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Ms. Johnson* • 90 year old with COPD • During yesterday’s visit • Increased confusion • Lethargic • Non-sensical questions • Somewhat withdrawn *Name changed for privacy
Ms.Johnson*
• 90yearoldwithCOPD• Duringyesterday’svisit
• Increasedconfusion• Lethargic• Non-sensicalquestions• Somewhatwithdrawn
*Name changed for privacy
Ms.Johnson*
• Lorazepam• Robinul• Miralax• Flovent• Spiriva• Acetaminophen
• Roxanol• Keppra• Duoneb• Nystatin• Oxygen
*Name changed for privacy
CouldMs.Johnsonhavedelirium?
a) Yesb) Noc) Notsure
WhatisMs.Johnson’sBedsideConfusionScalescore?
a) 0b) 1c) 2d) 3e) 4f) 5
• Monthsoftheyearresponse:• January• March• February• April• May• June• July• September• December
V-<(7<-&J"#8/(7"#&H*34-&
I. Assess level of alertness Normal = 0 Hyperactive = 1 Hypoactive = 1
II. Test of attention – a timed recitation of the month of the year in reverse order
Delay > 30 seconds – add 1 1 omission – add 1 2 omissions – add 2 >3 omissions, reversal of task or termination of task – add 3 Inability to perform – add 4
Total scores from section I and II Normal = 0; Borderline = 1; Diagnostic of confusion = 2-5 points
Sarhill N, Walsh D, Helson KA, et al. Am J Hospice and Pall Care 2001;18(5):335-341. Stillman MJ, Rybicki LA. J Pall Medicine 2000;3(4):449-456.
Delirium:ClinicalManifestations
Altered level of consciousness, wakefulness or arousal
Hyperactive Hypoactive Mixed
• “Quiet” • Somnolent
• Agitation • Hallucinations
• Alternates
Casarett 2001
DeliriumClinicalSubtypes
• Hyperactivedelirium• Confusion,agitation,hallucinations,myoclonus• Associatedwithincreasedriskoffalling,pullingoutlines,tryingtoleavehospital/bed
• Hypoactivedelirium• Confusion,somnolence,+/-withdrawn• Quietlydelirious• Increasedriskofaspirationpneumonia,skinulceration,andpoorcompliance
• Oftenmistakenfordepressionorfatigue
WhattypeofdeliriumisMs.Johnsonmostlikelytohave?
a) Hyperactiveb) Hypoactivec) Mixed
• Infection • Brain tumor/metastases • Hepatic/Renal Failure • Electrolyte Disturbances • Hypoxemia • Dehydration • Medications • Immobilization • Depression • Vision Impairment • Hearing Impairment • Uncontrolled Symptoms • Emotional Stress • Unfamiliar environment
Delirium
Casarett 2001
17- 40% of reported cases of delirium caused by drugs
Borovicka 2005
DrugsthatMayInduceDelirium
High Risk Moderate Risk Low Risk Alpha-blockers Anti-arrhythmic Beta-blockers Digoxin NSAIDs
ACEIs Theophylline Antibacterials Anticonvulsants Calcium channel blockers Diuretics H2-antagonists
Anticholinergics Antidepressants Antipsychotics Dopaminergic Agents Opioids Benzodiazepines Corticosteroids Lithium Alcohol Withdrawal
Borovicka 2005
Drug-InducedDelirium
• Dose-dependent• Duetometabolites• Drugwithdrawal
Drug-InducedDelirium:AnticholinergicsAgents
Antihistamine diphenhydramine, hydroxyzine
Antisecretory atropine, scopolamine, hyoscyamine, glycopyrrolate
Antipsychotics chlorpromazine, promazine, thioridazine
Tricyclic Antidepressants
amitriptyline*, nortriptyline, desipramine
Borovicka 2005; Casarett 2001; White 2007
Drug-InducedDelirium:Benzodiazepines
• Paradoxicalreaction• Associatedwith:
• Long-acting(diazepam)morethanshort-acting(lorazepam)• Higherdoses
Borovicka 2005
Drug-InducedDelirium:Opioids
• Codeine,meperidine,propoxyphene>otheropioids• Considerifrecentopioidchangeordose↑• Management:
• Dosereduction• Opioidrotation• Rehydration(?)
