COMMON END-OF-COMMON END-OF-LIFELIFE

PHYSICAL PHYSICAL SYMPTOMS:SYMPTOMS:

WEAKNESS, FALLS, ANDWEAKNESS, FALLS, AND

SKIN PROBLEMSSKIN PROBLEMS

By Dr. Mike MarschkeBy Dr. Mike Marschke

WEAKNESSWEAKNESS #1 Symptom – 80%#1 Symptom – 80% Multi-factorial:Multi-factorial:

Cachexia; muscle atrophyCachexia; muscle atrophy Effect of underlying disease – CA, CHF, COPD, infectionsEffect of underlying disease – CA, CHF, COPD, infections AnemiaAnemia Drug effect – including chemo and narcoticsDrug effect – including chemo and narcotics Radiation therapy effectRadiation therapy effect Dehydration; electrolyte imbalance (Na, K, Ca, Dehydration; electrolyte imbalance (Na, K, Ca,

Magnesium)Magnesium) DepressionDepression Poor sleep – pain, sleep apnea, anxietyPoor sleep – pain, sleep apnea, anxiety Neurologic impairment – stroke, tumor, cord paralysis, Neurologic impairment – stroke, tumor, cord paralysis,

neuropathiesneuropathies Endocrine problem – hypothyroid, hypercortisol, Endocrine problem – hypothyroid, hypercortisol,

syndrome of inappropriate ADH secretionsyndrome of inappropriate ADH secretion

TREATABLE CAUSESTREATABLE CAUSESAT THE END OF LIFEAT THE END OF LIFE

Dehydration may be treatable with IV fluids (but Dehydration may be treatable with IV fluids (but usually only if symptomatic orthostasis)usually only if symptomatic orthostasis)

Anemia – symptoms may improve with Anemia – symptoms may improve with transfusions or erythropoietintransfusions or erythropoietin

Depression may be treatable; stimulants like Depression may be treatable; stimulants like Ritalin may work faster and can also help other Ritalin may work faster and can also help other drug-related fatiguedrug-related fatigue

Poor sleep can be improved by treating cause, Poor sleep can be improved by treating cause, like pain-control, CPAP (continuous positive like pain-control, CPAP (continuous positive airway pressure) for apnea, but also with sleepersairway pressure) for apnea, but also with sleepers

Endocrine or electrolyte abnormalities may be Endocrine or electrolyte abnormalities may be treatabletreatable

COMPLICATIONS FROMCOMPLICATIONS FROMFATIGUE/WEAKNESSFATIGUE/WEAKNESS

Decreased quality of lifeDecreased quality of life Increased burden on othersIncreased burden on others Increased risk of suicideIncreased risk of suicide Increased risk of fallsIncreased risk of falls Impaired skin integrityImpaired skin integrity Aspiration, increased infections, Aspiration, increased infections,

increased thrombosis formationincreased thrombosis formation

EFFECTS ONEFFECTS ONQUALITY OF LIFEQUALITY OF LIFE

Inability to do Activities of Daily Inability to do Activities of Daily Living – including cooking, dressing, Living – including cooking, dressing, bathing, even toiletrybathing, even toiletry

Unable to work or be “useful”Unable to work or be “useful” Unable to enjoy social function Unable to enjoy social function

activitiesactivities Strain on financesStrain on finances Unable to enjoy sexual intimacyUnable to enjoy sexual intimacy Imposes on emotional well-beingImposes on emotional well-being

Increased burdenIncreased burdenon otherson others

Family, caregivers need to take up Family, caregivers need to take up slackslack

Need for rest, respiteNeed for rest, respite Need for assistance, especially for Need for assistance, especially for

caregivers to continue their livescaregivers to continue their lives Need for education on caringNeed for education on caring Caregiver stress, grief and anxiety Caregiver stress, grief and anxiety

over dying relativeover dying relative

SUICIDE VULNERABILITY SUICIDE VULNERABILITY FACTORS IN ADVANCED FACTORS IN ADVANCED

DISEASEDISEASE Pain; physical sufferingPain; physical suffering Advanced illness with poor prognosisAdvanced illness with poor prognosis Depression; hopelessnessDepression; hopelessness DeliriumDelirium Helplessness; lack of controlHelplessness; lack of control Substance/alcohol abuseSubstance/alcohol abuse Suicide history; family historySuicide history; family history Fatigue; exhaustionFatigue; exhaustion Lack of social supportLack of social support

FALLSFALLS- Risk factors -- Risk factors -

Sedative useSedative use Cognitive impairmentCognitive impairment Disability of lower extremitiesDisability of lower extremities Palmomental reflex present (a signof Palmomental reflex present (a signof

significant frontal lobe problems)significant frontal lobe problems) Abnormal balance or gaitAbnormal balance or gait Foot problemsFoot problems Others – poor vision, depression, anxiety, Others – poor vision, depression, anxiety,

poor vision, poor hearingpoor vision, poor hearing

0%

10%

20%

30%

40%

50%

60%

70%

80%

0 1 2 3 4+ riskfactors

% falling

FALLSFALLS- Consequences -- Consequences -

Serious injuries – fractures, hematomas, Serious injuries – fractures, hematomas, concussions, even death – from intracranial concussions, even death – from intracranial bleeds, consequences of hip fracturesbleeds, consequences of hip fractures

