Cadmore media player playing audio Agitation and Delirium: William Breitbart, MD, discusses agitation and delirium at the end of life.
Audio Player
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the audio. Pressing escape will close all displays and pressing it again will jump to the end of the player.
You can press A to open the Keyboard Shortcut Dialog which also provides an audio description of the player and all of its features.
Transcript
Result Count
of
Search
Segments
Result Count
of
Search
Name:
Agitation and Delirium: William Breitbart, MD, discusses agitation and delirium at the end of life.
Description:
Agitation and Delirium: William Breitbart, MD, discusses agitation and delirium at the end of life.
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/34deda92-0cb5-4028-9987-e2f185b1aead/thumbnails/34deda92-0cb5-4028-9987-e2f185b1aead.jpg?sv=2019-02-02&sr=c&sig=wOtwmKnefsmKeM820mQ10RbxpMNQWU%2BFhWC24aiaxow%3D&st=2025-01-15T08%3A32%3A21Z&se=2025-01-15T12%3A37%3A21Z&sp=r
Duration:
T00H13M36S
Embed URL:
https://stream.cadmore.media/player/34deda92-0cb5-4028-9987-e2f185b1aead
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/34deda92-0cb5-4028-9987-e2f185b1aead/6830505.mp3?sv=2019-02-02&sr=c&sig=g3V%2BVBPC2GFEGQfv06wkRfbUNE4u8tlAegTTaBrtvxM%3D&st=2025-01-15T08%3A32%3A21Z&se=2025-01-15T10%3A37%3A21Z&sp=r
Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
>> I'm Joan Stephenson, editor of JAMA's Medical News & Perspectives section. Today I have the pleasure of talking with Dr. William Breitbart about Agitation and Delirium at the End of Life. This is a topic discussed in Care at the Close of Life, in a chapter co-authored by today's guest. Welcome to the podcast, Dr. Breitbart. And please introduce yourself to our listeners. >> My name is Bill Breitbart, I'm Interim Chairman of the Department of Psychiatry and Behavioral Sciences at Memorial Sloan Kettering Cancer Center.
And a Professor of Clinical Psychiatry at the Weill Cornell Medical College of Cornell University. >> Dr. Breitbart, how is delirium defined, and what are some of the more common clinical features of delirium that clinicians may see? >> Well, the definition of delirium is evolving a bit. But essentially, delirium is an acute confusional state. It's marked by an alteration or disturbance in the level of consciousness or arousal, in combination with cognitive impairment, disorientation, memory problems, and things like that.
And again, the symptoms tend to fluctuate over time and the onset is relatively abrupt. And there's usually some medical or neurologic etiology that's causing the delirium. And so for instance, delirium is differentiated from other cognitive impairment disorders like dementia, because while delirium and dementia are both disorders of cognition, delirium is also a disorder of arousal. >> What is the prevalence of delirium in patients at the end of life?
>> That varies from study to study, but in general it's quite high. In some studies, the prevalence is as high as 80-85%. And I think it's fair to say that it's very difficult to get out of this world into the next without going through a phase of delirium. Some people are lucky in that they don't go through that, but up to 80-85% of people will develop delirium at some point during the last days or weeks of life, so it's quite prevalent. >> What screening and evaluation tools exist to help clinicians assess delirium in the palliative care setting?
>> Well, there are several delirium screening measures, and delirium diagnostic tools. Some are very lengthy, and others are shorter. Most of them were developed for clinical research purposes, but several have sort of evolved and been taken up by clinical practitioners, particularly in the palliative care setting. So the scale that's most often utilized in the palliative care setting happens to be a measure that [inaudible] it's called the Memorial Delirium Assessment Scale. It's 10-item scale.
And it helps diagnose delirium, and rate the severity of delirium. And also characterizes the subtype of delirium, which is probably important for clinicians to know about. We may want to talk about that later. The other commonly used scales are the Delirium Rating Scale, developed by Paula Trzepacz, and the Confusion Assessment Method developed by Sharon Inouye. And the Confusion Assessment Method also has a four-item sort of brief version, which is very helpful for screening.
>> What is the experience of delirium like for patients and for caregivers? >> That's very interesting. I think very often, clinicians will assume that a patient who is delirious and is agitated, is experiencing some distress. And that's where the issue of the subtype of delirium comes into play, because not all patients with delirium are agitated or hyperaroused. A significant percentage of patients with delirium in fact are hypoaroused, hypoactive, not sort of quietly delirious.
