Dementia, Delirium,
Depression, and Anxiety at
End of Life
Dr. Mike Marschke
Horizon Hospice
Objectives
To understand how mental status changes
like dementia and delirium impact care at the
end of life
To understand some of the main psychiatric
problems that can occur at this time
To learn how to manage these problems
effectively
Dementia
A symptom complex with declining mental functioning
with many causes:
Alzheimer’s dementia – 50-60%, pathologic diagnosis
and also diagnosis of exclusion
Vascular, multi-infarct – 10-20%, step-wise decline
Pseudodementia – from depression
Others – tumors, AIDS, alcohol, syphilis, hypothyroid,
B12 deficiency, hydrocephalus, Parkinsons, vasculitis
(<10% are potentially reversible)
End-stage Dementia
Prognosis < 6 mos:
Severe dementia with need for total
assistance in ADLs (dressing, bathing,
continence), unable to walk, only able to
speak a few words
Comorbid conditions – aspiration pneumonia,
urosepsis, decubiti, sepsis
*Unable to maintain caloric intake with weight
loss of 10% or more in 6 months (and no
feeding tubes)
Complications from dementia
Delusions in up to 50%, most with paranoia
Hallucinations in up to 25%
Depression, social isolation may also occur
Aggressive behavior in 20-40% (may be
related to above problems, misinterpretation)
Dangerous behavior – driving, creating fires,
getting lost, unsafe use of firearms, neglect
Sundowning – nocturnal episodes of
confusion with agitation, restlessness
Treatment of complications
Hallucinations, delusions, agitation, sun-downing may
be improved with anti-psychotics like haloperidol,
risperdal, mellaril…
If any signs of depression, may be beneficial to treat
Anxiety may respond to benzodiazepines
Behavioral mod – re-inforce good behavior, DON’T
fight aggressive behavior
Familiarity (change in environments make things
worse)
Safety – key locks, knobs off stoves, take away car
keys/cigarettes/firearms…, lights, watch stairs
Avoid restraints, use human contact/music/pets/
distraction
Artificial Nutrition in Dementia
Many excellent reviews demonstrate no
improvement in quality of life and quantity of
life with G-tubes.
5% morbidity and mortality with the procedure
itself
No decrease in aspiration with them
Risk of infection
Can keep patient comfortable without it
Other EOL care needs for dementia
In bedbound, watch out for and prevent
decubiti
Feeding instructions to prevent aspiration –
head up, chin tucked, thick consistency foods
like pudding/jello/ice cream…
Caregiver stress – difficult care, poor sleep,
education to prevent aggressive behavior,
early bereavement losing loved one before
they are gone, need for support/respite
Delirium
An acute disorder of awareness, attention, and
cognition
Usually presents with fluctuating levels of
consciousness
Usually treatable with quick resolution
Occurs in 15-50% of hospitalized elderly, with an
associated increase in mortality, in nursing home
placement, in costs and complications
Risks increase with advanced age, more medical
problems, change in environment
Beware of previous traumatic experiences
(Concentration camp, sexual abuse..)
