EEPPEECC

EEPPEECC

Depression, Anxiety, Delirium

Depression, Anxiety, Delirium

Module 6Module 6Module 6Module 6

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

ObjectivesObjectives

Identify depression, anxiety, delirium Identify depression, anxiety, delirium near end of life near end of life

Describe management plansDescribe management plans

Identify depression, anxiety, delirium Identify depression, anxiety, delirium near end of life near end of life

Describe management plansDescribe management plans

Depression, anxiety, deliriumDepression, anxiety, delirium Highly prevalent, under-diagnosedHighly prevalent, under-diagnosed

May prevent quality dyingMay prevent quality dying

Effective management is possibleEffective management is possible

Highly prevalent, under-diagnosedHighly prevalent, under-diagnosed

May prevent quality dyingMay prevent quality dying

Effective management is possibleEffective management is possible

DepressionDepression

25%–77% of patients25%–77% of patients

Intense sufferingIntense suffering

Not inevitableNot inevitable

Treatable in most casesTreatable in most cases

Early treatment is betterEarly treatment is better

25%–77% of patients25%–77% of patients

Intense sufferingIntense suffering

Not inevitableNot inevitable

Treatable in most casesTreatable in most cases

Early treatment is betterEarly treatment is better

Risk factors . . .Risk factors . . .

Pain, other symptomsPain, other symptoms

Progressive physical impairmentProgressive physical impairment

Advanced diseaseAdvanced disease

MedicationsMedications

steroidssteroids

benzodiazepinesbenzodiazepines

Pain, other symptomsPain, other symptoms

Progressive physical impairmentProgressive physical impairment

Advanced diseaseAdvanced disease

MedicationsMedications

steroidssteroids

benzodiazepinesbenzodiazepines

. . . Risk factors. . . Risk factors

Particular diseasesParticular diseases

pancreatic cancerpancreatic cancer

strokestroke

Spiritual painSpiritual pain

Preexisting risk factorsPreexisting risk factors

prior Hx, family Hx, social stressprior Hx, family Hx, social stress

suicide attempts, substance usesuicide attempts, substance use

Particular diseasesParticular diseases

pancreatic cancerpancreatic cancer

strokestroke

Spiritual painSpiritual pain

Preexisting risk factorsPreexisting risk factors

prior Hx, family Hx, social stressprior Hx, family Hx, social stress

suicide attempts, substance usesuicide attempts, substance use

Diagnosing depression in advanced illnessDiagnosing depression in advanced illness Somatic symptoms always presentSomatic symptoms always present

Look for psychological, cognitive Look for psychological, cognitive symptomssymptoms

pain not responding as expectedpain not responding as expected

sad mood / flat affect, anxious, irritable sad mood / flat affect, anxious, irritable

worthlessness, hopelessness, worthlessness, hopelessness, helplessness, guilt, despair helplessness, guilt, despair

anhedonia, lost self-esteemanhedonia, lost self-esteem

Somatic symptoms always presentSomatic symptoms always present

Look for psychological, cognitive Look for psychological, cognitive symptomssymptoms

pain not responding as expectedpain not responding as expected

sad mood / flat affect, anxious, irritable sad mood / flat affect, anxious, irritable

worthlessness, hopelessness, worthlessness, hopelessness, helplessness, guilt, despair helplessness, guilt, despair

anhedonia, lost self-esteemanhedonia, lost self-esteem

SuicideSuicide

Assess all depressed patients for Assess all depressed patients for riskrisk

Discussion of thoughts of suicide Discussion of thoughts of suicide may reduce the riskmay reduce the risk

Suicidal thoughts a sign of Suicidal thoughts a sign of depressiondepression

High risk if recurrent thoughts, plans High risk if recurrent thoughts, plans

Assess all depressed patients for Assess all depressed patients for riskrisk

Discussion of thoughts of suicide Discussion of thoughts of suicide may reduce the riskmay reduce the risk

Suicidal thoughts a sign of Suicidal thoughts a sign of depressiondepression

High risk if recurrent thoughts, plans High risk if recurrent thoughts, plans

Management of depressionManagement of depression Psychotherapeutic interventionsPsychotherapeutic interventions

cognitive approachescognitive approaches

behavioral interventionsbehavioral interventions

MedicationsMedications

Combination of psychotherapy, Combination of psychotherapy, medicationmedication

Psychotherapeutic interventionsPsychotherapeutic interventions

cognitive approachescognitive approaches

behavioral interventionsbehavioral interventions

MedicationsMedications

Combination of psychotherapy, Combination of psychotherapy, medicationmedication

Counseling goals . . .Counseling goals . . .