And there was a misconception in the literature for about several decades that the prevalence of this sort of quiet, hypoactive, hypoaroused delirium is quite low. But in studies that we've done and in meta-analyses and the literature, at least 50% of patients with delirium are of the hypoactive or hypoaroused subtype. And it's actually a little bit higher. It's closer to 60% in the palliative care setting. So when the patient is delirious, but not agitated and not bothering the nurses and not acting distressed, the assumption is that the patient is not distressed.
So we were very interested in our group at Sloan Kettering to look at what the experience of delirium is for patients who are delirious. And as you can imagine, it's a difficult research question to answer. But what we did is we looked at a series of patients who we treated for delirium in the hospital, about 150 or so. And we used the Memorial Delirium Assessment Scale to rate the severity and the phenomenology of it. And then we looked at the patients in whom the delirium resolved.
About 100 patients out of 150 actually had the delirium resolve; the other 50 died, which raises the other important issue, which is that delirium is often a harbinger of impending death in patients with advanced disease, advanced cancer. And then what we did is we asked patients a series of questions about whether they remembered being delirious, what the experience was like, et cetera. And we also asked the caregivers. And, as it turns out, about 95% of patients who are delirious rated as extremely distressing, about a 3.6 on a 0-4 scale.
And the caregivers, the relatives who are there at the bedside actually rate the distress even higher. And for the nurses it's about 3.2 out of 4. And the kind of things that make the delirium experience more distressing is the severity of it, the presence of hallucinations and delusions. Those things make delirium much, much more distressing for patients. And there's no difference in the rate of distress when you compare the hypoactive, hypoaroused, quietly delirious patients versus those who are agitated.
So even the quietly delirious patients are extraordinarily distressed, and that study has been replicated now a couple of times in the several different settings with very similar results. >> That's really fascinating. Dr. Breitbart, what are the underlying causes of delirium? And when a patient has a terminal illness, can the cause of the delirium be identified and treated? >> Well, the treatment for delirium often involves several things that have to happen concurrently.
The first is to try to identify and treat or reverse the cause of delirium, while you concurrently control the symptoms of delirium either with pharmacologic agents or non-pharmacologic strategies. And typically, any patient, particularly a patient with advanced disease who is in a palliative care setting, there are anywhere from three to seven different etiologies that usually occur concurrently. I think Peter Lawler, about 10 years ago, did a study in a palliative care setting in Canada showing the average number of etiologies.
And one individual patient was about three or four. So there are usually multiple medical etiologies. It's either infection, urosepsis, organ failure, metabolic derangements, bleeding in the central nervous system, swelling in the central nervous system, medication-induced things, opioid-induced delirium. So there are a variety of etiologies often occurring in multiple fashion. Most of the time, if a patient is relatively healthy despite being sick, perhaps with cancer getting treated with chemotherapy, et cetera, you can identify the cause of delirium.
Usually in about 70-80%, you're able to identify most of the causes of delirium and you're able to treat those causes of delirium. You're able to reverse the etiologies, a little bit of hypoxia you can treat that. But when patients are in the last days or hours of life and they're actively dying, and they have multiple organ failure as you can imagine, it's very difficult to reverse the dying process. And so the causes of delirium are at that point very difficult to reverse.
And also in a palliative care setting, perhaps if you're taking care of a patient, in-patient hospice or hospice at home, the aggressiveness with which you might investigate the etiologies of delirium will really depend on the degree to which you're providing comfort care versus care aimed at prolonging life. So you may not want to use very invasive kinds of diagnostic testing to determine the etiology, which then leads to a state where you really don't even know what the etiology is.
So in patients [inaudible] dying process with irreversible etiologies, the strategies and goal for treatment change. They change from the ideal goal, which is to try to have a patient who's awake and alert, communicating with the doctors and nurses and family. And where you're reversing the causes of delirium while you're controlling the symptoms of confusion, et cetera, with a neuroleptic drug for instance, it moves to primarily keeping the patient comfortable. And that may involve more of a strategy of sedation for comfort, rather than trying to achieve an alert and awake state.
>> What interventions, both pharmacologic and non-pharmacologic are available to help patients with agitation and delirium? >> Well, in terms of the non-pharmacologic interventions, the primary goal of non-pharmacologic interventions is to assure the safety of the patient and ensure the safety of the staff taking care of the patient. And that involves interventions to make sure that the patient is not alone, that there's someone sitting with the patient. That there's a reasonable plan to keep that patient safe and not pull out their IVs, and things like that.
