Palliative care in cancer patients: Neurological aspects

1. Palliative care in cancer patients: Neurological aspects By Dr Maged Abdel-Naseer Prof of Neurology Cairo university

2. Introduction Nervous system tumours are either: • Primary: glioma, meningioma, medulloblastoma, and acoustic neuroma. • Secondaries: - direct invasion (as in cholesteatoma, chordoma, or osteoma). - blood-borne metastases: cerebral or spinal cord

3. Introduction Cerebral metastases: • Commonly arise from primary malignancy of bronchi, breasts, kidneys, stomach, and thyroid. • Headache, mental and behavioral changes, focal weakness (hemiparesis, aphasia, and ataxia) are most common complaints and signs.

4. Introduction Spinal cord metastases: • Multiple myeloma, lymphoma, and cancer breast, lung and prostate are common primary sources. • Clinically, there is back pain without neurological deficits at early stage, then, subtle weakness and/or numbness in both legs which progresses rapidly to complete paraplegia in few days.

5. Paraneoplastic neurological syndromes • These are stereotyped syndromes through remote effects of primary cancer especially from breast, lung, and ovaries. • They are not the result of tumour invasion or metastases, treatment by chemotherapy or radiotherapy, malnutrition, or infection.

6. Paraneoplastic neurological syndromes These syndromes are immune-mediated and include: progressive cerebellar degeneration, limbic encephalitis, optic neuritis, opsoclonus, spinal cord syndromes, pure sensory neuropathy, and disorder of myoneural junction.

7. Disturbed conscious level is a common neurological manifestation of cancer patients Causes Primary or secondary brain tumours. Paraneoplastic syndrome. Metabolic encephalopathy: organ failure, hypercalcemia, electrolyte imbalance, drug, or sepsis. Complication of chemotherapy or radiotherapy.

8. *Confusion: inability to maintain a coherent stream of thoughts or action. * Drowsiness: ready arousal, ability to respond verbally, and by movement induced by verbal stimuli. * Stupor: incomplete arousal to noxious stimuli. No or little response to verbal commands, no verbal response is elicited. The motor responses are still of purposeful type. * Coma: motor responses to noxious stimuli are either primitive or totally absent.

9. Management of comatose patient 1- Care of circulation: fluids to maintain blood pressure and cardiac monitoring.

10. Management of comatose patient 2- Care of respiration: adequate oxygenation and avoid infection: a- remove dentures. b- short oropharyngeal airway to prevent the tongue from obstructing airflow. c- prevent aspiration by suction of secretions and lateral decubitus position. d- endotracheal intubation. e- nasogastric tube to evacuate gastric contents and prevent aspiration.

11. Management of comatose patient 3- Management of increased intracranial tension and brain oedema: a- avoid hypotonic IV solutions or fluids containing large amounts of free water e.g. glucose 5%. b- hyperosmolar agents: mannitol 20% may be given IV in a dose of 1 gm/kg over 10-30 minutes according to the severity of the condition. c- steroids: dexamethasone (decadron) 10 mg by rapid IV infusion followed by 4-6 mg IV/6 hours.

12. Management of comatose patient 4- Care of skin: change patient position every 2 hours and use airmatress. 5- Care of nutrition: initial IV fluids then nasogastric tube feeding. 6- Care of bladder: condom catheter for male patients. Indwelling catheter may be necessary. Clamp the catheter and release every 3-4 hours to maintain the bladder tone.

13. Management of comatose patient 7- Care of bowel: enema for fecal impaction. 8- Care of eyes: avoid corneal injury by using eye drops and ointment. 9- Management of restlessness and agitation: avoid unnecessary sedation. In case of excessive severity or duration of agitation, a short-acting benzodiazepine (e.g. dormicum) may be indicated.

14. Paraplegia is another neurological problem that may be: - presentation of primary or secondary spinal cord tumours. - represent a complication of radiotherapy as radiation-induced myelopathy.

15. Management of paraplegic patients 1- Bladder care: * The hyperreflexive bladder: many uninhibited detrusor contractions, reduced capacity, and spontaneous voiding with a strong stream. * The hyporeflexive bladder: very low pressure, no contractions, high capacity, high residual volume, and poor stream

16. Bladder care: Drug Therapy a- Bethanechol (urecholine) may increase detrusor activity and facilitate reflex voiding. The dosage is 10-50 mg/6 hours. b- Oxybutynin chloride (ditropan) has an atropine-like effect on smooth muscle and causes relaxation of detrusor muscle. The dose is 5 mg b.i.d. or t.i.d. c- Baclofen has been reported to reduce residual urine volume. d- Alpha-adrenergic blocking agents may reduce urethral pressure. Residual volume may be reduced and voiding is more complete. e- Beta-adrenergic blockers increase urethral resistance and may be helpful when incontinence is caused by uninhibited contractions that overcome the urethral pressure.

17. Management of paraplegic patients 2- Bowel care: the initial stage of bowel distension is treated by enemas. Later, stool softeners are used. As the bowel becomes more active, suppositories replace enemas. 3- Skin care. 4- Nutrition: high-calorie, high protein diet is essential. Fluid and electrolyte balance should be watched closely. 5- Pain control: aspirin for acute pain, carbamazepine and amitriptyline for neuropathic pain.

18. Management of paraplegic patients 6- Psychiatric care and therapy are essential for suicidal or excessively depressed patients: - Although tricyclic and tetracyclic antidepressant drugs are very effective against depression, side effects limit their use especially in elderly patients. - The new group of selective serotonin-reuptake inhibitors (SSRI) as prozac, cipralex, lustral, or seroxat have better safety profile.

19. Management of paraplegic patients 7- Avoid complications: decubitus ulcer, muscle spasm, deep vein thrombosis, pneumonia 8- Physiotherapy

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