Delirium and Palliative Care

MD Anderson Cancer Center
Date: October 2011

>> Hello everyone. My name is Catherine Tilley. I'm a Nurse Practitioner in Palliative Care. And this morning we're going to talk about delirium and the importance of the nurses and the nursing assistants at the bedside to assess and screen for delirium.

Our objectives are to define delirium, to talk about the prevalence of delirium especially in the cancer population and we will go into that further to recognize the clinical features, risk factors, and nursing interventions for delirium. I think the most important thing is for the nurses to always have delirium in the back of their mind when they take care of these patients especially with advance cancer because delirium is so prevalent and it's very distressing not only for the patients but also for the families and the nursing staff.

So here is a basic definition of delirium. Delirium affects the patient's mental status: it can affect their level of consciousness, their attention, their thinking perception, and their sleep-wake cycle. Disturbance in sleep-wake cycle is one thing you'll see quite often with delirium.

The occurrence and outcome of delirium as you can see here is very common in the inpatient population. The prevalence is 10 to 31 percent and incidence of new delirium per admission, 3 to 29 percent. Delirium can increase the length of stay and institutionalization for the patients and it can persist upon discharge.

In advanced cancer patients the numbers actually go up. It's very common in terminal disease, 50 to 85 percent of patients. As you can see, up to 48 percent of advanced cancer patients experience delirium at some point in time, and 85 to 90 percent of these patients experience delirium in the hours or days before death. When this occurs the median survival is 21 days.

And this even goes up, again, when you have patients that are on opioids. Which, again, with the advanced cancer population, a major percentage of our patients that are in the hospital are on opioids. So it's really important to monitor these patients. If delirium occurs, you will usually have to do an opioid reduction or rotation, sometimes just reducing the dose aids in clearing the delirium.

Delirium onset is usually rapid. It happens within hours or days. It is not a slow process. So if you notice that someone seems a little bit confused and it's been going on gradually or the family says they've been forgetful for a few months, that is usually not delirium, that's more of a dementia. A lot of time delirium is first noticed at night. It is dependent in part on what's causing the delirium. Sometimes there are prodome symptoms although these are hard to pick up: irritability and anxiety that may appear before the delirium onset.

There are three types of delirium: hyperactive, hypoactive, and mixed delirium. We are going to talk about each of these.

Hypoactive is the hardest to discover and that is why a good mental assessment is so important in these patients. A lot of times it is misdiagnosed as depression, especially in the advanced cancer patient because people think, "Oh, they're just depressed with everything that is going on, and it could actually be a delirium."

Hyperactive, of course is the easiest to spot. If a patient is climbing out of bed, or pulling out their lines, or screaming at the staff or their family members, that is usually the easiest type for us to diagnose.

Mixed delirium is probably the most common that we see It is a combination of hyperactive and hypoactive delirium. With the psychomotor activity, the patients can be, lethargic, in a depressed state times, and then within moments, they can get agitated and either be climbing out of bed or pulling at lines or experiencing hallucinations.

Clinical features of delirium, again, it is an acute onset, over hours or days. You may notice confusion, disorientation, and impaired reality testing, which we will go into the tool that we use here at MD Anderson for that. Patients have the inability to pay attention sometimes. Psychomotor again, they can be agitated or they can be very withdrawn or lethargic. Hallucinations are common, usually visual, but we do have patients that hear voices as well. And again it is worst at night and in the early morning.

You commonly see a sleep-wake cycle disruption, patients that may sleep all day and then they are up all night. They may have some periods where they are lucid. So when you do your testing, sometimes you may do it, say in the morning and the mental status appears fine with your assessment, and then midafternoon, all of a sudden if you do the same test again, you may find that the delirium has appeared. So it does fluctuate. You can see fear and anxiety, delusions are especially scary for patients.

There are multiple risk factors, including, history of cognitive impairment in the past, prior risk factors depending on their disease, electrolyte imbalances, etc. Alcohol or substance abuse history is a big risk factor. Of course, the older population especially when they are in the hospital, if they have a history of post-op agitation or they are going undergoing surgery, the anesthesia can play a part into delirium. Medications such as opioids and other medications on their own as well as polypharmacy, when you have several different medications together may cause delirium.

Also delirium can be cause by infection, fever. UTI is big especially in the elderly population as well as pneumonia, as well as again, the metabolic disturbances. We see a lot of hypercalcemia that causes delirium, elevated ammonia causes delirium in some patients as well. The impaired liver function is a big one as well as impaired kidney function.

Delirium can be directly related to the disease, to the progression of the disease, brain metastasis or primary tumors. And of course delirium at the end of the disease trajectory is also very common. Pain management, pain can cause delirium as well as the opioids managing the pain. It is important to monitor these patients.

Cancer therapy, several chemotherapy agents may contribute to delirium. In my experience in the past before I was in palliative care, we used a lot of iphosphamide and I saw delirium with this medication quite often. But there other agents like methotrexate that also contribute to delirium. Biotherapy agents, very common within interleukin. Brain radiation also can cause delirium. Delirium may appear early with the start of radiation or it may appear after the radiation has completed as well The agents that we use to support patients such as the opioids and benzodiazepines also contribute to delirium.