You actually want to try to minimize the number of invasive kind of tubes and lines, et cetera, and to hydrate someone, and to minimize unnecessary medications, and to treat infection if possible. So the thrust of non-pharmacological interventions is to keep the patient and the staff taking care of the patient safe. In terms of pharmacologic interventions, the main medications that are used, the ones that are most effective are essentially neuroleptic drugs or antipsychotic drugs. Drugs like haloperidol, which is an older drug, but still probably the agent that has the most established record of safety and efficacy in the treatment of delirium.
And then you have newer antipsychotic neuroleptic drugs that have less extrapyramidal side effects than haloperidol does. And there's a growing literature of randomized controlled trials suggesting that some of the more novel, new neuroleptic antipsychotic drugs like olanzapine, risperidone, and drugs like that are also quite effective. So you have a wide range of neuroleptic drugs that can be utilized.
Drugs like haloperidol can be given in a variety of routes of administration, orally, intravenously, subcutaneously. And other drugs that can be given orally, sublingually, et cetera. And they all have slightly different side effect profiles, some are more sedating than others. Occasionally, you need to move to a more sedating strategy, in which case you might use neuroleptic drugs like haloperidol in combination with a more sedating agent like an intravenous benzodiazepine, or opioids to achieve sedation.
>> Is there anything else you would like to tell our listeners about agitation and delirium at the end of life? >> Yeah. I think one of the important issues is in communicating the nature of delirium to family members who are witnessing a delirious event in their loved one, who is in the care of palliative care practitioners. It's a very frightening experience for family members. What I often hear from family members is something like this. It was bad enough that my husband is dying; now he's developed a psychiatric problem.
He's lost his mind. Because some of the manifestations of delirium include hallucinations, visual hallucinations, some paranoia, delusions, et cetera. And so, family members get very frightened. They think that suddenly their loved one not only has cancer and is dreadfully ill from that, but now is psychotic and has schizophrenia or something like that. It's very important, I think, to inform family members that delirium is in fact a neuropsychiatric complication of medical illness.
And it's usually an indication of profound medical problems that need to be attended to and controlled, and not a new onset of a psychotic illness or psychiatric disorder. I think that kind of information helps family members understand the process of delirium. >> Oh, I'm sure it does. Thank you, Dr. Breitbart, for this helpful discussion of agitation and delirium at the end of life. Additional information about this topic is available in Chapter 11 at Care at the Close of Life. This has been Joan Stephenson of JAMA, talking with Dr. William Breitbart about agitation and delirium at the end of life for JAMAevidence.
Segment:0 .
>> I'm Joan Stephenson, editor of JAMA's Medical News & Perspectives section. Today I have the pleasure of talking with Dr. William Breitbart about Agitation and Delirium at the End of Life. This is a topic discussed in Care at the Close of Life, in a chapter co-authored by today's guest. Welcome to the podcast, Dr. Breitbart. And please introduce yourself to our listeners. >> My name is Bill Breitbart, I'm Interim Chairman of the Department of Psychiatry and Behavioral Sciences at Memorial Sloan Kettering Cancer Center.
And a Professor of Clinical Psychiatry at the Weill Cornell Medical College of Cornell University. >> Dr. Breitbart, how is delirium defined, and what are some of the more common clinical features of delirium that clinicians may see? >> Well, the definition of delirium is evolving a bit. But essentially, delirium is an acute confusional state. It's marked by an alteration or disturbance in the level of consciousness or arousal, in combination with cognitive impairment, disorientation, memory problems, and things like that.
And again, the symptoms tend to fluctuate over time and the onset is relatively abrupt. And there's usually some medical or neurologic etiology that's causing the delirium. And so for instance, delirium is differentiated from other cognitive impairment disorders like dementia, because while delirium and dementia are both disorders of cognition, delirium is also a disorder of arousal. >> What is the prevalence of delirium in patients at the end of life?
>> That varies from study to study, but in general it's quite high. In some studies, the prevalence is as high as 80-85%. And I think it's fair to say that it's very difficult to get out of this world into the next without going through a phase of delirium. Some people are lucky in that they don't go through that, but up to 80-85% of people will develop delirium at some point during the last days or weeks of life, so it's quite prevalent. >> What screening and evaluation tools exist to help clinicians assess delirium in the palliative care setting?
