Supportive Care (Part 2) Flashcards
Causes of nausea
- Disease-related: tumour obstruction, intestinal obstruction, gastric stasis, raised ICP from brain metastases
- Biochemical: chemical/toxic causes (hypercalcemia, uraemia, drugs)
- Treatment-related: radiotherapy, chemotherapy
- Supportive medications: opioids
Before prescribing for established nausea/vomiting:
- History - a separate history for both nausea and vomiting
- exclude regurgitation
- check for other concurrent symptoms
Nausea and vomiting - management
- Metoclopramide (first-line, is a prokinetic)
2, Haloperidol (dopamine agonist, another option) - Ondansetron, mirtazapine, olanzapine - not first line
Nausea and vomiting - non-pharmacological advice
- Breaking up into smaller meals/day rather than 3 large meals
- Rinse mouth before eating with 1 teaspoon of soda/sodium bicarbonate powder to remove bad tastes
- Avoid hot spicy foods / foods that are very sweet, fatty or greasy
- Find a peaceful eating place / relaxed atmosphere
- Certain candies like lemon drops, peppermints can relieve nausea
- Drink clear liquids as much as possible to relieve diarrhoea
Dopamine receptor antagonists
- Types of drugs
- Causes
- Metoclopramide, haloperidol
2. Clinical toxicity, metabolic/biochemical upset
Drugs that cause motility disorders
Prokinetics - metoclopramide, domperidone
Drugs that cause intracranial disorders , as well as oral or pharyngeal irritation
Anticholinergic or antihistamine (hyoscine, prochlorperazine
Management of depression
- set aside time for patient to clarify concerns and express his feelings
- explain their disorder to them in terms of illness and situation, as well as supportive mechanism
- recommend CBT, relaxation and creative therapies with psychological benefits etc.
Assessment of depression (palliative care)
PHQ-9 tool
Antidepressant common treatment medications
SSRI, mirtazapine
Cause of xerostomia
- radiation therapy to the neck and head area
- surgery of the neck and head involving the removal of salivary glands
- certain chemotherapeutic agents
- oral infections
management of xerostomia
- frequent oral rinses and sips of water or juice (papaya).
- mouth care before or after meals. Avoid dry, sticky foods and choose soft, moist foods instead.
- Increase intake of fluids during meals (avoid alcohol and carbonated drinks)
- Suck on hard sugarless candies or chew on surgarless gum to lubricate the oral cavity
- Apply lip moisturiser (pilocarpine) to prevent drying and chapping of lips.
Characteristics of delirium, as well as types of delirium
- acutely confused, agitated and restless
- types:
1. hyperactive: increased arousal and agitation
2. hypoactive: quiet, withdrawn and inactive
3. mixed pattern
Assessment of delirium
- MMSE, CAM
- check for infection (urine infection in the elderly)
- assess for opioid toxicity (reduce opioid dose by a third, consider switching if delirium persists)
- check for sensory impairment
- check for constipation, urinary retention or catheter problems.
Pharmacological management
First choice: haloperidol, dose once orally or subcutaneously and repeat 2 hours again if necessary.
» maintenance dose may be needed.
Second choice: benzodiazepines
» do not improve cognition but help with anxiety.
» PO or SLT lorazepam
» SC midazolam 1-2 hourly, or PO diazepam 8-12 hourly