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10/27/2016 1 UTS:HEALTH UTS CRICOS PROVIDER CODE: 00099F health.uts.edu.au/cccc Delirium and Palliative Care Dr Annmarie Hosie Post-doctoral research fellow Presentation for ‘Complex Care at End of Life’ Advanced Practice in Palliative Care Workshop The Centre for Palliative Care Research and Education October 2016 Tota Tua OVERVIEW Definition Epidemiology Impact Four challenges in palliative care: o Re-thinking our over-acceptance o Prevention o Recognition and assessment o Management and supportive care Advocacy, policy and research links health.uts.edu.au
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Delirium and palliative care - Queensland Health · • Long-term care: ... advanced cancer in seven Canadian specialist palliative care inpatient ... • View about goal/benefit

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Page 1: Delirium and palliative care - Queensland Health · • Long-term care: ... advanced cancer in seven Canadian specialist palliative care inpatient ... • View about goal/benefit

10/27/2016

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UTS:HEALTH

UTS CRICOS PROVIDER CODE: 00099F

health.uts.edu.au/cccc

Delirium and Palliative Care

Dr Annmarie HosiePost-doctoral research fellow

Presentation for ‘Complex Care at End of Life’ Advanced Practice in Palliative Care Workshop The Centre for Palliative Care Research and Education

October 2016

Tota Tua

OVERVIEW

• Definition

• Epidemiology

• Impact

• Four challenges in palliative care:

o Re-thinking our over-acceptance

o Prevention

o Recognition and assessment

o Management and supportive care

• Advocacy, policy and research links

health.uts.edu.au

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LAY DEFINITION

Delirium is an acute alteration of mental state that is related to a physical cause

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DSM-5 DIAGNOSTIC CRITERIA

A. Disturbed Attention and Awareness

B. Disturbance develops over a short period of time, is a change from Baseline, tends to fluctuate in severity over the course of the day

C. An additional disturbance in Cognition

D. A and C are not better explained by another pre-existing, established or evolving neurocognitive disorder (i.e. Dementia) nor in context of severely reduced level of consciousness, such as coma

E. Evidence of an Etiological cause

American Psychiatric Association, 2013

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COGNITIVE CHANGES

• Memory deficit

• Disorientation

• Language

• Visuospatial ability

• Perceptual disturbances

o Illusions

o Hallucinations

o Delusions

American Psychiatric Association, 2013

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OTHER SYMPTOMS

• Lethargy

• Mood changes: fear, anxiety, depression

• Sleep-wake disturbance

(not required for a diagnosis)

American Psychiatric Association, 2013

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SUBTYPES

• Hypoactive – reduced psychomotor activity

• Hyperactive – increased psychomotor activity

• Mixed – fluctuating between both

• No sub-type

American Psychiatric Association, 2013

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PREVALENCE AND INCIDENCE

• Palliative care inpatient units:

• Prevalence on admission:13-42%, during admission: 26-62%, near death: 58-88%

• Incidence after admission to a palliative care unit: 33-45% (when screened daily)

• Older hospitalised patients:

• On admission: 10-15%

• During hospital stay: 5-40%

• Intensive Care Units: incidence 70%

• Post hip surgery: 40-56%

• Long-term care: incidence 40%

• Whole hospital point-prevalence: 20%

Clinical Epidemiology and Health Service Evaluation Unit Melbourne Health 2006; Hosie et al, 2013; Ryan et al 2013

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IMPACT AND CONSIDERATIONS

• Patients: frightening, humiliating, distressing, disconnection from loved ones, results in poorer outcomes (increased falls, pressure areas, length of hospital stay, admission to long term care, mortality)

• Family: distress, uncertainty, unmet information needs, increased need to be the decision maker

• Health professionals: distress associated with perceptual disturbance, uncertainty, poor knowledge, under-recognition, inadequate assessment

• Health care system: episode of delirium more than doubles the cost of a patient’s hospital admission

O'Malley et al., 2008; Steis and Fick, 2008; Leslie et al. 2008; NICE, 2010; Hosie, 2014

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OVER-ACCEPTANCE

• Almost all delirium guidelines exclude evidence and recommendations for patients at the end of life

• Palliative care practices in isolation from the growing delirium evidence base

• Illogical separation of delirium from dying in the wider hospital setting means delirium care at the end of life has been neglected in guidelines and research, and evidence-practice gaps in care of at risk palliative care patients occur

• Our care is centred on palliative care philosophy, rather than the individual needs of the patient

