3. Assessment and Management of Non-pain Symptoms Flashcards
State some non-pain symptoms commonly seen in Palliative Care patients.
- Breathlessness
- Nausea and Vomiting
- Constipation
- Delirium
Breathlessness is commonly seen in patients with …….. before their deaths?
Organ failure, Cancer, Frailty and others
Define dyspnea.
It is a subjective experience of breathing discomfort that consists of qualitatively distinct sensations varying in intensity.
Name some diseases in which dyspnea has a high percentage of prevalence.
- Lung cancer
- Advanced COPD
- Advanced Heart Diseases
- Dementia
- Cancers
What is the pathophysiology behind dyspnea?
Perception that the respiratory muscle response is inadequate or unsustainable due to impairment of the mechanical process of ventilation leading to an increased ventilatory demand.
Describe the BTF model of Breathlessness.
It is a vicious cycle of 3 criteria which influences breathlessness in a patient. The first criteria is BREATHING. Increased Resp. Rate, inappropriate accessory muscle use and dynamic hyperinflation of the patient’s lung leads to inefficient breathing and increased breathing labour. The second criteria is THINKING. Attention to the sensation, memories of past exp., misconceptions and thoughts of dying in turn lead to anxiety, panic, frustration and anger in the patient. The third criteria is FUNCTIONING. Reduced stimulation, social isolation and heavy reliance on help leads to cardiovascular and muscular deconditioning in the patient.
Why is the BTS model important?
To understand the severity of breathlessness in a patient
How do you assess dyspnea?
According to these 4 criteria :
- Quality
- Intensity
- Impact
- Distress
How do you assess the intensity of Breathlessness in a patient?
Using the Dalhousie Dyspnea Assessment Scale which has 3 criteria (Exertion before dyspnea, Lung Constriction, Bronchial Constriction) in which the patient has to grade (0-7).
State 2 other scales used to assess Breathlessness
- Medical Research Council Dyspnea Scale (MRC)
2. Modified Borg Dyspnea Scale
How do you grade a patient with the MRC Dyspnea Scale?
GRADE 1 : Breathless with strenuous exercise
GRADE 2 : Shortness of breath on hurried walking on a level or uphill
GRADE 3 : Walks slower than people of the same age, stops for breath when walking at own pace.
GRADE 4 : Cannot walk for more than 100 yards without stopping to breath
GRADE 5 : Too breathless to leave the house or carry out daily activities
How do you assess the impact of breathlessness in a patient?
Using a Oxygen-Cost Diagram.
What do you use to assess distress due to breathlessness in a patient and what are the important criteria to be observed?
Use a Respiratory Distress Observation Scale (RDOS)
- HR per min (0 points : Baseline + 5 beats, 1p : B + 6-10, 2p : B + >10)
- RR per min (0p : B + 3, 1p : B + 3-6, 2p : B + >6)
- Restlessness (0p : none, 1p : occasionally, 2p : frequent)
- Accessory muscle use (0p : none, 1p : slight, 2p : pronounced)
- Grunting at the end of respiration (0p : none, 2p : present)
- Nasal flaring (0p : none, 2p : present)
- Look of fear (0p : none, 2p : present)
How do you manage a case of Dyspnea?
- Correct the reversible causes
- Do not conduct futile treatments
- Do not add distress/financial burden
- Discuss all options with the patient and their family
- Prioritise quality over longevity
- Reduction of symptoms
State 4 ways to reduce symptoms in a patient.
- Minimise production of symptoms
- Diminish perception of symptoms
- Reduce the impact of symptoms
- Modify the impact of symptoms
How do you minimise symptoms of breathlessness?
- Conduct exercise training
- Teach breathing techniques (pursed lips)
- Provide supplemental oxygen
- Recommend proper nutrition
How do you diminish perception of breathlessness symptoms?
- Placing a fan in front of the patient
- Pharmacotherapy (Opioids,BZDs)
- Distract the patient with music, CBD, images
- Stimulate the afferent nerve by chest wall vibrations
How do you reduce the impact of breathlessness symptoms?
- Conserve energy
- Maintain posture and ergonomics
- Modify lifestyle
How do you modify the impact of breathlessness symptoms?
- Make a plan of action when patient is exacerbated
- Treat the underlying mood disorder
- Change patients interpretation of the symptom
What are the preferred drugs in management of Dyspnea?