Borovicka 2005; Casarett 2001
Drug-InducedDelirium:Prevention
• Obtaincompletemedicationhistory• Routinelyreviewmedicationlist• Avoiddelirium-inducingdrugs,whenpossible
• Uselowesteffectivedose• Minimizenumberofmedicationsused
Borovicka 2005
Drug-InducedDelirium:Management
• Identifycausativeagent• Stopoffendingagentor↓dose• Substituteanothermedicationifpossible• Identifyandreduceothercontributors
Borovicka 2005; Casarett 2001
ToTreat,orNotToTreat!ThatistheQuestion!
HospiceTeamMeeting
• RNreports,“Thepatientispleasantlyconfused.”
• ArethehallucinationsBOTHERINGthepatient?
ManagementPrinciples
1. PatientAssessment• Medicationhistory*• Medicalhistory• Physicalandneurologicexam• Patientandfamilyinterview• Cognitivetests• Laboratorytests(whenappropriate)
Casarett 2001; Trzepacz 1999
ManagementPrinciples
2. Addressanyreversiblecausesü Medications• Infections• Hypoglycemia• Urinaryretention• Fecalimpaction• Dehydration• Environmental
Casarett 2001; Trzepacz 1999
ManagementPrinciples
3. Monitorandensuresafetyl Removedangerousitemsl Increasesupervision(avoidrestraints!)l Assesspatient’sriskforfalls,wandering,
self-harml Usemedicationswhenappropriate
Trzepacz 1999
ManagementPrinciples
4. Implementnon-pharmacologicinterventions• Quiet,welllitroom• Familymemberpresence• Re-orientwithfamiliarthings,clock,calendar• Correctionofhearingorvisualimpairment• Rehydration(?)
Casarett 2001; Trzepacz 1999
ManagementPrinciples
5. PharmacologicInterventionsl Non-pharmacologicinterventionsinsufficientl Behaviorsdangerousl Goal:Returnpatienttobaselinementalstatus
Casarett 2001; Trzepacz 1999
DeliriumManagement:Antipsychotics
• Primarypharmacologicalintervention• NOTFDAapprovedfordelirium• Verylimiteddatasupportinguse:
• Openlabel,casereports,retrospectivereviews• Noplacebocontrolledtrials
• Superiortobenzodiazepines
Alici-Evcimen Y 2008; Jackson 2004; Lonergan 2007; Trzepacz 1999
RoleofBenzodiazepines
• Usefultotreatalcoholwithdrawal• AVOIDasfirstlinetherapyforallotherreversiblecausesofdelirium• Morelikelytocausefurtherdisinhibitionratherthansedationinthisstateandingeriatricpopulation
• Low-doselorazepammaybeusedinADDITIONtoantipsychoticmedicationwithantipsychoticinsufficient
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RankingtheEvidence• USPreventativeServicesTaskForce
Breitbart 2008
US Preventative Services Task Force Hierarchy of Research Design available at: http://www.ahrq.gov/clinic/ajpmsuppl/harris2.htm
Level I Randomized controlled trial(s) Haldol®, Thorazine®
Level II-1 Controlled trials without randomization
Risperdal®, Zyprexa®
Level II-2 Cohort or case control studies ---
Level II-3 Multiple time series with or without intervention
Seroquel®, Abilify®
Level III Opinions based on experience or descriptive studies
Geodon®
DeliriumManagement:Antipsychotics• Haloperidol(Haldol®)-drugofchoice
• Lowdosesaretypicallyeffective(1-3mg/d)• Dose0.5-2mgevery2-12hours
• Usuallymanagedorally;canbegivenSC,IV,IM• Mayaddbenzodiazepineforagitatedpatients
Breitbart 2008; Casarett 2001; Trzepacz 1999
DeliriumManagement:Antipsychotics• Chlorpromazine(Thorazine®)
• Dose:12.5-50mgevery4-6hours• AvailablePO,IV,IM,SC,PR• Moresedating&anticholinergicthanhaloperidol• Monitorforhypotension
