Palliative Care Symptom Guide

July 2010

Table of Contents General Principles of Pain Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Pain Scale for patients who cannot communicate (Abbey Pain Scale). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Select Opiate Products. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Equianalgesic dosing (Opioid conversion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Patient Controlled Analgesia (PCA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Transdermal Fentanyl Conversion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Guidelines for Naloxone Administration and Patient Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Nausea and Vomiting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-9 Constipation and Bowel Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-11 Delirium: Diagnosis and Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-14 Dementia: Course and Prognostication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15-16 Depression: Screening tools and Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17-19 End Stage Liver Disease: Prognostication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20-21 End of life care: Symptom Management Common Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Oral Secretions at the End of Life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Palliative Care and Pain Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

1

Pain Scale 0

1

2

3

4

5

6

7

8

No Pain None = 0;   Mild = 2.5;   Moderate = 5;   Severe = 7.5;   Excruciating = 10

9

10

Worst Pain Imaginable

General Principles of Pain Management

1. Assess pain using a standardized pain scale. Pain is a subjective feeling: ask the patient using the above 0-10 scale. If the patient is cognitively impaired, use the Abbey pain scale. (See page 2.) Frequency of assessment: at the time of the initial interview, every eight hours, and PRN (at least every two hours when pain is severe). 6. Determine the route the opiate will be given. 2. In opiate naive patients, start with short-acting opioids (morphine, hydromorphone, and oxycodone) to control acute, moderate to severe pain. a. IM should never be given. Never use long-acting opioids to control acute pain. 7. Determine the dosing schedule. 3. When titrating or changing opiate dose, start by calculating the a. For non-opiate naive patients, use long-acting pain medicine for ongoing pain, not previous day’s Oral Morphine Equivalent (OME). prn; for opiate naive patients use only prn until you have a sense of how much a.  Since all potent opioids produce analgesia by the same mechanism, they medicine the patient needs. will produce the same degree of analgesia if provided in equianalgesic b. Give 66-75% of patient’s stable daily OME as long acting. doses (see equanalgesic table). c. Consider a pca if the pain requirements are rapidly increasing or unknown. b. Rectal=oral 8. Determine break through dose (for acute pain in patient with otherwise c. S Q=IM=IV controlled pain). 4.  Determine if the dose is adequate for the pain and dose adjust. a. Use the same opiate for short- and long-acting pain when possible. a. Titrate at least every 24 hours when the pain is moderate and as often as every b. 5-15% of total daily long acting opiate dose every 3 hr prn. four hours when using IV opioids and the pain is severe. 9. Manage opiate side effects. Constipation must be treated prophylactically b. Increase dose 25-50% for moderate pain and 50-100% for severe pain. (see page 6). 5. Determine the opiate that will be used and dose adjust for incomplete 10. Determine whether co-analgesics would help. cross tolerance. a. The only reason to change from one opiate to another is side effects or renal failure. b. When rotating opiate, decrease the dose 25-50% to correct for incomplete cross tolerance.

1

Abbey Pain Scale Abbey Pain Scale for the assessment of pain in patients who cannot communicate. Rating Scale Absent = 0   Mild = 1   Moderate = 2   Severe = 3 Domain Vocalization



Scale 0-3

Facial expressions

0-3

Change in body language

0-3

Behavioral change (confusion, refuse to eat, alteration in usual patterns)

0-3

Physiological changes

0-3

Physical changes (skin tear, pressure area contractions, etc.)

0-3

Total Score No Pain = 0-2   Mild = 3-7   Moderate = 8-13   Severe = 14+

Reference: Abbey J., Piller N., DeBalis A., Esterman D. The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. International Journal of Palliative Nursing, 2004, Vol. 10, No 1, 6-13.

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PHARMACISTS WILL NOT MAKE SUBSTITUTIONS OR CORRECTIONS FOR OPIATES. IF SCRIPTS ARE NOT WRITTEN EXACTLY (e.g., CORRECT DRUG, DOSE, AND SCHEDULE), THEY WILL NOT BE FILLED. SELECT NON-INJECTABLE OPIOID PRODUCTS Drug Morphine Oxycodone Hydromorphone (Dilaudid) Codeine Fentanyl Oxymorphone