- Opioids
- Benzodiazepines
- Bronchodilators (oral/nebulized)
- Phenothiazine
- Diuretics
- Steroids (oral/inhaled)
- Anticholinergics
- Non-invasive ventilation
What are the mechanisms by which opioids reduce Dyspnea?
- Analgesic action
- Anxiolytic effect
- Suppression of respiratory awareness
- Alters neurotransmission with medullary Resp. Centre
- Blunts afferent transmission from pulm. mechanoreceptors to CNS
- Blunts medullary sensitivity and response to hypercarbia/hypoxia
- Decreases metabolic rate and ventilatory requirements
- Cause vasodilation and improves cardiac functions
Name the benzodiazepines preferred in breathlessness.
Short acting BZDs (Midazolam, Oxazepam)
Name the phenothiazine preferred in breathlessness.
Promethazine
When is bronchodilators preferred and name some.
When there is reversible airway obstruction.
- Methyl Xanthine
- Beta 2 agonists
When are diuretics preferred and name some.
When there is pulmonary congestion.
- Frusemide
When are steroids preferred and name some.
When there’s airway obstruction due to compressive lesions, lymphangitis carcinomatosis or COPD
- Dexamethasone
- Methyl Prednisolone
Name some Anticholinergics drugs.
- Hyoscinehydrobromide
- Glycopyrrolate
- Atropine
When is non-invasive ventilation indicated?
- Respiratory acidosis asso. w. COPD
- Hypoxemia of Congestive Cardiac Failure
- Advanced Neuromuscular disorders
Define nausea.
It is an unpleasant feeling of the need to vomit, accompanied by pallor, cold sweats, salivation and tachycardia.
Define vomiting.
It is the forceful expulsion of gastric contents through the mouth
Define retching
It is the rhythmic, laboured, spasmodic movement of the Diaphragm and Abdominal muscles.
Explain the ‘emetic pathway’
It starts with the relaxation of the gastric and lower esophageal sphincter -> retrograde contractions in the proximal small bowel and antrum -> contraction of the abdominal muscles -> Cricopharyngeus contracts, and subsequently relaxes -> expulsion of gastric contents.
What is main goals in treatment of a patient with nausea?
- Identify the aetiology (GI/Non-GI/Drugs)
- Treat the complications
- Provide targeted therapy
What would you elicit in the history of patient with nausea?
- Quality (Nausea/Vomiting/Retching/Regurgitation)
- Duration
- Persistent/Intermittent
- Intensity
- Colour/nature of vomitus
- Relief upon vomiting?
- Pain?
- Altered bowel habits?
- Aggravating factors? (Food, movement, after eating)
- Time factors
- Relieving factors
- Drug history (opioids, NSAIDS, Antibiotics)
- Anti cancer treatment
What would you look for in the physical examination of a patient with nausea?
- Organomegaly, Abd. Masses
- Bowel sounds (ileus/mechanical obstruction)
- Sepsis
- Liver failure
- Renal failure
- Hypercalcemia
- Neurological signs
What investigations would you carry out to confirm your diagnosis of nausea in a patient?
- Abdominal X-ray
- CT Scan
- MRI Scan
- Rule out sepsis, renal failure and hypercalcemia
A patient presents with intermittent nausea associated with early satiety and postprandial fullness and bloating. What does this suggest?
Impaired gastric emptying
A patient presents with persistent nausea, aggravated by the sight and smell of food, unrelieved by vomiting. What does this suggest?
The chemoreceptor trigger zone (CTZ) is activated by chemicals.
A patient presents with intermittent nausea associated with abdominal cramps and an altered bowel habit. The nausea is relieved upon vomiting which is large in volume and bilious/feculant. What does this suggest?
Bowel obstruction
A patient presents with early morning nausea and vomiting associated with headache. What does this suggest?
Raised intracranial pressure
A patient presents with nausea aggravated by movement including motion sickness or even by just turning his/her head. What does this suggest?
Vestibular component impairment
A patient presents with nausea and vomiting associated with anxiety. What does this suggest?
Cortical component impairment
What are the associated neurotransmitters and the recommended antiemetic when the aetiology is not definite (Not related to chemotherapy, radiotherapy, constipation, CNS disease, metabolic/drugs or Bowel obstruction)?
