TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPEC TM -O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

EPEC  – Oncology Education in Palliative and End-of-life Care – Oncology Module 3g: Symptoms – Delirium Module 3g: Symptoms – Delirium

Delirium l A disturbance of consciousness l A change in cognition l Acute onset, fluctuating course APA Practice guideline. Am J Psychiatry l A disturbance of consciousness l A change in cognition l Acute onset, fluctuating course APA Practice guideline. Am J Psychiatry

Associated changes l Day-night reversal l Emotional state l Nonspecific neurological abnormalities l Decline in functional ability l Day-night reversal l Emotional state l Nonspecific neurological abnormalities l Decline in functional ability

Types l Hyperactive  Associated behavioral disturbances  Hallucinations  Delusional beliefs l Hypoactive  Quiet  Mistaken for depression or fatigue l Mixed – waxing and waning l Hyperactive  Associated behavioral disturbances  Hallucinations  Delusional beliefs l Hypoactive  Quiet  Mistaken for depression or fatigue l Mixed – waxing and waning

Prevalence l 80 – 85% of terminally ill patients

Prognosis l Increased risk of  Complications  Protracted hospitalizations  Protracted postoperative recovery l 25% delirious patients die <6 months l In elderly delirious, risk of dying during a hospital admission is 22 – 76% l Increased risk of  Complications  Protracted hospitalizations  Protracted postoperative recovery l 25% delirious patients die <6 months l In elderly delirious, risk of dying during a hospital admission is 22 – 76%

Key points l Pathophysiology l Assessment l Management l Pathophysiology l Assessment l Management

Causes of delirium... l Infection l Withdrawal l Acute metabolic l Trauma l CNS pathology l Hypoxia l Infection l Withdrawal l Acute metabolic l Trauma l CNS pathology l Hypoxia l Deficiencies l Endocrinopathies l Acute vascular l Toxins or drugs l Heavy metals

... Causes of delirium l Don’t forget:  Constipation, fecal impaction  Urinary retention l Don’t forget:  Constipation, fecal impaction  Urinary retention

Neurophysiology l Multiple cortical, subcortical levels affected l Several neurotransmitters involved l Changes in regional cerebral perfusion l Multiple cortical, subcortical levels affected l Several neurotransmitters involved l Changes in regional cerebral perfusion

Assessment l Clinical history, physical examination, serial observations l Folstein Mini-Mental State exam l Review of medication regimen l Thorough medical and laboratory work-up to elucidate underlying cause l Clinical history, physical examination, serial observations l Folstein Mini-Mental State exam l Review of medication regimen l Thorough medical and laboratory work-up to elucidate underlying cause

Delirium vs. dementia DeliriumDementia Change in alertness YesNo Onset Hours to days Gradual Fluctuation YesNo

Management l Treat underlying causes l Nonpharmacologic l Pharmacologic l Consult psychiatrist for assistance l Treat underlying causes l Nonpharmacologic l Pharmacologic l Consult psychiatrist for assistance

Treat underlying causes l Medications o Anticholinergics o Analgesics l Ensure adequate hydration l Many other causes l Medications o Anticholinergics o Analgesics l Ensure adequate hydration l Many other causes

Non-pharmacologic management l Environmental factors o Materials (calendars, clocks) to reorient o Adequate soft lighting o Identify all individuals o Limit number of different individuals o Limit stimulation o Sitters for safety l Environmental factors o Materials (calendars, clocks) to reorient o Adequate soft lighting o Identify all individuals o Limit number of different individuals o Limit stimulation o Sitters for safety

Pharmacologic management l Antipsychotics o Haloperidol (nonsedating) o Chlorpromazine (sedating) o Risperidone (nonsedating) o Olanzapine (sedating) o Quetiapine (sedating) l Antipsychotics o Haloperidol (nonsedating) o Chlorpromazine (sedating) o Risperidone (nonsedating) o Olanzapine (sedating) o Quetiapine (sedating)

Day-night reversal l Use a sedating antipsychotic o Chlorpromazine o Olanzapine o Quetiapine l Use a sedating antipsychotic o Chlorpromazine o Olanzapine o Quetiapine

Managing adverse effects l Dystonic reactions  Diphenhydramine l Akathisia, parkinsonian reactions  Benztropine l Tardive Dyskinesia  Stop medications  Consult psychiatry l Dystonic reactions  Diphenhydramine l Akathisia, parkinsonian reactions  Benztropine l Tardive Dyskinesia  Stop medications  Consult psychiatry

Benzodiazepines l Delirium due to alcohol withdrawal l For all other causes, not first-line therapy  More likely cause disinhibition, particularly in elderly l Low dose with antipsychotic medications may be synergistic l Delirium due to alcohol withdrawal l For all other causes, not first-line therapy  More likely cause disinhibition, particularly in elderly l Low dose with antipsychotic medications may be synergistic

Reassess regularly l Monitor carefully l If negligible or partial response  Re-evaluate diagnosis  Inquire about adherence to medication  Consider dosage adjustment  Consider a different medication  Refer to a specialist l Monitor carefully l If negligible or partial response  Re-evaluate diagnosis  Inquire about adherence to medication  Consider dosage adjustment  Consider a different medication  Refer to a specialist

Terminal delirium l Delirium during the dying process o Signs of the dying process o Agitation, restlessness o Moaning, groaning l Multiple causes, irreversible l Lorazepam or midazolam to settle l Sedating antipsychotics Breitbart W, Strout D. Clin Geriatr Med l Delirium during the dying process o Signs of the dying process o Agitation, restlessness o Moaning, groaning l Multiple causes, irreversible l Lorazepam or midazolam to settle l Sedating antipsychotics Breitbart W, Strout D. Clin Geriatr Med

Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience.