE HEADACHE.
http://www.merckmanuals.com/home/brain_spinal_cord_and_nerve_disorders/stroke_cva/overview_of_stroke.html?qt=cva&alt=sh
CVA BASICS
• MOST STROKES ARE ISCHEMIC (USUALLY DUE TO BLOCKAGE OF AN ARTERY OR
VESSEL), BUT SOME ARE HEMORRHAGIC (DUE TO RUPTURE OF AN ARTERY OR
VESSEL).
• TRANSIENT ISCHEMIC ATTACKS RESEMBLE ISCHEMIC STROKES EXCEPT THAT NO
PERMANENT BRAIN DAMAGE OCCURS AND THE SYMPTOMS TYPICALLY RESOLVE
WITHIN 1 HOUR.
• SYMPTOMS OCCUR SUDDENLY AND CAN INCLUDE MUSCLE WEAKNESS,
PARALYSIS, ABNORMAL OR LOST SENSATION ON ONE SIDE OF THE BODY,
DIFFICULTY SPEAKING, CONFUSION, PROBLEMS WITH VISION, DIZZINESS, LOSS
OF BALANCE AND COORDINATION, AND, IN ONE TYPE, A SUDDEN, SEVERE
HEADACHE.
http://www.merckmanuals.com/home/brain_spinal_cord_and_nerve_disorders/stroke_cva/overview_of_stroke.html?qt=cva&alt=sh
CVA BASICS
• DIAGNOSIS IS BASED MAINLY ON SYMPTOMS, BUT IMAGING AND BLOOD
TESTS ARE ALSO DONE.
• RECOVERY AFTER A STROKE DEPENDS ON MANY FACTORS, SUCH AS THE
LOCATION AND AMOUNT OF DAMAGE, THE PERSON'S AGE, AND THE PRESENCE
OF OTHER DISORDERS.
• CONTROLLING HIGH BLOOD PRESSURE, HIGH CHOLESTEROL LEVELS, AND HIGH
BLOOD SUGAR LEVELS AND NOT SMOKING HELP PREVENT STROKES.
• TREATMENT MAY INCLUDE DRUGS TO MAKE BLOOD LESS LIKELY TO CLOT OR TO
BREAK UP CLOTS AND SOMETIMES SURGERY OR ANGIOPLASTY.
http://www.merckmanuals.com/home/brain_spinal_cord_and_nerve_disorders/stroke_cva/overview_of_stroke.html?qt=cva&alt=sh
LEFT-HEMISPHERE STROKE
SYMPTOMS
INABILITY TO SPEAK, UNDERSTAND
LANGUAGE, OR SPEAKING IN GIBBERISH
(APHASIA)
INABILITY TO PERFORM MOTOR TASKS OR
FOLLOW MOTOR COMMANDS (APRAXIA)
APPEARANCE OF ANXIETY AND HESITANCE
APPROACHING ALL TASKS.
CATASTROPHIC RESPONSE (ESPECIALLY IN
FIRST 2 WEEKS)
COMMON MISINTERPRETATION
PSYCHOSIS
UNCOOPERATIVE
MULTIPLE PSYCHIATRIC DISORDERS
PROFOUND SITUATIONAL DEPRESSION OR
CATATONIA
EXAMPLE OF APHASIA
THIS NEWS REPORTER SUFFERED A
STROKE WHILE BROADCASTING.
NOTE HOW HER SPEECH STOPS
MAKING SENSE (APHASIA).
RIGHT-HEMISPHERE STROKE
SYMPTOMS
LOSS OF PRAGMATICS OF “SOCIAL SENSE” IN SPEECH
AND GENERAL BEHAVIOR
COMMON MISINTERPRETATION
MANIA
DISINHIBITION (VERBAL, SEXUAL)
IMPULSIVE, WITH ORGANIC LACK OF UNDERSTANDING
OF DEFICITS AND LIMITATIONS (ANOSOGNOSIA)
VISUAL, VISUAL-SPATIAL, OR VISUAL INTERPRETATIVE
DEFICITS; ERRORS IN SENSORY INTERPRETATION ARE
OFTEN CALLED AGNOSIA
MANIA; IMPULSE CONTROL DISORDER;
PSYCHOSIS
PARANOIA; PSYCHOSIS
ANY STROKE
• DISORIENTATION AND DELIRIUM IN THE FIRST 14-30 DAYS
• FATIGUE
• SUDDEN EPISODES OF CRYING OR SOBBING/MARKED
EMOTIONAL LABILITY
• REACTIONS TO SENSORY DEPRIVATION DUE TO LOSS OF VISION,
HEARING, TACTILE INPUT, SMELL, OR TASTE, PLUS ISOLATION OF
BEING HOSPITALIZED
GENERAL SUGGESTIONS
• USE EXTREME CAUTION IN ASSUMING A PERSON IS HAVING PSYCHIATRIC
SYMPTOMS IF THE STROKE OCCURRED <30 DAYS
• CONSIDER CONSULTING NEUROLOGY OR SEEKING STROKE
REHABILITATION VS. PSYCHIATRIC CARE IF PROBLEMATIC BEHAVIOR OR
SYMPTOM PRESENTATION IS A DIRECT RESULT OF THE LOCATION OF THE
STROKE
• BEWARE OF USING AFFECT (FACIAL EXPRESSION) AS A MEASURE OF
PSYCHIATRIC STABILITY OR MOOD STATE IN INDIVIDUALS WITH A HISTORY
OF STROKE
• ALWAYS BE AWARE THAT STATE PSYCHIATRIC FACILITIES DO NOT OFFER
THERAPIES NECESSARY TO REHABILITATE DEFICITS FROM AN ACUTE STROKE.