Long lies – dehydration, pressure sores, Long lies – dehydration, pressure sores, pneumonia, rhabdomyolysispneumonia, rhabdomyolysis

Fear of falling – can lead to inactivity, poor Fear of falling – can lead to inactivity, poor life satisfaction, depressionlife satisfaction, depression

Hospitalization, nursing home placementHospitalization, nursing home placement

FALLSFALLS- Risk factors for serious injury - Risk factors for serious injury

-- Falling on stairsFalling on stairs Activities that displaced center of gravity (pulling Activities that displaced center of gravity (pulling

something, being pushed, carrying a heavy something, being pushed, carrying a heavy object, assuming an unusual position)object, assuming an unusual position)

When height of fall is at least body heightWhen height of fall is at least body height Cognitive impairmentCognitive impairment Presence of at least 2 chronic conditionsPresence of at least 2 chronic conditions Balance and gait problemsBalance and gait problems Low body massLow body mass FemalesFemales Other minor risks – hard surfaces, while walking, Other minor risks – hard surfaces, while walking,

older age, osteoporosis, mechanical restraintsolder age, osteoporosis, mechanical restraints

FALLSFALLS- Risk factors for inability to get - Risk factors for inability to get

up -up - age over 80age over 80 depressiondepression poor balance and gaitpoor balance and gait other minor risks – previous stroke and other minor risks – previous stroke and

sedative usesedative use

Fallers who could not get up were more Fallers who could not get up were more likely to have long-lasting decline in ADLs, likely to have long-lasting decline in ADLs, more likely to die soon, and to be more likely to die soon, and to be hospitalizedhospitalized

FALLSFALLS- Physical Assessments -- Physical Assessments -

Orthostasis with drop of 20mm of systolic BP Orthostasis with drop of 20mm of systolic BP when standingwhen standing

“ “Get up and go test” – arise from sitting without Get up and go test” – arise from sitting without help, stand still 10 sec, walk 10 ft, turn, walk back help, stand still 10 sec, walk 10 ft, turn, walk back than sitthan sit

Other balance tests – while standing – withstand Other balance tests – while standing – withstand a gentle nudge on chest, stand with eyes closeda gentle nudge on chest, stand with eyes closed

Knee strength, LE strength – timed chair stand Knee strength, LE strength – timed chair stand (poor if > 10 sec repeating standing 3 times)(poor if > 10 sec repeating standing 3 times)

Decreased neck or back flexibility; dizziness with Decreased neck or back flexibility; dizziness with neck extensionneck extension

Visual checkVisual check

FALLSFALLS- Risk modification -- Risk modification -

Balance problems – PT strength exercises, transfer Balance problems – PT strength exercises, transfer training, neck exercises, appropriate walking aids training, neck exercises, appropriate walking aids (canes for one weak extr, walkers for poor balance (canes for one weak extr, walkers for poor balance and bilat weak extr)and bilat weak extr)

Gait/strength problems – gait training and exercises, Gait/strength problems – gait training and exercises, walking aidswalking aids

Orthostasis – change meds, hydrate, pressure Orthostasis – change meds, hydrate, pressure stockings, arise slowlystockings, arise slowly

Foot disorders – podiatry eval to shave calluses, nails, Foot disorders – podiatry eval to shave calluses, nails, bunionsbunions

Reduced vision/ hearing – assistive devicesReduced vision/ hearing – assistive devices Medications – attempt reductions of sedatives, anti- Medications – attempt reductions of sedatives, anti-

hypertensives, diabetic agents, diuretics, hypertensives, diabetic agents, diuretics, psychotropicspsychotropics

FALLSFALLS- Environmental modification -- Environmental modification -

Lighting – well lit everywhere, night lights, Lighting – well lit everywhere, night lights, accessible switchesaccessible switches

Floors – tacked down thin-pile carpeting, paths clearFloors – tacked down thin-pile carpeting, paths clear Stairs – try to avoidStairs – try to avoid Bathroom – grab bars, raised toilet seats, shower Bathroom – grab bars, raised toilet seats, shower

chairchair High firm chairs with arms, hospital beds, beds on High firm chairs with arms, hospital beds, beds on

floorfloor Increase accessibility of things needed around bedIncrease accessibility of things needed around bed Footwear – shoes with nonskid low solesFootwear – shoes with nonskid low soles Alarms – monitors, bed alarms to alert others that Alarms – monitors, bed alarms to alert others that

patient wants to get out of bed or has fallenpatient wants to get out of bed or has fallen