Short Acting (mg) Tabs (15, 30 mg)  Caps (15, 30 mg) MSIR Oral Solution (10 mg/5 mL, 20 mg/5 mL) MSIR, Roxanol Oral Concentrate (100 mg/5mL) (1) Supp (5, 10, 20, 30 mg) Roxicodone Tabs (5, 15, 30 mg) OxyIR Caps (5 mg)  Roxicodone Oral Solution (5 mg/5 mL) OxyFAST, Oxydose, Roxicodone Intensol Oral Concentrate (20 mg/mL) (1,6) Dilaudid Tabs (2, 4, 8 mg) (8 mg brand-name scored)  Dilaudid Oral Solution (5 mg/5 mL) Supp (3 mg) Tabs (15, 30, 60 mg) Solution or Elixir (15 mg/5 mL) Actiq Lozenge (200, 400, 600, 800, 1200, 1600 mcg) (5) Opana (5, 10 mg)

Long Acting (mg) MS Contin Tabs (q12hr) (15, 30, 60, 100, 200 mg) Oramorph SR Tabs (q12hr) (15, 30, 60, 100 mg) Kadian Caps (q12hr or q24hr) (10, 20, 30, 50, 60, 80, 100, 200mg) (2, 6, 7) Avinza Caps (q24hr) (30, 60, 90, 120 mg) (2, 5) OxyContin Tabs (q12hr) (10, 15, 20, 30, 40, 60, 80 mg)

Duragesic Transdermal Patch (12.5, 25, 50, 75, 100 mcg/hr) Opana ER (5, 7.5, 10, 15, 20, 30, 40 mg)

SELECT COMBINATION OPIOID PRODUCTS

3

Drug

Formulation/Strength (mg/mg) (8)

Anexsia (hydrocodone/acetaminophen) (4,6) Empirin with Codeine (codeine/aspirin) (4,6) Lorcet (hydrocodone/acetaminophen) (3,4) Lortab (hydrocodone/acetaminophen) (3,4) Norco (Hydrocodone/acetaminophen) (3,4) Percocet (oxycodone/acetaminophen) (3,4) Percodan (oxycodone/aspirin) (4) Roxicet (oxycodone/acetaminophen) (4) Tylenol with Codeine (codeine/acetaminophen) (3) Vicodin (hydrocodone/acetaminophen) (3,4) Vicoprofen (hydrocodone/ibuprofen) (6) Zydone (hydrocodone/acetaminophen) (4,6)

Tabs 5/325 (scored), 5/500 (scored), 7.5/325, 7.5/650 (scored), 10/660 (scored) Tabs 30/325 (#3), 60/325 (#4) Tabs 7.5/650 (scored), 10/650 (scored) Caps 5/500 Tabs 2.5/500, 5/500 (scored), 7.5/500 (scored), 10/500 Elixir 7.5/500 per 15 mL Tabs 5/325, 7.5/325, 10/325 Tabs 2.5/325, 5/325, 7.5/325, 7.5/500, 10/325, 10/650 Tabs 5/325 Tabs 5/325 Caps 5/500 Oral Solution 5/325 per 5 mL Tabs 15/300 (#2), 30/300 (#3), 60/300 (#4) Oral Solution 12/120 per 5 mL Tabs 5/500, 7.5/750 (ES), 10/660 (HP) Tabs 7.5/200 Tabs 5/400, 10/400

(1) Orders for concentrated oral opioid solutions must include drug name and strength (e.g. 100 mg/5mL) to avoid confusion with other oral solutions. (2) Data supporting safe use with enteral feeding tubes (must use size 16 French or larger). See Kadian prescribing information and UPMC PUH SHY online formulary (Avinza) for product-specific instructions. (3) Maximum daily dose of acetaminophen is 4 grams in patients with normal liver function. (4) Many other brand name products contain similar combinations of opioids. (5) Formulary restricted. (6) Non-formulary. (7) Please note 200 mg not to be confused with 20 mg. (8) As of Fall 2008, all combination opiates with more than 325 mg of acetaminophen will be non-formulary.

