Objectives. Symptom Management in the Frail Elderly Population. Disclosures. Symptom Management: Pain 12/05/2014

Transcription

1 Objectives Symptom Management in the Frail Elderly Population Dr. Katie Marchington, MD, CCFP Palliative Care Physician Toronto Western Hospital Kensington Hospice To reflect on why we should identify this population To develop an approach to symptom management: Pain Delirium To learn through asking questions Disclosures No conflicts of interest to disclose I will discuss the off label use of some medications Discussions relate to symptom management from a palliative care perspective Symptom Management in the Frail Elderly Population Do we have to think of frail elderly patients differently than other patient populations? Pink Yes! Yellow No! Do we have to think of frail elderly patients differently than other patient populations? Not necessarily, as long as we think of an individualized treatment plan Some symptoms are more common Special consideration for the risk of side effects from treatments Symptom Management: Pain 1

2 Mr. B. 78 yo x 50 yo 48 yo 45 yo POA Mr. B. Dx Renal Cell Carcinoma 1996: Rt nephrectomy Several recent trips to ED for back pain Admitted with bilateral leg edema, Rt hip pain CT: Retroperitoneal lymphadenopathy Bony metastases to spine, Rt iliac crest Cr 330 μmol/l Lt nephrostomy tube Pain Common complication of incurable illnesses Up to 85% of patients with advanced cancer 1 but not inevitable! Up to 85% of pain syndromes can be controlled with basic pain management 2 Pain Assessment History Goals of care Examination Investigations 1. Grond S, Zech D, Diefenbach C, Radbruch L, Lehmann KA. Assessment of cancer pain: a prospective evaluation in 2266 cancer patients referred to a pain service. Pain. 1996; 64 (1): Zech DF, Grond S, Lynch J, Hertel D, Lehmann KA. Validation of World Health Organization guidelines for cancer pain relief: a 10 year prospective study. Pain. 1995; 63 (1): Individualized treatment strategy Pain Assessment: History Pain Assessment: History O P Q R S T U V O P Q R S T U V Onset Provoking/Palliating Quality Region/Radiation Severity Treatment Understanding/Impact on U Values CCO s Symptom Management Guide to Practice: Pain (2010) RNAO s Clinical Best Practice Guidelines: Assessment and Management of Pain 3 rd Ed. (2013) 2

3 Pain Assessment: Cognitive Impairment Pain Assessment In Advanced Dementia Scale PAINAD Scale Each item scored 0 2 Observational Total 0 (no pain) to 10 5 items: (severe pain): 1. Breathing 2. Facial expression 3. Body language 4. Negative vocalizations 5. Consolability indicates some pain Pain Assessment: Examination Full examination to determine underlying cause(s) of pain including: Mental status and cognitive function General examination Focused neurological examination Musculoskeletal examination Available online at Pain Assessment: Investigations Goals of care Renal function (blood creatinine level) Plain X rays Radionuclide bone scan CT scan Pain Assessment: Mr. B. History: Two sites of pain: Right hip, low back Right hip: Started several weeks ago Worse with movement ache Radiates down Rt lateral thigh Pain Assessment: Mr. B. History, continued: Right hip: Average severity: 5/10; at rest: 2/10; on movement: 8/10 Using occasional acetaminophen/percocet with little relief, makes him drowsy Worried that the pain is caused by recurrence of his cancer, worried about effect on independence Pain Assessment: Mr. B., continued Examination: Alert, attentive, answers questions appropriately Grimace when moving from sitting to standing, antalgic gait Tender on palpation over Rt iliac crest, ROM of Rt hip limited in all directions by pain Normal abdominal examination Normal neurological examination 3

4 Pain Assessment: Mr. B., continued Investigations: CT abdo pelvis: Retroperitoneal lymphadenopathy Bony metastases to spine, R iliac crest Cr 330 μmol/l 150 μmol/l post nephrostomy tube Treating Pain: Non pharmacological Patient education Psycho social spiritual interventions: Spiritual counseling Other therapies: Massage Physiotherapy Treating Pain: Non pharmacological Radiation therapy Surgery Anesthetic interventions Treating Pain: Mr. B. Education Referral to spiritual care Radiation therapy Mr. B. wants to make it clear he s not keen on those pills Fears about opioids Think, pair, share Fears about opioids It means the end is near Opioids cause addiction Opioids will lose their effectiveness over time, leaving nothing to treat severe pain at the end Opioids will make me a zombie or take away my mental capacity They will stop my breathing They will my shorten life 4

