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CASE
HISTORY - MASTER
CONFUSION IN PALLIATIVE CARE
Mr J.G. (John) is a 78-year-old man with a 2-year history of prostate cancer, with metastases to his spine and pelvis. He has until recently functioned at a high level, with apparently normal intellectual function according to his district nurse. He has severe pain in his back and left leg, in spite of palliative radiation therapy to known lumbar metastases. His GP has prescribed increasing doses of morphine.
John’s wife has diabetes and is registered blind. She is very dependent on John. His sister has been helping him by shopping and driving, as he is no longer coping with daily activities. His home care nurse is concerned that he is confused about time recently, he is not taking his medication as prescribed, and he seems vague and anxious. His pain remains moderate to severe, in spite of a steady increase in morphine doses. He has therefore agreed to be admitted to the local Cottage Hospital for symptom management. A niece has agreed to stay with his wife.
Following admission, John appears anxious, but quiet and compliant. He is oriented to person, time, and place on formal testing. He walks with a cane, and is independent with personal care. The nursing staff note that he tends to wander around, and sometimes appears to become lost on the ward. One nurse states that the patient is demented, while another is concerned that John is delirious.
QUESTION 1.
You are the nurse on duty. How would you assess John’s mental state?
- History of problem
- Features to differentiate delirium from dementia
- MSQ as baseline
John’s sister and his neighbour confirm that John has changed over the past few years. He has less initiative in pursuing activities he used to enjoy and, 1 year ago, he couldn’t seem to work out how to plant his garden. His sister has taken over his banking, for the past 9 months. Beginning with the use of morphine a few weeks ago, he became much more confused.
QUESTION 2.
You are the doctor on duty and decide to come in to the Cottage Hospital to see John.
What are the possible causes of his recent behaviour changes.
Table 5.1. Causes of delirium
Symptom Possible cause
Increased intracranial pressure
Tumour
Trauma
Hydrocephalus
Hypoxia
Infection
Drugs—particularly
note:
Anticholinergic
drugs
Benzodiazepines
Chemotherapy
CNS
stimulants
H2
receptor antagonists
Opioids
Corticosteroids
Anti-virals
Chemical imbalance
Hypercalcaemia
Hyponatraemia
Uraemia
Hyperglycemia or ketoacidosis
Hepatic failure
Endocrine disorders
Hypothyroidism
Psychotic reaction to illness
Vitamin deficiencies
Haematologic disorders
Severe anaemia
Vitamin B12 deficiency
Coagulopathy
Elimination disorders
Constipation
Urinary retention
Depression
Alcohol or drug withdrawal
Cancer-related causes of confusion
Hypercalcaemia secondary to bony metastases may cause confusion which persists for as long as a week after successful treatment of hypercalcaemia. Adenocarcinomas such as prostate cancer can be associated with disseminated intravascular coagulation which can present with encephalopathy as its only manifestation.
Brain metastases
Rarely, prostate cancer can metastasise to the dura, although it is extremely uncommon for prostate cancer to metastasise to brain parenchyma.
Pain
Severe, prolonged physical pain can alter mood, concentration, and energy. Sleep deprivation and decreased mobility, with reduced environmental contact, contribute to impaired cognition. Pain and its associated clinical accompaniments may appear to worsen transiently underlying dementia.
Depression
John may be clinically depressed due to his progressing disease and his inability to care for himself. Depressive illness is common in the elderly, common in the cancer population, and may present with apparent mental slowing as one of its manifestations.
Pre-existing dementia
The prevalence of dementia increases with advancing age. John is 78, and may have pre-existing Alzheimer’s disease or dementia from some other etiology.
QUESTION 3.
What investigations would you do?
U&E’s, Ca, LFTs, FBC, MSSU, ?CXR
Screening laboratory tests are within normal limits. You conclude that John has delirium which is probably related to recent institution of opioids. Based on historical evidence alone, he is at increased risk from delirium due to mild underlying dementia. Morphine is discontinued and immediate release hydromorphone, together with naproxen, is started.
.QUESTION 4.
What non-pharmacological measures might help reduce his confusion?
General measures for the management of delirium include:
• Ensure that the patient continues to be treated with courtesy and respect.
• Restraints should be avoided as far as possible.
• Bed rails can be hazardous, as patients may be provided with a launching pad leading to dangerous falls; it may be helpful to position the bed in a corner of the room, with the two exposed sides protected by mattresses on the floor.
• Allay fear and suspicion, and reduce misperceptions by:
• frankly discussing the problem with John;
• use of a night light and orientation measures (clocks and calendars);
• maintenance of a constant environment and familiar routine;
• clear explanation of procedures;
• non-verbal communication (touch, smile)—these measures are particularly important as comprehension and speech will be diminished;
• responding thoughtfully to John’s delusions with answers and comments relating to his frame of reference;
• encouraging the presence of a family member or close friend and familiar objects.
• Ensure that drug regimens are as simple as possible.
• Check recent drug orders for errors in prescription or administration.
QUESTION 5.
In addition to general measures and relief of the underlying cause of delirium, are there other specific treatments that you might use, as interim measures, to help control John’s delirious state?
Table 5.2. Medications useful in managing delirium in patients with advanced disease
Drug Approximate daily dosage range (mg) Route’
Neuroleptics
Haloperidol 0.5—5 every
4—12 h P0, IV, SC, IM
Chlorpromazine 10—50 every 4—12
h P0. IV, IM
Methotrimeprazine 10—50 every 4—8 h IV, SC, P0
Benzodiazepines
Lorazepam 0.5—2.0 every 4 h P0, SL, sc
Oxazepam 10—20 every 6—8 h PC
Midazolam 24-100 per 24 h IV SC
~‘ P0, oral forms of medication are preferred; IV, intravenous infusions or bolus injections should be
administered slowly; or SC. subcutaneous infusions are generally accepted modes of drug administration in the
terminally ill; IM, intramuscular injections should be avoided if repeated use becomes necessary; Parenteral doses are generally twice as potent as oral doses."
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