Dementia, Delirium, Depression, and Anxiety at End of Life

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Dementia, Delirium, Depression, and Anxiety at
End of Life

• Dr. Mike Marschke
• Horizon Hospice

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Objectives

• To understand how mental status changes like
  dementia and delirium impact care at the end of
  life
• To understand some of the main psychiatric
  problems that can occur at this time
• To learn how to manage these problems effectively

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Dementia

• A symptom complex with declining mental
  functioning with many causes
• Alzheimers dementia 50-60, pathologic
  diagnosis and also diagnosis of exclusion
• Vascular, multi-infarct 10-20, step-wise
  decline
• Pseudodementia from depression
• Others tumors, AIDS, alcohol, syphilis,
  hypothyroid, B12 deficiency, hydrocephalus,
  Parkinsons, vasculitis (lt10 are potentially
  reversible)

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End-stage Dementia

• Prognosis lt 6 mos
• Severe dementia with need for total assistance in
  ADLs (dressing, bathing, continence), unable to
  walk, only able to speak a few words
• Comorbid conditions aspiration pneumonia,
  urosepsis, decubiti, sepsis
• Unable to maintain caloric intake with weight
  loss of 10 or more in 6 months (and no feeding
  tubes)

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Complications from dementia

• Delusions in up to 50, most with paranoia
• Hallucinations in up to 25
• Depression, social isolation may also occur
• Aggressive behavior in 20-40 (may be related to
  above problems, misinterpretation)
• Dangerous behavior driving, creating fires,
  getting lost, unsafe use of firearms, neglect
• Sundowning nocturnal episodes of confusion with
  agitation, restlessness

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Treatment of complications

• Hallucinations, delusions, agitation, sun-downing
  may be improved with anti-psychotics like
  haloperidol, risperdal, mellaril
• If any signs of depression, may be beneficial to
  treat
• Anxiety may respond to benzodiazepines
• Behavioral mod re-inforce good behavior, DONT
  fight aggressive behavior
• Familiarity (change in environments make things
  worse)
• Safety key locks, knobs off stoves, take away
  car keys/cigarettes/firearms, lights, watch
  stairs
• Avoid restraints, use human contact/music/pets/
• distraction

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Artificial Nutrition in Dementia

• Many excellent reviews demonstrate no improvement
  in quality of life and quantity of life with
  G-tubes.
• 5 morbidity and mortality with the procedure
  itself
• No decrease in aspiration with them
• Risk of infection
• Can keep patient comfortable without it

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Other EOL care needs for dementia

• In bedbound, watch out for and prevent decubiti
• Feeding instructions to prevent aspiration head
  up, chin tucked, thick consistency foods like
  pudding/jello/ice cream
• Caregiver stress difficult care, poor sleep,
  education to prevent aggressive behavior, early
  bereavement losing loved one before they are
  gone, need for support/respite

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Delirium

• An acute disorder of awareness, attention, and
  cognition
• Usually presents with fluctuating levels of
  consciousness
• Usually treatable with quick resolution
• Occurs in 15-50 of hospitalized elderly, with an
  associated increase in mortality, in nursing home
  placement, in costs and complications
• Risks increase with advanced age, more medical
  problems, change in environment
• Beware of previous traumatic experiences
  (Concentration camp, sexual abuse..)
• Not uncommon in the final hours of life

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Causes of Delirium

• Infections (even simple UTIs)
• Medications, alcohol, withdrawal
• Hypoxia
• Metabolic abnormalities (low/hi Na, low K, hi Ca,
  low/hi glucose, hypothyroid, renal/liver failure)
• Head injury, subdural hematoma
• Stroke, seizure
• MI,CHF
• Fecal impaction urinary retention

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Management of Delirium

• Assure safety try to avoid restraints
• Re-assuring voice, dont fight them, play along,
  re-orient, bring in familiar things/people
• Companionship
• Reduce excessive stimulation/needle sticks
• Get back home
• Look for treatable causes

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Medical management of delirium

• If needed, anti-psychotics tend to be most
  effective
• - haloperidol 0.5-1mg po/iv/sc q1hr until
  settled
• - chlorpromazine, thioridazine 10- 25mg po/iv
  q4hr, more sedating
• - atypicals like risperidol 0.5-1mg,
  olanzepine 2.5-7.5mg q6hrs have less
  extra-pyramidal effects
• Benzodiazepines may work with agitation/anxiety

