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Understanding Mental Status Changes

Introduction

Cognitive changes may occur in patients receiving certain kinds of medication such as sedatives or opioid narcotics. Changes in mental alertness and clarity may also occur when the dosage of the sedative or opioid narcotic is escalated. Mental confusion can also occur as a result of electrolyte and metabolic imbalances. It is frightening for family members to care for their loved ones when communication is complicated by patients' persistent sedation, mental confusion, or hallucinations.

Patients may verbalize that they are "hazy" or that "things are not very clear." Patients and family caregivers need reassurance the these feelings are expected and usually temporary when opioid narcotics are initiated. These "hazy" feelings and increased sleeping may last from a few days to 1 - 2 weeks. It is uncommon for mental confusion related to opioid therapy to last more than 1 - 2 weeks. Patients and family caregivers need instructions about safety precautions (no driving or operating machinery, scatter rugs or other hazardous conditions in the home need to be eliminated).

It is common for patients who are near the end of life to demonstrate a decrease in mental alertness and clarity accompanied by periods of restlessness and agitation. Family members need emotional support and information that this is not an unusual occurrence. Hospice patients may have mental status changes and these should be reported to the Hospice nurse on call.

Assessment

Guidelines to Assess Persistent Sedation in Patients Receiving Chronic Opioid Therapy*

  1. Evaluate potential disease or treatment-related causes of persistent sedation (electrolyte imbalance, malignant involvement of central nervous system, sepsis, hypoxia, vital organ failure during dying process).
  2. Eliminate nonessential central nervous depressant medication
  3. If analgesia is satisfactory, discuss with MD a trial period to reduce opioid dose by 25% (during trial - assess pain level and mental alertness changes)
  4. If analgesia is unsatisfactory, or opioid dose reduction is not possible, discuss the possibility of obtaining a prescription for an alternate opioid with the MD, especially if the current opioid has a long half-life.
  5. Discuss with MD the possibility of adding an NSAID or adjuvant analgesic that may allow the opioid to be reduced without compromising the patient's pain relief.
  6. If sedation persists discuss the following options with the MD:
    • Addition of psychostimulant
    • Changing administration route of opioid
*Adapted from Coyle, N., Cherney, N.I., & Portenoy, R.K. (1995).

Guidelines to Assess Guidelines to Assess Confusion in Patients Receiving Chronic Opioid Therapy*

  1. Evaluate potential disease or treatment-related causes (sleep deprivation, hypoxia, electrolyte imbalance, CNS malignancy).
  2. Review medications with MD.
  3. If analgesia is satisfactory, discuss with MD a trial period to reduce opioid dose by 25% (during trial - assess pain level and mental clarity changes)
  4. If analgesia is unsatisfactory, or opioid dose reduction is not possible, discuss the possibility of obtaining a prescription for an alternate opioid with the MD, especially if the current opioid has a long half-life.
  5. Discuss with MD a trial of a neuroleptic (e.g. haloperidol)
*Adapted from Coyle, N., Cherney, N.I., & Portenoy, R.K. (1995).

Intervention

  1. Maintain patient's safety
  2. Provide information and emotional support to family caregivers who will be upset by the changes in the patient's mental status
  3. Provide adequate pain relief
  4. Start oxygen (2 liters) as ordered by MD
  5. Trial of neuroleptic medication for confusion

References

Coyle, N., Cherney, N.I., & Portenoy, R. K. (1995). Pharmocologic management of cancer pain. In D.B. McGuire, C.H. Yarbro, & B.R. Ferrell (Eds.), Cancer Pain Management, Boston: Jones & Bartlett Publishers.





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