• Delirium is common, but never normal

Hosie 2015

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PREVENTION

• Preventing delirium is more effective than trying to treat it once it has occurred

• Promoting physical and cognitive activity, sleep, hydration, vision and hearing reduces delirium incidence of delirium in older hospitalised patients:

1. Meta-analysis (n=4,267) of randomized or matched trials of non-pharmacological prevention strategies reported significant reduction in delirium incidence, with the odds of delirium 53% lower in the intervention group compared with controls (odds ratio 0.47, 95% confidence interval 0.38-0.58, p<0.001) (Hshieh et al. 2015)

2. Cochrane review of 39 trials (n=16,082) of 22 non-pharmacological, medication or anaesthetic interventions. Seven non-pharmacological intervention studies (n=1950) reduced delirium incidence compared to usual care (RR 0.69, 95% CI 0.59 to 0.81). Medication and anesthetic techniques for patients undergoing surgery were less conclusive (Siddiqi et al. 2016)

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PREVENTION IN PALLIATIVE CARE

• A study testing a delirium prevention intervention for 1516 people with advanced cancer in seven Canadian specialist palliative care inpatient units (non-randomised trial) reported no statistically significant difference in delirium incidence, total days in delirium, duration of first episode, severity or delirium-free survival

• Interventions were : i) written notice for physicians on delirium risk factors for each patient and a query about whether they would make medication changes in response; and ii) nurses orientating patients to time and place and providing information about early delirium symptoms to patients and their family.

• Adherence to the study elements was greater than 80%

• No difference in the overall use of psychoactive medications between the two arms

Gagnon et al 2012

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RECOGNITION - TOOLS

• Single Question in Delirium (SQiD) ‘Do you think [name of patient] has

been more confused lately?’ is asked of family or friend (Sands et al 2010)

• Nursing Delirium Screening Scale (NuDESC) (Gaudreau et al 2005)

• bCAM (Han 2013)

o http://eddelirium.org/delirium-assessment/bcam/

o http://eddelirium.org/delirium-assessment/bcam-calculator/

• 4AT (MacLullich, Ryan & Cash)

o www.the4at.com

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What would you assess before intervening?

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MANAGEMENT AND SUPPORT

• “Joining the dots”

• Obtain essential information about the person

• Include those with greatest contact with patient (who may have the weakest voice)

• Shared and interdisciplinary

• Language based on diagnostic/assessment framework

• Decision-making about reversibility

• Understanding the person’s wishes for active intervention

• Responsibility for delirium care

• View about goal/benefit and need for pharmacological and/or non-pharmacological therapies.

Hosie, 2014

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MANAGEMENT AND SUPPORT

• Coordinated

• (and congruent) communication with person and their family about cause of delirium, likely outcome, and management plan (short, medium and longer-term)

• Approach to care based on a positive attitude to people with delirium

• Safe space

• To raise conflicts about goals of particular therapies or perceived impact on patient

• Raise the possibility of a diagnosis of delirium

• To broach impact/stress of caring for a delirious patient

• To bring peace in the suffering and help loved ones to connect

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PHARMACOLOGICAL MANAGEMENT

• Changing recommendations for pharmacological management:

o “Pharmacological therapy should only be considered in the delirious patient with severe behavioural or emotional disturbance where their behaviour threatens their own safety or safety of others, is causing significant distress and likely to interfere with care.”

o “If a delirious person is distressed or a risk to themselves or other and verbal and nonverbal de-escalation techniques are ineffective or inappropriate, consider short term (usually one week or less) antipsychotic medication. Start at lowest clinically appropriate dose and titrate cautiously according to symptoms.”

Clinical Epidemiology and Health Service Evaluation Unit, 2006; NICE 2010

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PHARMACOLOGICAL MANAGEMENT

• More recent evidence does not support the effectiveness of anti-psychotics to improve patient outcomes either during or following delirium and they have associated adverse effects

• Similarly, benzodiazepines are not effective for delirium and have adverse effects.

Lonergan et al., 2009, Agar et al., 2015, Neufeld et al., 2016

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PHARMACOLOGICAL MANAGEMENT

• “Benzodiazepines should be avoided in patients at risk of delirium.”

• “There is no evidence to support the use of antipsychotics as a treatment for delirium in older hospitalized adults.”