RECENT SURGERY - OVERVIEW
• SOME PATIENTS DEVELOP POST-SURGICAL DELIRIUM (TYPICAL ONSET 0-7 DAYS) IN 1-2 WEEKS
FOLLOWING A SURGICAL PROCEDURE
• ACUTE AND OFTEN DANGEROUS CONDITION
• MORE COMMON IN:
• ELDERLY PATIENTS OR
• PATIENTS WITH KNOWN BRAIN INJURY OR
• PATIENTS WITH INTELLECTUAL DISABILITY
• FIRST NOTED IN 1891 BY PROFESSOR LE DENTU
• MODERN STATISTICS SUGGEST THAT 8%, OR ROUGHLY 1 IN 10 PATIENTS WITH POST-SURGICAL
DELIRIUM WILL DIE, OFTEN WITHIN 90 DAYS OF THE SURGERY
• CAUSES OF DEATH USUALLY TRACE TO SUDDEN ALTERATIONS IN BLOOD PRESSURES, CARDIAC
ABNORMALITIES, STROKE, OR OTHER METABOLIC DERANGEMENT
RECENT SURGERY -TREATMENT
• DEBATES CENTER AROUND USE OF CHEMICAL OR PHYSICAL RESTRAINTS TO CONTAIN PATIENTS DURING THE
WORST OF THE POST-SURGICAL DELIRIUM
• “SOCIAL RESTRAINT” OR THE USE OF SITTERS IS ALSO ADVOCATED
• TYPICALLY, BETTER OUTCOMES RESULT FROM SOCIAL RESTRAINT
• RESEARCH SUGGESTS THAT THE LESS MEDICATION GIVEN, AND THE MORE MEDICATIONS REMOVED, THE BETTER
THE OUTCOME
• CLOSE MEDICAL MONITORING WITH IMMEDIATE RESPONSE TO OFTEN RAPIDLY-DEVELOPING CONDITIONS IS
IMPORTANT. THESE CONDITIONS INCLUDE:
• HYPOTENSION
• HYPERTENSION
• RENAL INSUFFICIENCY
• RENAL FAILURE
• ARRHYTHMIAS
• STROKE
RECENT SURGERY -TREATMENT
• PHYSICIANS MAY PROCEED WITH COMMITMENT REQUESTS
• NOT APPROPRIATE TO REFER PATIENTS TO FACILITIES SUCH AS WESTERN STATE HOSPITAL,
EASTERN STATE HOSPITAL, CENTRAL STATE HOSPITAL, APPALACHIAN REGIONAL HOSPITAL,
OAKWOOD, OR OUTWOOD
• POST-SURGICAL DELIRIUM TREATMENT WOULD ENTAIL MULTIPLE RE-TRANSFERS BACK TO ACUTE
MEDICAL CARE
• WHAT HAPPENS TO THE INDIVIDUAL?
•
•
•
•
MULTIPLE ENVIRONMENTAL CHANGES
DISORGANIZATION IN MEDICAL APPROACHES
PROLONGED DELIRIOUS STATE
SIGNIFICANT WORSEN OUTCOME
ENVIRONMENTAL MANAGEMENT TIPS
• USE MAXIMUM FALLS PRECAUTIONS AND PROTECTIONS
• CONSIDER PLACING THE PATIENT IN A ROOM CLOSE TO THE NURSING STATION
• AVOID PLACING THE PATIENT IN BUSY, LOUD, OR CHAOTIC THERAPY ROOMS OR SETTINGS
(OVERSTIMULATION)
• IF THE PATIENT IS HALLUCINATING, CONSIDER ADDING CONTROLLED VISUAL STIMULI
(MOVIES, SCREEN SAVERS) AND LOW TO MODERATE VOLUME MUSIC
• KEEP LIGHTING ADEQUATE BOTH DAY AND NIGHT – DO NOT PLACE THE PATIENT IN THE
DARK
• MAKE CERTAIN HEARING AIDS, EYEGLASSES, AND OTHER DEVICES THAT ASSIST SENSORY
PERCEPTION ARE USED AS MUCH AS POSSIBLE AND SAFELY
MORE ENVIRONMENTAL MANAGEMENT TIPS
• ADD AN EASILY-SEEN CLOCK OR CALENDAR
• REORIENT IN ALL SPHERES MULTIPLE TIMES ACROSS THE DAY, PREFERABLY
EACH TIME STAFF INTERACTS WITH THE PATIENT
• DO NOT DIRECTLY REFUTE, ARGUE WITH, OR DENY DELUSIONS
• OFFER ALTERNATIVE EXPLANATIONS AND REASSURE THE PATIENT
• AS A RULE, THE SINGLE BEST ENVIRONMENTAL INTERVENTION IS ASKING
SUPPORTIVE FAMILY MEMBERS OR A SUPPORTIVE FRIEND TO STAY WITH THE
PATIENT
COMMON CONDITIONS: UTI
• CONFUSION, COMBATIVENESS, AND PARANOIA OFTEN ONSET 48-72 HOURS BEFORE
CONFIRMATORY LABORATORY FINDINGS
• DELIRIUM IS MOST COMMON COMPLICATION OF UTI
• SHOULD ALWAYS BE A FIRST SUSPECT IN NEW-ONSET DELIRIUM
• AFFECTS BOTH MALES AND FEMALES
