Terminal Agitation: Managing Symptoms at the End of Life Gregg VandeKieft, MD, MA Washington State Hospice and Palliative Care Annual Meeting Chelan, WA October 12, 2015 Speaker Bio Gregg VandeKieft, MD, MA System Lead Physician for Palliative Care, Providence Health and Services (PH&S), Renton, WA Regional Medical Director for Palliative Care,
PH&S Southwest Washington Region, Olympia, WA Inpatient and Outpatient Palliative Care, Providence St. Peter Hospital, Olympia, WA Formerly Hospice Medical Director, Providence Sound Home Care and Hospice, Olympia, WA [email protected] Disclosures Dr. VandeKieft has no commercial relationships or conflicts of interest to report. Learning Objectives
At the conclusion of this presentation, participants will be able to: Define delirium and terminal agitation List common causes of terminal agitation Describe the initial assessment for delirium Recommend non-pharmacologic interventions and medication management for delirium and terminal agitation Reflection Do not go gentle into that good night, Old age should burn and rave at close of day; Rage, rage against the dying of the light. Dylan Thomas, 1947
Key Points Delirium is a medical condition, rather than a psychiatric condition If possible identify and treat the underlying cause; less practical in the actively dying Underlying dementia increases risk of delirium 2-3x
Terminal agitation is very common, treatment is often nonpharmacological Delirium A transient global disorder of cognition not a disease but a syndrome - multiple causes that produce a similar array of symptoms A medical emergency 10-25% mortality in patients admitted with
delirium up to 75% mortality in patients who develop delirium during hospitalization early diagnosis and treatment correlates to better outcomes Terminal Agitation or Restlessness Clinical spectrum of unsettling behaviors and cognitive disturbance in the last hours to days of life Symptoms include: irritability, anxiety, distress, inattention, hallucinations, paranoia Signs include: restlessness, fidgeting,
grimacing, moaning, attempts to get out of bed Increased risk with certain medications Delirium: DSM-5 Criteria Disturbance in attention and awareness Change in cognition not better accounted
for by an established or evolving dementia. Acute onset (hours to days) and fluctuates over the course of the day History, exam, and/or labs indicate the disturbance is caused by a medical condition, intoxicating substance, medication, or more than one cause. Epidemiology Estimated incidence in hospital 40% of hospitalized patients >65 yrs old 10-20% of elderly patients at time of admission 50% of patients after hip fracture
40% of patients in ICU 20% of patients on general medical ward Advanced cancer patients 30-50% of on admission to hospital or hospice 80-90% of these patients experience delirium in their final hours to days of life can be effectively treated in 30-75% of cases Risk factors
Age >60 Men > women Major medical illness or major surgery Pre-existing brain pathology dementia, stroke, tumor Psychiatric illness, including depression Polypharmacy
Substance abuse Clinical Features of Delirium Acute onset hours to days Fluctuating levels of consciousness Decreased ability to maintain attention Emotional lability
Agitation or hypersomnolence Altered cognitive function Delirium vs. Dementia Delirium acute onset, cognitive changes fluctuate alertness and attention wax and wane, speech confused and disorganized Dementia gradual onset, chronic but stable memory deficits and executive function disturbance
intact alertness and attention, but deficits in speech and thought processes Characteristic Cognitive Deficits Speech disturbance slurred, mumbling, incoherent, disorganized Language impairments word finding difficulty
Memory dysfunction short-term memory impaired; disoriented to persons, place, time Perceptual disturbance delusions, hallucinations, misrepresentations Clinical Case: Rose 76 year old woman with non-small cell lung cancer, metastatic to pelvis
and spine s/p chemo and radiation, now on hospice no known psychiatric issues or dementia neighbors called police after she wandered into their house confused she became combative with the police Paramedics bring her to ER for evaluation Delirium in Oncology Patients Direct effects of cancer on CNS metastatic disease higher circulating cytokine levels
Indirect effects of cancer cancer related organ dysfunction - e.g., liver paraneoplastic syndromes infections, electrolyte disturbance Exogenous factors chemotherapy, radiation therapy opioids, polypharmacy Differential Diagnosis Brain metastasis delirium not typically initial manifestation, but
Medication reaction or interaction very common review med list, timing of medications relative to onset of symptoms eliminate all meds that are not essential Alcohol or drug withdrawal consider EtOH if onset 24-48 hrs after hospital admit has patient missed regular psychotropics or opioids? Intracranial bleed
consider unwitnessed fall, especially for debilitated or thrombocytopenic patients Types of delirium Hyperactive delirium agitated, may be combative e.g., alcohol withdrawal Hypoactive delirium hypersomnolent, unable to maintain attention when awake
e.g., hepatic encephalopathy, hypercapnea Mixed has features of both fluctuations more pronounced daytime sedation, nocturnal agitation Assessment Pitfalls in diagnosis Hyperactive: misinterpreted as primary psychiatric issue, medical workup is delayed Hypoactive: not a problem patient so delirium not recognized as quickly
Clinical diagnosis no single diagnostic test Targeted workup based on differential diagnosis thorough history is essential review chart for new symptoms and/or behavioral changes review medication list, lab work, diagnostic imaging Confusion Assessment Method
Feature 1: Acute onset, fluctuating course Feature 2: Inattention Feature 3: Disorganized thinking Feature 4: Altered level of consciousness CAM + for delirium if 1 and 2 plus either 3 or 4 http://www.hospitalelderlifeprogram.org/deliriuminstruments/ Clinical Case (cont.)
