De lir ium in Palliative c ar e Pre se nta tio n to Vo lunte e - - PowerPoint PPT Presentation

De lir ium in Palliative c ar e

Pre se nta tio n to Vo lunte e rs 2016 Da vid F a lk

De lir ium

 What is de lir

ium?

Case Study - De lir ium



60+ ye a r o ld PQ pre se nts to ho spic e ve ry so mno le nt. She was admitte d with he r adult daug hte r who sta te s he r mo the r ha s ha d pre vio usly we ll until 2-3 days ag o whe n she starting sho wing inc re asing c o nfusio n, bizzare be havio ur, and se e ing bug s o n the wall. She was diag no se d with bre ast c anc e r a fe w ye a rs a g o but de c line d a ny a c tive the ra py

• the r than Clo dro nate . As a re sult, she has

fung ating wo unds to he r rig ht bre ast and bo ne me tastase s fro m DI do ne abo ut two mo nths ag o . PQ is able to e ng ag e in me aning ful c o nve rsatio n so me time s but e spe c ially in the e ve ning s and nig hts, she wants to g e t o ut o f be d fo r no re aso n, talks no nse nse , and be c o me s parano id with so me o f the nursing c are .

What is De lir ium?

 De lirium is a se rio us disturbanc e in me ntal

abilitie s that re sults in c o nfuse d thinking and re duc e d aware ne ss o f yo ur e nviro nme nt. T he sta rt o f de lirium is usua lly ra pid — within ho urs o r a fe w days.



Be c ause sympto ms o f de lirium and de me ntia c an be similar, input fro m a family me mbe r

• r c are g ive r may be impo rtant fo r a do c to r

to make an ac c urate diag no sis.

Some symptoms of de lir ium

 Re duc e d awar

e ne ss of the e nvir

• nme nt

 T

his may re sult in:



An inability to stay fo c use d o n a to pic o r to switc h to pic s



Ge tting stuc k o n an ide a rathe r than re spo nding to que stio ns o r c o nve rsatio n



Be ing e asily distrac te d by unimpo rtant thing s



Be ing withdrawn, with little o r no ac tivity o r little re spo nse to the e nviro nme nt

Some symptoms of de lir ium

 Poor

thinking skills (c ognitive impair me nt)



T his may appe ar as:



Po o r me mo ry, partic ularly o f re c e nt e ve nts



Diso rie nta tio n, fo r e xa mple , no t kno wing whe re yo u are o r who yo u are



Diffic ulty spe a king o r re c a lling wo rds



Rambling o r no nse nse spe e c h



T ro uble unde rstanding spe e c h



Diffic ulty re a ding o r writing

Some symptoms of de lir ium

 Be havior c hange s



T his may inc lude :



Se e ing thing s tha t do n't e xist (ha lluc ina tio ns)



Re stle ssne ss, ag itatio n o r c o mbative be havio r



Calling o ut, mo aning o r making o the r so unds



Be ing quie t a nd withdra wn — e spe c ia lly in o lde r adults



Slo we d mo ve me nt o r le tharg y



Disturbe d sle e p habits



Re ve rsa l o f nig ht-da y sle e p-wa ke c yc le

Some symptoms of de lir ium

 E

motional distur banc e s

 T

his may appe ar as:



Anxie ty, fe ar o r parano ia



De pre ssio n



I rritability o r ang e r



A se nse o f fe e ling e late d (e upho ria)



Apathy



Rapid and unpre dic table

Diffe r e nc e s be twe e n de lir ium & de me ntia



Onse t. T

he o nse t o f de lirium o c c urs within a sho rt time , while de me ntia usua lly be g ins with re la tive ly mino r sympto ms that g radually wo rse n o ve r time .



Atte ntion. T

he ability to stay fo c use d o r maintain a tte ntio n is sig nific a ntly impa ire d with de lirium. A pe rso n in the e arly stag e s o f de me ntia re mains g e ne rally ale rt.



F luc tuation. T

he appe aranc e o f de lirium sympto ms c a n fluc tua te sig nific a ntly a nd fre que ntly thro ug ho ut the da y. While pe o ple with de me ntia have be tte r and wo rse time s o f day, the ir me mo ry and thinking skills stay at a fairly c o nstant le ve l during the c o urse o f a day.

Cause s

 De lirium o c c urs whe n the no rma l se nding

and re c e iving o f sig nals in the brain be c o me impaire d. T his impairme nt is mo st like ly c a use d by a c o mbina tio n o f fa c to rs tha t make the brain vulne rable and trig g e r a malfunc tio n in brain ac tivity.

Cause s

 De lirium may have a sing le c ause o r mo re

tha n o ne c a use , suc h a s a me dic a l c o nditio n a nd me dic a tio n to xic ity. So me time s no c a use c a n be ide ntifie d. Po ssible c a use s inc lude :

F r e que nt E tiologie s

Some Cause s



Ce rtain me dic atio ns o r drug to xic ity



Alc o ho l o r drug a buse o r withdra wa l



A me dic a l c o nditio n



Me ta bo lic imba la nc e s, suc h a s lo w so dium o r lo w c a lc ium



Se ve re , c hro nic o r te rminal illne ss



F e ve r and ac ute infe c tio n, partic ularly in c hildre n



E xpo sure to a to xin



Ma lnutritio n o r de hydra tio n



Sle e p de privatio n o r se ve re e mo tio nal distre ss



Pa in



Surg e ry o r o the r me dic al pro c e dure s that inc lude ane sthe sia

Common Re ve r sible Cause s @ E OL

 C-onstipation  H-hype r

c alc e mia, hypoglyc e mia, hypokale mia

 I- nfe c tion  M-e dic ations  B-ladde r

• utle t obstr

uc tion

 O-2 de fic ie nc y  P-ain

Risk F ac tor s

 Any c o nditio n that re sults in a ho spital stay  Bra in diso rde rs  Olde r ag e  Pre vio us de lirium e piso de s  Visual o r he aring impairme nt  Multiple me dic a l pro ble ms  E

nd o f life

Pr e ve nting or Minimizing De lir ium

 Always ask your

se lf, “Could this be de lir ium?”

