1 / 96

AMSA Presentations Depression, Anxiety & Delirium GU Symptoms Anorexia & Fatigue The Last Days of Life

AMSA Presentations Depression, Anxiety & Delirium GU Symptoms Anorexia & Fatigue The Last Days of Life. Jeffrey M. Behrens, MD, FACP, CMD Medical Director, VITAS Innovative Hospice of Palm Beach County. Depression, Anxiety & Delirium. Depression. Objectives.

crystal
Download Presentation

AMSA Presentations Depression, Anxiety & Delirium GU Symptoms Anorexia & Fatigue The Last Days of Life

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. AMSA PresentationsDepression, Anxiety & DeliriumGU SymptomsAnorexia & FatigueThe Last Days of Life Jeffrey M. Behrens, MD, FACP, CMD Medical Director, VITAS Innovative Hospice of Palm Beach County

  2. Depression, Anxiety & Delirium

  3. Depression

  4. Objectives • Understand how to diagnose depression • Review risk factors for depression • Review risk factors for suicide • Understand management of depression

  5. Definition of depression • Dysphoric mood or loss of interest or pleasure in all or almost all usual activities &m past-times. • Word to describe include: • Depressed • Sad • Blue • Hopeless • Low • Down in the dumps • Irritable

  6. Diagnosis of depression • At least four of the following symptoms have been present nearly every day for a period of at least 2 weeks: • Poor or incresed appetite • Weight gain or loss • Insomnia or hypersomnia • Psychomotor agitation or retardation • Loss of interest or pleasure in usual activities or decreased sexual drive • Loss of energy or fatigue • Feelings of worthlessness, or excessive or inappropriate guilt • Diminished ability to think or concentrate • Recurrent thoughts of death or suicide or actual attempts

  7. Risk Factors • Pain • Progressive physical impairment • Advanced disease

  8. Risk Factors • Advanced age >70 (1 in 6 of people over age 65) • Admission to a nursing home • Psychosocial (isolation, loss of dignity, financial burden, fear of abandonment) • Spiritual pain • Preexisting risk factors (prior psychiatric disease, substance abuse)

  9. Risk Factors • Medications • Benzodiazepines (lorazepam, etc.) • Chemotherapy • Steroids • Beta blockers • Calcium channel blockers • Analgesics

  10. Suicide • Incidence in the elderly is double that in other populations • Discussion of thoughts of suicide may reduce the risk • High risk if recurrent thoughts/plans

  11. Suicide Risk Factors • Depression • Substance abuse • Psychiatric admission within the year • Psychotic disorders • Widowed or divorced • Poor social network • Family discord

  12. Management of Depression • Identify risk factors • Early intervention (improves symptoms, restores function) • Psychotherapeutic interventions (cognitive and behavioral) • Medications

  13. Psychotherapeutic Interventions • Improve patient understanding • Explore religious and spiritual concerns • Create a different perspective • Identify strengths • Re-establish self-worth • Develop new coping strategies • Educate about modifiable factors • Possible use of electroconvulsant therapy. • Review level of care

  14. Pharmacologic Management • Psychostimulants • SSRI’s • Tricyclics • Atypical antidepressants

  15. Psychostimulants • Rapid effect (2-3 days) • Diminishes opioid sedation • Not usually an appetite suppressant • May exacerbate • Tremulousness • Anxiety • Anorexia • Insomnia

  16. Psychostimulates • Methylphenidate (Ritalin) • Modafinil (Provigil) • Dextroamphetamine • Pemoline (Cylert) (no longer available)

  17. SSRI’s (Serotonin Specific Reuptake Inhibitors) • Latency of 2-4 weeks • Highly effective (70%) • Well tolerated • Once daily dosing • Low doses may be effective in advanced illness

  18. SSRI’s • Citalopram (Celexa) • Escitalopram (Lexapro) • Fluoxetine (Prozac) • Paroxetine (Paxil) • Sertraline (Zoloft)

  19. SSRI’s • Side effects (dose related) • Increased intestinal motility-loose stools, nausea & vomiting • Asthenia • Sleep disturbance • Headaches • Sexual dysfunction • Hyponatremia

  20. Tricyclic Antidepressants • Amitriptyline (Elavil) • Desipramine (Norpramin) • Doxepin (Sinequan) • Imipramine (Tofranil) • Nortriptyline (Pamelor)

  21. Tricyclic Antidepressants • Not recommended as first-line therapy • Latency 3-6 weeks • Adverse effects are common (contraindicated in cardiovascular disease) • May be appropriate with • Chronic/neuropathic pain • Weight loss/insomnia • Urinary urgency