Oral and Parenteral Opioid Analgesic Equivalencies and Relative Potency of Opioids as Compared with Morphine* When converting from one opioid to another, you should use 50–75% of the equivalent dose. Allow for incomplete cross-tolerance between different opioids (may need to titrate up rapidly and use PRN dose to ensure effective analgesia for the first 24 hours). Avoid IM injections because of inconsistent absorption and patient discomfort. Opioid Agonists Parenteral mg (2) Oral mg (3) Duration of Effect Morphine 10 30 3–4 hours Oxycodone 20–30 3–4 hours Hydromorphone 1.5 7.5 3–4 hours Meperidine (1) (not recommended) 75 300 3 hours Fentanyl (4) 0.1** 1–2 hours Codeine 130 200 3–4 hours Hydrocodone 25–30 Oxymorphone 1 10 3–6 hours *These are rough approximations; individual patients may vary. ** Equivalency for a one time dose of IV Fentanyl only. For Fentanyl patch conversion, see page 6. 1) Meperidine is not a first-line opioid. Avoid in patients with renal dysfunction. Contraindicated with MAOIs. Please see UPMC Meperidine Guidelines before prescribing. 2) Parenteral opioid: onset of action, 5 minutes; peak, 15 min. 3) Oral opioid: onset of action, 15–30 minutes; peak, 45–60 min. 4) Equivalency if acute; when long-term, potency is 100 mcg=4 mg IV morphine. Please refer to APS Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (2003); American Pain Society (APS) Guideline for the Management of Cancer Pain in Adults and Children (2005).

4

Patient Controlled Analgesia (PCA) Use the preprinted PCA order form for all new PCA orders and dose The following are suggestions for the PCA order for adults. Like all opioid orders, doses must be individualized. changes. EDUCATE FAMILIES NOT TO PRESS THE PCA BUTTON! Loading Starting Patient Lockout One-hour Dose Continuous infusion dose(s) (1) Administered Dose* (2) Interval (3) Limit (optional) (4) rate in mg/hr (5) Morphine (6) Opioid naive: 1 mg 8 –20 min. 7–10 mg 2-4 mg q 15 min Elderly (>70 yrs.) 0.5 mg 8 –20 min. 4– 6 mg When indicated, 2mg q 20 min. calculate based on titrated to pain relief intermittent PCA use Hydromorphone Opioid naive: 0.2 mg 8 –20 min. 0.7–1.4 mg or previous opioid (Dilaudid) 0.2–0.3 mg q 15 min requirement. Elderly (>70 yrs.) Elderly: 0.1 mg 8 –20 min. 0.4–0.6 mg 0.2mg q 20 min titrated to pain relief

5

*Opioid tolerant and chronic/cancer pain patients may require higher doses press the button and be able to comprehend instructions on when to press and continuous infusions. the button. In the elderly, consider a longer lockout interval. 1.PCA alone is a maintenance technique. Patients should receive loading 4.The hour limit should not be less than the available total hourly patient doses (delivered through the infuser) that are titrated to achieve an adequate administered dose. Bolus doses and the continuous infusion are included level of analgesia (pain score less than or equal to 4/10). in the one-hour dose limit count. 2.Quantity delivered when button is pressed. Reduce doses by 30-50% 5.Not recommended for patients who are opioid naive, the elderly, patients in elderly and patients with liver disease. Do not increase dose based with altered mentation, or with Obstructive Sleep Apnea, COPD, or asthma. on increased body weight; this is especially important in patients with 6.Morphine is generally the opioid of choice. Hydromorphone is preferred in Obstructive Sleep Apnea. Dosing depends on the patient—young vs. patients with impaired renal function. elderly/opioid naive vs. tolerant. If pain unrelieved following administration of loading dose(s), increase 3.How frequently demand dose can be activated. Patient must be able to loading dose by 50% and titrate to pain score less than or equal to 4/10.

To convert to transdermal fentanyl—Not used for acute pain or initial opioid therapy. Use for patients who are unable to take po or have chronic cancer pain. Determine the 24-hr parenteral morphine equivalent. Dose patch at 50–75% of the previous 24-hr opioid use. Prescribe a short-acting opioid for breakthrough pain

Parenteral Morphine Equivalent (mg/24 hours) 8 to 22 23–37 38–52 53–67 68–82 83–97

Transdermal Fentanyl Equivalent (mcg/hr) 25 50 75 100 125 150

(5-15% of total daily long acting opiate dose every 3 hr prn). Patch duration = 72hrs. Increase the patch dose based on the average amount of additional short-acting opioid required in the previous 72 hrs. Allow patch at least 48hrs before adjusting the dose. For dosages of transdermal fentanyl over 100 mcg/hr multiple patches can be used.

TWENTY-FOUR HOUR ORAL MORPHINE EQUIVALENT DIVIDED BY 2 IS EQUAL TO FENTANYL PATCH DOSE IN MCG/HR. IV fentanyl dose/hr=transdermal fentanyl dose NOTE: PATCH TAKES 12–24 HRS TO ACHIEVE FULL EFFECT. WHEN REMOVING A PATCH, REMEMBER THE ANALGESIC EFFECT CAN STILL LAST 24 HRS.

