The IAHPC Manual of Palliative Care
2nd Edition

IV. Symptom Control Con't

Table of Contents

Prevention of constipation

• factors and situations that predispose to constipation are well known
• preventive treatment should be introduced before clinical problems develop
• general measures (where feasible)

• increased food intake
• increased dietary fibre or bulk forming laxative
• increased fluid intake
• encourage activity

• laxatives

• docusate 240-480mg nocte or bisacodyl 10-20mg nocte
• ± senna 15mg nocte
• ± lactulose 30ml nocte
• and titrate the dose against the clinic effect

• explanation to patient, family
• treatment of painful rectal conditions
• ensure access and ability to use toilet facilities
• avoid constipating drugs if possible
• keep a record of bowel actions

Management of neurogenic bowel

• Spinal cord lesion - spastic bowel, hypertonic anal sphincter, sacral reflexes intact
• adequate fluid and fibre intake
• oral laxatives (avoid laxatives that cause excessive softening)
• rectal suppositories or stimulation leads to increased peristalsis and sphincter relaxation

• Sacral nerve root lesion - reduced peristalsis, flaccid sphincter, sacral reflexes absent
• adequate fluid and fibre intake
• oral laxatives
• rectal suppositories or stimulation may lead to evacuation
• straining and abdominal massage

• Patients with a short life expectancy, for whom bowel training is not feasible
• dietary fibre is reduced and bulk laxatives avoided
• constipation is induced with codeine or loperamide
• regular bowel evacuations are planned once or twice weekly using suppositories or enemas

Terminal care

• significant symptoms due to constipation are rare during the last days or week of life
• oral intake is frequently limited and laxatives can usually be discontinued
• a suppository or microenema can be used

• if the patient has pain, feels the urge to defaecate but is unable to do so
• if there is faecal incontinence due to impaction

LAXATIVES

ANOREXIA

Anorexia is a reduced desire to eat

Cause - often due to multiple causes

• cancer
• pain
• disordered taste, smell
• cancer
• stomatitis
• malodorous ulcer or fungating tumour

• gastrointestinal
• stomatitis, xerostomia mucositis, infection
• oesophagitis, dysphagia
• small stomach: gastrectomy, linitis plastica
• gastric compression: hepatomegaly, ascites
• gastric distension: delayed gastric emptying
• bowel obstruction, constipation
• hepatic metastases, liver disease
• chemotherapy, abdominal radiotherapy

• intracranial disease
• metastases, radiotherapy, infection
• metabolic
• abnormalities of sodium, calcium, glucose
• organ failure: liver, kidney, adrenal
• infections
• medications
• psychological

• anxiety, depression, confusion, dementia

• organisational

• poor food preparation or presentation

• religious or cultural customs

Treatment

Treatment of anorexia is important as it

• will improve patient morale
• reduce family anxiety
• the preservation of optimal nutrition may delay the onset of cachexia
• assistance of a dietician may be invaluable

Treatments

• treat or palliate the underlying cause
• activity, exercise
• dietary
• dietary advice (dietician)
• visually appealing food
• tasty small frequent meals
• what they want, when they want it
• sitting up, at a table, in a room free of odours

• appetite stimulants
• alcohol
• corticosteroids, e.g. prednisolone 15-30mg/d, dexamethasone 2-4mg/d
• progestogens, e.g. megestrol 160mg/d

• explanation, counselling.

Counselling

• anorexia and poor food intake frequently cause much distress for patients and families, requiring careful discussion and explanation
• when advanced and progressing cancer is the prime cause, it needs to be explained that enteral or parenteral nutrition will not be of benefit

WEIGHT LOSS & CACHEXIA

Cause

• in patients with advanced cancer, this is primarily due to alterations in protein, carbohydrate and lipid metabolism caused by inflammatory cytokines released by the tumour
• in patients with AIDS, it usually relates to systemic infections and chronic gastrointestinal dysfunction

The causes of weight loss include

• malnutrition
• poor intake due to anorexia
• functional blockage: mouth, oesophagus, stomach
• malabsorption
• vomiting, diarrhoea, fistulas
• protein loss: ulceration, haemorrhage, repeated paracenteses

• metabolic abnormalities secondary to cancer (cancer cachexia)
• increased energy expenditure
• systemic infections
• chronic fevers
• tumour metabolism

Treatment

The treatment options for weight loss include

• correct or palliate cause of malnutrition, anorexia
• treat tumour where feasible
• drug treatment
• there is no satisfactory drug therapy for cachexia
• corticosteroids and alcohol may reduce anorexia but have no effect on the metabolic abnormalities of cancer cachexia
• progestogens may exert an anabolic effect and reduce or prevent weight loss
• dronabinol is effective in maintaining weight for some patients with AIDS
• dietary measures
• small frequent meals
• what the patient wants and when they want it
• dietary supplements
• enteral nutrition
• will not reverse or prevent cancer cachexia
• may be appropriate for patients with upper gastrointestinal obstruction who may otherwise suffer starvation
• may cause fluid overload, abdominal cramps and diarrhoea
• parenteral nutrition
• will not reverse or prevent cancer cachexia
• is appropriate for patients who are temporarily unable to eat for two weeks or more because of anticancer treatment
• is associated with significant complications and cost
• management of the psychosocial consequences

Counselling

• for both the patient and the family, progressive weight loss and cachexia represents progression of the disease
• counselling and discussions may facilitate acceptance and understanding
• the family needs to be dissuaded from trying to force the patient to eat, as this will only cause physical distress and guilt
• the family needs to be helped to show love to the patient by means other than feeding them or pressuring them to eat

WEAKNESS AND FATIGUE

Asthenia is generalised weakness associated with fatigue and lassitude

Cause

In palliative care, asthenia is most frequently associated with progression of the cancer or other underlying disease, but other causes need to be considered, as some are amenable to treatment or palliation. Most relatives attribute weakness to poor eating or to medications.

