Geriatrics - Palliative Care

Question 1

Palliative Care - Definition & Focus

Answer 1

improving QOL for those with serious illness unresponsive to curative treatment

control of pain and other symptoms
psychological, social, and spiritual problems

Question 2

Dying Process - 1-3 Months Before Death

Answer 2

withdrawal from the world and people
decreased communication
decreased food intake
increased sleep

Question 3

Dying Process - 1-2 Weeks Before Death

Answer 3

mental: agitation, confusion, talking with the unseen, picking at clothes

physical: decreased blood pressure, change in pulse, change in skin color, respiration irregularities, change in body temperature

Question 4

Dying Process - Days to Hours Before Death

Answer 4

surge of energy
decrease in BP
eyes glassy, tearing
restlessness or no activity
weak pulse, hard to find
decreased urine output

Question 5

Dying Process - Minutes Before Death

Answer 5

“fish out of water” breathing
cannot be awakened
loss of ability to swallow

Question 6

End of Life - Nausea & Vomiting Types

Answer 6

• gut wall (due to gastric irritants)
• area postrema (due to morphine, digoxin, hypercalcemia, clonidine, chemo)
• cerebral cortex (due to fear, anxiety, increased ICP, hyponatremia)
• vestibular nuclei (due to movement, vertigo)

Question 7

End of Life - Nausea & Vomiting - Gut Wall Treatment

Answer 7

1. H2RA or PPI
2. metoclopramide
3. ondansetron

Question 8

End of Life - Nausea & Vomiting - Area Postrema Treatment

Answer 8

1. haloperidol or metoclopramide
2. add dexamethasone; pamidronate if hypercalcemia
3. ondansetron and dexamethasone

Question 9

End of Life - Nausea & Vomiting - Cerebral Cortex Treatment

Answer 9

1. dexamethasone
2. amitriptyline or haloperidol or lorazepam
3. limit free water +/- 3% saline +/- haloperidol

Question 10

End of Life - Nausea & Vomiting - Vestibular Nuclei Treatment

Answer 10

1. diphenhydramine or dimenhydrinate
2. meclizine
3. glycopyrrolate or scopolamine

Question 11

End of Life - Dyspnea Causes

Answer 11

• obstruction by tumor
• carcinomatous lymphangitis
• bronchospasm
• cardiac failure
• chest infections
• pleural effusions
• ascites
• anemia

Question 12

End of Life - Dyspnea - Obstruction by Tumor Treatment

Answer 12

radiotherapy

Question 13

End of Life - Dyspnea - Carcinomatous Lymphangitis Treatment

Answer 13

steroids

Question 14

End of Life - Dyspnea - Bronchospasm Treatment

Answer 14

bronchodilators

Question 15

End of Life - Dyspnea - Cardiac Failure Treatment

Answer 15

diuretics

Question 16

End of Life - Dyspnea - Chest Infections Treatment

Answer 16

antibiotics +/- physiotherapy

Question 17

End of Life - Dyspnea - Pleural Effusions Treatment

Answer 17

pleural aspiration

Question 18

End of Life - Dyspnea - Ascites Treatment

Answer 18

abdominal paracentesis
diuretics

Question 19

End of Life - Dyspnea - Anemia Treatment

Answer 19

transfusion if hemoglobin < 8 g/dL

Question 20

End of Life - Dyspnea - General Next Steps

Answer 20

2. ipratropium / albuterol
3. morphine +/- dexamethasone
4. morphine and chlorpromazine / diazepam / midazolam

Question 21

End of Life - Cough Treatment

Answer 21

1. treat underlying cause
2. promote production: nebulized saline and / or guaifenesin
3. suppress cough - morphine / hydrocodone / dextromethorphan
4. dexamethasone or glycopyrrolate / atropine / NAC
5. nebulized lidocaine if triggered by lung tumor

Question 22

End of Life - Anxiety Treatment

Answer 22

1. non-pharmacological measures
2. short-term lorazepam / alprazolam / amitriptyline if depression
3. long-term buspirone / escitalopram / sertraline / mirtazapine if insomnia or anorexia

Question 23

End of Life - Delirium Treatment

Answer 23

1. haloperidol
2. haloperidol + lorazepam
3. haloperidol + midazolam or chlorpromazine

Question 24

End of Life - Constipation Prevention

Answer 24

1. senna or bisacodyl +/- docusate +/- metoclopramide if OIC; fiber or docusate if not OIC
2. sorbitol, PEG, lactulose
3. MOM, magnesium citrate, bisacodyl suppository - improve preventive therapy if got to this step

Question 25

End of Life - Bowel Obstruction Treatment

Answer 25

1. metoclopramide +/- dexamethasone if not a complete obstruction
2. glycopyrrolate +/- morphine +/- haloperidol
3. octreotide +/- above
4. PEG tube or stent

Question 26

End of Life - Depression Treatment

Answer 26

1. escitalopram or sertraline +/- methylphenidate until SSRI effective
2. amitriptyline +/- methylphenidate
3. if less than 4 weeks survival, methylphenidate or ketamine

Question 27

End of Life - Anorexia & Cachexia Treatment

Answer 27

1. treat underlying causes
2. metoclopramide if early satiety / gastroparesis
3. dexamethasone if survival < 3 months; mirtazapine or megestrol if survival > 3 months
4. dronabinol

Question 28

End of Life - Insomnia Treatment

Answer 28

1. treat underlying causes, remove offending drugs
2. • trazodone or melatonin if sundowning
   • temazepam or zolpidem if bed-bound
   • haloperidol if disturbing dreams
   • mirtazapine or amitriptyline if concomitant depression

Question 29

End of Life - Xerostomia Treatment

Answer 29

1. ice chips, gum, lemon drops
2. saliva substitute
3. pilocarpine 5 mg QID

Question 30

End of Life - Terminal Secretions Treatment

Answer 30

atropine 1% ophthalmic drops SL every 2-3 hrs prn
scopolamine patch
glycopyrrolate

Question 31

Insomnia - Drugs That Worsen

Answer 31

diuretics
steroids
caffeine
sympathomimetics
sedative withdrawal
alcohol

Question 32

End of Life - Asthenia Treatment

Answer 32

methylphenidate or dexamethasone