6

Guidelines for Naloxone Administration and Patient Monitoring 1. Nurses may administer naloxone without a physician’s order when patients who have received an opioid meet the following criteria: (a) Sedation Scale = 3 (Somnolent; Difficult to arouse), (b) RR < 8 OR Oxygen Saturation < 92% and RR < 12 2. If the criteria listed above are met, stop the administration of the opioid (including fentanyl patches) and benzodiazepines. 3. Provide oxygen via face mask STAT. 4. Method for naloxone administration: Naloxone 0.04 mg IV q 1 minute until a change in alertness is observed. Dilute 0.4mg naloxone (one ampule) with NSS to a total volume of 10ml (1 ml = 0.04 mg) in a 10 ml syringe. 5. Notify the primary physician and/or house staff of the need to immediately evaluate the patient. If the house staff does not arrive within five minutes or if the nurse assesses the need, a “Condition C” should be called.

6 Titrate the prescribed naloxone until the patient is responsive. The half-life of naloxone (ONE HOUR) is shorter than the half-life of opioid agonists. Naloxone administration should not cause pain to return or precipitate opioid withdrawal. If a response is not obtained after one ampule of naloxone (10 cc of diluted solution) is administered, examine the patient for alternate causes of sedation and respiratory depression. For assistance with further naloxone dosing, please contact the Toxicology Treatment Program (412-647-7000). 7. Re-evaluate the events leading to the need for naloxone administration. In cases where the prescribed opioid dosing was too high, reassess the therapeutic plan for pain management. Consider decreasing the opioid dose by 50%. Resume opioid administration when the patient is easily aroused, is beginning to experience pain, and after the RR increases to > 9. 

7

Nausea and Vomiting: Treatment Mechanism-based therapy involves the following steps: 1. A complete history and physical including oropharyngeal, abdominal, rectal and neurological exams 2. Consider labs: BUN/Cr, Na, LFT’s, amylase/lipase, Ca, drug levels 3. Consider imaging: flat plate of the abdomen to assess for constipation, Abdominal CT to evaluate for obstruction, Head CT/MRI 4. Determine which receptors are mediating the symptoms (see below) 5. Choose an antiemetic to block the implicated receptors (see next page) Pathophysiology of nausea and vomiting Nausea and vomiting are triggered by activation of one of four main pathways: 1. Chemoreceptor Trigger Zone (CTZ): Main receptors: D2, 5HT3, NK1 2. Cortex: Main receptors are in the vomiting center. 3. Vestibular apparatus: Main receptors: Ach, H1 4. Peripheral pathways: Mediates nausea from triggering of GI/visceral chemoreceptors (local toxins) and mechanoreceptors (stretch). Enterochromaffin cells release 5HT3 when damaged (ie by chemotherapy or radiation) which activates local 5HT3 receptors. These four pathways send signals to the vomiting center

(main receptors: H1, Ach, 5HT2) which triggers nausea and vomiting when thresholds are reached. If nausea is persistent, severe or refractory: • Schedule antiemetics around the clock, not PRN • Choose second and third antiemetics which work on different receptors. • Consider Palliative Care consult for second and third line therapies IN ADDITION TO USING ANTIEMETICS, ALWAYS TREAT ANY REVERSIBLE CAUSES (medications, anxiety, constipation, hypercalcemia, thrush, increased ICP, GERD, pain) ALWAYS EVALUATE FOR CONSTIPATION AND PERFORM A RECTAL EXAM Avoid use of promethazine because of adverse effects including sedation and respiratory depression Avoid benzodiazepines unless the nausea is from anxiety because they can sedate the patient and increase risk of aspiration For nausea associated with vomiting, give antiemetics via the IV route until symptoms are controlled Evaluate for clinical signs of bowel obstruction (persistent nausea briefly relieved by vomiting, abdominal pain, distended abdomen, obstipation) If bowel obstruction, consider surgery and/or GI consults for possible surgical repair or venting PEG tube

Consider palliative care consult for medical management of bowel obstruction. References: Wood GJ, Shega JW, Lynch B, Von Roenn JH. Management of intractable nausea and vomiting in patients at the end of life “I was feeling nauseous all of the time…nothing was working.” JAMA. 2007;298(10): 1196-1207. Receptors: D2: Dopamine type 2 receptor, 5HT3: 5-hydroxytryptamine type 3 receptor, 5HT2: 5-hydroxytryptamine type 2 receptor, Achm: muscarinic acetylcholine receptor, H1: histamine type 1 receptor, NK1: Neurokinin type 1 receptor