- Asso. NTs : Dopamine, Serotonin (5HT3, 5HT4), Acetylcholine
- Antiemetic :
1ST LINE : Metoclopramide 10mg Q4-6H until max. 60mg per day
2ND LINE : 5HT3 receptor antagonists (Ondansetron, Palonosetron, Granisetron)
What are the associated neurotransmitters and recommended antiemetic in a case of Chemotherapy Induced Nausea and Vomiting (CINV)?
- Asso. NMs : 5HT3, Neurokinin-1
- Antiemetic :
1ST LINE : 5HT3 receptor antagonists, Neurokinin-1 antagonist, Dexamethasone
2ND LINE : Dopamine receptor antagonists, Haloperidol, Metoclopramide, Nabilone or Dronabinol.
What are the associated neurotransmitters and recommended antiemetic in a case of Radiotherapy Induced Nausea and Vomiting (RINV)?
- Asso. NMs : 5HT3, Dopamine
- Antiemetic :
1ST LINE : 5HT3 receptor antagonists, Dexamethasone
2ND LINE : Dopamine Receptor Antagonists
What are the associated neurotransmitters and recommended antiemetic in a case of Gastroparesis?
- Asso. NMs : Dopamine, 5HT3, 5HT4, Acetylcholine
- Antiemetic :
1ST LINE : Metoclopramide 5-10 mg 4x daily PO/IV/SC
2ND LINE : Mirtazapine/Erythromycin
3RD LINE : Domperidone/Cisapride
What are the associated neurotransmitters and recommended antiemetic in a case of Bowel Obstruction?
- Asso. NMs : Dopamine, Somatostatin, Acetylcholine
- Antiemetic :
1ST LINE : Haloperidol 0.5-2mg every 6-8 hours PO/IV/SC max. 20mg per day., can add Dexamethasone 4mg every 12 hours IV, Octreotide 0.1mg every 8 hours IV/SC up to 0.3 mg every 8 hours, depending on the response.
2ND LINE : Chlorpromazine/Cyclzine
What are the associated neurotransmitters and recommended antiemetic in a case of Nausea due to Intracranial Malignancy?
- Asso. NMs : Unknown
- Antiemetic :
1ST LINE : Dexamethasone 10mg (loading dose), followed by 4mg every 6 hours/ 8mg every 12 hours, orally/intravenously.
How does cannabinoids function in preventing nausea and vomiting?
By acting as an agonist on CB1 receptors found in the area postrema, nucleus tractus solitarius and dorsal motor nucleus in the brainstem.
What are the non-pharmacological measures that can be taken to treat nausea and vomiting?
- Uncover hidden concerns and unasked questions
- Educate the patient and families regarding the situation and the condition of the patient’s body at the moment
- Understand the patient’s hopes, fears and review all possibilities
- Suggest consumption of ginger roots and lemon peels
What can be done to enhance gastric emptying and to decrease gastric distension?
Consume a liquid diet, have small meals frequently and have food which are low in lipids and fiber, and high in protein.
What can be done to minimise other noxious or associated stimuli which cause nausea and vomiting?
Consume food which have a pleasant appearance, cool and odourless
In CINV, what are the drugs prescribed and why?
They are prescribed based on the frequency of vomiting.
- > 90% : Cisplatin, Cyclophosphamide
- 30%-90% : Rubicins and other playing
- 10%-30% : 5FU, Etoposide
- <10% : Vincristine, MABS
How would you grade the emetogenic potential due to radiotherapy?
It depends on the site on the body that radiotherapy is conducted.
- > 90% : Total Body Irradiation (TBI), Total Nodal Irradiation (TNI)
- 60%-90% : Upper Hemibody Irradiation (UHI), Half Body Irradiation (HBI), Upper Abdomen Irradiation (UAI)
- 30%-60% : Cranium, Craniospinal, Head n Neck, Lower Thorax Region, Pelvis
- <30% : Breast, Extremities
A patient who had TBI presented with emesis. What is the risk level for this condition and which antiemetic would you prescribe?
- Risk Level : High
- Antiemetic : Prophylaxis with 5-HT-3-R.A. + Dexamethasone
A patient who had an UAI/HBI/UBI presented with emesis. What is the risk level for this condition and which antiemetic would you prescribe?
- Risk Levels : Moderate
- Antiemetic : Prophylaxis with 5-HT-3-RA + optional Dexamethasone
A patient who had Irradiation of the Cranium/Craniospinal/ Head n Neck/ Lower Thorax region/ Pelvis presented with emesis. What is the risk level for this condition and which antiemetic would you prescribe?