• FOLLOWING ONSET OF TREATMENT, DELIRIUM AND OTHER BEHAVIORAL SYMPTOMS
TYPICALLY WILL BEGIN TO CLEAR (48-72 HOURS)
COMMON CONDITIONS: PNEUMONIA
• CONFUSION, STUPOR, AND DELIRIUM ARE COMMON CONSEQUENCES, ESPECIALLY IN ELDERLY
PATIENTS, PATIENTS WITH KNOWN BRAIN COMPROMISE, AND INDIVIDUALS WITH MAJOR
NEUROCOGNITIVE DISORDER (DEMENTIA)
• LOW O2 SATURATION ON ROOM AIR OR WITH EXERTION MAY BE PREDICTIVE OF DELIRIUM
AND CONFUSION
• INDIVIDUALS REQUIRING STEROIDS MAY DEVELOP ACUTE AND SEVERE PSYCHOSIS RELATED TO
THESE MEDICATIONS
• CONFUSED INDIVIDUALS WITH PNEUMONIA ARE OFTEN PHYSICALLY COMBATIVE DURING
PERSONAL CARE, DUE TO SENSATIONS OF SMOTHERING AND THE CONFUSION ITSELF
• COGNITIVE AND BEHAVIORAL SYMPTOMS TYPICALLY CLEAR AT AROUND THE SAME PACE AS THE
CHEST X-RAY
COMMON CONDITIONS: RENAL FAILURE/DIALYSIS
• ABNORMALITIES IN BUN AND CREATININE FREQUENTLY RESULT IN PARANOIA, WHICH MAY BE CHRONIC OR
ACUTE -- THIS IS OFTEN NOT TREATABLE DUE TO RENAL STATUS
• INDIVIDUALS ON REGULAR DIALYSIS, ESPECIALLY IN LATER STAGE DISEASE, WILL SHOW COGNITIVE,
BEHAVIORAL AND EMOTIONAL DECOMPENSATION AS TIME FOR DIALYSIS APPROACHES
• DELIRIUM IS COMMON IN RENAL FAILURE, AND CAN BECOME CHRONIC IN DIALYSIS PATIENTS
• ENCEPHALOPATHY, OR GRADUAL SLOWING OF BRAIN FUNCTIONS, AT TIMES WITH SIGNIFICANT MOTOR
SYMPTOMS SUCH AS TICS, MYOCLONIC JERKS, OR OTHER MOVEMENT DISORDERS IS A RELATIVELY
COMMON OCCURRENCE IN LATER-STAGE RENAL DISEASE AND LONG-TERM DIALYSIS PATIENTS
• END-STAGE RENAL PATIENTS ON LONG-TERM DIALYSIS WHO ASK TO STOP TREATMENT ARE NOT
NECESSARILY DEPRESSED OR SUICIDAL.
• IF THEY ARE COMPETENT, ASSESSMENT SHOULD CONSIDER LENGTH OF DISEASE AND ILLNESS AND REALISTIC
PROGNOSIS
• THIS IS FREQUENTLY AN END-OF-LIFE ISSUE, MUCH AS CANCER PATIENTS REFUSING CHEMOTHERAPY, AND SHOULD
BE TREATED AS SUCH
• MOST PSYCHIATRIC HOSPITALS DO NOT, UNDER ANY CIRCUMSTANCES, ACCEPT INDIVIDUALS ON DIALYSIS
FOR TREATMENT. THIS IS FAR BEYOND PSYCHIATRIC SCOPE OF CARE, AND REQUIRES A MED-PSYCH MODEL
SEIZURE DISORDER (EPILEPSY)
• PRE-ICTAL (ALSO SPELLED PRE-ICTAL) IS THE PERIOD OF TIME, USUALLY RELATIVELY SHORT,
BUT POSSIBLY AS MUCH AS 24 HOURS, PRIOR TO THE ONSET OF SEIZURE ACTIVITY. EEG
ABNORMALITIES ARE OFTEN SEEN, BUT DO NOT RISE TO THE ICTAL LEVELS
• ICTAL IS THE PERIOD OF TIME DURING WHICH EEG IS ABNORMAL AND REFLECTIVE OF
SEIZURE ACTIVITY
• POST-ICTAL (ALSO SPELLED POSTICTAL) IS THE PERIOD OF TIME FROM 5-15 MINUTES
(ACUTE, EEG NORMALIZATION OCCURRING) TO SEVERAL HOURS (POST-ACUTE RECOVERY,
WHEN THE INDIVIDUAL IS USUALLY SLEEPING AND IRRITABLE OR CONFUSED IF ROUSED)
AFTER A SEIZURE
• INTER-ICTAL IS THE PERIOD OF TIME BETWEEN POSTICTAL AND PRE-ICTAL STATES
SEIZURE DISORDER GENERAL INFO
• MOST INDIVIDUALS WITH A KNOWN EPILEPTIC CONDITION WILL BE UNDER THE TREATMENT OF
A NEUROLOGIST OR PRIMARY CARE PHYSICIAN (PCP) AND NEVER REFERRED FOR BEHAVIORAL
HEALTH CARE
• PRESENCE OF SEIZURE DISORDER IS NOT PREDICTIVE OF MENTAL ILLNESS, THOUGH INCIDENCE
OF MENTAL ILLNESS IS HIGHER IN INDIVIDUALS WITH EPILEPSY
• DEPRESSION WITH BOTH FUNCTIONAL AND ORGANIC CAUSATION IS THE MOST COMMON