8

Nausea and Vomiting: Treatment Drug (Generic Name)

Receptor activity

Common Clinical Indications

Dosage/Route

Cost

Comments/ Side Effects

Haloperidol

D2

Opioid Induced N/V

0.5-4 mg PO or SQ or IV Q6h

$

IV has less EPS compared to PO

Metoclopramide

Peripheral D2

Impaired GI motility Opioid Induced N/V

5-20 mg PO or SQ or IV AC and HS

$

EPS, esophageal spasm,and colic in GI tract obstruction

Prochlorperazine

D2

Opioid Induced N/V N/V of unknown etiology

5-10 mg PO or IV every 6 h or 25mg PR Q6h

$

EPS and sedation

Scopolamine

Ach, H1

Motion induced N/V

1.5 mg Transdermal patch every 3 d

$

Dry mouth, blurred vision, ileus, urinary retention, and confusion

Ondansetron

5HT 3

Chemotherapy or radiation induced N/V

4-8 mg PO as a pill or dissolvable tablet or IV every 4-8 h

$$

Headache, fatigue, and constipation

Dexamethasone

Decrease ICP

N/V related to Increased ICP

4-8mg QAM or BID, PO (as pill or liquid) and IV

$

Agitation, Insomnia, Hyperglycemia

N/V: Nausea/Vomiting

9

Constipation and Bowel Protocol Medication Osmotic laxatives

Onset of action

Usual starting dosage

Site and Mechanism of Action

Lactulose

24-48h

15-30ml q12-24h

Colon; osmotic effect

Polyethylene Glycol

48-96h

17g (1tbsp) powder in 8oz water q24h

GI tract; osmotic effect

Sorbitol

24-48h

15-30ml q12-24h, max 150ml/d

Colon; delivers osmotically active molecules to the colon

Magnesium citrate

30min-3h

120-240ml x1; 10oz q24h

Small and large bowel; attracts and retains water in the bowel lumen

Magnesium hydroxide (MOM)

30min-3h

30ml q12-24h

Colon; osmotic effect & increased peristalsis

Bisacodyl

6-10h

5-15mg x1

Colon; stimulates peristalsis

Bisacodyl (PR)

15min-1h

10mg x1

Colon; stimulates peristalsis

Senna

6-10h

2 tabs qhs

Colon; stimulate myenteric plexus, alters water and electrolyte secretion

24-72h

100mg q12-24h

Small and large bowel; detergent activity; softens feces

Saline Laxatives*

Stimulant laxatives

Surface laxatives Docusate

Bulk laxatives alone are not useful in the treatment of opiate induced constipation *Avoid use of MOM and related products (including sodium phosphate enema products) in patients with renal dysfunction because of risk of hyperphosphatemia Reference: Reuben DB, Herr KA, Pacala JT, et al. Geriatrics at Your Fingertips 2009, 11th edition. New York: The American Geriatrics Society; 2009 BOWEL REGIMEN: With few exceptions, all patients on opioid therapy need an individualized bowel regimen. When and effective regimen is found it must be continued for the duration of the opioid therapy. If a patient has not been on a bowel regimen, the step 1 regimen should be started. If there is no response in 24 hours, move to the next step. At any given time, if there has been no bowel movement in four or more days, a sodium phosphate or mineral oil enema should be administered. If this is not effective, a high colonic tap water enema should be administered. Be aware of the possibility of bowel obstruction or fecal impaction. A digital rectal exam should be performed prior to starting a bowel regimen and if no BM for 4 days.

10

Constipation and Bowel Protocol BOWEL REGIMEN: With few exceptions, all patients on opioid therapy need an individualized bowel regimen. Start with the step 1 regimen. When an effective regimen is found it must be continued for the duration of the opioid therapy. Step 1—Begin with a laxative. The following are some suggestions: a. MOM 30cc po qd b. Senna 1 tab po qd Step 2—Senna 2 tabs bid Step 3—Senna 3 tabs bid Step 4—Senna 4 tabs bid + Lactulose 15cc po bid Step 5—Senna 4 tabs bid+ Lactulose 30 cc po bid Step 6—Senna 4 tabs bid + Lactulose 30 cc po qid

Other drugs that can exacerbate constipation: anticholinergics (tricyclic antidepressants, scopolamine, oxybutinin, promethazine, diphenhydramine), lithium, verapamil, bismuth, iron, aluminium, calcium salts Opiod Antagonists to treat refractory constipation: Methylnaltrexone (MNTX) is a quaternary amine which does not cross the blood brain barrier to cause reversal of opioid analgesia or withdrawal. Use of 11 oral naloxone for constipation has been associated with these effects. MNTX is approved for use in patients who have been on a steady opioid regimen for 2 weeks and laxative regimen for 3 days. Greater than 50% of patients will have a bowel movement within 4 hours of being given the dose by subcutaneous injection. In general, it is recommended that oral and rectal laxative regimens should have been tried, prior to utilizing MNTX. Pts with fecal ostomy bags and PD catheters were excluded from the studies. There is a dosing order set in the EMR.