There are more medications, as you can see, several different categories of medications that can cause delirium. Here are more specific drugs that are associated with delirium. It is interesting to see it crosses all categories, antihypertensives, antiarrhythmics, antivirals; Reglan for nausea, several medications that you use on a daily basis that you may not suspect that could cause some delirium or confusion. There are antifungals, amphotericin is a big one, some of the antibiotics as well. Cortical steroids, dexamethasone is a drug that we use commonly with our patients. Medications for dyspnea, fatigue, etc, may contribute and you have to be mindful when using these medications and monitor patients’ mental status.

Narcotics of course is a big one, the anti-inflammatories, benzodiazepines and we'll talk more about those, delirium is very common.

It is important to do an assessment of all these patients. I would say any patient that is hospitalized and especially the advanced cancer patients, you have to really monitor for delirium. And as you can see here, if you don't assess, go through all the risk factors, do a mental status evaluation, delirium may go undetected in 20 to 30 percent of cases. And this is mainly in the hypoactive delirium the easiest to miss. And also, if you involve RNs in screening and as well as helping to monitor the patients with the mental status tools, then you are going to dectect delirium sooner than you would otherwise prompting quicker diagnosis and treatment .

So It is important to recognize changes in cognition, feelings of uneasiness in the patient, mood changes, increased restlessness especially at night, that may be the most--the first thing that you see, as well as increased feelings of anxiety. And a lot of times, a family member will alert you to these changes.

Here is just a quick and I know you've seen this probably before, the difference between delirium and dementia. And of course the most important thing to remember is that delirium is an acute onset. It happens within hours to days, not in months, which is more common with dementia. It does affect the patient’s mood. Their activity again can be lethargic or agitated. And with dementia, you are going to see more of a normal to lethargic activity. Most of the time, you are going to see myoclonus,with opioid toxicity, or we sometimes see in medications such as metoclopromide in delirium, and you may see myoclonus with dementia patients late in the stage.

It is important to do a thorough assessment, assessing psychological distress, look for history, substance abuse, other factors, any visual impairments, their illness, degree of illness, disease progression, or any preexisting cognitive dysfunction that may contribute to delirium. Dementia patients can also develope delirium. So it's important to assess those patients as well, also assess opioid use and polypharmacy, simplify medications as much as possible.

The tool that we use in the Palliative Care Department to assess and diagnose delirium is the Memorial Delirium Assessment Scale, (MDAS), and this can be easily used, after a quick training session with the physicians, nurse practitioners, or physician assistants that work with the tool on a regular basis. The tool can capture distressing behavioral manifestations of delirium, which makes it unique as a mental status tool. Behavior is observational. The patients do not have to answer as many questions or write, draw pictures as in some mental status exams. The MDAS makes it easier to assess the delirium patient. The scores may be prorated,, which is very useful for physicians and nursing staff at the clinical bedside. The tool is very effective for patients with dyspnea, fatigue, or severe delirium where the patients cannot participate as fully as you would like them to. But even though this is good because of the observational factors and it captures the behavioral--sometimes it makes it difficult to use in research.

For diagnosis, you need a good history, observation; what do you see, what does the family see, what are the other staff members seeing, the interview with the patient and the family, and then the mental status examination. A lot of times, the nurses, will do the screening and the observation, they will notice, and they talk to the families and then to the physicians and say, "Hey, something's going on with this patient." So the physicians and the mid-levels can take it to the next level and do more intense assessment, the mental status examination, and start looking at possible causes for the delirium.

The treatment goals, of course, are to calm the patient and family, education is essential, talk to the family, you have to reassure them that you understand that this is not how their family member normally acts. You have to support them because delirium is very distressing to watchIt is also distressing for the patient.

Once the diagnosis is made, you have to try to figure out if the delirium is reversible or not. If you can identify a causative factor then it may possibly be reversed. —Check labs for example if, the calcium is high, if there's possibility to correct that, the ammonia levels, those types of things. X-rays can tell you if you have a pneumonia going on, you can do a UA and urine culture to find out if there's a UTI. One of the first things that we would do is rotate the opioids, especially if they are on high doses of of narcotics , you want to simplify medications as much as possible. If they are on more than one opioid, a lot of times you try to clear the deck and start over with one medication. One of the red flags with delirium, is when you go into the patient's room and the patient says their pain is 10 out 10, they can't pinpoint where the pain is ,” it hurts everywhere”. That is a red flag that you are dealing with delirium. If you look at the records and the opioids have been suddenly escalated, they are using medications every hour or every other hour, or the pain is not controlled at all per the patient those are also red flags. A mental exam needs to be completed and you probably need to rotate the opioid. Again simplify medications as much as possible. Constipation is another that can cause delirium--people don't think about that constipation can cause confusion and delirium itself. Dehydration may also be a cause.