- Risk Levels : Low
- Antiemetic : Prophylaxis/Rescue with 5-HT-3-R.A.
A patient who had Irradiation of the extremities/breasts presented with emesis. What is the risk level for this condition and which antiemetic would you prescribe?
- Risk Levels : Minimal
- Antiemetic : Rescue with Dopamine Receptor Antagonists/5-HT-3-R.A.
Define constipation.
It is the passage of small, hard faeces infrequently or with difficulty, and passes faeces less often than normal.
State some symptoms seen in a patient with constipation.
- Abdominal pain
- Rectal pain
- Distension
- Nausea
- Vomiting
- Psychological distress
- Agitation
- Flatulent
- Bloating
- Urinary retention
What information would you like elicit in a patient with constipation?
Enquire about the normal and current bowel patterns in terms of frequency, consistency, ease of passage, presence of blood and pain on passing stool.
Enquire about current and previous laxatives taken regularly (or as needed) and it’s effectiveness.
How would you assess the condition and confirm your diagnosis (constipation)?
Use the ROME IV CRITERIA for Constipation.
A patient must have experienced at least 2 of the following symptoms over the preceding 3 months :
- Fewer than 3 spontaneous bowel movements per week
- Straining for >25% of defecation attempts
- Lumpy/Hard stools for at least 25% of defection attempts
- Sensation of Anorectal Obstruction/Blockage for at least 25% of defecation attempts
- Manual manuevering required to defecate for at least 25% of defecation attempts
How would you assess the quality of stools?
Use the BRISTOL STOOL CHART
- TYPE 1 : Separate hard lumps, like nuts (hard to pass)
- TYPE 2 : Sausage-shaped but lumpy
- TYPE 3 : Sausage-shaped, but with cracks on the surface
- TYPE 4 : Sausage or snake-like, smooth and soft
- TYPE 5 : Soft blobs with clear-cut edges (easy to pass)
- TYPE 6 : Fluffy pieces with ragged edges, mushy
- TYPE 7 : Watery, no solid pieces (entirely liquid)
What are the possible causes of Constipation?
- Medication (Opioids, Antacids, Diuretics, Iron, 5-HT-3-R.A.)
- Secondary effects of illness (Dehydration, Immobility, Poor diet, Anorexia)
- Tumour in/compressing the bowel wall
- Damage to lumbosacral spinal cord/cauda equina/pelvic nerves
- Hypercalcemia
- Concurrent Disease (Diabetes, Hypothyroidism, Diverticular disease, Anal fissure, Haemorrhoids, Parkinson’s, Hypokalemia)
What is the aim and laxatives of choice when managing Constipation?
The aim is to achieve comfortable defecation, rather than any particular frequency of bowel motion. (Quality over Quantity)
There are 3 laxative choices. Option A (Stimulant +/- Softener), Option B (Osmotic laxative) and if A and B don’t work, there’s Option C (Rectal treatment).
What would you prescribe in Option A?
(Stimulant +/- Softener)
- Bisacodyl tabs 5mg-10mg, at bedtime
- Liquid paraffin 10ml-20ml, HS daily (if stools are hard)
*if significant colic occurs, discontinue stimulant and use softener only.
What would you prescribe in Option B?
(Osmotic Laxative)
- Macrogol 1-3 sachets daily
- if severe constipation, consider a higher dose for 3 days
What would you prescribe in Option C?
(Rectal Treatment)
- Soft Loading : Bisacodyl suppository, sodium citrate/phosphate enema
- Hard Loading : Glycerol suppository (lubricant/stimulant); then treat as above.
- Very Hard Loading : Arachis Oil enema overnight, phosphate enema
When is Arachis Oil Enema contraindicated?
When patient has ‘nut allergy’
What general advice would you give to a patient with Constipation and what measures would you take to ensure patient is well cared for?
- Encourage good oral fluid intake (2L per day)
- Review dietary intake
- Ensure patient has privacy and accessible to toilets
- Encourage daily exercises according to ability
- Correct any reversible factors leading to constipation
- Titrate laxative dosages according to individual response and use oral laxative if possible
- If current regiment is satisfactory and well-tolerated, continue with it but review the patient regularly and explain the importance of preventing constipation
A paraplegic patient with a lesion above T12-L1 presents with constipation. How do you manage the patient?
The patient most likely has a spastic bowel with intact anal reflexes.
Administer 2 glycerol suppository/microenema and wait for 30-60 mins.