• neuromuscular
• cachexia-related loss of muscle mass
• cachexia-related muscular dysfunction
• polymyositis
• overactivity, prolonged immobility
• polyneuropathy
• intracranial tumour, paraneoplastic encephalopathies
• acute confusion or delirium

• metabolic
• electrolyte imbalance, dehydration
• renal, hepatic failure

• endocrine
• adrenal insufficiency
• ectopic ACTH secretion
• diabetes

• malnutrition
• inanition, malabsorption

• anaemia
• infection
• psychological
• anxiety, depression, dependency, boredom, insomnia

• anticancer therapy
• radiotherapy, chemotherapy, interferon

• drugs
• opioids, tranquillisers, sedatives, antidepressants diuretics, antihypertensives, hypoglycaemics and others

Treatment

• treatment of underlying cause, where possible
• drug therapy
• corticosteroids

• symptomatic improvement, improved feeling of well-being
• proximal myopathy with continued therapy

• amphetamines and methylphenidate

• physical therapy
• encourage exertion and activity, physiotherapy

• within the patient's physical limitations
• may help maintain dwindling muscle strength

• encourage activities providing diversion from a patient's feeling of weakness
• assistance with the activities of daily living
• physical aids
• reorganisation of the immediate environment to accommodate reduced mobility

• counselling
• supportive therapy: physical and psychological
• redefinition of goals and expectations

ACUTE CONFUSION OR DELIRIUM

Acute confusion or delirium is an organic brain syndrome characterised by the acute onset of disturbance of the conscious state associated with disordered

attention, cognition, perception and psychomotor behaviour

Clinical features of delirium

Cause - in many cases due to more than one cause

• intracranial pathology
• tumour
• haemorrhage
• encephalopathy - radiation, chemotherapy
• infection - abscess, meningitis, encephalitis
• post seizure
• cerebrovascular disease, stroke

• metabolic
• respiratory failure - hypoxia, hypercapnia
• liver failure, hepatic encephalopathy
• renal failure
• acidosis, alkalosis
• electrolyte disturbance - sodium, calcium
• hyperglycaemia, hypoglycaemia
• adrenal, thyroid and pituitary dysfunction

• infection, fever
• circulatory
• dehydration
• hypovolaemia
• heart failure
• shock

• anaemia
• nutritional
• general malnutrition
• vitamin B1, B6, B12 deficiency

• drug withdrawal
• alcohol, benzodiazepine, barbiturate, opioids, nicotine
• drugs
• alcohol, anticholinergics, anticonvulsants, antidepressants, antiemetics (phenothiazines, metoclopramide, nabilone), antihistamines, antiparkinsonian, antipsychotics, anxiolytics and hypnotics (benzodiazepines, barbiturates), corticosteroids, NSAIDs, opioid analgesics, stimulants (amphetamine, methylphenidate, cocaine) and, less frequently, many other drugs

Other potentially reversible contributing factors that may precipitate or aggravate delirium

• anxiety, depression
• pre-existing cerebral disease, dementia general debility
• pain, discomfort
• sleep deprivation
• altered environment

Treatment

• treatment of the cause
• identify and treat the underlying cause
• withhold all non-essential medications
• consider alternatives for essential drugs
• alcohol or drug withdrawal
• consider allowing continued use
• nicotine skin patches
• general measures
• appropriate physical environment
• quiet and well lit room, night light
• minimise number of different staff having contact
• avoid disturbances
• presence of a family member or trusted friend

• develop a regular daily routine
• repeated calm reassurance and explanation
• do not move from familiar surroundings
• avoid physical restraints
• restless patients can be allowed to ambulate if accompanied
• habitual smokers should be allowed to smoke with supervision
• reassure family and patient that the confusional state is due to organic disease

• drug therapy

• haloperidol
• is the most frequently used drug for delirium in medically ill patients
• improves cognitive function and provides sedation
• mild delirium: 1-5 mg/d PO, in divided doses
• severe delirium: 2-5 mg IV or SC, q30-60 min, if required
• alternatives
• chlorpromazine
• levomepromazine
• benzodiazepine
• can be given in addition to haloperidol
• given alone cause sedation without any effect on cognitive function and may aggravate confusion

TERMINAL RESTLESSNESS

Terminal restlessness is an agitated delirium that occurs in some patients during the last few days of life

Clinical features

• agitation, restlessness
• impaired conscious state
• muscle twitching
• multifocal myoclonus
• seizures
• distressed vocalizing

Treatment

• exclude restlessness due to
• anxiety, fear
• unrelieved pain
• urinary retention, faecal impaction
• drug, alcohol or nicotine withdrawal

• review opioid use
• benzodiazepines
• clonazepam 0.5 mg SL or SC q12h or 1-2 mg/24h CSCI and titrate
• midazolam 2.5-10 mg SC, q2h or 20-60 mg/24h CSCI and titrate
• diazepam 5-10 mg IV or 10-20 mg PR, q6-8h and titrate
• lorazepam 1-2.5 mg SL, q2-4h and titrate
• for benzodiazepine failure
• haloperidol 5mg SC, followed by 20-3-mg/24h CSCI and titrate
• levomepromazine 12.5-50mg SC q4-8h and titrate; continue as CSCI
• phenobarbitone 100-200mg SC q4-8h and titrate; continue as CSCI

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©2008 Published by IAHPC Press