Breitbart 2008; Jackson 2004
DeliriumManagement:AtypicalAntipsychotics
• Risperidone(Risperdal®)• Dose:0.25-1every12-24hours• Availablebymouthonly• Nodifferenceinefficacyfromhaloperidol
Breitbart 2008; Casarett 2001; Han 2004
DeliriumManagement:AtypicalAntipsychotics
• Olanzapine(Zyprexa®)• Dose:2.5-5mgevery12-24hours
• Quetiapine(Seroquel®)• Dose:12.5-100mgevery12-24hours• Monitorfororthostatichypotension• Maybepreferredinpatientswithmovementdisorders
Breitbart 2008; Casarett 2001; Han 2004
DeliriumManagement:AtypicalAntipsychotics
• Aripiprazole(Abilify®)• Dose:5-30mgevery24hrs• Monitorforakathisia
• Ziprasidone(Geodon®)• Dose:10-40mgevery12-24hours• Leastpreferredinmedicallyillduetocardiaceffects
Breitbart 2008; Casarett 2001; Han 2004
DeliriumManagement:AntipsychoticAdverseEvents
• ProlongedQTInterval• Thioridazine• Ziprasidone>Quetiapine,Risperidone,Olanzapine
DeliriumManagement:AntipsychoticAdverseEvents
• ExtrapyramidalSymptoms• Morecommonw/typicalantipsychotics• Higherdosesofatypicalantipsychotics(i.e.,risperidoneexceeding6mg/day)
• Recommendtomonitordaily
DeliriumManagement:AntipsychoticAdverseEvents
• NeurolepticMalignantSyndrome• Uncommon• Characterizedby:
• Severerigidity• Hyperthermia• Alteredmentalstatus• Autonomicdysfunction
DeliriumManagement:AntipsychoticAdverseEvents
• RiskofMortalityBlackBoxWarning:Increasedriskofdeathwhenusedtotreatelderlypatientswithdementia-relatedpsychosis• Typical&atypicalantipsychotics• 1.6-1.7greaterriskfordeath
Medication Avg. Cost/dose Haloperidol $0.22 Chlorpromazine $0.36 Risperidone $2.90 Seroquel® $4.51 Geodon® $8.43 Zyprexa® $11.76 Abilify® $19.05
Mr.Smith*• 72yearoldwithmetastaticlungcancer
• AdmittedtoIPUwith:• Confusion• Aggressivebehavior• Agitation• Disorientation
*Name changed for privacy
Mr.Smith*
• Dexamethasone• Gabapentin• Lorazepam• Morphine
*Name changed for privacy
Mr.Smith*
• VitalSigns:• BloodPressure:150/90• HeartRate:110• RespiratoryRate:18
• CTScan:cerebralmetastases• FolsteinMMSE:18/30
• Problemsinorientation,recall,retention
*Name changed for privacy
WhattypeofdeliriumisMr.Smithmostlikelytohave?
a) Hyperactiveb) Hypoactivec) Mixed
Whatriskfactorsmightbecontributingtothispatient’ssymptoms?
a) Brainmetastasisb) Dehydrationc) Emotionaldistressd) Hypoxemiae) Infectionf) Medicationsg) Unfamiliarenvironment
WhatmanagementplanwouldyourecommendforMr.Smith?
a) Discontinue contributing medications b) Non-pharmacologic interventions c) Start an antipsychotic d) Start a benzodiazepine
Mr.Jones*
• 86yearoldwithmetastaticprostatecancer
• Wifereports:• Notthesame“rascal”• Lucidattimes,butoutofitat
others• Sleepingduringtheday,
wanderingatnight
*Name changed for privacy
Mr.Jones*
• Yourobservation:• Repetitivelyasks“Whatdayisit?”• Easilydistractedbyoutsideshadows• Fallsasleepmid-sentence
• Vitalsigns:• Bloodpressure:80/55• Respiratoryrate:16
*Name changed for privacy
Mr.Jones*
• Hydrochlorothiazide• Lopressor• Zantac• Lorazepam• MSContin
(increased4daysago)
• MSIR
• TylenolPM(started3daysago)
• Decadron• Elavil• Senna-S
*Name changed for privacy
AccordingtotheConfusionAssessmentMethod(CAM),doesMr.Jonesappeartohavedelirium?
