Part of St Vincent’s Hospital and a Collaborative Centre of The University of Melbourne

Abnormal mental States in

Palliative Care:

ANZPM conference 28-29 June 2013

Altered mind states as a result of disease

or treatments

Case 1 - Muriel

Muriel 78 years

Widowed, lives alone,

family live nearby but kept

at distance

Metastatic colorectal Ca

Vascular disease ++

Disinterested, looks flat,

distressed and agitated

when moved to another

room, not participating in

physiotherapy, slightly

suspicious of staff

Case 1 – differential diagnoses

• Dementia

• Depression

• Delirium

• Fatigue

• Sedation

• (Sick)

• (Dying)

Case 1 - Muriel

• Muriel becomes more confused in the

evenings, calls out, wanders, becomes

incontinent, refuses medications,

accuses staff of poisoning her food

Case 1 - issues

• Assessment of delirium – clinical, instruments

• Delirium and dementia

• Reducing the threshold for delirium

• Antipsychotics in this population

• Use of delirium guidelines

• Communication between night and day staff

• Environmental factors

Case 2 – Gabor

Gabor, 67 years

Married, 3 adult children, retired

civil engineer; son suicided 12

months ago (BPAD).

Past history BPAD on sodium

valproate and quetiapine.

Met prostate cancer 10yr, H/T,

Respite admission – wife not

coping – not eating (what’s the

use?’), no energy, withdrawn

Case 2 – issues

• Grief vs Depression

• Melancholia

• Trans-generational trauma

• Importance of whole-person understanding

• Antidepressants

• Special considerations in BAD – switching to

mania, steroids, long-term side-effects of

antipsychotics

• Suicide risk evaluation

Take-home messages – 1 Antipsychotics

• Antipsychotics: • 17% all new admissions to nursing home, only 10% receive

single script.

• Risks: • Appear within weeks, and are well demonstrated within a variety

of settings.

• Risk AMI highest in first month – hazard ratio of roughly double

that of matched population. Risks of CVA, falls, EPSE and death

– roughly 3-4 times rate in control population

• Same risks evident in FGA and SGA, but more common in FGA.

Take-home messages – 2 Antipsychotics

• cerebrovascular safety ok for atypical antipsychotics

in older adults with dementia

• typical antipsychotics appear to be associated with a

higher risk of CVA, although the risk disappears after

discontinuation

Take-home messages – 3 Delirium

• Delirium assessment:

– perceptual disturbances and delusions are

much more common than assumed across

motor subtypes – especially in hypoactive

states.

– in all motoric subtypes, these correlate with

poor attention and arousal disturbance, not

cognitive impairment.

Take-home messages – 4 Delirium

• Delirium treatment:

– antipsychotic use continues to be

supported – important to be aware of

Cmax and dose again if no response – 60

minutes for oral HPL / 30 min for s/c.

– No compelling new evidence regarding

choice of agent, or for different motoric

subtypes. Guidelines differ eg Canadian vs

ours.

– quetiapine / aripiprazole / olanzapine all

found efficacious

Atypical Neuroleptics in Delirium

• risperidone – 0.25-2mg 12-24hr # * (some EPSE)

• olanzapine – 2.5-10mg 12-24hr + * (wafers)

• quetiapine - 12.5-200mg 12-24hr # + #

• ziprasidone º – 10-40mg 12-24hr

• aripiprazole º – 10-30mg 24hr

• clozapine xx

*QTc #hypotension +anticholinergic #low EPSE

as effective as haloperidol

lack of parenteral preparations a problem

Take-home messages – 5 Delirium

• Delirium treatment

– Psychostimulants – low level evidence –

not recommended.

– Benzodiazepines – only in selected cases

eg alcohol withdrawal delirium.

Take-home message – 7 Delirium

• Assess whether incipient, mild,

moderate, severe

• Have guidelines for course of action to

treat adequately

• Remember an agitated delirium is a

medical emergency

• Treat even a hypoactive delirium

Take-home messages – 7 Delirium

• Delirium prevention:

– Whilst multi-component intervention

programs have shown success, a recent

palliative care based program found no

difference in incidence, duration, severity

or delirium free survival in a large cohort

study

Take-home messages – 8 Delirium

• Delirium prevention:

– Cholinesterase inhibitors unhelpful in

prevention of delirium.

Take-home messages – 9 Delirium

• Antipsychotics:

– Haloperidol remains the gold standard in

delirium.

• Delirium

– Treat adequately (pharmacological and

environmental), attend to distress

Take-home message – 10 Wish for death

• Can arise out of

– Demoralisation

– Depression

– Fatigue

– Existential pain

– Unrelieved suffering

– A ‘rational’ choice

Take-home messages – 11 Wish for death

• Can persist in spite of good palliative

care

• Often has an unrecognised and

disturbing impact on staff

References – 1

Seitz DP, Gill SS, Herrmann N, Brisbin S, Rapoport MJ, Rines J,

Wilson K, Le Clair K & Conn DK. (2013) Pharmacological

treatments for neuropsychiatric symptoms of dementia in long-term

care: a systematic review. International Psychogeriatrics 25(2):

185-203

Dolder C, Nelson M & Stump A (2010). Pharmacological and

clinical profile of newer antidepressants. Implications for the

treatment of elderly patients. Drugs Aging 27(8): 625-640

Rayner L, Price A, Hotopf M & Higginson IJ (2011). The

development of evidence-based European guidelines on the

management of depression in palliative cancer care. European

Journal of Cancer 47: 702-712.

Satin JR, Linden W & Phillips MJ (2009). Depression as a

predictor of disease progression and mortality in cancer patients: a

meta-analysis. Cancer. Nov 15:5349-5361.

References – 2

Mitchell AJ, Chan M, Bhatti H, Halton M, Grassi L, Johansen C &

Meader N (2011). Prevalence of depression, anxiety, and

adjustment disorder in onological, haematological, and palliative

care settings: a meta-analysis of 94 interview-based studies. The

Lancet 12:160-174

Schwartz TL, Uderitz D (2011). Tailoring antidepressant treatment:

factors to individualize medication selection.

http://www.medscape.org/viewarticle/755180

Grassi L, Nanni MG, Uchitomi Y & Riba M. (2010)

Pharmacotherapy of depression in people with cancer. In

Depression and Cancer (eds DW Kissane, M Maj, N Sartorius),

John Wiley & Sons, Ltd, Chichester, UK. Ch

Robson A, Scrutton F, Wilkinson L & MacLeod F (2010) The risk of

suicide in cancer patients: a review of the literature. Psycho-

Oncology 19:1250-1258

References

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older adults newly admitted to nursing homes: incidence, dose and

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• Canadian Coalition for Senior's Mental Health. National guidelines for

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Canadian Coalition for Senior's Mental Health, Toronto, Canada (2006).

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