EEPPEECC

EEPPEECC

Constitutional Symptoms

Module 10b

The Education in Palliative and End-of-life Care program at Northwestern University Feinberg School of Medicine, created with the support of the American Medical Association and the Robert Wood Johnson Foundation

Objectives Discuss pathophysiology of three

constitutional symptoms in palliative care

Anorexia/cachexiaFatigueInsomnia

Discuss assessment strategies Understand management strategies

Anorexia / cachexia ...

Cachexia – wasting syndrome Lean tissue Performance status Altered resting energy expenditure Appetite

≥ ≥ 5% weight loss and poor 5% weight loss and poor prognosis prognosis

Trend toward lower chemotherapy Trend toward lower chemotherapy response ratesresponse rates

Anorexia and poor prognosisAnorexia and poor prognosis QOL, functionQOL, function Affects caregiversAffects caregivers

ImpactImpact

Pathophysisiology

Chronic inflammation Metabolic changes Lipolytic / proteolytic substances Hormonal changes Role of neurotransmitters Cytokine impact on hypothalamus

Reversible causes of weight loss

Psychological factors

Mucositis Nausea /

vomiting Constipation Early satiety Taste perversion

Malabsorption

Pain

Endocrine

Comorbid conditions

Social / economic

Management

Treat comorbid conditions Educate, support Favorite foods / nutritional

supplements / counseling Treat reversible causes (eg, early

satiety, mucositis)

Management of anorexia

Dexamethasone Megestrol acetate Tetrahydrocannabinol (THC) Androgens

Fatigue ...

Persistent sense of tiredness Interferes with function Unrelieved by rest

... Fatigue

High prevalence-varies with stage and primary

High impact Patterns of fatigue

chemotherapyradiotherapy

Pathophysiology

Multifactorial Abnormal energy metabolism Increased cytokine production Contributing factors

depressionsleep disordersneuromuscular dysfunction

... Assessment

History / physical exam Disease status Current medications Associated symptoms Malnutrition / deconditioning Comorbidities

Management ...

Treatable etiologies Anemia Depression Pain Hypothyroidism Hypogonadism

Promote physical activity Include other disciplines Energy conservation strategies

Non-pharmacologic therapies

Methylphenidate/Dexmethylphenidate

Dexamethasone, prednisone Modafinil

Pharmacologic management

Insomnia ...

Definition: inadequate or poor quality sleep

difficulty falling asleepdifficulty maintaining sleepearly morning awakeningnon-refreshing sleep

... Insomnia

Impact: tiredness or fatigue, anergia, poor concentration, or irritability

Up to 63% of cancer patients Restful sleep can often be restored

Pathophysiology

Multiple possible cause Prior sleep disorder Uncontrolled symptoms

pain, pruritisdepression, anxiety

Medications

Assessment

Determine course and patternlifelong pattern or recent?difficulty falling asleep?early awakening?spouse observations?

Other unrelieved symptoms?

Management ...

Sleep hygieneregular sleep schedule, avoid staying in bed

avoid caffeine/nicotine, assess alcohol intake

cognitive / physical stimulationavoid overstimulationcontrol pain during the nightdaytime psychostimulant

… Management

Behavioral managementrelaxation, imagerysleep restrictionstimulus controlcognitive therapy

Pharmacologic management Antihistamines Benzodiazepines Sedating antidepressants Careful titration Attention to adverse effects GABA-receptor agonists Daytime stimulants

Skin wounds ...

Acute vs. chronic; likely to heal or not

Chemotherapy agent extravasation Radiation damage Decubitus ulcers Malignant wounds

... Skin wounds

Associated with: Pain Depression Anxiety Poorer interpersonal interactions

Skin symptoms

Organ system Highly innervated Visible Psychological, social, and spiritual Interdisciplinary care Symptom control

Assessment

Acute versus chronic Malignant vs decubitus

Decubitus ulcers

Assessmentrisk factors

Preventionskin protection- shear/tear/moisturepressure reduction and pressure relief

Decubitus ulcers: staging Non-blanchable erythema Partial-thickness skin loss Full-thickness skin loss Extensive necrosis exposing

muscle or bone

Decubitus ulcers

Goals: healing vs non-healing Healing

debridementdressings that promote healing

Non-healingpain control, comfortprevent worsening

Malignant wounds: management Healing vs non-healing Infections Odors Pain Exudate Bleeding

Summary