Delirium: Diagnosis DSM-IV criteria for delirium include four components: A. Acute onset, over hours to days. B. Behavioral disturbance, marked by a reduced clarity in the patient’s awareness of the environment, with impaired ability to focus, sustain, or shift attention. The patient may be agitated, irritable, and emotionally labile, OR drowsy, quiet, and withdrawn. C. Consciousness level fluctuates over the course of the day. D. Different from dementia, delirium cannot be accounted for by a patient’s preexisting, established, or evolving dementia. Delirium is conceptualized as a reversible illness, except in the last 24–48 hours of life.

1. Delirium occurs in at least 25–50% of hospitalized cancer patients, and in a higher percentage of patients who are terminally ill. Delirium increases the risk of in-hospital and six-month mortality. 2. Differential diagnosis: D: Drugs (opioids, anticholinergics, sedatives, benzodiazepines, steroids, chemo- and immunotherapies, some antibiotics); E: Eyes and Ears (poor vision and hearing, isolation); L: Low flow states (hypoxia, MI, CHF, COPD, shock); I: Infections; R: Retention (urine/ stool), Restraints; I: Intracranial (CNS metastases, seizures, subdural, CVA, hypertensive encephalopathy); U: Under-hydration, Under-nutrition, Under-sleep; M: Metabolic disorders (sodium, glucose, thyroid, hepatic, deficiencies of vitamin B12, folate, niacin, and thiamine) and Toxic (lead, manganese, mercury, alcohol). 3. Routinely screen for delirium, and monitor delirious patients frequently.

Confusion Assessment Method (CAM) ICU for the Diagnosis of Delirium Diagnosis positive with 1 and 2, plus 3 or 4 Feature 1. Acute onset and fluctuating course AND 2. Inattention PLUS 3. Disorganized thinking >2 errors OR 4. Altered level of consciousness

Assessment Ask family or friends of patient Patient is easily distracted. Abnormal Digit Span: Inability to repeat a series of five digits (start with reading aloud a string of two random digits, then increase) and Vigilance A: At least two errors (read aloud in neutral normal tone a list of 10 letters with four A’s. Patient taps when A is read). Rambling or irrelevant conversation, unclear or illogical flow of ideas, or topic switching, or ask patient’s family. Ask: 1) Can a rock float? 2) Are there fish in the sea? 3) Is one pound more than two pounds? 4) Do you use a hammer to pound a nail? 5) Command say to patient, “Hold up this many fingers.” (Examiner holds two fingers in front of patient.) Next, do the same thing with the other hand (not repeating holding up the number of fingers). Hyper-alert, drowsy, stuporous, or unarousable

See www.icudelirium.org for more information and http://elderlife.med.yale.edu for more information on the CAM and delirium in the hospital.

12

Delirium: Treatment Rule out other medical causes of delirium. Review medications, and discontinue or decrease anticholinergic and/or benzodiazepine doses. Check for drugdrug interactions. Rotate opioids, reduce doses by 25% if possible, and avoid meperidine. Benzodiazepines are NOT effective in treating delirium, may worsen delirium, and should be used cautiously only as adjunct therapy with neuroleptics when relief of agitation is required. Neuroleptics are used for treatment of delirium. Haloperidol is the standard neuroleptic for treatment of delirium. Risperidone, olanzapine, and quetiapine are atypical neuroleptics, generally with fewer side effects. All neuroleptics can cause QT prolongation. Supportive care to prevent and reduce delirium includes frequent orientation (well-lit rooms, caregivers, calendars, clocks, communication), therapeutic activities (patient mobilization 3x/day when possible), non-pharmacologic sleep aids (see page 12), treatment of hearing and vision problems, treatment of incontinence, and volume repletion. Confusion increases the risk of falls. Pay attention to patient safety. Constant supervision (sitter) may be more beneficial than restraints or sedation.