5 Treating Pain: Principles Treating Pain: WHO Ladder for Pain Control By the mouth... By the clock With breakthroughs For the individual Addressing all aspects of suffering Monitor treatment efficacy regularly Identify and treat the underlying cause Treating Pain: WHO Ladder for Pain Control Step 1: 1 3/10 Non opioids: NSAIDs, acetaminophen, other adjuvants Step 2: 4 6/10 Opioids: codeine, tramadol Non opioids Step 3: 7/10 Opioids: morphine, hydromorphone, oxycodone, fentanyl, methadone Non opioids Treating Pain: Mr. B. How would you treat Mr. B. s pain? Regular acetaminophen Dexamethasone (+ gastric mucosa protection) Regular and p.r.n. hydromorphone How do we know what dose to start with? Treating Pain: Mr. B. Is Mr. B. opioid naïve? Pink Yes! Yellow No! Treating Pain: Mr. B. Should we pick a short acting formulation or long acting formulation of hydromorphone? Pink Short acting! Yellow Long acting! 5

6 Opioids in the Frail Elderly Decreased clearance and longer duration of action Applies to both short and long acting formulations Increased risk of neurotoxicity Polypharmacy risk of drug interactions Opioids in the Frail Elderly Start at a lower dose Consider increasing the dosing interval e.g. for short acting opioids, q6h instead of q4h Titrate cautiously Treating Pain: Mr. B. What dose and dosing frequency of hydromorphone? a) 2 mg p.o. q4h b) 0.5 mg p.o. q6h c) 0.5 mg p.o. q6h, and 0.5 mg p.o. q2h p.r.n. d) 0.5 mg p.o. q4h, and 0.5 mg p.o. q1h p.r.n. What about opioid side effects? Constipation: Almost everyone! Regular laxative to ensure BM at least q2 3d Nausea: 2/3 patients but it gets better! Anti emetic prn e.g. metoclopramide 10 mg po q4h prn Sedation: Some patients but it gets better! Monitor Respiratory depression (RR < 8) Rare if start at a low dose and titrate appropriately Mr. B s Individualized Pain Treatment Plan Non Pharmacological: Education Referral to spiritual care Radiation therapy Pharmacological: Regular acetaminophen Dexamethasone (+ gastric mucosa protection) Regular and prn hydromorphone Regular laxative, antiemetic prn Dyspnea Management Same principles of opioid use in pain management apply to dyspnea management 6

7 Symptom Management: Delirium Mr. J. 67 yo x 48 yo 49 yo POA Mr. J. Delirium Dx Prostate Cancer 2007 metastases to spine, hip Recent pathological fracture of left hip total hip replacement rehab D/c home x 1 week but returned to E.D. with worsening pain, decreased mobility and confusion! Common complication of incurable illnesses Up to 85% of patients in the last weeks of life 1 but often reversible! Up to 50% of cases of delirium are reversible even in the setting of advanced illness 2 1. Pereira J, Hanson J, Bruera E. The frequency and clinical course of cognitive impairment in patients with terminal cancer. Cancer (4) Lawlor, PG et al. Occurrence, causes and outcome of delirium in patients with advanced cancer: a prospective study, Arch Intern Med. 2000; 160 (6): Delirium Is distressing to patients, loved ones and caregivers Alters symptom assessment and control Is under diagnosed and under treated Constitutes a medical emergency in palliative care Delirium DSM V Criteria: A disturbance in attention and awareness Develops over a short period of time, represents a change of baseline, and tends to fluctuate during the day An additional disturbance in cognition 7

8 Delirium: Common Causes DIMS Drugs Infections Metabolic Or Medications Structural Delirium and the Frail Elderly Baseline risk factors for delirium in elderly medical patients 1 : Cognitive impairment Visual impairment Severe illness High blood urea nitrogen/creatinine ratio 1. Inouye SK et al. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med Sep 15;119(6): Delirium and the Frail Elderly Delirium Assessment Goals of care Examination History Investigations Inouye SK et al. Predictive Factors for Delirium in Hospitalized Elderly Persons. JAMA, 1996, Vol. 275, No. 11, pp Individualized treatment strategy Delirium Assessment: History Hallucinations Are you seeing strange things that are unusual? Paranoia: Do you feel safe? Sleep disturbance Sun downing Emotional lability Increase (agitation) or decreased psychomotor activity Delirium Assessment: History Aggravating factors E.g. agitation/confusion worsen after a specific drug Review of systems E.g. urinary symptoms UTI Review medical history Review medications recently started or discontinued 8