a) Yesb) Noc) Notsure
ConfusionAssessmentMethod(CAM)RequiresBOTHAandB:
A. Acuteonsetandfluctuatingcourse• Isthereevidenceofanacutechangeinmentalstatusfrompatientbaseline?• Doestheabnormalbehavior:
• Comeandgo?• Fluctuateduringtheday?• Increase/decreaseinseverity?
B. Inattention• Doesthepatient:
• Havedifficultyfocusingattention?• Becomeeasilydistracted?• Havedifficultykeepingtrackofwhatissaid?
www.viha.ca/mhas/resources/delirium
ConfusionAssessmentMethod(CAM)ANDeitherCorD:
C. Disorganizedthinking• Isthepatient’sthinkingdisorganizedorincoherent?
• Ramblingspeech/irrelevantconversation?• Unpredictableswitchingofsubjects?• Unclearorillogicalflowofideas?
D. Alteredlevelofconsciousness• Overall,isthepatient’slevelofconsciousness:
• Alert(normal)• Vigilant(hyper-alert)• Lethargic(drowsybuteasilyroused)• Stuporous(difficulttorouse)• Comatose(unrousable)
www.viha.ca/mhas/resources/delirium
Whatmedicationsmightbecontributingtohissymptoms?
a) Hydrochlorothiazideb) Lorazepamc) MSContind) TylenolPMe) Elavilf) Senna-S
Whatmedications,ifany,shouldbeconsideredfordiscontinuation?
a) Hydrochlorothiazideb) Lopressorc) Zantacd) Lorazepame) TylenolPMf) Decadrong) Elavil
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• An86yearoldwomanwithmoderatedementia,anxietyandapriorhistoryofdepression.
• Shedevelopedchestpainandconfusion,washospitalizedandfoundtohavesufferedamyocardialinfarction,hersecond.
• Sheremainedconfused.• Furtherneurologicalworkuprevealedembolicstrokes,butnotofasufficientsizetoadequatelyexplainherdelirium.
• Labvalueswerewithinnormallimits.• Becauseofherconfusion,thepatient’sdiazepamhadbeenheld,butnowdiazepamwasresumedatheroutpatientdoseof5mgtwicedailyorallybecauseofconcernsaboutpossiblebenzodiazepinewithdrawal.
• Herconfusiondidnotimprove.
125
• Codestatuswasdiscussedwiththepatient’selderlyspouseatthetimeofadmission,lateatnight.
• Herequestedshebeafullcode.Hesaid,“Idon’twanthertolingerandsuffer;ifherheartstops,Iwantthecodetobe“full”sotheydon’tbringherbackjust“partway”!”
• Healsostated“Idon’twanthertostarvetodeath–canyouputinoneofthosetubes?”
• Thoughts?
126
• InitiallyCMhadlucidintervalswhenshespokecoherentlytofamilymembers.
• CMhadalwayshadadifficultpersonality.• Oneofherchildrencommentedthatduringherlucidintervalsshewas“nicerthanshehadeverbeen.”
• Herdeliriumbecausepersistenthowever,asshecontinuedtodeteriorate.• Shebecameagitatedandaggressive,scratchingandkickingatstaff,andrequiredrestraints.
• Herspousewasconcernedthatshewasaggressivebecauseshewasangrywithherhusbandforbringinghertothehospital.
• Doyoubelievethistobethecase?Whyorwhynot?Whatdoyousaytothehusbandatthistime?Thoughts?
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• CMwasstartedonquetiapine,and,atadosageof25mgorallyatbedtimeshebecausecalmandonlymildlysedated.
