Transcript What is delirium? - University of Alabama at Birmingham

Geriatrics for
Hospice and
Palliative Care
Providers
Heather Herrington, MD
Division of Geriatrics, Gerontology
and Palliative Care
University of Alabama at
Birmingham
A little bit about me…
…and tell me about you…
…and what are we doing today?
Question:
An 88yo woman has dementia and
metastatic lung cancer. She was recently
discharged from the hospital to home
hospice. Her daughter has noticed
increased agitation and confusion over the
past couple of days. What is the best first
step?
What do you think??
a.
b.
c.
d.
e.
The patient needs a sedating medicine such
as lorazepam (Ativan)
The patient needs an antipsychotic
medicine such as haloperidol (Haldol)
The patient should be checked for fecal
impaction and/or urinary retention
The patient should be checked for
dehydration or liver dysfunction
The patient needs a pain medicine such as
morphine
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HOLD THAT THOUGHT…
lets talk about a patient
Which of the following best
describes what is going on
with Mrs. Lloyd?
 She
has worsening of her dementia
 She is having a psychotic episode
 She has a potentially reversible delirium
 She is dying and has terminal delirium
 She has a severe depression
Answer:
 c.
She has a potentially reversible delirium
Why is this the best answer?
What is delirium?
a potentially reversible condition with many
possible causes or contributors…
 Why
is this not dementia?
http://www.youtube.com/watch?v=9QUR
zexhWP4
Delirium vs dementia
 Delirium



Acute change
Fluctuating course with inattention
Presumed to be reversible
 Dementia



Chronic
Progressive- worsens over time
Not reversible in most cases
How do we define or describe
delirium?
How do we define or describe
delirium?
 Disturbance
of consciousness
 Change in cognition or perceptual
disturbance that is not better accounted
for by a dementia
 Disturbance develops over a short period
of time and fluctuates during the day
 Result of a general medical condition,
medication side effect, substance
intoxication or withdrawal, or multiple
etiologies

DSM
Confusion Assessment Method
(CAM)
 Acute
onset and fluctuating course
 Inattention
 Disorganized thinking
 Altered level of consciousness

Inouye, Annals of Internal Medicine, 1990
What are some of Mrs.
Lloyd’s underlying risk factors
for delirium?
Understanding delirium
 Generally
multifactorial in origin
 Predisposing risk factors- these increase a
person’s vulnerability to delirium
 Precipitating risk factors- these may be
avoided
Predisposing risk factors
 Advanced
age
 Cognitive impairment
 ADL dependence
 Sensory impairments
 Multimorbidity
Precipitating risk factors









Infections
Catheters or other restraints
Constipation/impaction; urinary retention
Uncontrolled pain
Psychoactive medications
Recent hospitalization or other care transition
Metabolic derangements
Withdrawal or intoxications
Acute cardiac, neurologic, pulmonary events
Mrs. Lloyd continues to be
agitated and confused. How
would you want to evaluate
her delirium?
 Mrs.
Lloyd’s daughter reveals that Mrs.
Lloyd has not had a BM since before she
left the hospital. The daughter also notes
that Mrs. Lloyd has only urinated one time
today.
 A rectal exam reveals hard stool in the
rectal vault. After disimpaction, a small,
firm mass is noted in the lower pelvis (the
distended bladder); a foley catheter is
inserted with 1 liter of urine return.
 Mrs. Lloyd’s other symptoms of mild
dyspnea and back pain are treated with
prn low-dose opioids.
What should Mrs. Lloyd’s
daughter know about
delirium?
What medications might be
contributing to Mrs. Lloyd’s
delirium? Are any of her
medicines on the Beers list?
Case resolution



After fecal disimpaction, placement of a
foley catheter and discontinuing contributing
medications including Tylenol PM
(Benadryl/diphenhydramine), lorazepam,
ranitidine and promethazine, Mrs. Lloyd is
back to her baseline mental status.
Roxanol (morphine concentrate) is helping
with dyspnea, but it is used sparingly because
it can make her more confused.
The foley catheter is removed and she is able
to void afterwards. Mrs. Lloyd’s daughter is
very pleased with the care she has received.
Other thoughts….
Are delirious patients always
agitated?
Hypoactive and Hyperactive
Delirium

HYPOactive




HYPERactive



More common
Patients are somnolent with decreased function
Less often recognized
More often recognized
Patients are agitated, and if severe they may
have hallucinations or be physically aggressive
Mixed delirium- hypoactive and hyperactive
Do people remember
delirium?
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



“The impact of delirium and recall on the
level of distress in patients with advanced
cancer and their family caregivers”
74% of patients remembered the delirium
episode; 81% reported the experience as
distressing
Delirium distress score was higher in family
caregivers than in patients
Delirium distress score was low in nurses and
palliative care specialists
Bruera et al. Cancer. 2009.
Mrs. Lloyd could have had
terminal delirium, but we don’t
think so…
Why not?
Why is it important to differentiate
between potentially reversible
delirium and terminal delirium in
this patient?
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