Bisacodyl suppository 10-20mg is also recommended.
If both doesn’t work, opt for digital rectal stimulations.
A paraplegic patient with a lesion below T12-L1 presents with constipation. How do you manage the patient?
Patient most likely has a flaccid bowel.
Opt for Digital Rectal Evacuation
What are the key points to be considered when managing a paraplegic with a bowel condition?
- Regular evacuations are required everyday if paraplegic/ 1-3 days in cancer patients
- Provide high fluid and roughage in diet
- Provide adequate laxatives
Define Delirium.
It is an acutely disturbed state of mind characterised by restlessness, illusions and incoherence, which occur in intoxication, fever and other disorders.
State the different types of delirium.
- Hyperactive Delirium
- Hypoactive Delirium
- Mixed Delirium
What are the common clinical features in a patient with Delirium?
- Hyperactive Delirium : Combativeness , Agitation, Restlessness
- Hypoactive Delirium : Lethargy, Sedated, Stupor
- Mixed Delirium : All of the above.
- Altered sleep-wake cycle
- Anxiety, Paranoia, Irritability, Fear
- Loss of orientation of time/place/person
- Difficult to maintain attention
- Disorganised thinking
- Illogical speech
- Altered sensorium
What are the causes of delirium in a cancer patient?
- Cancer byproducts (Proinflammatory Cytokines)
- Intracranial Disease
- Electrolyte Imbalance
- Dehydration
- Organ Failure
- Paraneoplastic Syndromes
- Endocrine
- Infection
- Hypoxemia
- Other medical conditions
- Side effects of radiation/chemotherapy
- Medications
State some examples of Intracranial Diseases that may cause delirium in a cancer patient.
- Primary Brain Tumour
- Metastatic Brain Tumour
- Leptomeningeal Disease
- Stroke
State some examples of Electrolyte Imbalance that may cause delirium in a cancer patient.
- Hypercalcemia
- Hyponatremia
- Hypernatremia
- Hypomagnesemia
State some examples of Endocrine Disorders that may cause delirium in a cancer patient.
- Hypoglycaemia
2. Hypothyroidism
State some examples of Infections that may cause delirium in a cancer patient.
- Pneumonia
2. U.T.I
State some examples of Medical Conditions that may cause delirium in a cancer patient.
- Withdrawal Symptoms (Alcohol, Medication, Nicotine)
- Nutritional deficiency
- Coagulopathy
- Anemia
State some examples of Medications that may cause delirium in a cancer patient.
- Opioids
- Anticholinergics
- Corticosteroids
- Antidepressants
- Benzodiazepines
- Neuroleptics
What are the criteria assessed in delirium?
Alertness, Awareness, Awakeness
How do you grade a patient with delirium?
Use the RICHMOND AGITATION SEDATION SCALE - PALLIATIVE VERSION (RASS-PAL)
Score, Term, Description
+4 = Combative (Overtly combative, violent, immediate danger to staff, trying to get out of bed/chair, throwing items)
+3 = Very Agitated (Pulls/Removes lines/catheters, aggressive, trying to get out of bed/chair)
+2 = Agitated (Frequent non-purposeful movements, trying to get out of bed/chair)
+1 = Restless (Occasional non-purposeful movements but not aggressive or vigorous)
0 = Alert and calm
-1 = Drowsy (Not fully alert but has sustained awakening (eye contact) to voice for 10s or more)
-2 = Light Sedation (Briefly awakens with eye contact for <10s)
- 3 = Moderate Sedation (Any movements (eye/body) to voice, but no eye contact)
- 4 = Deep Sedation (No response to voice but any movement/ eye opening to stimulation by light touch)
-5 = No arousal (No response to voice/stimulation by light touch)
-
What bedside tests would you conduct to assess attention of patient?
- Orientation of time/year/date
- Multiplication of 2
- Counting (100-7/20-1)
- Spelling and reversal spelling
- Short-term memory recall (Examiner name, 3 paired objectives)
- Dysgraphia
What are the goals in delirium management
- Prevention of Delirium
- Modify risk factors
- Remove aetiology
- Provide non-pharmacological/pharmacological treatment
What drugs would you prescribe for a patient with delirium?
- Typical antipsychotic (low dose Haloperidol <5mg per day)
2. Atypical antipsychotics (Olanzapine, Risperidone, Quetiapine)
Which drug is contraindicated in patients with delirium?
Benzodiazepines