Weave counseling into routine Weave counseling into routine interventionsinterventions

include family when possibleinclude family when possible

Improve patient understandingImprove patient understanding

Create a different perspectiveCreate a different perspective

Identify strengths, coping strategiesIdentify strengths, coping strategies

Weave counseling into routine Weave counseling into routine interventionsinterventions

include family when possibleinclude family when possible

Improve patient understandingImprove patient understanding

Create a different perspectiveCreate a different perspective

Identify strengths, coping strategiesIdentify strengths, coping strategies

. . . Counseling goals. . . Counseling goals

Reestablish self-worthReestablish self-worth

New coping strategiesNew coping strategies

Educate about modifiable factorsEducate about modifiable factors

Reestablish self-worthReestablish self-worth

New coping strategiesNew coping strategies

Educate about modifiable factorsEducate about modifiable factors

Pharmacologic management . . .Pharmacologic management . . . PsychostimulantsPsychostimulants

SSRIsSSRIs

Tricyclic and atypical Tricyclic and atypical antidepressantsantidepressants

PsychostimulantsPsychostimulants

SSRIsSSRIs

Tricyclic and atypical Tricyclic and atypical antidepressantsantidepressants

. . . Pharmacologic management. . . Pharmacologic management Choose by time to effectChoose by time to effect

days – psychostimulantsdays – psychostimulants

weeks / months – SSRIs, tricyclic / weeks / months – SSRIs, tricyclic / atypical antidepressantsatypical antidepressants

Start dosing low, titrate slowly Start dosing low, titrate slowly

Consider consultationConsider consultation

Choose by time to effectChoose by time to effect

days – psychostimulantsdays – psychostimulants

weeks / months – SSRIs, tricyclic / weeks / months – SSRIs, tricyclic / atypical antidepressantsatypical antidepressants

Start dosing low, titrate slowly Start dosing low, titrate slowly

Consider consultationConsider consultation

Psychostimulants . . .Psychostimulants . . .

Rapid effectRapid effect

Methylphenidate, 5 mg q am + q Methylphenidate, 5 mg q am + q noon, titrate to effect noon, titrate to effect

Alone or in combinationAlone or in combination

Continue indefinitelyContinue indefinitely

Rapid effectRapid effect

Methylphenidate, 5 mg q am + q Methylphenidate, 5 mg q am + q noon, titrate to effect noon, titrate to effect

Alone or in combinationAlone or in combination

Continue indefinitelyContinue indefinitely

. . . Psychostimulants. . . Psychostimulants

Diminish opioid sedation Diminish opioid sedation

Not usually an appetite suppressantNot usually an appetite suppressant

May exacerbateMay exacerbate

tremulousnesstremulousness

anxietyanxiety

anorexiaanorexia

insomniainsomnia

Diminish opioid sedation Diminish opioid sedation

Not usually an appetite suppressantNot usually an appetite suppressant

May exacerbateMay exacerbate

tremulousnesstremulousness

anxietyanxiety

anorexiaanorexia

insomniainsomnia

SSRIsSSRIs

Latency 2–4 weeksLatency 2–4 weeks

Highly effective (70%)Highly effective (70%)

Well toleratedWell tolerated

Once-daily dosingOnce-daily dosing

Low doses may be effective in Low doses may be effective in advanced illnessadvanced illness

Latency 2–4 weeksLatency 2–4 weeks

Highly effective (70%)Highly effective (70%)

Well toleratedWell tolerated

Once-daily dosingOnce-daily dosing

Low doses may be effective in Low doses may be effective in advanced illnessadvanced illness

Tricyclic antidepressantsTricyclic antidepressants Not recommended as first-line Not recommended as first-line

therapytherapy

Latency 3–6 weeksLatency 3–6 weeks

Adverse effects are commonAdverse effects are common

nortriptyline, desipramine have fewer nortriptyline, desipramine have fewer adverse effectsadverse effects

Atypical antidepressants still being Atypical antidepressants still being studiedstudied

Not recommended as first-line Not recommended as first-line therapytherapy

Latency 3–6 weeksLatency 3–6 weeks

Adverse effects are commonAdverse effects are common

nortriptyline, desipramine have fewer nortriptyline, desipramine have fewer adverse effectsadverse effects

Atypical antidepressants still being Atypical antidepressants still being studiedstudied

Anxiety . . .Anxiety . . .