In ER Rose undergoes lab tests, receives IV fluids, electrolytes, meds, becomes marginally oriented a mental health professional is consulted, determines she is able to make her own health care decisions and cannot be hospitalized against her wishes she refuses admission and is discharged home against medical advice the following day, her hospice nurse finds her covered with feces, rambling Common Reversible Clinical Causes of Delirium
Electrolyte disorders hypercalcemia, hyponatremia, hyperkalemia Drug reactions, interactions, or toxicity benzodiazepenes, opioids, anticholinergics, steroids, digoxin, Parkinsons meds, H2-blockers, alcohol
Infection Hypoxemia Hyper- or hypoglycemia Hypotension Hepatic or renal encephalopathy Most cases are multifactorial Causes of Terminal Agitation Biochemical abnormalities as organs fail Hypercalcemia especially common in cancer
Opioid or other drug toxicity Drug interactions Pain Fever, with or without infection Spiritual or existential distress Unresolved psychosocial issues Obtain history Interview patient when possible
delirium covers a wide range of presentations, some patients can provide significant history If possible, talk to family or caregivers who know patients baseline Review records carefully Typical tests of cognitive function (e.g., MMSE) not very helpful in delirium
Targeted workup For all studies, ask: Will it alter treatment? how does test fit within broader context of illness trajectory and treatment goals? Brain mets: cranial CT or MRI Infection: CBC, UA, cultures, x-rays
Electrolyte abnormalities: chem panel Liver failure: hepatic panel, ammonia Renal failure: BUN/Cr, monitor I/Os Respiratory failure: O2 sat, ABGs Clinical Case (cont.) Rose is brought back to ER, remains disoriented, admitted Hospice GIP status work-up showed UTI, possible pneumonia started on IV antibiotics required 1:1 sitter due to behavioral outbursts responded well to p.r.n. haloperidol but
no SNF would take her while she needed 1:1 or was receiving haloperidol risperidone added, good response, transferred to SNF, did well until she died 6 Treatment Identify and treat underlying cause, if able Often not practical during actively dying phase When etiology uncertain, treat symptoms Environmental therapy
Facilitate a quiet, peaceful setting Provide cues: family photos, calendar, clock Address psychosocial issues, spiritual or existential concerns Involve family, staff, spiritual care, music Treatment (cont.) Pharmacologic debridement Review med profile, look for potential offending agents, eliminate all unnecessary meds
Pharmacotherapy if nonpharmacologic interventions unsuccessful Target patients who are severely agitated Behavior interferes with essential interventions or poses a safety hazard to self, family, staff Avoid restraints! Usually worsens agitation Medical Managment Benzodiazepenes generally avoid - can paradoxically worsen symptoms helpful for alcohol withdrawal, anxiety
Conventional antipsychotics haloperidol 1st line in hospital or home, but usually not an option in nursing homes IV or oral onset of action 5-20 min for IV route Atypical antipsychotics helpful for maintenance use, especially olanzapine or risperidone Key Points
Delirium is a medical condition, rather than a psychiatric condition If possible identify and treat the underlying cause; less practical in the actively dying Underlying dementia increases risk of delirium 2-3x Terminal agitation is very common, treatment is often nonpharmacological Questions?
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