End of life delirium?

[Keila]

Hi everyone. I am not a hospice nurse -- I am still a student, but I am slowly losing my grandmother to stage IV breast cancer (and CHF, diabetes, and a laundry list of other ailments). I am not asking for medical advice; instead I am wondering what your experiences have been with end-stage hyperactive delirium. I'm almost positive this is what we're seeing in my grandmother, and I'm just trying to understand the condition as much as I possibly can.

Do you all have any good articles or resources for information? Also, when re-orientation is not possible, what are the best therapeutic communication tools that you can use? My grandmother is experiencing hallucinations and delusions that cause her a great deal of anxiety, and I would just like to find a way to communicate with and soothe her.

Thank you all so much for reading.

[Leda1st]

Regarding the statement that opiods and benzos can also cause confusion: PLEASE don't hesitate, however, to use this if needed to keep your grandmother comfortable - try to figure out the best dosages and combinations to do this. I have a patient with mets to the brain that I am working with, and I had to have a talk with her family where it came down to these choices: let their family member be in pain, but not confused at times, or let her be confused at times but not in pain and not agitated? Hang in there - and I wish you, your grandmother, and your family peace during this time.

[Keila]

Thanks Leda :)

We will definitely do everything we can to keep her comfortable -- I would much rather see her confused, but calm and pain-free, than in pain, agitated, and A&O.

Gran had a really good, clear day yesterday (the best we've seen her in about a month or longer), but we just got a phone call from my uncle, who lives with her -- she's been really 'thick-tongued' and thought she saw my great-grandmother on the roof of her house. My mother and I are going down there in about 30 minutes.

Thank you for the well wishes... Gran and my family can use all of them we can get. Thank you all for being so understanding and supportive :redbeathe

[Whispera, MSN, RN]

This may not be relevant at all, but has she had her dosage of benzos or opiates reduced lately? I'm thinking there could be some withdrawal going on if that's the case. Just a thought... I've seen lots of little old ladies who have been hospitalized, and while hospitalized haven't been given their benzos...and away they go into withdrawal....

[Keila]

Thanks for the thought, Whispera... but nope. She hasn't had any med changes in the last 4-5 months. She's on an opiate (Lortab 10 mg) for pain, but she doesn't take it everyday. I don't think that she would have built up any sizable tolerance -- she'll only take one/day maybe twice a week or less. We've actually been really lucky so far -- her physical pain has been tolerable without having to use a very high dose of meds.

She is on a benzo for sleep, and she takes that every night. She was in the hospital for about 4 days back at the beginning of May, and I don't know if she got her sleeping pill when she was there... but would that be affecting her LOC now?

We went down to her house the day before yesterday and when we got there, she was calm again. No agitation, no nonsensical speech; she was good. It's like flipping a switch sometimes. I've never seen anything quite like it before.

[Keila]

Another quick question.... sorry if I'm driving you all crazy!

I think Gran might be experiencing something like sundowner's, maybe. The odd thing is, she gets most agitated right before dawn; my mother and aunt have received several phone calls from my uncle asking for 'back-up' around 4 or 4:30 am. I know that traditionally, sundowner's is just that -- it presents when it becomes dark outside. But if Gran has her days and nights mixed up, could this notable increase in agitation be sundowner's?

She is still in the pattern of confusion (thinking she's not in her home, that her mother is there, etc) at all other times during the day, but early in the morning is when it's the worst to try and calm her down. She displays a lot of anger, hatefulness, and will to leave her house during the early morning hours.

[Leda1st]

I wouldn't say it is "sundowner's" necessarily. In my very brief hospice experience thus far, I have noticed, however, that my folks with dementia seem to have most of their falls and their "episodes" of getting out of bed, etc., in the very early morning hours. This has also been the case with my folks with metastatic cancer (mets to the brain looks so much like dementia to me - I could be wrong, but as I said, I am still new to hospice). The doc I work with likes to give folks Risperdal at HS, although some of the nurses I work with (who have been doing this a lot longer) like Haldol better. Giving at bedtime helps them sleep through the night (at least that is the thinking - sometimes it works, sometimes not so much).

I'm not sure if any of this helps, but at the very least, be reassured that it is not that unusual a behavior.

[Keila]

Thanks for the information, Leda!

It's interesting that you mention how brain mets looks so much like dementia. My great-grandmother had dementia and Alzheimer's before she passed away, and my family and I have discussed the similarities in the behaviors we saw in her and that we're seeing now in Gran. But in ways, Gran's behavior is sooo different. She'll have these moments of absolute clarity in the middle of complete and total confusion. Example: She was talking to my father the other morning on the phone (my uncle had called wanting someone else to try and calm her down). She told my father, "Edward, you don't need to be messing with me. You've got to go to work," and that was followed by a jumbled up story about how she needed to leave and find my great-grandmother because she was lost, etc.

It's the strangest, most unnerving, heartwrenching thing I've ever seen. And it's so frustrating because it seems like there is nothing we can do.

[Whispera, MSN, RN]

Risperdal is a better drug as far as having more limited side effects than Haldol. Haldol is known to often have some pretty bad side effects. It does, however, help patients sleep and works quickly. Haldol also costs alot less than Risperdal. If someone was going to need more long term treatment for hallucinations, delusions, etc., Risperdal is a kinder choice.

With regard to brain mets looking like dementia...that makes total sense, since both conditions are in the brain and likely to strike the same parts of the brain, yielding confusion and all sorts of other problems with thinking.

I've often wondered if the reason people get "sundowners" has something to do with gravity. The brain isn't solid like a brick. It would seem there could be some movement of the things in it, even if the movement is microscopic. Someone sleeps and gravity might pull "whatever" (tiny neurons, plaque, fibers, liquid) to the part of the brain most near the floor. Then when the person wakes up and sits up, the parts that were toward the top while sleeping are more"clear," so to speak. Maybe these parts operate more realistic thinking? Then over the course of the day, the parts migrate back toward where they were before, yielding sundowners by the end of the day, only to go through the process again. It's all my own personal thought, but I think it could make some sense.