Delirium in Palliative care - Alberta Hospice Palliative ...€¦ · What is Delirium? Delirium is a serious disturbance in mental abilities that results in confused thinking and

Delirium in Palliative care

Presentation to Volunteers2016

David Falk

Delirium

What is delirium?

Case Study - Delirium 60+ year old PQ presents to hospice very somnolent.

She was admitted with her adult daughter who states her mother has had previously well until 2-3 days ago when she starting showing increasing confusion, bizzare behaviour, and seeing bugs on the wall. She was diagnosed with breast cancer a few years ago but declined any active therapy other than Clodronate. As a result, she has fungating wounds to her right breast and bone metastases from DI done about two months ago.

PQ is able to engage in meaningful conversation sometimes but especially in the evenings and nights, she wants to get out of bed for no reason, talks nonsense, and becomes paranoid with some of the nursing care.

What is Delirium? Delirium is a serious disturbance in mental

abilities that results in confused thinking and reduced awareness of your environment. The start of delirium is usually rapid — within hours or a few days. Because symptoms of delirium and dementia

can be similar, input from a family member or caregiver may be important for a doctor to make an accurate diagnosis.

Some symptoms of delirium

Reduced awareness of the environment

This may result in: An inability to stay focused on a topic or to

switch topics Getting stuck on an idea rather than

responding to questions or conversation Being easily distracted by unimportant things Being withdrawn, with little or no activity or

little response to the environment

Some symptoms of delirium

Poor thinking skills (cognitive impairment)

This may appear as: Poor memory, particularly of recent events Disorientation, for example, not knowing where

you are or who you are Difficulty speaking or recalling words Rambling or nonsense speech Trouble understanding speech Difficulty reading or writing

Some symptoms of delirium

Behavior changes This may include:

Seeing things that don't exist (hallucinations) Restlessness, agitation or combative behavior Calling out, moaning or making other sounds Being quiet and withdrawn — especially in older

adults Slowed movement or lethargy Disturbed sleep habits Reversal of night-day sleep-wake cycle

Some symptoms of delirium

Emotional disturbances This may appear as:

Anxiety, fear or paranoia Depression Irritability or anger A sense of feeling elated (euphoria) Apathy Rapid and unpredictable

Differences between delirium & dementia

Onset. The onset of delirium occurs within a short time, while dementia usually begins with relatively minor symptoms that gradually worsen over time.

Attention. The ability to stay focused or maintain attention is significantly impaired with delirium. A person in the early stages of dementia remains generally alert.

Fluctuation. The appearance of delirium symptoms can fluctuate significantly and frequently throughout the day. While people with dementia have better and worse times of day, their memory and thinking skills stay at a fairly constant level during the course of a day.

Causes Delirium occurs when the normal sending

and receiving of signals in the brain become impaired. This impairment is most likely caused by a combination of factors that make the brain vulnerable and trigger a malfunction in brain activity.

Causes Delirium may have a single cause or more

than one cause, such as a medical condition and medication toxicity. Sometimes no cause can be identified. Possible causes include:

Frequent Etiologies

Some Causes Certain medications or drug toxicity

Alcohol or drug abuse or withdrawal

A medical condition

Metabolic imbalances, such as low sodium or low calcium

Severe, chronic or terminal illness

Fever and acute infection, particularly in children

Exposure to a toxin

Malnutrition or dehydration

Sleep deprivation or severe emotional distress

Pain

Surgery or other medical procedures that include anesthesia

Common Reversible Causes @ EOL

C-onstipation

H-hypercalcemia, hypoglycemia, hypokalemia

I- nfection

M-edications

B-ladder outlet obstruction

O-2 deficiency

P-ain

Risk Factors Any condition that results in a hospital stay

Brain disorders

Older age

Previous delirium episodes

Visual or hearing impairment

Multiple medical problems

End of life

Preventing or Minimizing Delirium

Always ask yourself, “Could this be delirium?”

Studies show that early detection means early minimizing of delirium, shorter duration of delirium, & less distress

Preventing or Minimizing Delirium

Promote good sleep habits To promote good sleep habits:

Provide a calm, quiet environment Keep inside lighting appropriate for the time of

day Plan for uninterrupted periods of sleep at night Help the person keep a regular daytime schedule Encourage self-care and activity during the day

Preventing or Minimizing Delirium

Promote calmness and orientation To help the person remain calm and well-oriented:

Provide a clock and calendar and refer to them regularly throughout the day

Communicate simply about any change in activity, such as time for lunch or time for bed

Keep familiar and favorite objects and pictures around, but avoid a cluttered environment

Approach the person calmly Identify yourself or other people regularly Avoid arguments Use comfort measures, such as reassuring touch,

when appropriate Keep noise levels and other distractions to a minimum

Preventing or Minimizing Delirium

Prevent complicating problems Help prevent medical problems by:

Giving the person the proper medication on a regular schedule

Providing plenty of fluids and a healthy diet Encouraging regular physical activity Getting treatment for potential problems, such as

infection or metabolic imbalances, early Avoid frequent room changes, invasive

procedures, poor lighting, lack of natural light, loud noises

Preventing or Minimizing Delirium

Caring for the caregiver Providing regular care for a person with

delirium can be scary and exhausting. Take care of family/nursing staff/yourself, too.

Ask for educational materials or other resources from a health care provider to share with family.

Share caregiving with family and friends who are familiar the person so everyone get a break.

Treatment of Delirium Maximize the preventing/minimizing factors

Identify reversible illnesses (CHIMBOP)

Review present medications & minimize them or rotate them to something else

Avoid alcohol

If a medication has been withdrawn, it or it’s equivalent needs to be re-introduced

Hydrate

Share information with family/friends about delirium

Treatment of Delirium Use particular medications to control

behaviour only if necessary: Neuroleptics -e.g. Haldol, olanzepine,

seroquil, Benzodiazepines –e.g. Ativan, Versed

Case Study continued PQ is investigated for reversible factors using

CHIMBOP. Medications were changed & behaviour control was attempted with Haldol and low dose Versed – unsuccessfully. Both husband and daughter were not too sure what PQ’s desire would be in a case like this. She had been so independent with her husband going to work each day and her daughter continuing with her EMS job. They both appeared to be reluctant in seeing PQ die in a few days so bloodwork was done. It showed marked hypercalcemia.

Case Study continued The hypercalcemia was treated and the delirium

resolved over the next 4-5 days. When talking with PQ after it’s resolution, she stated she could not remember most of those days so we had to fill her in on some of the activities.

One day I asked her if she could remember any sensation and if it was scary. She denied it being scary but she did state she lived a vivid dream where her guardian angels were all around her and physically restrained her from going over a precipice. She then added. This experience has taken away the existential fear I have held for years from my abusive past. I am much more at peace with myself than I have ever been.

Delirium @ EOL Questions?