13 Table 2: Drugs used for treatment of delirium in the hospital setting Generic name (Common brand name)

Starting dose

Dosing interval

Max q24h dose

Formulations

EPS

Anticholinergic

Sedation

Comments**

Haloperidol (Haldol®)

0.5-1mg (2mg in ICU*)

0.5-1hour for urgent symptoms. Otherwise Q6H or Q8H

20mg

0.5, 1, 2, 5, 10 mg tablets. Available as oral solution and as an injectable product.

+++

+

++

IV has less EPS compared to PO.***

(continued)

Delirium: Treatment Generic name (Common brand name) Risperidone (Risperdal®)

Starting dose

Dosing interval

Max q24h dose

Formulations

EPS

Anticholinergic

Sedation

Comments**

0.25-1mg

6mg

+

+

Caution with renal failure.

2.5-10mg

20mg

+

++

++

Debilitated or elderly: 2.5 mg. 12.550mg

IM: Q2H (Maximum: 3 doses daily) BID

0.25, 0.5, 1, 2, 3, 4mg tablets. Available as ODT 2.5, 5, 7.5, 10, 15, 20 mg tablets. Available as ODT and IM injection

++

Olanzapine (Zyprexa®)

BID or up to Q6H PRN DAILY

Patients with hypoactive delirium, >70years CNS malignancy may not respond well.

800mg

25, 50, 100, 200, 300, 400 mg tablets

+

++

+++

Start DAILY at 4pm for sundowning† and then time subsequent, additional doses based on symptoms.

5-15mg

Q AM

30mg

2, 5, 10. 15, 20, 30mg. Available as IM and oral solution

++

+

++

Useful for hyperactive delirium. Can cause insomnia if given at night

Quetiapine (Seroquel®)

Aripiprazole (Abilify®)

Abbreviations: EPS: extrapyramidal symptoms; IM: intramuscular; IV: intravenous; ODT: oral disintegrating tablet; SQ: subcutaneous. Definition: †Sundowning: Onset of confusion in the elderly that typically begins in the evening *Refer to the UPMC Presbyterian Shadyside “Acute Agitation Management” order set. ** The FDA has determined that the use of antipsychotic medications in the treatment of behavioral disorders in elderly patients with dementia is associated with increased mortality. This risk appears to be highest during the first two weeks of use. *** Use IV haloperidol with caution in patients with prolonged QT interval. Increased risk of arrhythmia and sudden death exists with high IV doses.

14

Dementia: Course Estimated frequencies of Causes of Dementia Alzheimers Disease (AD): 60-70% Other progressive disorders: 15-30% (eg, vascular, Lewy body, frontotemporal) Completely reversible dementia (eg, drug toxicity, metabolic changes, thyroid diseases, subdural hematoma, normal pressure hydrocephalus: 2-5%

Progression of AD

Common clinical features

Usual MMSE; CDR* scores

Mild Cognitive impairment (preclinical)

Report by patient or caregiver of memory loss No functional impairment Objective signs of memory impairment 6-15% annual conversion rate to dementia syndrome

26-30; 0.5

Early, mild impairment Yr 1-3 from onset of symptoms

Disoriented to date; naming difficulties; recent recall problems Decreased insight; social withdrawal; irritability, mood changes

21-25; 1

Middle, moderate impairment Yr 2-8 from onset of symptoms

Disoriented to date, place; comprehension difficulties; impaired new learning; getting lost in familiar areas Delusions, agitation, aggression; restless, anxious, depression Not cooking, shopping, banking Problems with dressing, grooming

11-20; 2

Late, severe impairment Yr 6-12 from onset of symptoms

Nearly unintelligible verbal output; remote memory gone No longer grooming or dressing; incontinent Motor or verbal agitation

0-10; 3

15

* MMSE: Mini Mental Status Exam, CDR: Clinical Dementia Rating Scale Reference: Reuben DB, Herr KA, Pacala JT, et al. Geriatrics at Your Fingertips 2009, 11th edition. New York: The American Geriatrics Society; 2009

Dementia: Prognostication Functional Assessment Staging (FAST)

Mortality Risk Index Score (Mitchell)

Stages

Points

Risk Factor

1. 2. 3. 4. 5. 6. 7.