Fear, uncertainty about futureFear, uncertainty about future

Physical, psychological, social, Physical, psychological, social, spiritual, practical issuesspiritual, practical issues

PresentationPresentation

agitation, insomnia, restlessness, agitation, insomnia, restlessness,

sweating, tachycardia, hyperventilation,sweating, tachycardia, hyperventilation,

panic disorder, worry, tensionpanic disorder, worry, tension

Fear, uncertainty about futureFear, uncertainty about future

Physical, psychological, social, Physical, psychological, social, spiritual, practical issuesspiritual, practical issues

PresentationPresentation

agitation, insomnia, restlessness, agitation, insomnia, restlessness,

sweating, tachycardia, hyperventilation,sweating, tachycardia, hyperventilation,

panic disorder, worry, tensionpanic disorder, worry, tension

. . . Anxiety. . . Anxiety

Assessment complexAssessment complex

Differentiate fromDifferentiate from

delirium, depressiondelirium, depression

bipolar disorderbipolar disorder

medication effectsmedication effects

insomniainsomnia

alcohol, caffeinealcohol, caffeine

Assessment complexAssessment complex

Differentiate fromDifferentiate from

delirium, depressiondelirium, depression

bipolar disorderbipolar disorder

medication effectsmedication effects

insomniainsomnia

alcohol, caffeinealcohol, caffeine

Management of anxietyManagement of anxiety

Counseling, supportive therapyCounseling, supportive therapy

BenzodiazepinesBenzodiazepines

short vs long half-lifeshort vs long half-life

diazepam diazepam

lorazepam lorazepam

alprazolam, oxazepam alprazolam, oxazepam

Atypical antidepressantsAtypical antidepressants

Counseling, supportive therapyCounseling, supportive therapy

BenzodiazepinesBenzodiazepines

short vs long half-lifeshort vs long half-life

diazepam diazepam

lorazepam lorazepam

alprazolam, oxazepam alprazolam, oxazepam

Atypical antidepressantsAtypical antidepressants

DeliriumDelirium

Global change in cognition, Global change in cognition, awareness, acute onsetawareness, acute onset

PresentationPresentation

fluctuating level of consciousnessfluctuating level of consciousness

cognitive impairmentcognitive impairment

distinguish from dementia, depression, distinguish from dementia, depression, anxietyanxiety

Global change in cognition, Global change in cognition, awareness, acute onsetawareness, acute onset

PresentationPresentation

fluctuating level of consciousnessfluctuating level of consciousness

cognitive impairmentcognitive impairment

distinguish from dementia, depression, distinguish from dementia, depression, anxietyanxiety

Causes to consider . . .Causes to consider . . .

Infections, sepsisInfections, sepsis

Medications, street drugs (including Medications, street drugs (including withdrawal)withdrawal)

HypoxemiaHypoxemia

MetabolicMetabolic

Infections, sepsisInfections, sepsis

Medications, street drugs (including Medications, street drugs (including withdrawal)withdrawal)

HypoxemiaHypoxemia

MetabolicMetabolic

. . . Causes to consider. . . Causes to consider

Vitamin deficienciesVitamin deficiencies

Fecal impaction, urinary retentionFecal impaction, urinary retention

Renal, hepatic failureRenal, hepatic failure

Tumor burden, secretionsTumor burden, secretions

Changes in environmentChanges in environment

Vitamin deficienciesVitamin deficiencies

Fecal impaction, urinary retentionFecal impaction, urinary retention

Renal, hepatic failureRenal, hepatic failure

Tumor burden, secretionsTumor burden, secretions

Changes in environmentChanges in environment

Medical managementMedical management

NeurolepticsNeuroleptics

haloperidolhaloperidol

chlorpromazinechlorpromazine

Atypical neurolepticsAtypical neuroleptics

risperidonerisperidone

olanzepineolanzepine

Benzodiazepines for acute agitationBenzodiazepines for acute agitation

NeurolepticsNeuroleptics

haloperidolhaloperidol

chlorpromazinechlorpromazine

Atypical neurolepticsAtypical neuroleptics

risperidonerisperidone

olanzepineolanzepine

Benzodiazepines for acute agitationBenzodiazepines for acute agitation

Terminal deliriumTerminal delirium

Day-night reversalDay-night reversal

Agitation, restlessnessAgitation, restlessness

Moaning, groaningMoaning, groaning

Day-night reversalDay-night reversal

Agitation, restlessnessAgitation, restlessness

Moaning, groaningMoaning, groaning

Evaluate treatmentEvaluate treatment

Monitor carefullyMonitor carefully

If negligible or partial responseIf negligible or partial response

reevaluate diagnosisreevaluate diagnosis

inquire about adherence to medicationinquire about adherence to medication

consider dosage adjustmentconsider dosage adjustment

consider a different medicationconsider a different medication

refer to a specialistrefer to a specialist

Monitor carefullyMonitor carefully

If negligible or partial responseIf negligible or partial response

reevaluate diagnosisreevaluate diagnosis

inquire about adherence to medicationinquire about adherence to medication

consider dosage adjustmentconsider dosage adjustment

consider a different medicationconsider a different medication

refer to a specialistrefer to a specialist

EEPPEECC

EEPPEECC Depression, Depression,

Anxiety, Delirium Anxiety, Delirium

SummarySummary

Depression, Depression, Anxiety, Delirium Anxiety, Delirium

SummarySummary