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

ium ium? De lir  What is de lir

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 o 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 o 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 onme 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r than re spo nding to que stio ns o r c o nve rsatio n  Be ing e asily distrac te d by unimpo rtant thing s  Be ing withdrawn, with little o r no ac tivity o r little re spo nse to the e nviro nme nt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.  luc tuation. T he appe aranc e o f de lirium sympto ms F 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 :

tiologie s e que nt E r F

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 outle 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 of de lir ium, & le ss distr e ss

Pr e ve nting or Minimizing De lir ium  Pr omote good sle e p habits  T o 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 omote c almne ss and or ie ntation  T o 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 oble 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 otate 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 oduc e d  Hydr ate  i um Shar e infor mation with family/ fr ie nds about de lir

T r e atme nt of De lir ium  Use par tic ular me dic ations to c ontr ol be haviour only if ne c e ssar y:  Ne ur ole ptic s -e .g. Haldol, olanze pine , se r oquil,  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.