ISSUE
• PROVIDED SEIZURES ARE CONTROLLED, INDIVIDUALS CAN BE TREATED IN INPATIENT PSYCHIATRIC
SETTINGS IF NECESSARY—FOR EMOTIONAL ISSUES, NOT FOR THE SEIZURES THEMSELVES
• INDIVIDUALS WITH UNTREATED OR POORLY TREATED SEIZURES OFTEN BEHAVE IN A CONFUSED,
IMPULSIVE, OR DISORGANIZED FASHION DURING PRE-ICTAL, ICTAL, AND POST-ICTAL STATES
SEIZURE DISORDER POTENTIAL ISSUES
• INDIVIDUALS WITH TRUE POST-ICTAL DELIRIUM ARE RARE; HOWEVER, INDIVIDUALS DO STOP TREATMENT,
OR UNFORTUNATELY, MAY NOT BE ABLE TO AFFORD TREATMENT
• INDIVIDUALS WITH POST-ICTAL DELIRIUM CAN PRESENT SIGNIFICANT DANGER TO THEMSELVES OR
OTHERS DUE TO EXTREME CONFUSION AND CONFUSION-RELATED VIOLENCE
• VIOLENCE IS TYPICALLY UNPROVOKED, SUDDEN AND EXTREME, AND IS USUALLY PRECEDED BY RAPID
PUPILLARY DILATION
• POST-ICTAL DELIRIUM CAN ALSO BE ASSOCIATED WITH MASSIVE AND COMPLEX VISUAL HALLUCINATIONS
• INDIVIDUALS WITH UNCONTROLLED OR POORLY CONTROLLED SEIZURES ARE NOT APPROPRIATELY FOR
INPATIENT PSYCHIATRIC HOSPITALIZATION, EVEN IF THE ABOVE-DESCRIBED DANGEROUS SYMPTOMS ARE
OCCURRING. THIS IS A LIFE-THREATENING SITUATION, BOTH DUE TO THE BEHAVIORAL FACTORS AND THE
RISK FROM THE SEIZURES THEMSELVES.
• LOCKED SEIZURE UNITS ARE AVAILABLE AT MANY MAJOR MEDICAL CENTERS IF UNTREATED OR VERY
POORLY CONTROLLED SEIZURES ARE THE KNOWN OR SUSPECTED CAUSE OF THE INDIVIDUAL’S PROBLEMS.
OVER 40 TYPES OF SEIZURES
This is a seizure
(Complex Partial).
Absence seizures are easy to miss.
Simple Partial seizures
can look like tics.
Many seizures, like this
Myoclonic Absence
seizure,
happen so fast
people never notice.
COMPLEX-PARTIAL SEIZURES
• ALSO CALLED PARTIAL COMPLEX
• OLDER OR RELATED TERMS: PSYCHOMOTOR SEIZURE OR TEMPORAL LOBE
EPILEPSY
• USUALLY BEGIN BETWEEN LATE CHILDHOOD AND EARLY THIRTIES
• CAN ONSET FOLLOWING BRAIN TRAUMA AT ANY AGE
• OCCUR IN 65% OF INDIVIDUALS WITH EPILEPSY
• MORE LIKELY TO BE REFERRED TO A BEHAVIORAL HEALTH PROFESSION FOR
TREATMENT
COMPLEX PARTIAL SEIZURES
• A SMALL PERCENTAGE OF INDIVIDUALS DEVELOP INTER-ICTAL PSYCHOTIC STATES AND THIS MOST OFTEN OCCURS
WHEN SEIZURES ARE POORLY CONTROLLED
• INDIVIDUALS WHO EXPERIENCE HALLUCINATIONS ONLY DURING PRE-ICTAL, ICTAL, OR POST-ICTAL STATES DO NOT
NECESSARILY HAVE PSYCHIATRIC DISORDER, AND IN FACT, MOST DO NOT
• INDIVIDUALS IN COMPLEX PARTIAL ICTAL STATES CAN ENGAGE IN SIMPLE ACTIVITIES SUCH AS STANDING, WALKING,
PACING AND DRIVING
• INDIVIDUALS IN ICTAL STATES CAN RESPOND VERBALLY WITH SIMPLISTIC OR TELEGRAPHIC ANSWERS, OFTEN
ACCURATELY.
• MANY INDIVIDUALS EXPERIENCE ABDOMINAL SENSATIONS PRIOR TO SEIZURE, AND MAY MAKE CONFUSIONAL
COMPLAINTS OF SNAKES OR OTHER ANIMALS IN THEIR STOMACH
• ICTAL SEX, OR COMPLETE SEXUAL ACTS WHILE IN AN ICTAL STATE, WHILE POPULAR IN MOVIES AND LITERATURE, IS
EXCEEDINGLY RARE
• ICTAL VIOLENCE IS EXCEEDINGLY RARE
SOURCES OF INFORMATION FOR
SEIZURE DISORDER SECTION
• KAUFMAN, DAVID (1990). CLINICAL NEUROLOGY FOR PSYCHIATRISTS, 3RD EDITION.
PHILADELPHIA: HARCOURT BRACE JOVANOVICH
• NIEDERMEYER, ERNST (1990). THE EPILEPSIES: DIAGNOSIS AND MANAGEMENT.