 Studie s show that e ar

ly de te c tion me ans e ar ly minimizing of de lir ium, shor te r dur ation

• f de lir

ium, & le ss distr e ss

Pr e ve nting or Minimizing De lir ium

 Pr

• mote good sle e p habits



T

• pro mo te g o o d sle e p habits:



Pro vide a c alm, quie t e nviro nme nt



K e e p inside lig hting a ppro pria te fo r the time o f day



Plan fo r uninte rrupte d pe rio ds o f sle e p at nig ht



He lp the pe rso n ke e p a re g ular daytime sc he dule



E nc o urag e se lf-c are and ac tivity during the day

Pr e ve nting or Minimizing De lir ium

 Pr

• mote c almne ss and or

ie ntation



T

• he lp the pe rso n re ma in c a lm a nd we ll-o rie nte d:



Pro vide a c lo c k a nd c a le nda r a nd re fe r to the m re g ularly thro ug ho ut the day



Co mmunic ate simply abo ut any c hang e in ac tivity, suc h as time fo r lunc h o r time fo r be d



K e e p familiar and favo rite o bje c ts and pic ture s aro und, but avo id a c lutte re d e nviro nme nt



Appro ac h the pe rso n c almly



I de ntify yo urse lf o r o the r pe o ple re g ula rly



Avo id arg ume nts



Use c o mfo rt me a sure s, suc h a s re a ssuring to uc h, whe n appro priate



K e e p no ise le ve ls and o the r distrac tio ns to a minimum

Pr e ve nting or Minimizing De lir ium

 Pr

e ve nt c omplic ating pr

• ble ms



He lp pre ve nt me dic al pro ble ms by:



Giving the pe rso n the pro pe r me dic atio n o n a re g ular sc he dule



Pro viding ple nty o f fluids a nd a he a lthy die t



E nc o urag ing re g ular physic al ac tivity



Ge tting tre atme nt fo r po te ntial pro ble ms, suc h as infe c tio n o r me ta bo lic imba la nc e s, e a rly



Avo id fre que nt ro o m c ha ng e s, inva sive pro c e dure s, po o r lig hting , la c k o f na tura l lig ht, lo ud no ise s

Pr e ve nting or Minimizing De lir ium

 Car

ing for the c ar e give r



Pro viding re g ular c are fo r a pe rso n with de lirium c an be sc ary and e xhausting . T ake c are o f family/ nursing staff/ yo urse lf, to o .



Ask fo r e duc atio nal mate rials o r o the r re so urc e s fro m a he alth c are pro vide r to share with family.



Share c are g iving with family and frie nds who are familiar the pe rso n so e ve ryo ne g e t a bre ak.

T r e atme nt of De lir ium



Maximize the pr e ve nting/ minimizing fac tor s



Ide ntify r e ve r sible illne sse s (CHIMBOP)



Re vie w pr e se nt me dic ations & minimize the m or r

• tate the m to some thing e lse



Avoid alc ohol



If a me dic ation has be e n withdr awn, it or it’s e quivale nt ne e ds to be r e -intr

• duc e d



Hydr ate



Shar e infor mation with family/ fr ie nds about de lir ium

T r e atme nt of De lir ium

 Use par

tic ular me dic ations to c ontr

• l

be haviour

• nly if ne c e ssar

y:



Ne ur

• le ptic s -e .g. Haldol, olanze pine ,

se r

• quil,



Be nzodiaze pine s –e .g. Ativan, Ve r se d

Case Study c ontinue d



PQ is inve stig ate d fo r re ve rsible fac to rs using CHI

• MBOP. Me dic atio ns we re c hang e d &

be havio ur c o ntro l was atte mpte d with Haldo l and lo w do se Ve rse d – unsuc c e ssfully. Bo th husband and daug hte r we re no t to o sure what PQ’ s de sire wo uld be in a c ase like this. She had be e n so inde pe nde nt with he r husband g o ing to wo rk e ac h day and he r daug hte r c o ntinuing with he r E MS jo b. T he y bo th appe are d to be re luc tant in se e ing PQ die in a fe w days so blo o dwo rk was do ne . I t sho we d marke d hype rc alc e mia.

Case Study c ontinue d



T he hype rc alc e mia was tre ate d and the de lirium re so lve d o ve r the ne xt 4-5 da ys. Whe n ta lking with PQ afte r it’ s re so lutio n, she state d she c o uld no t re me mbe r mo st o f tho se days so we had to fill he r in

• n so me o f the a c tivitie s.



One day I aske d he r if she c o uld re me mbe r any se nsatio n and if it was sc ary. She de nie d it be ing sc ary but she did state she live d a vivid dre am whe re he r g uardian ang e ls we re all aro und he r and physic ally re straine d he r fro m g o ing o ve r a pre c ipic e . She the n adde d. T his e xpe rie nc e has take n away the e xiste ntia l fe a r I ha ve he ld fo r ye a rs fro m my abusive past. I am muc h mo re at pe ac e with myse lf than I have e ve r be e n.

De lir ium @ E OL

 Que stions?