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Victor BNF Notes > Prescribing in Palliative Care and Elderly Patients > Flashcards

Prescribing in Palliative Care and Elderly Patients Flashcards

1
Q

What is the first line oral analgesic used in palliative care

A

morphine

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2
Q

What oral morphine forms are there

A

Immediate release
- 4 hourly (not more then 1/2 of the total daily dose per increment)

Modified Release
- 12 hourly
- 24 hourly
when pain is controlled, switch from quick to slow release within 4 hours of last dose

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3
Q

What is breakthrough pain

A

pain the occurs between regular doses of strong opioids

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4
Q

How to treat breakthrough pain

A

use a rescue dose
1/10 to 1/6 of total daily dose immediate release

repeat every 2 to 4 hours when required

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5
Q

When should you use parental forms of analgesics

A
  • dysphagia
  • severe nausea / vomiting
  • coma
  • weakness
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6
Q

Parental morphine dose compared to oral

A

Parental is half of oral dose

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7
Q

Parental diamorphine dose compared to oral

A

parental is third of oral dose of morphine

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8
Q

Why is parental diamorphine preferred over parental morphine

A
  • more soluble
  • large dose in small quantity
  • ideal in emaciated patient (huge loss of muscle and fat)
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9
Q

What are the two solutions for injection

A
  • Saline
  • Water for injection
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10
Q

SC diamorphine concentration and injections solutions

A
  • Diamorphine concentration goes up to 250mg/ml
  • If the strength prescribed is 40mg/ml or above, the injection solution used must be water for injection to avoid precipitation
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11
Q

When should you use transdermal patches over parental analgesia

A

if a patients pain can be managed by in immediate release opioid

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12
Q

Why should you use transdermal patches over parental analgesia for patients with pain stabilised by immediate release opioid

A

This stability suggests that their pain management needs are predictable and can be maintained with a consistent delivery system like a patch.

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13
Q

What should happen to a patch’s dose if switching due to hyperplasia

A

reduce dose by 25 to 30%

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14
Q

What are opioid side effects

A
  • constipation
  • nausea / vomiting
  • dry mouth
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15
Q

Managing opioid side effects: Constipation

A

laxative should be prescribed
- senna + lactulose
- co-danthramer

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16
Q

Managing opioid side effects: Nausea / vomiting

A
  • Metoclopramide
  • Haloperidol (4 to 5 days)
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17
Q

Managing opioid side effects: Dry mouth

A
  • maintain good oral hygiene
  • suck on ice cubes
  • artificial saliva
  • can be due to candidiasis (antifungal= nystatin, fluconazole)
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18
Q

Other types of pain and how to treat

A
  • Neuropathic
    (tricyclic antidepressants / anti-epileptic)
  • Bone Metastases
    (bisphosphonates, strontium ranelate)
  • Pain due to nerve compression
    (dexamethasone)
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19
Q

Symptoms in palliative Care

A
  • Anorexia
  • Bowel colic and excess respiratory secretions
  • capillary bleeding
  • convulsions
  • dysphagia due to obstruction by tumour
  • Dyspnoea
  • Fungating tumours
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20
Q

Symptoms in Palliative Care Part 2

A
  • Gastric distenion
  • Hiccup due to gastric distension
  • insomnia
  • intractable coughs
  • muscle spasms
  • nausea and vomiting
  • pruritis
  • headache due to raised intracranial pressure
  • Restlessness and confusion
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21
Q

How to treat Symptoms on palliative care: Anorexia

A
  • Prednisolone
  • Dexamethasone

increases appetite/weight gain

22
Q

How to treat Symptoms on palliative care: Bowel colic and excess respiratory secretions