BALTIMORE: URBAN & SCHWARZENBERG
END-STAGE ORGAN FAILURE
• INDIVIDUALS WITH END-STAGE ORGAN FAILURE, OR ANY END-STATE MEDICAL ILLNESS, MAY NOT BE
APPROPRIATE FOR INPATIENT PSYCHIATRIC ADMISSION
• CARDIAC DISEASE
• INDIVIDUALS WITH END-STAGE CARDIAC DISEASE ARE FREQUENTLY SHORT OF BREATH, DELIRIOUS, CONFUSED,
AND COMBATIVE
• DEMENTIA IS OFTEN PRESENT
• LUCID PATIENTS WITH END-STAGE CARDIAC DISEASE OFTEN STATE A WISH TO DIE DUE TO MARKED LIFE
LIMITATIONS
• PULMONARY DISEASE
• INDIVIDUALS WITH END-STAGE LUNG DISEASE FREQUENTLY SHOW PSYCHOSIS, PROLONGED PANIC, AND
INCREASING DELIRIUM, STUPOR, AND COGNITIVE DEFICITS
• LUCID PATIENTS WITH END-STAGE PULMONARY DISEASE OFTEN EXPRESS A WISH TO DIE, OR FOR THE
SENSATIONS TO STOP AT ANY COST
END-STAGE ORGAN FAILURE
• HEPATIC DISEASE
• INDIVIDUALS WITH END-STAGE LIVER DISEASE OFTEN SHOW:
• MARKED DELIRIUM;
• INTERMITTENT COMA;
• SEVERE COMBATIVENESS WHEN AWAKE;
• MOVEMENT DISORDER
• ASTERIXIS OR FLAPPING OF THE WRISTS/HANDS USUALLY ACCOMPANIED BY SHORT ARRHYTHMIC LOSSES OF VOLUNTARY
MUSCLE CONTRACTIONS ); AND
• ASSOCIATED SHORT, QUICK LAPSES OF POSTURE
• EVEN WHEN AWAKE, THESE INDIVIDUALS CAN BE EVALUATED WITH THE GLASGOW COMA SCALE
END OF LIFE AGITATION
• END OF LIFE AGITATION:
• CONFUSIONAL AND DELIRIOUS STATES THAT OCCUR AS AN INDIVIDUAL APPROACHES DEATH
• SENSITIVE ISSUE FOR BOTH PHYSICIANS AND FAMILIES
• MANY FAMILIES AND MEDICAL PROFESSIONALS PREFER NOT TO DISCUSS OR ADDRESS THESE
ISSUES
• MANY NURSING FACILITIES FAIL TO RECOGNIZE THE DIFFERENCE BETWEEN EVOLVING
BEHAVIORAL AND PSYCHIATRIC DISORDERS AND THE ONSET OF END OF LIFE AGITATION
• REFERRALS FOR INPATIENT CARE MAY BE BASED IN DENIAL, LACK OF KNOWLEDGE, OR
UNCERTAINTY ABOUT THE INDIVIDUAL’S STATUS
END OF LIFE AGITATION
• MOST INPATIENT PSYCHIATRIC FACILITIES CANNOT BY POLICY, ACCREDITATION, OR SCOPE OF
CARE OFFER HOSPICE CARE
• MOST INPATIENT PSYCHIATRIC FACILITIES CANNOT HONOR DNR REQUESTS WITHOUT REINITIATING THEM AT THE NEW FACILITY
• MOST INPATIENT PSYCHIATRIC FACILITIES CANNOT HONOR ADVANCED DIRECTIVES (SUCH AS
REFUSAL OF FEEDING TUBES) UNDER ANY CIRCUMSTANCES
• INDIVIDUALS WITH END OF LIFE AGITATION, WITH OR WITHOUT PRE-EXISTING MENTAL ILLNESS,
CANNOT BENEFIT FROM INPATIENT PSYCHIATRIC CARE
END OF LIFE AGITATION
“TERMINAL CONDITION” MEANS A CONDITION CAUSED BY INJURY, DISEASE, OR ILLNESS, WHICH
TO A REASONABLE DEGREE OF MEDICAL PROBABILITY, AS DETERMINED SOLELY BY THE PATIENT’S
ATTENDING PHYSICIAN AND ONE (1) OTHER PHYSICIAN, IS INCURABLE AND IRREVERSIBLE AND
WILL RESULT IN DEATH WITHIN A RELATIVELY SHORT TIME, AND WHERE THE APPLICATION OF LIFEPROLONGING TREATMENT WOULD SERVE ONLY TO ARTIFICIALLY PROLONG THE DYING
PROCESS.”
MICHIE’S KENTUCKY REVISED STATUTES, CERTIFIED VERSION
VOLUME 12, CHAPTERS 309-341
UNDERSTANDING THE DYING PROCESS
1 TO 2 WEEKS PRIOR TO DEATH
• DISORIENTATION, CONFUSION
1 TO 3 MONTHS PRIOR TO DEATH
• WITHDRAWAL FROM WORLD AND
PEOPLE
• DECREASED FOOD INTAKE
• AGITATION
• TALKING WITH UNSEEN
• PICKING AT CLOTHES
• DECREASED BLOOD PRESSURE
• PULSE INCREASE OR DECREASE
• INCREASED SLEEP
• COLOR CHANGES; PALE, BLUISH
• GOING INSIDE SELF
• INCREASED PERSPIRATION
• LESS COMMUNICATION
• RESPIRATION IRREGULARITIES
• CONGESTION
• SLEEPING BUT RESPONDING
RESOURCE: “Gone From My Sight:
The Dying Experience” by Barbara
Karnes, RN
• COMPLAINTS OF BODY TIRED AND HEAVY
• NOT EATING, TAKING LITTLE FLUIDS
• BODY TEMPERATURE HOT/COLD
UNDERSTANDING THE DYING PROCESS
DAYS OR HOURS
• INTENSIFICATION OF 1-2 WEEK SIGNS
• SURGE OF ENERGY
• DECREASE IN BLOOD PRESSURE
• EYES GLASSY, TEARING, HALF-OPEN
• IRREGULAR BREATHING, START/STOP
MINUTES
• FISH OUT OF WATER BREATHING
• CANNOT BE AWAKENED
• RESTLESSNESS OR NO ACTIVITY
• PURPLISH KNEES, FEET, HANDS, BLOTCHY
• PULSE WEAK AND HARD TO FIND
• DECREASED URINE OUTPUT
• MAY WET OR STOOL THE BED
RESOURCE: “Gone From My Sight:
The Dying Experience” by Barbara
Karnes, RN
THE LAST STAGES OF LIFE
• MANY PHYSICAL CHANGES OCCUR DURING THE PROCESS OF DYING THAT AFFECT THE
EMOTIONAL, SOCIAL, AND SPIRITUAL ASPECTS OF AN INDIVIDUAL’S LIFE.
