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12/05/2014
1
Symptom Management in the Frail Elderly Population
Dr. Katie Marchington, MD, CCFPPalliative Care PhysicianToronto Western HospitalKensington Hospice
Objectives
• 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 anindividualized treatment plan
• Some symptoms are more common
• Special consideration for the risk of side effects from treatments
Symptom Management: Pain
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Mr. B.
78 yo x50 yo 48 yo 45 yo
POA
Mr. B.
• Dx Renal Cell Carcinoma 1996: Rtnephrectomy
• 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/LLt nephrostomy tube
Pain
• Common complication of incurable illnesses…
– Up to 85% of patients with advanced cancer1
• …but not inevitable! – Up to 85% of pain syndromes can be controlled
with basic pain management2
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): 107‐14.
2. 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): 65‐76.
Pain Assessment
Individualized treatment strategy
Individualized treatment strategy
HistoryHistory
ExaminationExamination
InvestigationsInvestigations
Goals of care
Pain Assessment: History
O
P
Q
R
S
T
U
V
Pain Assessment: History
O Onset
P Provoking/Palliating
Q Quality
R Region/Radiation
S Severity
T Treatment
U Understanding/Impact on ‘U’
V Values
CCO’s Symptom Management Guide‐to‐Practice: Pain (2010)RNAO’s Clinical Best Practice Guidelines: Assessment and Management of Pain 3rd Ed. (2013)
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Pain Assessment: Cognitive Impairment
• Pain Assessment In Advanced Dementia Scale– PAINAD Scale
• Observational
• 5 items:1. Breathing
2. Facial expression
3. Body language
4. Negative vocalizations
5. Consolability
• Each item scored 0‐2• Total 0 (no pain) to 10 (severe pain):- 1‐2 indicates some
pain
Available online at http://www.mhpcn.ca/uploads/PAINAD.1276125778.pdf
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
Goals of care
Pain Assessment: Investigations
• 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 Rthip limited in all directions by pain
– Normal abdominal examination
– Normal neurological examination
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Pain Assessment: Mr. B., continued
• Investigations:
– CT abdo‐pelvis:
• Retroperitoneal lymphadenopathy
• Bony metastases to spine, R iliac crest
– Cr 330 μmol/L150 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”
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Treating Pain: Principles
• 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
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!
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Opioids in the Frail Elderly
• Decreased clearance and longer duration of action
– Applies to both short‐ and long‐acting formulations
• Increased risk of neurotoxicity
• Polypharmacyrisk 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 poq4h 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
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Symptom Management: Delirium
Mr. J.
67 yo x48 yo 49 yo
POA
Mr. J.
• Dx Prostate Cancer 2007metastases to spine, hip
• Recent pathological fracture of left hiptotal hip replacementrehab
• D/c home x 1 week but returned to E.D. with worsening pain, decreased mobility
…and confusion!
Delirium
• Common complication of incurable illnesses…
– Up to 85% of patients in the last weeks of life1
• …but often reversible! – Up to 50% of cases of delirium are reversible
even in the setting of advanced illness2
1. Pereira J, Hanson J, Bruera E. The frequency and clinical course of cognitive impairment in patients with terminal cancer. Cancer 1997 79 (4) 835‐42.
2. Lawlor, PG et al. Occurrence, causes and outcome of delirium in patients with advanced cancer: a prospective study, Arch Intern Med. 2000; 160 (6): 786‐94.
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
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Delirium: Common Causes
• ‘DIMS’
– Drugs
– Infections
– Metabolic
– Or Medications
– Structural
Delirium and the Frail Elderly
• Baseline risk factors for delirium in elderly medical patients1:
– 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. 1993 Sep 15;119(6):474‐81
Delirium and the Frail Elderly
Inouye SK et al. Predictive Factors for Delirium in Hospitalized Elderly Persons. JAMA, 1996, Vol. 275, No. 11, pp. 852‐857
Delirium Assessment
Individualized treatment strategy
Individualized treatment strategy
HistoryHistory
ExaminationExamination
InvestigationsInvestigations
Goals of care
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 symptomsUTI
• Review medical history
• Review medications recently started or discontinued
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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: 941‐948.
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
• 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
Goals of care
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
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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: O2 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:– Ca2+ (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
Screen
Identify and treat underlying causes
if possible and if appropriate
Treatment of symptom
(Non-Rx + Rx)
Communicate:Explain situation
to patient and familyand reassure
+ +
Goals of care
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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 aloneto treat symptoms of delirium
Treating Delirium: Communication
• We know delirium is a distressing experience for caregivers…
….and this distress is reduced by educating caregivers about delirium
Treating Delirium: Communication
RNAO’s Clinical Best Practice Guidelines: Caregiving Strategies for Older Adults with Delirium, Dementia and Depression (2010)
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Treating Delirium: CommunicationMr. 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
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