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Depression at End of Life

• 25-75 of patients will experience it
• Most have an intense sadness, maybe with anxiety,
  about their illness but tends to resolve in days
  to weeks
• Persistent symptoms of depression are not normal
  at the end of life
• Depression is often viewed with shame or a sign
  of weakness and may be hidden

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Risk factors for depression

• Pain or other uncontrolled symptoms
• Physical impairment
• Advanced disease
• Medications like steroids, benzodiazepines
• Spiritual suffering
• Family history of depression or alcohol abuse
• History of alcohol/substance abuse
• Women experience it twice as much as men

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Signs of Major Depression

• May be hard to determine in advanced disease
  the somatic symptoms of fatigue, decreased
  appetite, decreased libido, sleep disturbances
  may all be related to the underlying disease
• Dysphoria sad, flat affect, distraught
• Anhedonia lack of anything pleasurable
• Feelings of worthlessness, hopelessness,
  helplessness, guilt, and despair
• Do you feel depressed most of the time? is a
  sensitive question to ask
• Watch out for it in pain not responding as
  expected
• Watch out for it with requests to end life early

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Suicide

• Women attempt it twice as much, but men are 4x
  more likely to succeed
• White men over 85 are at highest risk to do it
• All patients with depressive symptoms should be
  assessed for it
• Talking about it can decrease risks
• High risk of attempt if thoughts are recurring or
  if have thought out the plan
• ONE OTHER POTENTIAL HOSPICE EMERGENCY
• If risk high DONT leave patient alone,
  immediately consult a psychiatrist may need
  in-patient care or involvement of authorities

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Management of depression

• Psychotherapy behavioral, cognitive, and other
  supportive approaches by psychologists, licensed
  social workers, chaplains, even bereavement
  counselors may help
• New coping strategies like meditation,
  relaxation, guided imagery, hypnosis may help
• Medications

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Pharmacological management of depression

• Tricyclic antidepressants (Elavil, desimpramine,
  Nortriptyline) take 4-6 weeks, need to titrate
  slowly to avoid cardiac failure, can cause
  sedation, dry mouth, constipation
• SSRIs or other newer agents (Prozac, Zoloft,
  Paxel, Effexor) work in 1-2 weeks, less side
  effects, may cause insomnia, anxiety, confusion
• Psychostimulants (Ritalin, dextro-amphetamine)
  work within 1-2 days, increase energy and
  well-being, can improve opioid sedation, may
  cause anxiety, tremors, insomnia, anorexia

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Anxiety

• May be a normal response to the situation
  fears, uncertainty, reaction to physical
  condition, social or spiritual needs
• Usually with 1 or more of the following signs
  agitation, restless, sweating, tachycardia,
  hyperventilation, insomnia, excessive worry,
  tension
• Look for signs of depression, delirium,
  alcohol/drug abuse, caffeine abuse
• About 5 are affected by agoraphobia

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Related anxiety conditions

• Panic attacks acute onset of palpitations,
  sweating, hot, shaking, chest pain, nausea,
  dizzy, derealization, fear, numbness usually
  short lived
• Phobias fears with avoidance, feelings of being
  trapped, exposed
• Post-traumatic Stress Syndrome in response to
  severe trauma, get more intense fear, terror,
  dreams, feelings of helplessness, detachment that
  can occur later on

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Management of Anxiety

• Counseling or supportive therapy
• Medications
• - Benzodiazepines valium longer half-life so
  may accumulate, ativan (0.5-2mg PO/SL/IV
  q4-6hrs), xanax shorter half-life so more
  withdrawal effects
• - SSRIs, Remeron, Serzone are anti-depressants
  that may work for general anxiety or panic attacks

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Summary

• A change in mental or emotional status of the
  patient is not uncommon with a life-threatening
  illness
• Need to be aware of conditions that may be normal
  reactions or have causes that are potentially
  reversible, but at the end of life, may need to
  focus on acute management of these conditions
• Need compassionate, supportive care for patient
  and caregiver, always addressing safety