Chapter 5- management of non-physical symptoms

Question 1

what are some non-physical symptoms in palliative patients?

Answer 1

fatigue
anxiety, depression, apathy
delirium and agitation 
spiritual pain
intimacy and sexual issues

Question 2

what are some questions to ask patients suffering from fatigue?

Answer 2

impact on daily life?
exacerbating/relieiving factors?
what helps relieve your fatigue?
on a scale of 1-10, how bad is your fatigue?

Question 3

what are some contributing factors to fatigue?

Answer 3

anxiety and depression
sleep disturbance
pain
fluid or electrolyte inbalance 
anaemia
poor oral intake 
cachexia
hypothyroidism

Question 4

what is the management of fatigue?

Answer 4

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

Question 5

what are some presenting features of anxiety?

Answer 5

difficulty sleeping
tremors 
nausea and vomiting 
dry mouth
feeling "clammy"
fluttering stomach 
palpitations 
hyperventilation 
breathlessness
frequency/urgency of elimination 
anorexia
headaches
irritability

Question 6

what are some important questions to ask patients with anxiety?

Answer 6

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?

Question 7

which scale is used to assess anxiety?

Answer 7

HADS - Hospital Anxiety and Depression Scale

Question 8

what are some non-pharmacological interventions for anxiety?

Answer 8

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

Question 9

what are some pharmacological therapies for anxiety?

Answer 9

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)

Question 10

what are the contraindications for TCA’s?

Answer 10

cardiac arrhythmias, heart block, MI

Question 11

what is the prevalence of depression in the palliative care population?

Answer 11

25%

Question 12

symptoms of depression?

Answer 12

feeling low
weight loss/gain
sleep disturbance 
lethargy
feelings of worthlessness
suicidal ideation 
guilt

Question 13

what are risk factors for depression?

Answer 13

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

Question 14

1st line pharmacological management of depression?

Answer 14

sertraline 50mg PO OD

citalopram 20mg PO OD

Question 15

what is the second line pharmacological management of depression?

Answer 15

paroxetine 20mg OM

fluoxetine 20mg OM - used with caution as can cause restlessness and increased anxiety

Question 16

risks of taking SSRI’s?

Answer 16

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

Question 17

side effects of TCA’s?

Answer 17

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

Question 18

what is apathy?

Answer 18

persistent lack of interest and loss of motivation

Question 19

what are some possible causes of apathy?

Answer 19

loss of confidence
social isolation 
withdrawal
underlying conditions - stroke, Parkinson's, Huntington's disease
damage to frontal lobe of brain 
dementia

Question 20

management of apathy?

Answer 20

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

Question 21

what is delirium?

Answer 21

common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has acute onset and fluctuating course
usually develops over 1-2 days

Question 22

what factors can exacerbate delirium?

Answer 22

old age
moving from familiar surroundings
deafness
poor vision

Question 23

what are some causes of delirium?

Answer 23

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

Question 24

non-pharmacological interventions for delirium?

Answer 24

orientation with clocks/soft lighting

clear and open discussions with family

Question 25

pharmacological interventions for delirium?

Answer 25

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

Question 26

what should be given for restlessness/delirium in the terminal phase?

Answer 26

midazolam 5-100mg/24 hours CSCI

leveomepromazine 5-150mg / 24 hrs CSCI

Question 27

what is spirituality?

Answer 27

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.

Question 28

what is the model used for taking a spiritual history?

Answer 28

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?

Question 29

how can sexual function be impacted in illness?

Answer 29

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

Question 30

interventions to assist with sexual intimacy?

Answer 30

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