Symptom Management in Palliative Care: Part 2

1. Symptom Management in Palliative Care: Part 2 Scott Akin MD Scott.akin@hsd.cccounty.us

2. Outline • Pain control: That was part #1 of this talk…e-mail me for a copy • Depression • Dyspnea • Nausea and vomiting • Anorexia

3. Depression in Palliative Care • Common: numbers hover around 30% • Misunderstood • Myth that all dying patients “should” be depressed, and it is a “normal” part of dying • Underdiagnosed • Clinicians fearful of upsetting patients • Undertreated: only 10% in one study

4. Depression • Sadness, grief, depressed mood, and feeling of loss are all appropriate responses to dying…but • Feelings of hopelessness, worthlessness, helplessness, guilt, no desire for pleasure…are NOT • Bottom line: • Depression is NOT a normal part of dying • Depression is an illness, with symptoms that need to be recognized and treated

5. How Do You Diagnose Depression? • DSM-IV….But not really set up for the medically ill. Many depressive symptoms in medically ill patients may be a result of their medical illness or treatment. • Careful interview. • Consider simple 1-2 word screening tools: • Are you depressed? • Have you been depressed for most of the time for the past 2 weeks? • One of the above + loss of interest of usual activities.

6. Treatment of Depression • First, relieve uncontrolled symptoms (pain, nausea, dyspnea, etc.) • Psychosocial interventions • Psychotherapy • CBT • Pharmacologic interventions

7. Treatment of Depression: Drugs • Not much data in palliative care setting • As when treating depression in other settings, use side effect profile -Poor appetite/insomnia: Mirtazapine (Remeron) -neuropathic/other pain: TCAs, duloxetine (cymbalta), venlafaxine (effexor) -Fatigue/psychomotor slowing: activating SSRI (fluoxitine, venlafazine) or psychostimulants • The “default” is probably an SSRI…unless

8. Depression in Last Weeks of Life • SSRIs need 4-6 weeks to work, so why start one if your patient is in last weeks of life? • Instead, use pychostimulants such as methylphenidate (Ritalin) or modafinil (Provigil) • Very rapid onset of action (hours) • Start low (2.5 of methlyphenidate daily) and titrate upwards slowly • You should see effect after 1-2 doses

9. Dyspnea • “discomfort in breathing” • “breathlessness” • “Shortness of breath” • “uncomfortable awareness of breathing” -------------------------------------------- Dyspnea is a SUBJECTIVE sensation, for which the standard of assessment is the patient’s self-report (different from tachypnea which is an OBJECTIVE, measured number)

10. Dyspnea • Common in cancer patients (21-78%) • Common in non cancer patients • 70% Dementia patients • 68% terminal HIV/AIDS patients • 65% CHF patients • 56% COPD patients • 50% ALS patients • 36% CVA patients

11. Dyspnea Treatment * Goal in terminally ill: Improve subjective sensation expressed by patient * In order to do that you must think about cause… • Sometimes interventions may be consistent with patient’s goals of care… • Other times they may not be…

12. Causes of Dyspnea“BREATH AIR” • Bronchospasm: Nebs and steroids? • Rales: Stop IVF, diuretics, antibiotics? • Effusions: Tap? • Airway obstruction: Change diet? Suction? • Thick secretions: Thin with: -Atropine drops • Nebulized saline (3%) -Glycopyrrolate • Nebulized NAC (mucomyst) -scopolamine (patch) Hemolgobin low: Transfusion?

13. Causes of Dyspnea“BREATHE AIR” • Anxiety: *Sit upright, bedside fan, music -Benzos if primary anxiety (if anxious because sobopiates) -antidepressants • Interpersonal issues: emotional support • Religious concerns: emotional support, coordinate connection with chaplain/spiritual advisor

14. Treatment of Dyspnea • General Measures • Proper positioning: vertical (if comfortable)…or compromised lung down if horizontal • Modify activity level (bathroom aids, wheelchair) • Instruct on pursed lip breathing • Fan (?stim V2, decreasing dyspnea perception) • Open windows • Avoid strong odors • Keep room cool…humidifier • Family/friends at bedside

15. Treatment of dyspnea • Opioids: FIRST LINE • Decrease receptor response to elevated CO2 • Vasodilitation/preload reduction • Anxiolytic -Nebulized opoids? Not yet… • Which one to use? Probably doesn’t matter • Morphine 2.5-5 mg PO q 4 hours titrate • Hydrocodone 2.5-5mg PO q 4 hrs up • Oxycodone 5mg PO q 4 hours 25-50% • Hydromorphone 1-2mg PO q 4 hours q 12 hrs

16. Treatment of Dyspnea • Oxygen: Interestingly, there is no clear evidence that O2 works to relieve dyspnea any better than air…even in hypoxemic patients (studies poor). • Anxiolytics: Anxiety usually response to dyspnea. • 4 of 5 RCTs found no benefit of benzos in dyspnea. • Benzos more for refractory dyspnea worsened by anxiety symptoms…(although some try when one cannot titrate the opioid up further due to side effects). • Lorazepam is probably 1st choice (fast onset of action, and lasts 4-6 hours).