1.9 1.9 1.7 1.6 1.6 1.5 1.5 1.5 1.5 1.5 1.4 1.4

Complete dependence with ADLs Male gender Cancer Congestive heart failure O2 therapy needed w/in 14 days Shortness of breath 83 y Not awake most of the day

No difficulties Subjective forgetfulness Decreased job functioning and organizational capacity Difficulty with complex tasks, instrumental ADLs Requires supervision with ADLs Impaired ADLs, with incontinence A. Ability to speak limited to six words B. Ability to speak limited to single word C. Loss of ambulation D. Inability to sit E. Inability to smile F. Inability to hold head up

National Hospice and Palliative Care Organization- FAST Stage 7A- hospice appropriate 7C or worse, median survival- 3.2 months

Risk estimate of death within 6 months Score Risk %

Compared to FAST Stage 7C, the MRI had greater predictive value of six-month prognosis.

0 1-2 3-5 6-8 9-11 ≥12

Mortality Risk Index has been validated only in newly admitted nursing home residents.

8.9 10.8 23.2 40.4 57.0 70.0

Tsai S, Arnold RA. Fast Fact and Concept #150. Prognostication in Dementia. February 2006. End-of-Life/Palliative Education Resource Center (www.eperc.mcw.edu).

16

Depression: Screening Tools and Treatment A shorter screening test for depression is to ask: 1. Are you feeling either depressed or hopeless most of the time over the last 2 weeks? 2. Have you found little brings you pleasure or joy over the last 2 weeks? From: R Arnold. Fast Fact and Concept #146: Screening for Depression in Palliative Care. End-of-Life/Palliative Education Resource Center (www.eperc .mcw.edu). 2005

Spiritual Distress Screen—A Quick Screen 1. Ask “Are you at peace”? 2. If the answer is no, ask the patient if he/she would like to see a chaplain. Source: Archives of Internal Med 2006:166:101-5.

Some select antidepressants are listed in the table next page:

17

Commonly used antidepressants: dosing, formulations Category

Generic (Common Brand Name)

Starting PO dose (depression)*

Dosing interval

Therapeutic dose/day range*

SSRIs

Citalopram (Celexa®)

10-20mg

DAILY

10-60mg

Y

10, 20, 40 (tablets) 10mg/5mL (solution)

Escitalopram (Lexapro®)

5-10mg

DAILY

10-20mg

N

5,10, 20 (tablets) 5mg/5mL (solution)

Sertraline (Zoloft®)

25-50mg

DAILY

50-200mg

Y

25, 50, 100 (tablets) 100mg/5mL (solution)

Venlafaxine (Effexor®) Venlafaxine XR (Effexor XR®)

75mg/day divided

BID-TID

150-375mg

Y

25, 37.5, 50, 75, 100 (tablets)

37.5-75mg

DAILY

75-225mg

N

37.5, 75, 150 (capsules)

Duloxetine (Cymbalta®) Methylphenidate (Ritalin®)

20mg

BID

30-60mg

N

2.5-5mg

BID 8a,12p

5-40mg (for depression)

Y

20, 30, 60 (delayed-released capsules) 5, 10, 20 (tablets)

SNRIs

Stimulants

Generic (Y/N)

Formulations (mg)

Abbreviations: CR, SR, XL, XR: sustained-release products SSRIs: Serotonic Specific Reuptake Inhibitors, SNRIs: Serotonin Norepinephrine Reuptake Inhibitors Others: Use the following w/caution in renally impaired patients: all SNRIs, all formulations of buproprion and mirtazapine Use the following w/caution in hepatically impaired patients: All SSRIs, methylphenidate, all SNRIs and bupropion *The therapeutic dose/day range varies from the minimum efficacious dose up to the maximum tolerated or daily recommended amounts. Maximum daily doses are dependent upon indication for use and should only be used as a guide. Initial doses should be low in elderly patients and increased gradually. Doses of up to 300 mg of venlafaxine XR have been used in practice, but are not FDA-approved. The doses for methylphenidate can be higher than 20mg but are generally not recommended.

18

Commonly used antidepressants: costs, side effects, comments Drug (Common brand name) Citalopram (Celexa®) Escitalopram (Lexapro®) Sertraline (Zoloft®) Venlafaxine (Effexor®) Venlafaxine XR (Effexor® XR)

Cost per day* $

Anticholinergic

Insomnia

Arrhythmia

GI Distress

Comments**

+

+

+

++

$

+

+++

+++

++

1.3 and ventilator closer to 95+%

20

End-Stage Liver Disease (continued)

SUPPORT data for prognosis in cirrhosis: Cr 1-2

1 pt

Age >65

Cr > 2

2 pt

PT>16

1 pt 1 pt

Glasgow 10-14

1 pt

Vent or pO2