• THERE ARE SOME SIGNS AND SYMPTOMS OF DYING THAT ARE OBSERVABLE, ALTHOUGH
NOT EVERYONE FOLLOWS A PREDICTABLE SEQUENCE OF EVENTS OR STAGES
• HEALTH PROFESSIONALS SPEAK OF “DYING TRAJECTORIES” THAT SUGGEST HOW
INDIVIDUALS WITH SPECIFIC DISEASES WILL DIE:
• THOSE WITH A TERMINAL ILLNESS, SUCH AS ADVANCED CANCER, WILL SHOW A STEADY DECLINE
TOWARD DEATH
• THOSE WITH SERIOUS CHRONIC ILLNESSES MAY HAVE PEAKS AND VALLEYS THAT SOMETIMES GIVE
THE IMPRESSION OF RECOVERY
• REMEMBER EACH INDIVIDUAL’S DEATH IS UNIQUE
SOURCE: http://kokuamau.org/resources/last-stages-life
END OF LIFE – WITHDRAWAL FROM THE EXTERNAL
WORLD
• INDIVIDUAL MAY HAVE A FEELING OF
DETACHMENT FROM THE PHYSICAL WORLD
WHAT YOU CAN DO:
• LOSS OF INTEREST IN THINGS FORMERLY
FOUND PLEASURABLE
• ALWAYS SPEAK GENTLY AND IDENTIFY YOURSELF BEFORE
SPEAKING
• TENDENCY TO SLEEP MORE
• USE GENTLE TOUCH AND PROVIDE REASSURANCE
• LESS DESIRE TO TALK
• DYING REQUIRES ENERGY AND FOCUS
• DAYS OR HOURS BEFORE DEATH, THE
INDIVIDUAL BECOMES LESS AND LESS
RESPONSIVE TO VOICE AND TOUCH MAY NOT
AWAKEN
• INDIVIDUAL MAY BE ALERT AND TALKATIVE –
USE THIS AS A “WINDOW OF OPPORTUNITY”
TO SAY WHAT YOU NEED TO SAY AND HAVE
CLOSURE
• TRY NOT TO DISTRACT THE INDIVIDUAL FROM THIS
NECESSARY PREPARATION
• ALLOW TIME FOR SILENCE
• REMEMBER THAT YOU ARE SUPPORTING THE INDIVIDUAL
TO “LET GO.”
SOURCE: http://kokuamau.org/resources/last-stages-life
END OF LIFE – VISIONS AND HALLUCINATIONS
WHAT YOU CAN DO:
• VISUAL OR AUDITORY HALLUCINATIONS
ARE OFTEN PART OF THE DYING EXPERIENCE
• APPEARANCE OF FAMILY MEMBERS OR
LOVED ONES WHO HAVE DIED IS
COMMON
• VISIONS ARE CONSIDERED NORMAL
• INDIVIDUAL MAY TURN THEIR FOCUS TO
“ANOTHER WORLD” AND TALK TO PEOPLE
OR SEE THINGS THAT OTHERS DO NOT SEE
• DO NOT JUDGE OR BE CRITICAL OF WHAT IS
HAPPENING.