17. Next topic: Nausea and Vomiting • What is the cause? • Opioids • Other drugs • Constipation CORRECT • PUD THE • Autonomic insufficiency UNDERLYING • Metabolic abnormalities CAUSE • Bowel obstruction • Increased ICP

18. Nausea and Vomiting • Opioid induced n/v (stimulation of CTZ) • Mild nausea tends to be self-limited with time • If not, or severe symptoms, change to other opioid • Consider long acting opioids to lessen the potential fluctuation of levels which can stimulate the CTZ

19. Nausea and Vomiting • Opioid induced n/v • Best drugs to treat: • Haloperidol* (Haldol: THE most potent anti-dopinergic) • Prochlorperazine* (compazine: Potent anti-dopa, weak antihis) • Promethazine* (phenergan: Antihistamine, weak anti-dopa) • Scopolamine (especially if vestibular symptoms) • Diphenhydramine (benadryl….Careful in elderly) • Metabolic induced n/v: • Correct the metabolic derangement • Best drugs to treat: Dopamine antagonists* as above

20. Nausea and Vomiting • Constipation induced n/v • First step: prevention • Everyone on opioids gets DSS + cathartic (senna, ducolax) • Hydration, physical activity • If develops despite prophylaxis • 1st r/o obstruction (rectal examdisimpaction helped by mineral oil, glycerine supp, saline enemas) • then treat with osmotic laxative (lactulose, PEG, Mag citrate)

21. Nausea and Vomiting • Constipation induced n/v • If patient too nauseated to take pos • Sodium Phos (fleet) enema • Bisocodyl suppository • Refractory constipation induced n/v: • Neostigmine • opioid antagonists • oral naloxone (?systemic absorption) • SQ methylnaltrexone (selective peripheral antagonist)

22. Nausea/vomiting • Dysmotilityabdominal distension (gastric stasis) • Common in pts on opioids/anticholinergics • Pts c/o early satietynausea (not fasting n/v) • Metoclopramide (5-10mg PO qHS and qAC…or higher): don’t use in renal failure, Parkinson’s • DON’T USE Promethazine (phenergan)…which is an anticholinergic • Anorexia or increased ICP • Dexamethasone (2-4mg PO bid-QID)

23. Nausea/vomiting • Anticipatory nausea: • Benzos: Lorezepam (0.5-2mg q 6 hrs)…avoid as single agent (very weak antiemetic). • Vestibular nausea: • Scopolamine. • Promethazine (Phenergan). • Chemotherapy induced nausea/vomiting: • 5HT3 antagonists (Ondansetron 4-8mg q 6 hours). • Also in postoperative setting, or sometimes after other agents have failed. Can cause mild headache, constipation.

24. Anorexia-Cachexia • ACS (Anorexia Cachexia Syndrome) • Loss of body weight (muscle mass and fat) in the setting of cancer…predicts 3-6 month survival ------vs------ • General anorexia/cachexia at the end of life • Reflects end result of metabolic, neuroendocrine cascade (ketones, uremia, etc)…part of disease process • Probably universal in the dying process

25. Anorexia-Cachexia • Frequent cause of considerable concern for families. • Goals of treatment: • Symptomatic not nutritional. • Establish therapeutic relationship with patient/family. • Emphasis on social aspects of eating (pleasure, nurturing, bonding experience). • Education, Education, Education.

26. Anorexia/Cachexia • Reversible causes? • Pain -Dry Mouth • Nausea -Candidiasis • Constipation -Gastritis • Depression -Iatrogenic (XRT, chemo)

27. Anorexia/Cachexia • Appetite stimulants. • Rare to use…mostly when underlying cause cannot be addressed, and in setting of being consistent with patient’s goals of care. • Consider time limited “therapeutic trial” in selected patients after discussing goals of care (goal might be to gain strength/independence which can be reevaluated weekly for a few weeks).

28. Appetite Stimulants • Megesterol acetate (megace) • Initially for AIDS associated wasting • No change in muscle mass • “Increases” weight (of >5% in only 15-20% of patients) by increasing water retention and fat deposition…over 6-8 weeks • No survival benefit…risk of thrombosis • If decide to use it, use elixir (cheaper, easier), start at 400mg daily800mg daily

29. Appetite Stimulants • Coricosteroids (dexamethasone, prednisone). • Have temporary effect (up to a few weeks) on appetite without increase in body mass…used mostly if prognosis measured in weeks and if other target symptoms might respond to steroids also (nausea, bronchospasm, bone pain). • May increase energy for brief period. • Side effects! (mood swings, elevated BP, inc glucose). • Stop if no benefit within a week or so.

30. Appetite Stimulants • Others: Data mixed and routine use not recommended. • Eicosapentaenoic acid (omega 3 fish oil). • Thalidomide (in HIV/AIDS). • Melatonin. • NSAIDs. • Cannabinoids…(i.e. dronabinol).

31. Hydration at end of life *Arguments for: • Dehydrationelectrolyte problemsconfusion. • Dying patients more comfortable if hydrated (?) • Withholding fluid might set precedent for withholding other therapies which might be appropriate (patients labeled “comfort care”).

32. Hydration at end of life *Arguments against: -No evidence fluids significantly prolong life. -Interferes with acceptance of death. -Less UOPless need for bed pain, urinal, foley. -Less GI fluidless vomiting. -Less pulm secretions/cough/congestion/edema -Electrolyte disturbances/uremia may lead to decreased level of consciousnessless suffering.

33. What to avoid • “The tube feeding death spiral” • Patient admited for massive stroke/urosepsis with advanced underlying dementia • Can’t swallow/aspirating/losing weight tube feeds • Patient agitated with NGTremoves • NGT replacedrestraints placed • Aspiration PNA develops moved to ICU/pulse ox • Repeat PNA 3-4 more times • Family meeting • Death

34. Summary • Depression: recognize and treat at end of life • Don’t forget about psychostimilants • Dyspnea = subjective sensation. Goal of therapy is patient telling you they are better • Treat underlying cause (if appropriate) • Opiates are first line

35. Summary • Nausea/vomiting: • Consider cause before treating • Most common cause is medication related which is most effectively treated with Dopamine antagonists: • Haldol >Compazine > Phenergan • Anorexia/cachexia • Educate families • Medications not that helpful