  22. Tricyclic Antidepressants • Side effects • Constipation • Dry mouth • Orthostatic hypotension (increased risk of falls)

  23. Atypical Antidepressants • Mirtazapine (Remeron) • Venlafaxine (Effexor) • Duloxetine (Cymbalta) • Bupropion (Wellbutrin) • Trazodone

  24. Mirtazapine (Remeron) • Attractive choice in the elderly • Increased appetite and weight gain • Increased somnolence at lower doses • Lack of cardiotoxicity • Low risk for drug to drug interactions

  25. Mirtazapine (Remeron) • Adverse effects • Dry mouth • Constipation • Dizziness • Abnormal dreams • headache

  26. Norepinephrine and Dopamine Reuptake Blockers • Bupropion (Wellbutrin) • Advantages in elderly patients due to lack of sedative effects, cardiotoxicity, and sexual dysfunction • Side effects • Agitation, headache, dizziness, tremor, insomnia, anorexia, nausea • Seizures have been reported with doses greater than 400 mg/day

  27. Serotonin 2 Antagonists/Serotonin Reuptake Inhibitors • Trazodone • Very sedating at low doses (<100mg) • Increased orthostatic hypotension • Adjunct to analgesics

  28. Summary • Depression is……. • Challenging…difficult to treat • Overwhelming to patients, families, and caregivers • A reason for placement in LTCF • Easily misdiagnosed • An opportunity to improve the quality of life for the patient and/or caregiver

  29. Anxiety

  30. Objectives • Understand how to diagnose anxiety • Review risk factors for anxiety • Understand management of anxiety

  31. Diagnosis of Anxiety • Psychological reactions • Insomnia • Irritability • Inability to concentrate • Poor coping skills • Symptoms and physical features • Anorexia • Nausea • Hyperventilation • Palpitations • Sweating.

  32. Risk Factors • Changes in life situations • Direct or indirect effects of terminal illness • Exacerbation of preexisting conditions.

  33. Pharmacologic Treatment of Anxiety • Benzodiazepines • Lorazepam (Ativan) • Temazepam (Restoril) • Oxazepam (Serax) • Diazepam (Valium) • Barbiturates • Pentobarbital • Thioridazine (Mellaril) • Haloperidol (Haldol).

  34. Delirium & Terminal agitation

  35. Objectives • Define Delirium and Terminal Agitation • Describe the Causes for Delirium and Terminal Agitation • Identify the key factors for assessment of Delirium and Terminal Agitation • Explain the goals and interventions for treatment of Delirium and Terminal Agitation • Discuss patient and family education regarding Delirium and Terminal Agitation

  36. Delirium & Terminal Agitation • Must be differentiated from anxiety and dementia • Impacts cognitive skills • Acute process • Waxes and wanes, usually worse at night • Must assess over 24 hour related to erratic symptoms seen over day • Occasional incoherent word usage, but not verbal loss • Hallucinations • Hyperawareness, and possible emotional liability • May show apathy, fear, or rage • Treatment must include psychosocial support and calm environment

  37. Common Causes of Delirium & Terminal Agitation • Drugs, especially psychotropics • Electrolyte or glucose abnormality • Liver failure • I schemia or hypoxia • Renal failure • I mpaction of stool • Urinary tract or other infection • Mestastases to the brain

  38. Step 1: Assessment • Maintain a high index of suspicion for delirium. It may be life threatening; proper assessment is essential. • Use a screening tool to assess cognition even in patients who do not appear confused. Do not rely solely on orientation questions.

  39. Step 1: Assessment (cont.) • Ask specifically about hallucinations (usually visual and tactile) and paranoid ideation. • Examine and look for signs of infection, opioid toxicity (myoclonus, hyperalgesia), dehydration, uremia, hepatic encephalopathy, etc. • Order investigation when appropriate, e.g., CBC, electrolytes, ionized calcium, urea, and creatinine, urinalysis, CXR, O2 sats, etc.

  40. Step 2 : Treating the Underlying Cause if Appropriate • Opioid toxicity: Change to another opioid. • Sepsis: Start antibiotics if appropriate, considering the goals of care. • Drugs: Stop, wean, or decrease possible offending drugs, e.g., tricyclic antidepressants, benzodiazepines

  41. Step 2 : Treating the Underlying Cause if Appropriate (cont.) • Dehydration: Consider Hypodermocyclis with normal saline (if the site leaks or swelling is uncomfortable, give 150 u hyaluronidase into the SC site before infusion; usually unnecessary); reassess daily. If IV line is already established, hydration can be given IV.