Not uncommon in the final hours of life
Causes of Delirium
Infections (even simple UTIs)
Medications, alcohol, withdrawal
Hypoxia
Metabolic abnormalities (low/hi Na, low K, hi Ca,
low/hi glucose, hypothyroid, renal/liver failure)
Head injury, subdural hematoma
Stroke, seizure
MI,CHF
Fecal impaction; urinary retention
Management of Delirium
Assure safety – try to avoid restraints
Re-assuring voice, don’t fight them, play
along, re-orient, bring in familiar things/people
Companionship
Reduce excessive stimulation/needle sticks
Get back home
Look for treatable causes
Medical management of delirium
If needed, anti-psychotics tend to be most effective:
- haloperidol 0.5-1mg po/iv/sc q1hr
until settled
- chlorpromazine, thioridazine 10-
25mg po/iv q4hr, more sedating
- atypicals like risperidol 0.5-1mg,
olanzepine 2.5-7.5mg q6hrs have
less extra-pyramidal effects
Benzodiazepines may work with agitation/anxiety
Depression at End of Life
25-75% of patients will experience it
Most have an intense sadness, maybe with
anxiety, about their illness but tends to
resolve in days to weeks
Persistent symptoms of depression are not
normal at the end of life
Depression is often viewed with shame or a
sign of weakness and may be hidden
Risk factors for depression
Pain or other uncontrolled symptoms
Physical impairment
Advanced disease
Medications like steroids, benzodiazepines
Spiritual suffering
Family history of depression or alcohol abuse
History of alcohol/substance abuse
Women experience it twice as much as men
Signs of Major Depression
May be hard to determine in advanced disease – the
somatic symptoms of fatigue, decreased appetite,
decreased libido, sleep disturbances may all be
related to the underlying disease
Dysphoria – sad, flat affect, distraught
Anhedonia – lack of anything pleasurable
Feelings of worthlessness, hopelessness,
helplessness, guilt, and despair
“Do you feel depressed most of the time?” is a
sensitive question to ask
Watch out for it in pain not responding as expected
Watch out for it with requests to end life early
Suicide
Women attempt it twice as much, but men are 4x
more likely to succeed
White men over 85 are at highest risk to do it
All patients with depressive symptoms should be
assessed for it
Talking about it can decrease risks
High risk of attempt if thoughts are recurring or if
have thought out the plan
ONE OTHER POTENTIAL HOSPICE EMERGENCY:
If risk high – DON’T leave patient alone, immediately
consult a psychiatrist – may need in-patient care or
involvement of authorities
Management of depression
Psychotherapy – behavioral, cognitive, and
other supportive approaches by
psychologists, licensed social workers,
chaplains, even bereavement counselors
may help
New coping strategies like meditation,
relaxation, guided imagery, hypnosis may
help
Medications
Pharmacological management of
depression
Tricyclic antidepressants (Elavil, desimpramine,
Nortriptyline…) – take 4-6 weeks, need to titrate
slowly to avoid cardiac failure, can cause sedation,
dry mouth, constipation
SSRIs or other newer agents (Prozac, Zoloft, Paxel,
Effexor…) – work in 1-2 weeks, less side effects, may
cause insomnia, anxiety, confusion
Psychostimulants (Ritalin, dextro-amphetamine…) –
work within 1-2 days, increase energy and well-being,
can improve opioid sedation, may cause anxiety,
tremors, insomnia, anorexia
Anxiety
May be a normal response to the situation –
fears, uncertainty, reaction to physical
condition, social or spiritual needs
Usually with 1 or more of the following signs –
agitation, restless, sweating, tachycardia,
hyperventilation, insomnia, excessive worry,
tension
Look for signs of depression, delirium,
alcohol/drug abuse, caffeine abuse
About 5% are affected by agoraphobia
Related anxiety conditions
Panic attacks – acute onset of palpitations,
sweating, hot, shaking, chest pain, nausea,
dizzy, derealization, fear, numbness; usually
short lived
Phobias – fears with avoidance, feelings of
being trapped, exposed
Post-traumatic Stress Syndrome – in
response to severe trauma, get more intense
fear, terror, dreams, feelings of helplessness,
detachment that can occur later on
Management of Anxiety
Counseling or supportive therapy
Medications:
- Benzodiazepines – valium – longer half-life
so may accumulate, ativan (0.5-2mg
PO/SL/IV q4-6hrs), xanax – shorter half-life
so more withdrawal effects
- SSRIs, Remeron, Serzone are anti-
depressants that may work for general
anxiety or panic attacks
Summary
A change in mental or emotional status of the
patient is not uncommon with a life-
threatening illness
Need to be aware of conditions that may be
normal reactions or have causes that are
potentially reversible, but at the end of life,
may need to focus on acute management of
these conditions
Need compassionate, supportive care for
patient and caregiver, always addressing
safety