ACSQHC, 2013

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NON-PHARMACOLOGICAL STRATEGIES

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RESPONDING TO AMBIGUOUS LOSS

https://www.youtube.com/watch?v=xDlSGbPitXY&feature=youtu.be

Boss, 2009; Lobb, 2016

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ADVOCACY, POLICY AND RESEARCH LINKS

http://www.delirium.org.au/

http://americandeliriumsociety.org/

http://www.europeandeliriumassociation.com/

http://www.idelirium.org/

https://www.safetyandquality.gov.au/our-work/clinical-care-

standards/delirium-clinical-care-standard/

http://www.icudelirium.org

http://dementiacare.health.nsw.gov.au/

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THANK YOU

[email protected]

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REFERENCES

• Agar, M., et al. Phase III randomized double-blind controlled trial of oral risperidone, haloperidol or placebo with rescue subcutaneous midazolam for delirium management in palliative care. in Australian and New Zealand Society for Geriatric Medicine Annual Scientific Meeting. 2015. Perth: Australasian Journal on Ageing.

• Ahmed, S., B. Leurent, and E.L. Sampson, Risk factors for incident delirium among older people in acute hospital medical units: a systematic review and meta-analysis. Age and Ageing, 2014. 43(3): p. 326-333.

• American Psychiatric Association 2013. Diagnostic and statistical manual of mental disorders, Fifth Edition (DSM-5), Arlington, VA, American Psychiatric Publisher.

• Australian Commission on Safety and Quality in Health Care, Evidence for the safety and care of patients with a cognitive impairment in acute care settings: a rapid review. 2013, ACSQHC: Sydney.

• Boss, P., The Trauma and Complicated Grief of Ambiguous Loss. Pastoral Psychology, 2009(59): p. 137-145.

• Canadian Coalition for Seniors’ Mental Health, Guideline on the Assessment and Treatment of Delirium in Older Adults at the End of Life, 2010, Canadian Coalition for Seniors’ Mental Health (CCSMH): Toronto.

• Caraceni, A., Drug-associated delirium in cancer patients. European Journal of Cancer, Supplement, 2013. 11(2): p. 233-240.

• Clinical Epidemiology and Health Service Evaluation Unit Melbourne Health, Clinical Practice Guidelines for the Management of Delirium in Older People, 2006, Australian Health Ministers’ Advisory Council (AHMAC): Melbourne.

• Gagnon, P., et al., Delirium prevention in terminal cancer: assessment of a multicomponent intervention. Psycho-Oncology, 2012. 21(2): p. 187-194.

• Han, J.H., et al., Diagnosing Delirium in Older Emergency Department Patients: Validity and Reliability of the Delirium Triage Screen and the Brief Confusion Assessment Method. Annals of emergency medicine, 2013. 62(5): p. 457-465.

• Hosie, A., et al., Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: A systematic review. Palliative Medicine, 2013. 27(6): p. 486-498.

• Hosie, A., et al., Palliative care nurses' recognition and assessment of patients with delirium symptoms: A qualitative study using critical incident technique. International Journal of Nursing Studies, 2014. 51(10): p. 1353-1365.

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REFERENCES

• Hosie, A., 2015. Delirium epidemiology, systems and nursing practice in palliative care inpatient settings: A descriptive mixed methods project (The DePAC Project) In: College of Nursing. University of Notre Dame Australia.

• Hshieh, T.T., et al., Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Internal Medicine, 2015. 175(4): p. 512-20.

• Leslie, D.L., et al., One-year health care costs associated with delirium in the elderly population. Archives Internal Medicine, 2008. 168(1): p. 27-32.

• National Clinical Guideline Centre for Acute and Chronic Conditions, Delirium: diagnosis, prevention and management, NICE Clinical Guideline 103, 2010, National Institute for Health and Clinical Excellence: London.

• Neufeld, K.J., Yue, J., Robinson, T.N., Inouye, S.K., Needham, D.M., 2016. Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-Analysis. Journal of the American Geriatric Society 64 (4), 705-714.

• O'Malley G, Leonard M, Meagher D, O'Keeffe ST. The delirium experience: A review. Journal of Psychosomatic Research. 2008;65(3):223-8.

• Ryan, D.J., et al., Delirium in an adult acute hospital population: predictors, prevalence and detection. BMJ Open, 2013. 3(1).

• Sands, M., et al., Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale. Palliative Medicine, 2010. 24(6): p. 561-565.

• Siddiqi, N., et al., Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database of Systematic Reviews, 2016(3).

• Steis, M.R. and D.M. Fick, Are nurses recognizing delirium? A systematic review. Journal of Gerontological Nursing, 2008. 34(9): p. 40-49.

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