Chapter 5- management of non-physical symptoms Flashcards
what are some non-physical symptoms in palliative patients?
fatigue anxiety, depression, apathy delirium and agitation spiritual pain intimacy and sexual issues
what are some questions to ask patients suffering from fatigue?
impact on daily life?
exacerbating/relieiving factors?
what helps relieve your fatigue?
on a scale of 1-10, how bad is your fatigue?
what are some contributing factors to fatigue?
anxiety and depression sleep disturbance pain fluid or electrolyte inbalance anaemia poor oral intake cachexia hypothyroidism
what is the management of fatigue?
MDT approach - early involvement of physio/OT/psychological support
encourage energy conservation
optimise nutrition and hydration
daytime naps and good sleep hygiene
plan activity for when patient most energised
relaxation and stress management techniques
what are some presenting features of anxiety?
difficulty sleeping tremors nausea and vomiting dry mouth feeling "clammy" fluttering stomach palpitations hyperventilation breathlessness frequency/urgency of elimination anorexia headaches irritability
what are some important questions to ask patients with anxiety?
when did it start?
how severe do they perceive the anxiety to be?
how severe do those close to the patient perceive the anxiety to be?
is it related to starting on or withdrawing specific medications?
is it situational?
is it compounded by anxiety within the patients family?
is it due to alcohol / nicotine / drug withdrawal?
which scale is used to assess anxiety?
HADS - Hospital Anxiety and Depression Scale
what are some non-pharmacological interventions for anxiety?
guided imagery and visualisation techniques - thoughts are like clouds in the sky/leaves in a river
CBT
hypnotherapy
progressive muscular techniques - tensing and relaxing different muscle groups
talking therapies
what are some pharmacological therapies for anxiety?
benzodiazepines:
diazepam 1-5mg PRN orally usually at night time - works as a sedative and anxiolytic
lorazepam 0.5-1mg pro orally or sublingual (shorter acting but more addictive)
midazolam 2.5-5mg SC - in extreme anxiety or panic
antidepressants: doses start lower in anxiety than depression
TCA: amitriptyline 10-50mg
SSRI: citalopram (20-40mg), paroxetine (20-40mg), sertraline (50-100mg)
what are the contraindications for TCA’s?
cardiac arrhythmias, heart block, MI
what is the prevalence of depression in the palliative care population?
25%
symptoms of depression?
feeling low weight loss/gain sleep disturbance lethargy feelings of worthlessness suicidal ideation guilt
what are risk factors for depression?
history of mental illness lack of social support isolation and loneliness chronic pain poor performance status advanced disease at diagnosis underlying illness- Parkinson's, dementia
1st line pharmacological management of depression?
sertraline 50mg PO OD
citalopram 20mg PO OD
what is the second line pharmacological management of depression?
paroxetine 20mg OM
fluoxetine 20mg OM - used with caution as can cause restlessness and increased anxiety
risks of taking SSRI’s?
increased risk of suicide in patients under 30 years in first few weeks of starting
increased risk of GI bleed - make sure not on NSAIDs
serotonin syndrome
side effects of TCA’s?
antimuscarinic side effects:
dry mouth, hypotension, confusions and difficulties with passing urine
may take up to 6 weeks to see beneficial effect in depression, effect seen slightly quicker in anxiety
what is apathy?
persistent lack of interest and loss of motivation
what are some possible causes of apathy?
loss of confidence social isolation withdrawal underlying conditions - stroke, Parkinson's, Huntington's disease damage to frontal lobe of brain dementia
management of apathy?
cognitive stimulation therapy - playing specific games to recognise objects and facial expressions through pictures, played in a group lasts 45 mins
daily routine
encourage to focus on positive things/stay positive
break down activities into chunks so they don’t seem too overwhelming
what is delirium?
common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has acute onset and fluctuating course
usually develops over 1-2 days
what factors can exacerbate delirium?
old age
moving from familiar surroundings
deafness
poor vision
what are some causes of delirium?
drugs and drug interactions - steroids, opioids, benzos, digoxin, lithium cancer with cerebral mets hypercalcaemia hypo/hypernatraemia, hypo/hyperglycaemia drug and or alcohol withdrawal constipation urinary retentions infection pain breahtlessness/hypoxia
non-pharmacological interventions for delirium?
orientation with clocks/soft lighting
clear and open discussions with family
pharmacological interventions for delirium?
haloperidol 0.5mg orally 1-2 hourly PRN, max dose 5mg
if anxiety main issue - diazepam 2-5mg TDS PO or PR, midazolam 2.5-5mg SC or buccal
what should be given for restlessness/delirium in the terminal phase?
midazolam 5-100mg/24 hours CSCI
leveomepromazine 5-150mg / 24 hrs CSCI
what is spirituality?
a persons perceptions of what and whom is important to them, and how they make sense of the world - for some this may be linked to faith and religion, but not for everyone.
what is the model used for taking a spiritual history?
FICA:
1) Faith, belief, meaning - what things do you believe in that give meaning to your life?
2) Importance and influence - is it important in your life? what influences does this have on how you take care of yourself? have your beliefs influenced your behaviours during your illness?
3) community - is there a person or group of people you really love or who are important to you?
4) address/action in care - how would you like me as your health care provider address these issues in your healthcare?
how can sexual function be impacted in illness?
psychosocial issues - altered body image, anxiety, depression, fatigue, lack of communication with spouse/partner
physical issues - fatigue, nausea, altered sexual function
pain
drugs - e.g hormone treatments
interventions to assist with sexual intimacy?
ensure privacy
consider pushing two beds together
give permission for them to lie together on bed
timings of medications to maximise symptom relief
practice positioning with pillows
innovative ways to overcome issues such as incontinence/catheters