If medications are needed to treat the delirium, first line is still considered to be haloperidol. It is an inexpensive medication that can be used in all settings. Some of the benefits are: it is one of the least sedating medications. It has less chance of reducing the blood pressure and it's available in several different routes as you see here, oral, intermuscular, subcutaneous, and IV. The most common that we use is subcutaneous and IV. Of course, if you're in a different setting and they have delirium for other reasons, you may see the intermuscular use. And occasionally, we'll use the oral as well sending the patients home. One of the things you have to watch for with haloperidol is EPS symptoms, the extrapyramidal side-effects although it is rare. With the positive symptoms, if you have an agitated patient, the first thing you start out with is haloperidol, it is the best thing to use for those patients.

But occasionally if you have a patient that has a lot of anxiety, if there is more of a hypoactive delirium without agitation, they may benefit from olanzapine. It has fewer extrapyramidal reactions. You can use olanzapine with renal and hepatic insufficiency. It is good for the negative symptoms Olanzapine may stimulate the appetite, also may help with nausea. It is not for agitated patients. It is expensive, although I think within the next year, olanzapine is going to become generic. So at that point in time, the cost of the drug will go down. Right now, there's only an oral administration, so that makes it difficult for patients if they can't take oral medications. That limits them. There is an oral version that will dissolve underneath the tongue and there're also studies going on with subcutaneous use of olanzapine. So we will just have to see what happens there. But I expect in the next few years we'll see different routes. And again, the cost of the olanzapine will go down as well.

Thorazine is usually our second line. If the haloperidol, if we've escalated the dose and it doesn't seemed to be holding the patient, if they are still very agitated, then we will change to Thorazine. It is more sedating. You do have to watch the blood pressure because it can decrease that. There are again the risk for EPS symptoms. You have to be cautious in renal impairment. It is a pretty inexpensive medication and as you can see here, we can use it in several different routes. Ativan which you will see, this is used sometimes as first line in other settings of the hospital. Lorazepam is a benzodiazepine, has alot of side-effects. Sedation is a big one.

Ativan should only be used in treatment of alcohol withdrawal related delirium only. Not in a setting of delirium caused by other factors that we have talked about today. So benzodiazepines, again, are for treatment of withdrawal, but we do not use them as first line in the treatment of delirium, what we may do at times, however, if a patient is highly agitated, and we are having a hard time getting them settled down with the haloperidol or the Thorazine, we may use a low dose Ativan to assist with that, in addition to the haloperidol or Thorazine. A risk for benzodiazepines is profound sedation that can decrease the respiratory status which does not happen with the haloperidol. Haloperidol and Thorazine do not tend to decrease the respirations. Benzodiazepines may increase restlessness and agitation as well, so it can also hinder the treatment of the delirium.

Most importantly are the nursing interventions, what can we do at the bedside? Education is a big one. Talk to the family. Sometimes, you know, especially if you have an agitated patient, you are not going to be able to talk to the patient about what is going on. So you just use calm voices, support. You try to provide a relaxing and safe environment. You want to limit visitors in the room It is important that the patient has familiar faces and objects, things that are reassuring to them. A clock is helpful in most cases, a calendar is as well to help with reorientation. But again, most importantly is your reassurance, the emotional support and support for the patient and their family.

You want to try to prevent falls, prevent agitated patients from pulling out lines, catheters, etc Someone needs to be at the bedside at all times whether it is a family member which is most important if you can involve the family. That is the most reassuring for the patient. In some cases a sitter may be needed.

The physical environment needs to stay as calm as possible; minimize noise; Try to break that sleep-wake cycle if it's disturbed. So you want the lights on during the day. You want the blinds open. You want to talk about how it is daytime and not nighttime. If the patient has a hypoactive delirium, maybe you can put them in a wheelchair, go downstairs with family, that type of thing. Patients need to be reorientated frequently. At night time, reduce the lighting, close the blinds just like you would in the normal nighttime environment. Family presence, is most important and most comforting for the patient.

It is important to educate family with what is happening with the patient as well as educate other staff members that are involved with the patient. Effective communication is vital between, the physicians, the midlevels, the bedside nurses, consult teams, the nursing assistants, the family, everyone that is involved with the patient. Talk about what we can fix, and what we can't fix. Talk about the fluctuations and symptoms and how cognition can change rapidly.

In recent years there have been studies on delirium recall. Delirium very distressing for the patients, their families and the bedside caregivers. Patients that do awake from the delirium, if it is able to reversed, usually do remember. The patient’s do not always always remember exactly what happened but they do remember and it is usually very distressing for them and sometimes they get very embarrassed in talking about it. I've had patients apologize saying, "I don't know exactly what I did, but I know I wasn't very nice and I'm sorry." You have to reassure them, provide lots of emotional support and education with what happened and what caused the delirium. The spouses, caregivers are also usually very distressed so you have to provide them support as well and give them a good opportunity to talk. The patients that have delusions, hallucinations may be the most stressful for every one involved. Nurses as well, the severity of delirium, if the patient is climbing out of bed, if they are pulling out lines, etc, the nurses are afraid they may hurt themselves or someone else. Hallucinations are also very distressing for the nurses.

Included are the references, if you would like some more information. Thank you very much and I hope this was helpful in the discussion of delirium.