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Delirium in Palliative Care

Oct 31, 2015

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  • International Palliative Care NetworkLecture Series 2012 Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • Delirium in Palliative Care Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • William Breitbart, M.D.Memorial Sloan-Kettering Cancer Center Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • About the PresenterWilliam Breitbart, M.D. is Chief of the Psychiatry Service, Interim Chairman, and Attending Psychiatrist, Department of Psychiatry & Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY. Dr. Breitbart is also Attending Psychiatrist, Pain & Palliative Care Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center. Dr. Breitbart is board-certified in Internal Medicine, Psychiatry, and Psychosomatic Medicine. He was President of the Academy of Psychosomatic Medicine in 2007, and Immediate Past President of the International Psycho-oncology Society. Dr. Breitbart's research efforts have focused on psychiatric aspects of cancer and palliative care. Dr Breitbart received the 2003 Research Award from the Academy of Psychosomatic Medicine, and the 2007 Donald Oken Award from the American Psychosomatics Society. He is the 2009 recipient of the Arthur Sutherland Lifetime Achievement Award for the International Psycho-oncology Society. In 2011, Dr Breitbart was the recipient of the Thomas P. Hackett Award for Lifetime Achievement from the Academy of Psychosomatic Medicine. Dr Breitbart has edited 8 major textbooks on Psycho-oncology and psychiatric palliative care. He is Editor-in-Chief of the international palliative care journal Palliative &Supportive Care. Published by Cambridge University Press

    Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • Conflict of Interest or Funding SourceWith respect to the following presentation, there has been no relevant (direct or indirect) financial relationship between the party listed above (and/or spouse/partner) and any for-profit company in the past 24 months which could be considered a conflict of interest.The following lecture contains content on the use of medications that have not been approved by the US Food and Drug Administration for the treatment of Delirium or Depression

    Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • Delirium in Advanced CancerHighly Prevalent: ranges from 15% - 30% in hospitalized patients. 40% - 80% in advanced disease, palliative careAssociated with increased morbidity/distress/mortality in patients, family, staff ; increased risk of self harm, harm to staff, and mortality- a harbinger of deathInterferes with symptom assessment and controlUntreated Delirium can progress into dementia or worsen pre-morbid cognitive disorders Pathophysiology of delirium supports the role of psychopharmacologic management (e.g. dopamine blockers) Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • Under-recognition and treatment of Delirium Delirium is under-recognized and under-treated.One of the barriers to adequate clinical intervention in delirium is the lack of appreciation for the distress experienced by patients with delirium , as well as the impact of delirium on spouses/caregivers and staff.Patients with hypoactive delirium are often misdiagnosed and /or perceived to be in less distress than agitated patients with hyperactive delirium. Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • DSM-IV Criteria for DeliriumA. Disturbance of consciousness (i.e., disturbance of awareness of the environment) with reduced ability to focus, sustain or shift attention

    B. Change in cognition (such as memory deficit, disorientation, language disturbance, perceptual disturbance) that is not better accounted for by a pre-existing, established or evolving dementia

    Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • DSM-IV Criteria for Delirium (Cont)C. The disturbance evolves over a short period of time (usually hours to days) and tends to fluctuate during the course of the day

    D. There is evidence from the history, physical examination, or laboratory findings of a general medical condition judged to be etiologically related to the disturbance Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • Delirium Assessment MethodsDiagnostic classification systemsDSM-III, DSM-III-R, DSM-IV ICD-9, ICD-10

    Diagnostic interview instrumentsDelirium symptom interview (DS)Confusion Assessment Method (CAM)- ICU & Peds versions

    Delirium rating scalesDelirium Rating Scale (DRS)Confusion Rating Scale (CRS)Memorial Delirium Assessment Scale (MDAS)

    Cognitive impairment screening scalesMini-Mental State Exam (MMSE)Short Portable Mental Status Questionnaire (SPMSQ)Cognitive Capacity Screening Examination Test (BOMC) Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • Subtypes of DeliriumDelirium is a disturbance of arousal and cognition.Subtypes of delirium are based on the type of motoric or arousal disturbance: Hyperactive Hypoactive Mixed Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • Subtypes of DeliriumIn 12 studies, the prevalence of each of the subtypes of delirium has varied widelyA meta-analysis of these studies suggest the following average prevalence for each subtype:Hypoactive: 48% (ranges: 15-71%)Hyperactive: 24% (ranges: 13-46%)Mixed: 36% (ranges: 11-55%)

    Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • Hypoactive Delirium: Controversies and Barriers to Treatment- IHypoactive Delirium is thought to be very rare, but in fact accounts for an average of 50% of delirium cases Hypoactive Delirium is thought not to cause morbidity and therefore does not require pharmacologic intervention Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • The Delirium ExperienceDelirium is a highly distressing experience for patients, spouses/ caregivers and nursesDelirium is especially distressing when delirium is more severe and is characterized by the presence of delusions and hallucinationsHypoactive delirium is as distressing as hyperactive deliriumSymptoms of Delirium are important to treat with antipsychotics because of association with significant suffering in patients, spouses/caregivers and staff

    Breitbart, et al, Psychosomatics, 2002 ; DiMartini, et al. 2007; Cohen et al, 2009 Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • Hypoactive Delirium: Controversies and Barriers to Treatment- IIHypoactive Delirium, because of its phenomenologic differences with Hyperactive Delirium, is thought not to respond to pharmacologic interventions with neuroleptics - antipsychotics Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • Phenomenologic Differences between Hypoactive and Hyperactive Delirium Hypoactive and Hyperactive Delirious patients have similar ages, delirium severity, and degree of cognitive impairmentEarly studies suggest Hyperactive Delirious patients are more likely to have Hallucinations (57% vs. 3%) and Delusions (50% vs. 3%) than patients with Hypoactive DeliriumRoss, et al. 1991 Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • Differences in MDAS Items Between Hyperactive and Hypoactive Patients (n=101)Patients with hyperactive delirium had significantly higher incidence of delusions and hallucinations:

    Delusions: Hyperactive- 78% (MDAS# 8) Hypoactive- 43%

    Hallucinations: Hyperactive- 70% (MDAS# 7) Hypoactive-51%Boettger, Passik, Breitbart, Pall Supp Care, 2012 E pub ahead of print Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • Overview of Delirium ManagementTerminalDeliriumDELIRIUM TREATMENT OUTCOMEAimed at Delirium isPreventing or reversibleReversing etiology

    Aimed at Deliriumcontrolling is irreversiblesymptomatology Palliative Care NetworkInternational Palliative Care Network Lecture Series 2012

    International Palliative Care Network Lecture Series 2012

  • Causes of Delirium in CancerDirectPrimary brain

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