>> Well, there are several delirium screening measures, and delirium diagnostic tools. Some are very lengthy, and others are shorter. Most of them were developed for clinical research purposes, but several have sort of evolved and been taken up by clinical practitioners, particularly in the palliative care setting. So the scale that's most often utilized in the palliative care setting happens to be a measure that [inaudible] it's called the Memorial Delirium Assessment Scale. It's 10-item scale.
And it helps diagnose delirium, and rate the severity of delirium. And also characterizes the subtype of delirium, which is probably important for clinicians to know about. We may want to talk about that later. The other commonly used scales are the Delirium Rating Scale, developed by Paula Trzepacz, and the Confusion Assessment Method developed by Sharon Inouye. And the Confusion Assessment Method also has a four-item sort of brief version, which is very helpful for screening.
>> What is the experience of delirium like for patients and for caregivers? >> That's very interesting. I think very often, clinicians will assume that a patient who is delirious and is agitated, is experiencing some distress. And that's where the issue of the subtype of delirium comes into play, because not all patients with delirium are agitated or hyperaroused. A significant percentage of patients with delirium in fact are hypoaroused, hypoactive, not sort of quietly delirious.
And there was a misconception in the literature for about several decades that the prevalence of this sort of quiet, hypoactive, hypoaroused delirium is quite low. But in studies that we've done and in meta-analyses and the literature, at least 50% of patients with delirium are of the hypoactive or hypoaroused subtype. And it's actually a little bit higher. It's closer to 60% in the palliative care setting. So when the patient is delirious, but not agitated and not bothering the nurses and not acting distressed, the assumption is that the patient is not distressed.
So we were very interested in our group at Sloan Kettering to look at what the experience of delirium is for patients who are delirious. And as you can imagine, it's a difficult research question to answer. But what we did is we looked at a series of patients who we treated for delirium in the hospital, about 150 or so. And we used the Memorial Delirium Assessment Scale to rate the severity and the phenomenology of it. And then we looked at the patients in whom the delirium resolved.
About 100 patients out of 150 actually had the delirium resolve; the other 50 died, which raises the other important issue, which is that delirium is often a harbinger of impending death in patients with advanced disease, advanced cancer. And then what we did is we asked patients a series of questions about whether they remembered being delirious, what the experience was like, et cetera. And we also asked the caregivers. And, as it turns out, about 95% of patients who are delirious rated as extremely distressing, about a 3.6 on a 0-4 scale.
And the caregivers, the relatives who are there at the bedside actually rate the distress even higher. And for the nurses it's about 3.2 out of 4. And the kind of things that make the delirium experience more distressing is the severity of it, the presence of hallucinations and delusions. Those things make delirium much, much more distressing for patients. And there's no difference in the rate of distress when you compare the hypoactive, hypoaroused, quietly delirious patients versus those who are agitated.
So even the quietly delirious patients are extraordinarily distressed, and that study has been replicated now a couple of times in the several different settings with very similar results. >> That's really fascinating. Dr. Breitbart, what are the underlying causes of delirium? And when a patient has a terminal illness, can the cause of the delirium be identified and treated? >> Well, the treatment for delirium often involves several things that have to happen concurrently.
The first is to try to identify and treat or reverse the cause of delirium, while you concurrently control the symptoms of delirium either with pharmacologic agents or non-pharmacologic strategies. And typically, any patient, particularly a patient with advanced disease who is in a palliative care setting, there are anywhere from three to seven different etiologies that usually occur concurrently. I think Peter Lawler, about 10 years ago, did a study in a palliative care setting in Canada showing the average number of etiologies.
And one individual patient was about three or four. So there are usually multiple medical etiologies. It's either infection, urosepsis, organ failure, metabolic derangements, bleeding in the central nervous system, swelling in the central nervous system, medication-induced things, opioid-induced delirium. So there are a variety of etiologies often occurring in multiple fashion. Most of the time, if a patient is relatively healthy despite being sick, perhaps with cancer getting treated with chemotherapy, et cetera, you can identify the cause of delirium.
Usually in about 70-80%, you're able to identify most of the causes of delirium and you're able to treat those causes of delirium. You're able to reverse the etiologies, a little bit of hypoxia you can treat that. But when patients are in the last days or hours of life and they're actively dying, and they have multiple organ failure as you can imagine, it's very difficult to reverse the dying process. And so the causes of delirium are at that point very difficult to reverse.
And also in a palliative care setting, perhaps if you're taking care of a patient, in-patient hospice or hospice at home, the aggressiveness with which you might investigate the etiologies of delirium will really depend on the degree to which you're providing comfort care versus care aimed at prolonging life. So you may not want to use very invasive kinds of diagnostic testing to determine the etiology, which then leads to a state where you really don't even know what the etiology is.
