Geriatrics for Hospice and Palliative Care ProvidersHeather Herrington, MDDivision of Geriatrics, Gerontology and Palliative CareUniversity 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. The patient needs a sedating medicine such

as lorazepam (Ativan)b. The patient needs an antipsychotic

medicine such as haloperidol (Haldol)c. The patient should be checked for fecal

impaction and/or urinary retentiond. The patient should be checked for

dehydration or liver dysfunction e. 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=9QURzexhWP4

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

More common Patients are somnolent with decreased function Less often recognized

HYPERactive 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? “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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