• REFRAIN FROM DISCOUNTING THE EXPERIENCE AND
ORIENTING THE INDIVIDUAL TO “REALITY”
• IMPORTANT TO DIFFERENTIATE VISIONS FROM
HALLUCINATIONS OR “BAD DREAMS” THAT MAY BE
CAUSED BY MEDICATIONS OR METABOLIC CHANGES
• “BAD DREAMS” MAY FRIGHTEN THE DYING PERSON –
ALERT THE DOCTOR OR NURSE ABOUT “BAD DREAMS”
SOURCE: http://kokuamau.org/resources/last-stages-life
END OF LIFE – LOSS OF APPETITE
WHAT YOU CAN DO:
• INDIVIDUAL MAY LOSE INTEREST IN FOOD AND DRINK
• REFRAIN FROM GIVING LIQUIDS OR
FOOD UNLESS REQUESTED
• ABILITY TO SWALLOW BECOMES IMPAIRED
• EARLY STAGES OF DYING HE/SHE MAY PREFER ONLY SOFT
FOODS AND LIQUIDS
• VERY LAST STAGES THEY MAY NOT WANT ANY FOOD OR DRINK
BUT MAY WANT TO SUCK ON ICE CHIPS OR TAKE A SMALL
AMOUNT OF LIQUID TO WET AND FRESHEN THE MOUTH
• IMPORTANT TO REMEMBER: AS THE PHYSICAL BODY IS DYING,
THE VITAL ORGANS ARE SHUTTING DOWN; NOURISHMENT IS NO
LONGER REQUIRED TO KEEP THEM FUNCTIONING
• WET THE LIPS AND MOUTH WITH A
SMALL AMOUNT OF WATER, ICE
CHIPS, OR A SPONGE-TIPPED
APPLICATOR DIPPED IN WATER
• PROTECT LIPS FROM DRYNESS WITH
A PROTECTIVE LIP BALM
• CONTINUE TO BE A CARING AND
LOVING PRESENCE
SOURCE: http://kokuamau.org/resources/last-stages-life
END OF LIFE – CHANGE IN BOWEL AND BLADDER
FUNCTIONS
CONSTIPATION
INCONTINENCE
• MAY BE CAUSED BY LACK OF MOBILITY, PAIN,
MEDICATION, DECREASED FLUID INTAKE
• LOSS OF BLADDER CONTROL IS LIKELY TO BE
DISTRESSING TO THE INDIVIDUAL AND THOSE IN
ATTENDANCE
• IF LEFT UNTREATED, FECAL IMPACTION MAY
OCCUR AND CAN BECOME
UNCOMFORTABLE
• LAXATIVES ARE GENERALLY NEEDED TO KEEP
BOWELS CLEAN
WHAT YOU CAN DO:
• Keep affected areas clean and dry to avoid rashes or
bedsores
• Watch for signs of constipation and incontinence
• Talk to doctor or nurse about advantages of reducing
food/fluid in last stages of dying
• IN THE EARLY STAGES, “ACCIDENTS” CAN OCCUR
• AS DEATH NEARS, MUSCLES IN THESE AREAS
(INCLUDING BOWEL) RELAX FURTHER AND
CONTENTS ARE RELEASE
• URINE IS HIGHLY CONCENTRATED, SPARSE, AND
MAY LOOK TEA-COLORED
• SOMETIMES A URINARY CATHETER IS INSERTED
SOURCE: http://kokuamau.org/resources/last-stages-life
END OF LIFE – CONFUSION, RESTLESSNESS,
AND AGITATION
WHAT YOU CAN DO:
• RESTLESSNESS AND AGITATION ARE
COMMON
• NEVER STARTLE THE INDIVIDUAL WITH BRIGHT
LIGHTS, HARSH TONES, OR ABRUPT MOVEMENT
• SYMPTOMS MAY BE CAUSED BY:
• ALWAYS IDENTIFY YOURSELF
• REDUCED OXYGEN TO THE BRAIN
• METABOLIC CHANGES
• DEHYDRATION
• PAIN MEDICATIONS
• “TERMINAL DELIRIUM” IS MARKED BY
EXTREME RESTLESSNESS AND AGITATION BUT
IS NOT CONSIDERED TO BE PAINFUL
• BE AWARE: DYING INDIVIDUALS MAY TRY TO
HOLD ON UNTIL THEY FEEL A SENSE OF
SECURITY AND COMPLETION
SOURCE: http://kokuamau.org/resources/last-stages-life
• USE A GENTLE VOICE AND REASSURING TOUCH
• WITH MINDFUL AWARENESS, BE SENSITIVE TO ANY
CUES THAT MIGHT SIGNAL THERE IS SOMETHING
THE INDIVIDUAL WANTS TO RESOLVE BEFORE
HE/SHE CAN LET GO
• CONSIDER THE USE OF LIGHT MASSAGE AND
SOOTHING MUSIC
• ASK THE DOCTOR IF THERE ARE ANY MEDICATIONS
THAT MIGHT HELP RELIEVE THE AGITATION
END OF LIFE – CHANGES IN BREATHING,
CONGESTION IN LUNGS OR THROAT
WHAT YOU CAN DO:
• BREATHING MAY BE SHALLOW AND
QUICKENED OR SLOW AND LABORED
• INDIVIDUAL MAY MAKE GURGLING
SOUNDS – REFERRED TO AS “DEATH
RATTLE”
• CHEYNE-STOKES BREATHING PATTERN IS
MARKED BY PERIODS OF NO BREATHING
AT ALL, FOLLOWED BY DEEPER AND MORE
FREQUENT RESPIRATIONS
• CONDITION IS NOT UNCOMFORTABLE OR
PAINFUL FOR THE INDIVIDUAL
• THE “DEATH RATTLE” OR CHEYNE-STOKES
BREATHING INDICATE DEATH IS NEAR
• DO NOT PANIC
• RAISE HEAD OF THE BED TO HELP BREATHING
• IF SECRETIONS ARE POOLING IN THE MOUTH, TURN THE
INDIVIDUAL’S HEAR AND POSITION THE BODY SO
GRAVITY CAN DRAIN THEM
• IF APPROPRIATE, WIPE OUT THE MOUTH WITH A SOFT,
MOIST CLOTH TO CLEANSE EXCESS SECRETIONS