So in patients [inaudible] dying process with irreversible etiologies, the strategies and goal for treatment change. They change from the ideal goal, which is to try to have a patient who's awake and alert, communicating with the doctors and nurses and family. And where you're reversing the causes of delirium while you're controlling the symptoms of confusion, et cetera, with a neuroleptic drug for instance, it moves to primarily keeping the patient comfortable. And that may involve more of a strategy of sedation for comfort, rather than trying to achieve an alert and awake state.
>> What interventions, both pharmacologic and non-pharmacologic are available to help patients with agitation and delirium? >> Well, in terms of the non-pharmacologic interventions, the primary goal of non-pharmacologic interventions is to assure the safety of the patient and ensure the safety of the staff taking care of the patient. And that involves interventions to make sure that the patient is not alone, that there's someone sitting with the patient. That there's a reasonable plan to keep that patient safe and not pull out their IVs, and things like that.
You actually want to try to minimize the number of invasive kind of tubes and lines, et cetera, and to hydrate someone, and to minimize unnecessary medications, and to treat infection if possible. So the thrust of non-pharmacological interventions is to keep the patient and the staff taking care of the patient safe. In terms of pharmacologic interventions, the main medications that are used, the ones that are most effective are essentially neuroleptic drugs or antipsychotic drugs. Drugs like haloperidol, which is an older drug, but still probably the agent that has the most established record of safety and efficacy in the treatment of delirium.
And then you have newer antipsychotic neuroleptic drugs that have less extrapyramidal side effects than haloperidol does. And there's a growing literature of randomized controlled trials suggesting that some of the more novel, new neuroleptic antipsychotic drugs like olanzapine, risperidone, and drugs like that are also quite effective. So you have a wide range of neuroleptic drugs that can be utilized.
Drugs like haloperidol can be given in a variety of routes of administration, orally, intravenously, subcutaneously. And other drugs that can be given orally, sublingually, et cetera. And they all have slightly different side effect profiles, some are more sedating than others. Occasionally, you need to move to a more sedating strategy, in which case you might use neuroleptic drugs like haloperidol in combination with a more sedating agent like an intravenous benzodiazepine, or opioids to achieve sedation.
>> Is there anything else you would like to tell our listeners about agitation and delirium at the end of life? >> Yeah. I think one of the important issues is in communicating the nature of delirium to family members who are witnessing a delirious event in their loved one, who is in the care of palliative care practitioners. It's a very frightening experience for family members. What I often hear from family members is something like this. It was bad enough that my husband is dying; now he's developed a psychiatric problem.
He's lost his mind. Because some of the manifestations of delirium include hallucinations, visual hallucinations, some paranoia, delusions, et cetera. And so, family members get very frightened. They think that suddenly their loved one not only has cancer and is dreadfully ill from that, but now is psychotic and has schizophrenia or something like that. It's very important, I think, to inform family members that delirium is in fact a neuropsychiatric complication of medical illness.
And it's usually an indication of profound medical problems that need to be attended to and controlled, and not a new onset of a psychotic illness or psychiatric disorder. I think that kind of information helps family members understand the process of delirium. >> Oh, I'm sure it does. Thank you, Dr. Breitbart, for this helpful discussion of agitation and delirium at the end of life. Additional information about this topic is available in Chapter 11 at Care at the Close of Life. This has been Joan Stephenson of JAMA, talking with Dr. William Breitbart about agitation and delirium at the end of life for JAMAevidence.
Form Title Download
Media
Transcript
Form Title Bookmark
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Share
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Accessibility
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html audio player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the audio player are generally tabs, one of which shows a scrolling transcript of the audio and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the audio player is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the audio by opening up an explore dialog which contains an about tab which contains rich metadata about the media, a segments tab which contains further information about the audio, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
E: Explore Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Form Title Embed Media
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Embed Size
-
You Size - Responsive
-
We Size - Responsive
-
Picture Overlay Popup
-
400 x 225
-
512 x 288
-
400 x 700
-
768 x 1024
-
1024 x 512
-
1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the media.
You can press A to open the Accessibility Dialog.
This describes many other keyboard shortcuts for media controls.
Exit Clip Mode
The video is currently set-up to show just a clip from 0:00 to video end. You have requested to see a portion of the media outside of the clip.
Click OK to switch to the full media or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode