BEDSIDE SYMPTOM A SSESSMENT COMMON CHALLENGES AND PITFALLS

1. BEDSIDE SYMPTOM ASSESSMENT COMMON CHALLENGES AND PITFALLS Dr. Pablo H. Amigo, MD, MCFP Attending Physician, Tertiary Palliative Care Unit Grey Nuns Hospital, Covenant Health. Associate Clinical Professor, Division of Palliative Medicine, Department of Oncology, University of Alberta

2. Objectives: At the end of the presentation, participants will be able to: • List factors impacting their ability to assess symptoms at the bedside . • Provide strategies for appropriate assessment of symptoms in their clinical practice. • Take home strategies that will result in adequate symptom management.

3. PAIN ASSESSMENT

4. Pain assessment: • Pain is a subjective, complex and multidimensional experience. • Gold standard in symptom assessment is patients’ self-report. • Health care providers attempt to make a subjective experience objective using assessment tools, balancing between burden and clinical information obtained. • Patients reliability can be compromised in some circumstances.

5. Clinical Scenario: • Mr. Glenn Morangie, 70 year old gentleman with diagnosis of Prostate Cancer for 8 years. • Known extensive metastatic deposits to bone in axial and appendicular skeleton and skull. • Treated initially with radiotherapy and hormonal treatment, followed by 8 cycles of chemotherapy. • Cancer has become hormone-refractory. • No further oncological treatment options available, discharged from cancer treatment center recently.

6. Clinical Scenario (cont’d): • PMH: Significant for hypertension, Type II Diabetes, Hypercholesterolemia, Coronary Artery Disease with AMI in 2009. • Social history: Widower, lives independently. Has 2 children, one son age 45 living in the U.S and one daughter age 42 living in Ontario. Has some friends in town, who are supportive. No religious affiliation, believes in High Power. No PD or POA. • Habits: Ex smoker 40 pack/ year, drinker of 6-8 glasses of alcoholic beverages/ day/ 30 years.

8. Clinical Scenario (cont’d): • Assessed at home, with main concern of pain. • Pain is localized in the back, severity 5/10 at rest and 10/10 with movement, radiates to the buttock and right leg with “shooting “episodes, tingling and numbness in the right leg. • Has developed difficulties with walking in the last couple of days as his leg “gives up”, and has fallen twice. • Other symptoms: he also reports tiredness, feeling sleepy, sadness and “not knowing what to do with himself”.

9. Clinical Scenario (cont’d): • Other assessments: declined assessment of alcohol abuse and cognition, jokingly talks about having “old timer`s”, rambles for 15 minutes and is difficult to redirect. • On exam: appears thin, skin pallor. BP: 100/ 60, HR: 100 x min, afebrile. Dry mucous membranes. SEM 2/6, pedal edema with pitting. Liver not palpable, diffuse pain in abdomen. Weakness in hip flexion right side, decreased sensation L4-5 dermatome and decreased patellar reflex on the right side. Pain on palpation of lumbar spine.

10. Clinical Scenario (cont’d): What is the advantage of a systematic approach to symptom assessment with validated tools?

11. Assessment Tools: Edmonton Symptom Assessment System-revised (ESAS-r). CAGE questionnaire. Folstein’s Mini Mental Status Exam (MMSE). Edmonton Classification System-Cancer Pain (ECS-CP). Palliative Performance Status (PPS).

12. ESAS-r

13. ESAS-r

14. ESAS-r • Revised version of the original tool. • Different order for symptoms, with expanded definitions. • Easier to understand for patients, preferred by tool administrators. • Same 10 items: pain, tiredness, drowsiness, nausea, lack of appetite, shortness of breath, depression, anxiety, wellbeing, and other (constipation, etc.) • Allows the discussions/ better appreciation of multidimensional aspects of suffering.

15. Clinical scenario: • Other ESAS-r scores: tiredness 9/10, drowsiness 8/10, nausea 5/10, lack of appetite 8/10, shortness of breath 4/10, depression 9/10, anxiety 8/10, wellbeing 9/10, other: constipation 9/10. • Multiple elements suggestion “total pain” syndrome. • Depressed since wife died, anxious about future and lack of treatment options, fear of loss of independency and social isolation, does not want to be a burden to his children.

16. Steps in the pain experience: Production (Nociception) Psychological Social Perception Spiritual Cultural Expression Treatment

17. CAGE:

18. Clinical scenario: • Patient felt that he had to “cut down” alcohol use. • “Annoyed” by his children’s criticism of his drinking. • Has felt “guilty” lately. • No “eye opener” in the morning. • CAGE score: 3/4.

19. MMSE:

20. Clinical scenario: • Upon formal assessment of cognition, patient scores 21/30 on MMSE with expected for age and education of 26/30. • Lost points in orientation, recall, drawing. • Likely multi-factorial (aging process, multiple co-morbid conditions, smoking, alcohol abuse, chemotherapy, disease progression?). • Acute superimposed delirium on dementia?

23. ECS-CP:

24. Clinical scenario: • Helps identify poor predictors to achieve good pain control rapidly. • Presence of neuropathic pain, incident pain, psychological distress (affecting pain perception and expression), addictive behavior and cognitive impairment are poor predictors. • Patients has them all!! (perfect storm scenario).

25. PPS:

26. Clinical scenario: • Patient’s PPS is 40%. • Mainly in bed, unable to do most activities, requires considerable assistance / mainly assistance, reduced intake, drowsy conscious level. • Home Care assistance maximized, concerns about patient’s safety. • Staying home no longer an option, patient aware and distressed by this.

27. Clinical scenario: • Complex pain syndrome : neuropathic and incident components. • Complex patient: older, frail, poor coping skills, alcohol addiction, psychological distress affecting patient’s pain perception and expression, cognitive impairment (?chronic vs. acute or both), declining functional status. • Complex social circumstances: socially isolated, supports maximized, unsafe situation.

28. Clinical scenario: • Patient will likely require admission to Tertiary Center (likely PCU) for symptom control and multi-disciplinary support for his “total pain” syndrome. • Unlikely to return home in view of functional limitations and little social supports. • May be appropriate for hospice if physical and psychosocial symptoms controlled.

29. Clinical scenario: lessons learned Tools can help assessing: • Multidimensional aspects of the pain experience. • Alcohol addiction/ poor coping skills. • Cognitive impairment complicating symptom evaluation. • Patients who require intensive resources to adequately control symptoms. • Poor functional status making patient’s unsafe to remain at home.

31. CONSTIPATION ASSESSMENT

32. Scope of the problem: • Common gastrointestinal motility disorder • 12% - 19% of adult population in North America1 • 23% – 70% of terminally ill patients2,3 • 87% of palliative care patients receive laxatives4 • adds significantly to suffering & burden of care 1. Higgins PD, Johanson JF. Am J Gastroenterol 2004; 99:750 2. Curtis EB, Krech R, et al. J Palliative Care 1991; 7:25 3. Solano JP, Gomes B, et al. J Pain Symptom Manage 2006; 31:58 4. Sykes NP. Palliative Medicine 1998; 12:375

33. Constipation definitions • Unsatisfactory defecation • Infrequent stools • Difficult stool passage • Straining • Sense of difficulty passing stool • Incomplete evacuation • Hard/lumpy stools • Prolonged time to pass stool • Need for manual maneuvers to pass stool Thompson W. Gut 1999;45 (Suppl II):II43

34. Etiologies • Pre-existing constipation (elderly, poor bowel habits) • Neurological abnormalities (spinal cord lesions, autonomic dysfunction ) • Metabolic disorders (Hypothyroidism, uremia, hypercalcemia, dehydration) • Structural obstruction (Adhesions, strictures, tumor) • Decreased food, fiber & fluid intake • Uncontrolled pain (Increased with straining, inability to toilet because of pain) . 13

35. Etiologies • Limited mobility (exercise has been shown to increase bowel movements) • Medications (opioids, tricyclic antidepressants, anticholinergic drugs, NSAIDs) • Hypomotility of the bowel (diabetes? postoperative or paraneoplastic?) • Generalized weakness/ cachexia/ sarcopenia (limited ability to empty bowel and/or get to the toilet ) • Environmental issues (lack of privacy) 15

36. Constipation: challenges • Patients/ caregivers may not remember last BM. • Self-perception of constipation may differ from clinical reality. • Patient may decrease/ discontinue laxatives due to “diarrhea” (overflow diarrhea). • Little correlation between constipation questionnaires and objective findings.

37. Constipation score: • Developed by the Edmonton Palliative Care Program. • Assessment of fecal loading in the ascending, transverse, descending and recto-sigmoid bowel. • Score in each section ranging from 0 to 3 (maximum 12/12). • 0/3: no stool, 1/3: <50% of lumen, 2/3: >50% of lumen, 3/3: full of stool. • 7/12 or less is acceptable. Bruera et al, JPSM 1994,9:515-519.

39. Constipation: lesson learned • Clinical assessment can be challenging. • Patients’ perception may not correspond with clinical reality. • No correlation between constipation questionnaires and objective assessment. • Abdominal flat plate, if indicated and feasible, can ascertain clinical situation. • Bowel routine critical to maintain BM q2 or 3 days maximum.

40. The next best thing for our patients?

41. DYSPNEAASSESSMENT

42. Definition: “Subjective experience of breathing discomfort consisting of qualitative distinct sensations, derived from the interactions among multiple physiological, psychological, social, and environmental factors” American Thoracic Society, 1998

43. Multidimensional aspects: 1. Production Mechano-receptors Chemo-receptors Respiratory centers 2. Perception Modulators: Anxiety-depression Somatization Opioids 3. Expression Intrapsychic Beliefs Cultural 4. Assessment and Treatment Ripamonti et al, JPSM 1997;13:220-232

44. Prevalence: • National Hospice Study: 70% of the patients in their last six weeks of life. • Fainsinger et al: 49.1% of 100 patients admitted to a Tertiary PC Unit. • Dudgeon et al: 46% of the general cancer population in a regional cancer center.

45. Assessment Tools: • Most used in non cancer patients with chronic dyspnea. • No single tool takes into account all the different components of dyspnea. • Choice of tool according to the purpose of the assessment. • Should not worsen patient’s QOL (burdensome, complicated tools). • VAS, NRS, VRS-D: useful in daily assessment and assessment of therapies. Mancini et al, Supp Care Cancer (1999) 7:229-232

46. Dyspnea: • No correlation with respiratory effort (use of accessory muscles, respiratory rate, laboured breathing, presence of respiratory secretions, tachypnea, etc) • No correlation between dyspnea and objective measurements (PFT, oxygen saturation, Chest X-Ray). • Patients under Midazolam sedation or comatose can not experience dyspnea, as per the definition!

47. Opioids: • Mainstay of the treatment of dyspnea since the late nineteenth century. • Respiratory depression potential recognized in 1950. • Physicians reluctant to prescribe opioids ever since. • Respiratory depression from opioids: depends on the rate of change of the dose, previous opioid exposure and route of administration.

48. Sometimes it’s not our fault.......

49. Dyspnea assessment: lessons • Subjective and multidimensional experience! • No correlation with anything we can measure or objectively assess. • Ignore what you see, listen to what the patient says! • If a patient is sedated pharmacologically or in a comatose state, can’t experience dyspnea.

50. Summary: • Self-report is the gold standard of symptom assessment in Palliative Care, however in some situations patient’s perception may be unreliable. • Validated tools can help assess the multidimensional elements of patients’ suffering. • Investigations , when indicated, can yield relevant information in symptom assessment. • Objective findings sometimes are not helpful to assess patients’ discomfort.