  42. Step 2 (cont.) • Hypercalcemia: Treat for dehydration. Consider Calcitonin, saline + furosemide, IV Biphosphonates (Alendronate, Pamidronate) • Hypoxia: Treat underlying cause and administer O2. • Urosepsis: If possible remove indwelling urinary catheter and treat infection with appropriate antibiotics

  43. Medications Used to Manage Delirium & Terminal Agitation in Patient with Advanced Disease • Generic Name Approximate Daily Dose Route • Neuroleptics • Haloperidol 0.5-5 mg every 2-12 h po, IV, SC, IM • Thioridazine 10-75 mg every 4-8 h po • Chlorpromazine 12.5-50 mg every 4-12 h po, IV, IM • Methotrimeprazine 12.5-50 mg every 4-8 h IV, SC, po • Molindone 10-50 mg every 8-12 h po • Drioerudol 0.625-2.5 mg every 4-8 h IV, IM • Atypical Neuroleptics • Olanzapine 2.5-20 mg every 12-24 h po • Risperidone 1-3 mg every 12-24 h po • Quetiapine 25-200 mg every 12-24 h po

  44. Medications for Delirium & Terminal Agitation (cont.) • Generic Name Approximate Daily Dose Route • Benzodiazephines • Lorazepam 0.5-2.20 mg every 1-4 h po, IV, IM • Midazolam 30-100 mg every 24 h IV, SC • Anesthetics • Propofol 10-70 mg every h IV Up to 200-400 mg/h

  45. Step 3Treatment for Moderate to Severe Agitated Delirium • For Moderate Delirium • Haloperidol (Haldol) 1 to 2 mg PO or SC hourly as needed to calm a crisis; then q 6 to 12 h PO or by infusion If more sedation is needed consider: • Thioridazine (Mellaril), or 25-50 mg PO hr until calm, then q 6 to 12 h • Chlorpromazine (Thorazine) 25-50 mg PO, PR, or IV hr until calm: then q 6 to 12 h or by infusion • For Severe Agitated Delirium: Reassess for reversible causes and if necessary, consider the addition of benzodiazepines or a high dose of a sedating phenothiazine, even though they may cause more clouding of the sensorium.

  46. Step 3 (cont.) • Lorazepam (Ativan) 1-2 mg hourly, PO, SL, or IV • Midazolam (Versed) 0.4 to 4 mg/h continuous, SC{ a mean dose of 2.9 mg/h (70 mg/d) was effective in 22 of 23 patients in one series} • Chlorpromazine (Thorazine) 100 mg every hour IV, PO, PR • Some patients are held by a combination of: • Haloperidol (Haldol) 5 to 20 mg/d and midazolam (Versed) 10 to 100 mg/d via continuous subcutaneous infusion • In rare cases, when none of the above methods work during the final hours of life, consider therapeutic sedation with: • Phenobarbital 130 mg SC hourly until calm and then subcutaneous infusion (600 to 1200 mg/d) • When all else fails, consider: • Thiopental (20 to 200 mg/h) or methohexiatal sodium (Brevital Sodium) continuous IV infusion titrated to unconsciousness

  47. Step 4 Psychological Supports for the Restless Patient • Provide information in accord with individual wishes. • Permit expression of emotion. • Clarify concerns and problems. • Involve patient in decision making. • Provide continuity of care from named staff. • Provide group discussion for information and support. • Provide music therapy. • Provide art therapy. • Teach relaxation techniques. • Provide aromatherapy. • Arrange for a change of scenery.

  48. Step 5: Family and Staff Education • Confusion and agitation are often expression of brain dysfunction. Misinterpretation of symptoms as pain can result in excessive use of opioids, resulting in aggravation of the agitation. • Most patients have limited or no recollection of their symptoms after the episode subsides.

  49. Step 5 (cont.) • The treatment goal is comfort, not prolongation of life. • Delirium may be superimposed on preexisting dementia unrecognized by family or healthcare professionals. • Urinary retention and constipation in cognitively impaired patients can be misdiagnosed as agitated delirium or “crescendo” pain.

  50. Summary • Delirium &Terminal agitation is multifactorial. • Must be recognized early and differentiated from anxiety or dementia • Reversible causes, if any, should be corrected • Rapid & efficient therapy should be initiated as soon as possible

More Related