• SPEAK GENTLY AND LOVINGLY
• USE GENTLE REASSURING TOUCH TO EASE FEAR
• ALERT DOCTOR OR NURSE IF BREATHING IS ESPECIALLY
LABORED OR YOU NOTICE THE “DEATH RATTLE” AND
CHEYNE-STOKES BREATHING
SOURCE: http://kokuamau.org/resources/last-stages-life
END OF LIFE – CHANGE IN SKIN TEMPERATURE
AND COLOR
WHAT YOU CAN DO
• TRY TO KEEP THE INDIVIDUAL AS
COMFORTABLE AS POSSIBLE
• USE A DAMP, COOL WASHCLOTH TO
COOL A PERSON WHO FEELS TOO HOT
• AS THE BODY DIES, THE BLOOD MOVES AWAY
FROM THE EXTREMITIES TOWARD THE VITAL
ORGANS
• EXTREMITIES MAY BE COOL WHILE ABDOMEN
IS WARM
• INDIVIDUAL MAY FEEL HOT ONE MINUTE AND
COLD THE NEXT
• COVER THE INDIVIDUAL WITH A BLANKET IF
HE/SHE FEELS TOO COLD
• AS DEATH APPROACHES, THERE MAY BE HIGH
FEVER
• ALERT THE DOCTOR/NURSE IF NOTICE
CHANGES IN SKIN COLOR
• MAY ALSO SEE PURPLISH-BLUISH BLOTCHES
AND MOTTLING ON LEGS, ARMS, OR
UNDERSIDE OF BODY
• USE A FAN TO CIRCULATE AIR MAY MAKE
INDIVIDUAL MORE COMFORTABLE
• AS DEATH NEARS, THE BODY MAY APPEAR
YELLOWISH OR WAXEN IN COLOR
SOURCE: http://kokuamau.org/resources/last-stages-life
END OF LIFE –
MANAGING PHYSICAL PAIN
• MOST PHYSICAL PAIN CAN BE CONTROLLED
• NO ONE SHOULD DIE IN PAIN WHEN THE MEANS TO RELIEVE IT ARE AVAILABLE
• ALL INDIVIDUALS HAVE THE RIGHT TO HAVE THEIR PAIN CONTROLLED
• PAIN IS REAL
• ALWAYS BELIEVE AN INDIVIDUAL WHO SAYS HE/SHE HAS PAIN
• REMEMBER: EACH PERSON IS AN INDIVIDUAL AND PERCEPTIONS OF PAIN DIFFER
SOURCE: http://kokuamau.org/resources/last-stages-life
END OF LIFE
TIPS FOR CAREGIVERS
• YOU CAN BE A CARING PRESENCE THROUGHOUT THE DYING PROCESS
• YOUR PRESENCE FOR THE DYING INDIVIDUAL AND HIS/HER LOVED ONES INDICATES
LOVING KINDNESS, COMPASSION, AND WILLINGNESS TO PROVIDE PRACTICAL HELP
• LEARN WHAT YOU CAN ABOUT THE INDIVIDUAL’S ILLNESS AND THE DYING PROCESS
SO YOU CAN PROVIDE COMFORT AND ASSURANCE
• REALIZE YOUR LIMITATIONS
• NO ONE IS PERFECT
• NO ONE CAN DO EVERYTHING
• GET HELP WHEN YOU NEED IT
• TAKE A BREAK WHEN YOU NEED ONE
• ENCOURAGE THE INDIVIDUAL AND HIS/HER LOVED ONES TO CALL THE DOCTOR OR
NURSE WITH QUESTIONS
“SAYING GOODBYE”
INDIVIDUALS WHO ARE DYING OFTEN WANT “PERMISSION TO DIE” FROM
THOSE THEY LOVE. OFTEN, THEY WANT TO BE ASSURED OF FIVE THINGS:
• THINGS THEY WERE ONCE RESPONSIBLE FOR WILL BE TAKEN CARE OF.
• THE SURVIVORS WILL SURVIVE WITHOUT THEM.
• ALL IS FORGIVEN.
• THEIR LIFE HAD MEANING.
• THEY WILL BE REMEMBERED.
SOURCE: http://kokuamau.org/resources/last-stages-life
BEING PRESENT AT THE MOMENT OF DEATH
• IT IS NOT UNCOMMON FOR THE DYING INDIVIDUAL TO WAIT TO DIE
UNTIL LOVED ONES HAVE LEFT THE ROOM
• MAKE SURE YOU ALLOW FOR THIS
• IF A PERSON SEEMS TO BE HOLDING ON, YOU MAY SIMPLY SAY, “I’M
GOING TO LEAVE THE ROOM FOR AWHILE. I LOVE YOU.”
• IN SOME CULTURES, SPECIFIC PRAYERS, SUTRAS, OR OTHER RITUALS
MAY EASE THE PASSAGE TO DEATH. ASK YOUR CLERGY PERSON FOR
ASSISTANCE
SOURCE: http://kokuamau.org/resources/last-stages-life
AFTERCARE FOR YOURSELF AND OTHERS
• FOLLOWING THE DEATH OF A PERSON YOU SUPPORT, IT IS NORMAL TO
GRIEVE. ALLOW YOURSELF TO REST AND GRIEVE IN THE WAYS HEALTHIEST
FOR YOU.
• YOUR AGENCY MAY WISH TO CONSIDER A TIME-LIMITED GRIEF SUPPORT
GROUP, OR A FEW SESSIONS OF DEBRIEFING.
• IF CARE STAFF CANNOT BE INVOLVED IN FUNERAL OR MEMORIAL SERVICES,
IT MAY BE USEFUL TO HAVE A PRIVATE MEMORIAL OR CELEBRATION OF LIFE.
DEATH AND DYING: CONCLUSION
• DYING IS A NATURAL PART OF ANY LIFE, AND YOU MAY SUPPORT PEOPLE IN CARE SETTINGS
AND HOME SETTINGS DURING THEIR DYING PROCESS.
• YOUR GENTLENESS AND CARING DURING THESE LAST MONTHS, WEEKS, DAYS, AND MOMENTS
OF LIFE IS A GIFT TO THE PERSON SUPPORTED, AND CAN ALSO BE A GIFT TO YOU.
• EDUCATING YOURSELF AND OTHERS IN THE CARE ENVIRONMENT MAY BE VERY BENEFICIAL.
• RESPECT YOUR OWN NEED TO GRIEVE WHEN THE PROCESS ENDS.