A
  • subcutaneous injections of Hyoscine

Bowel colic (painful cramps)
- Loperamide

23
Q

How to treat Symptoms on palliative care: Capillary Bleeding

A
  • Tranexamic acid
  • Adrenaline
  • Vitamin K
24
Q

How to treat Symptoms on palliative care: Convulsions

A
  • Phenytoin
  • Carbamazepine
  • SC Midazolam
25
Q

How to treat Symptoms on palliative care: Dysphagia due to obstruction by tumour

A

Dexamethasone

26
Q

How to treat Symptoms on palliative care: Dyspnoea (shortness of breath)

A
  • Oral morphine

Dyspnoea with anxiety
- Diazepam

Bronchospasm or partial obstruction
- Corticosteroids

27
Q

How to treat Symptoms on palliative care: Fungating Tumours

A

Metronidazole

28
Q

How to treat Symptoms on palliative care: Gastric Distension

A
  • Antacids
  • Anti-flatulent
  • Prokinetic Drug (gastro motility)
29
Q

How to treat Symptoms on palliative care: Hiccup due to Gastric Distension

A
  • Antacids with Anti-flatulence

if fails…
- add metoclopramide

30
Q

How to treat Symptoms on palliative care: Insomnia

A

Benzodiazepines

31
Q

How to treat Symptoms on palliative care: Intractable coughs

A
  • oral morphine (reduces respiratory drive)
  • avoid methadone linctus as it can accumulate
32
Q

How to treat Symptoms on palliative care: Muscle Spasms

A
  • Diazepam
  • Baclofen
33
Q

How to treat Symptoms on palliative care: Nausea and Vomiting

A

Prokinetic antiemetic
- Haloperidol
- Levomepromazine
- Cyclizine
- Metoclopramide
- Dexamethasone

34
Q

How to treat Symptoms on palliative care: Pruritis (severe itching)

A

Emollients

35
Q

How to treat Symptoms on palliative care: Headache due to raised intracranial pressure

A

Dexamethasone (before 6 to reduce risk of insomnia)

36
Q

How to treat Symptoms on palliative care: Restlessness and Confusion

A
  • Haloperidol
  • Levomepromazine
37
Q

At what age is a person considered elderly

A

65+

38
Q

What are elderly doses meant to be compared to adult doses

A

50% of adult dose

39
Q

What is an examples of a drug that should be avoided in elderly patients

A

Glibenclamide

40
Q

What are the impacts of polypharmacy in elderly patients

A
  • increased amount of drugs taken
  • increased chance of interaction
  • increase chance of non-adherence
41
Q

What is the impact of reduced renal clearance in elderly patients

A
  • excretes drugs slowly
  • more susceptible to nephrotoxic drugs
  • acute illnesses can lead to rapid decline in renal function
42
Q

What is the impact of reduced hepatic metabolism in elderly patients

A
  • reduced metabolism of lipid soluble drugs and vitamins due to reduced liver volume
  • this will affect narrow therapeutic drugs
43
Q

What is the impact of increased nervous system sensitivity in elderly patients

A
  • more prone to side effects
44
Q

Common elderly side effects

A
  • confusion
  • constipation with antimuscarinics and antipsychotics
45
Q

What is the impact of long term diuretics in elderly patients

A
  • postural hypotension
  • falls
  • gravitational oedema
    (raise or move legs/ use stockings)
46
Q

What drugs have increased risk of bleeding in elderly patients

A

NSAIDs

Warfarin

47
Q

What two complications can come from taking NSAIDs as an elderly patient

A
  • cardiac disease
  • renal impairment
48
Q

If an elderly patient has osteoarthritis, soft lesions and back pain what is the 1st Line

A
  • weight reduction if obese
  • warmth
  • walking stick
49
Q

If an elderly patient has osteoarthritis, soft lesions, back pain and pain in rheumatoid arthritis what is the treatment

A

1st Line:
- paracetamol
or
- low dose NSAID

2nd Line:
- max dose paracetamol
and
- low dose NSAID

or
- give opioid with paracetamol

50
Q

What is the usual maintenance dose of digoxin in elderly

A

125mcg daily

(if renal impairment then 62.5 mcg daily)

Victor BNF Notes (25 decks)

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