9 Delirium Assessment: History Nurse on a particular shift or visitor may not notice any agitation while a colleague on a different shift may note agitation or confusion Delirium: Screening Confusion Assessment Method (CAM): Acute onset and fluctuating course + Inattention + Disorganized thinking OR altered level of consciousness Inouye, S.K. et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med (1990) 113: Delirium Assessment: Examination Full examination to determine underlying cause(s) of delirium including: Vital signs Hydration status Signs of toxicity E.g. myoclonus Full neurological examination Exclude urinary retention, bowel obstruction or constipation Delirium Assessment: Investigations Goals of care Factors to consider when deciding whether or not to proceed with investigations: Overall disease burden Life expectancy Probability of reversibility Wishes of patient and family Setting of care Burden of investigation Delirium Assessment: Investigations Bloodwork: CBC, electrolytes, creatinine, liver function tests, calcium and albumin Urine dip +/ C & S In select cases: Blood C & S CXR CT head (enhanced) Delirium Assessment: Mr. J. History Mr. J. seems to answer questions inconsistently ( yes then no to the same question) Niece: awake a night, sleepy during the day, increasingly confused x 5 d, hallucinating last night Taking hydromorphone 21 mg po q8h, hydromorphone prn dose/use in last 24 h unknown 9

10 Delirium Assessment: Mr. J. Examination Mental status examination: drowsy but rouses to voice, disoriented to time and place, unable to count backwards 20 1, unable to describe pain Vital signs: O 2 sat 88% on RA, RR 18 Respiratory: decreased air entry Rt anterior lung>lt lung Myoclonic Delirium Assessment: Mr. J. Is this patient Confusion Assessment Method (CAM) positive? Pink Yes! Yellow No! Delirium: Screening Confusion Assessment Method (CAM): Acute onset and fluctuating course + Inattention + Disorganized thinking OR altered level of consciousness Delirium Assessment: Mr. J. Investigations: Ca 2+ (corr) 3.10 mmol/l Cr 88 μmol/l Hgb 85 g/l WBC normal Urine dip ( ) CXR: bilateral pleural effusions, venous congestion, atelectasis CT head pending Delirium Assessment: Mr. J. Differential diagnosis: Hypercalcemia Opioid toxicity Congestive heart failure Disease progression? Treating Delirium Goals of care Screen Identify and treat underlying causes if possible and if appropriate + + Treatment of symptom (Non-Rx + Rx) Communicate: Explain situation to patient and family and reassure 10

11 Treating Delirium: Non pharmacological Communication: E.g. identify self by name at each contact Environment: E.g. use calendars and clocks E.g. avoid physical restraints whenever possible (use sitter or family member) Sound and Light: E.g. use music which has individual significance to the patient RNAO s Clinical Best Practice Guidelines: Caregiving Strategies for Older Adults with Delirium, Dementia and Depression (2010) Treating Delirium: Non pharmacological Social interaction: E.g. encourage family and friends to visit Other: E.g. limit choices, and offer decision making only when patients are capable of making these judgments RNAO s Clinical Best Practice Guidelines: Caregiving Strategies for Older Adults with Delirium, Dementia and Depression (2010) Treating Delirium: Pharmacological Typical antipsychotic neuroleptic drug Regular antipsychotic is often beneficial in addition to as needed dose E.g. haloperidol 0.5 mg 2mg po/subcut q8h q12h E.g. haloperidol 0.5 mg po/subcut q2h prn Monitor for extrapyramidal side effects E.g. akathisia or feeling of restlessness Treating Delirium: Pharmacological While you re looking at medications Could one the patient s medications be exacerbating delirium? Is pain contributing to delirium? Avoid the use of opioids or benzodiazepines alone to treat symptoms of delirium Treating Delirium: Communication Treating Delirium: Communication We know delirium is a distressing experience for caregivers.and this distress is reduced by educating caregivers about delirium RNAO s Clinical Best Practice Guidelines: Caregiving Strategies for Older Adults with Delirium, Dementia and Depression (2010) 11

12 Treating Delirium: Communication Mr. J s Individualized Pain Treatment Plan Treat the underlying cause (within goals of care): Opioid rotation from hydromorphone to fentanyl Treatment of hypercalcemia Non pharmacological: Calendar, identify self by name Encourage family to visit Pharmacological: Haloperidol 0.5 mg po q12h and 0.5 mg po q2h prn Multiple discussions with pt s niece to explain delirium: cause, what to expect, what she can do to help patient feel calmer Resources 12