• Shewasthenstableenoughfordischargetohomehospicecare.Shediedpeacefullythere,withherhusbandatthebedside.
• Heregrettedtherehadbeennodeathbedresolutionoftheirlifelongissues,blaminghimselfforCM’schronicunhappiness.
• Thoughts?
128
TakeHomePoints
• Deliriumis….• Complexandmultifaceted• Under-detectedandunder-treated• Distressing
• Routinelyuseinstrumentstodetectdelirium• Addressreversibleissues&implementnon-pharmacologicinterventions
• Despitelimitedevidence,antipsychoticsaretheprimarypharmacologictreatment
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Insomnia
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Casecontinues…
• Thewomantoldthenurseshefelt“jittery,”gotupatnighttourinate,andthat“takingallthatmedicationbeforebedmakesmystomachhurt.”
• Thenurseaskedhertoexpandfurtheronherbedtimeroutine.• ShediscoveredthatthepatientoftenwatchedTV,thenchangedintoherbedclothingandtookhermedications,includingdiureticsandbronchodilatorsataround9pm,priortogoingtobed.
132
Casecontinues…
• Shealsonotedthatshedidnotfallasleepuntilaftermidnight,awakenedaround10am,thenwasnappingfrom2pmto5pm,tomakeupforlostsleep.
• Shealsoreportedthatherinabilitytosleepworsenedafterherhusbandpassedaway6monthsago.
• Shetoldthenursethatshehadbeenwithherhusbandfor25yearsandhadnotsleptalonesincetheyweremarried.
• Sheexpressedfearrelatedtohisend-of-lifejourneyandconcernastohowherlifejourneywouldend.
133
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Non-pharmacologicmanagementofinsomniaTherapy Techniques
Sleephygiene • Activityastoleratedwitheliminationofexercises4hourspriortobedtime• Avoidlargemeals• Limitfluidintakeintheevenings• Limitcaffeine,tobacco,alcohol• Bedroomforsleepandsexonly• Maintainroutinesleep-wakecycle• Decreasedaytimenapping• Decreasedistractingstimuliclosetotimeofsleepsuchasnoise,lights,computers,
phone,television,extremetemperatures
Stimuluscontrol • Liedowninbedforsleeponlywhensleepy• Avoidwakefulactivitiesatbedtime,television,phone,eating• Leavethebedifunabletofallasleepwithin20minutes,donotengageinstimulating
activity,returntobedwhensleepy• Maintainsleep-wakecycles,setalarm,gotobedatthesametime
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Non-pharmacologicmanagementofinsomniaTherapy Techniques
Sleeprestrictions • Limitnappingduringtheday• Arisefromthebedwhenawake
Relaxation • Imagery,mindfulness,meditation,hypnosis• Yoga,abdominalbreathing,progressivemusclerelaxation
Cognitivetherapy • Counseling• Identifyandreplacedysfunctionalbeliefsregardingsleep• Addressoverestimationandapprehensiveaboutsleep• Journaling
CBT • Combinationofcognitivetherapies,stimuluscontrol,sleeprestrictiontherapy,relaxation
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Medication
OnsetofAction Duration Costfor10days
BenzodiazepineReceptorAgonists
Eszopiclone(Lunesta) <30min Intermediate $10
Zaleplon(Sonata) <30min Ultra-short <$10
Zolpidem(IRtablets)(Ambien) <30min Short <$10
Benzodiazepines
Estazolam 15-60min Intermediate <$10
Flurazepam(Dalmane) 10-30min Long <$10
Temazepam(Restoril) 30-60min Intermediate <$10
Triazolam(Halcion) 15-30min Short $22
MelatoninReceptorAgonist
Ramelteon(Rozerem) 15-30min Short $95
TricyclicAntidepressant
Doxepin(Silenor) 30min Long $105
OrexinReceptorAntagonist
Suvorexant(Belsomra) 30min Intermediate $90
Wecan’tleaveourladyhanging…
Whatdowedowithourladywhosleepsduringtheday,andupmostof
thenight…
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