PRESSURE ULCERSPRESSURE ULCERS- Pathogenesis -- Pathogenesis -

Pressure – exposure to 60-70 mmHg for 1-Pressure – exposure to 60-70 mmHg for 1-2 hrs can breakdown muscle and skin by 2 hrs can breakdown muscle and skin by occluding blood vessels (can get pressures occluding blood vessels (can get pressures of 100-150 mmHg over bony prominences of 100-150 mmHg over bony prominences on a regular mattress)on a regular mattress)

Shearing – sliding over mattress pulls skin Shearing – sliding over mattress pulls skin over subcutaneous tissue also occluding over subcutaneous tissue also occluding blood supplyblood supply

Friction can cause intrapidermal blistersFriction can cause intrapidermal blisters Moisture can increase the friction and Moisture can increase the friction and

produce maceration of skinproduce maceration of skin

PRESSURE ULCERSPRESSURE ULCERS- Risk factors -- Risk factors -

Immobility, decreased spontaneous Immobility, decreased spontaneous movementsmovements

HypoalbuminemiaHypoalbuminemia IncontinenceIncontinence Pressure of a fracturePressure of a fracture

PRESSURE ULCERSPRESSURE ULCERS- Stages -- Stages -

STAGE 1 – nonblanchable erythema STAGE 1 – nonblanchable erythema of intact skin (the first sign of of intact skin (the first sign of underlying ischemia)underlying ischemia)

STAGE 2 – superficial ulcer involving STAGE 2 – superficial ulcer involving epidermis or dermisepidermis or dermis

STAGE 3 – ulcer with full thickness STAGE 3 – ulcer with full thickness skin loss to the fasciaskin loss to the fascia

STAGE 4 – ulcer extending to muscle STAGE 4 – ulcer extending to muscle or boneor bone

PRESSURE ULCERSPRESSURE ULCERS- Prevention -- Prevention -

Reposition at least every 2 hrs., avoiding Reposition at least every 2 hrs., avoiding on side at 90 degreeson side at 90 degrees

Low pressure mattresses – reducing Low pressure mattresses – reducing pressures to < 32 mmHg – low-air-loss pressures to < 32 mmHg – low-air-loss mattresses if have ulcers, egg crates with mattresses if have ulcers, egg crates with frequent turning can help prevent new frequent turning can help prevent new onesones

Keep clean, avoid excessive drynessKeep clean, avoid excessive dryness Turning and transferring techniques to Turning and transferring techniques to

avoid friction, shearavoid friction, shear Avoid massaging over boney prominencesAvoid massaging over boney prominences Nutrition?Nutrition?

PRESSURE ULCERSPRESSURE ULCERS- Treatment -- Treatment -

STAGE 1 & 2 – keep pressure off, keep clean, STAGE 1 & 2 – keep pressure off, keep clean, vapor- permeable protective dressings that vapor- permeable protective dressings that promote healing (i.e. – duoderm, polymem, promote healing (i.e. – duoderm, polymem, vigilon….)vigilon….)

STAGE 3 & 4 – will need low-air-loss mattressSTAGE 3 & 4 – will need low-air-loss mattress - DIRTY – remove devitalized tissue - DIRTY – remove devitalized tissue

(debride surgically or with wet-to-dry, enzymatic (debride surgically or with wet-to-dry, enzymatic debriders like elase, collagenase), clean infected debriders like elase, collagenase), clean infected areas (irrigation, short-term cleansers like areas (irrigation, short-term cleansers like peroxide or Dakin’s solution, or antibiotic creams peroxide or Dakin’s solution, or antibiotic creams like silvadene, flagyl)like silvadene, flagyl)

- CLEAN – moist clean dressing that - CLEAN – moist clean dressing that absorbs exudate (calcium alginate packings, absorbs exudate (calcium alginate packings, silvadene guaze, wet dressings)silvadene guaze, wet dressings)

PRESSURE ULCERSPRESSURE ULCERS- Goal at end-of-life -- Goal at end-of-life -

Prevent ulcers from worseningPrevent ulcers from worsening Prevent pain, especially with Prevent pain, especially with

frequent dressing changesfrequent dressing changes Minimize dressing changesMinimize dressing changes Keep comfortableKeep comfortable

EDEMAEDEMA

CAUSES – From decreased venous return CAUSES – From decreased venous return increasing permeability of interstitial fluid increasing permeability of interstitial fluid into extravascular space, or from under into extravascular space, or from under nutrition with low albumin states increasing nutrition with low albumin states increasing capillary permeabilitycapillary permeability Venous obstruction (extravascular compression Venous obstruction (extravascular compression

or intravascular clots/tumor)or intravascular clots/tumor) Increased intra-abdomenal pressure (tumor, Increased intra-abdomenal pressure (tumor,

ascites)ascites) Cirrhosis, nephrosis, heart failureCirrhosis, nephrosis, heart failure MalnutritionMalnutrition

COMPLICATIONS FROM EDEMACOMPLICATIONS FROM EDEMA

Pain/discomfort from the pressurePain/discomfort from the pressure ImmobilityImmobility Stasis vasculitisStasis vasculitis Stasis ulcersStasis ulcers

TREATMENT OF EDEMATREATMENT OF EDEMA

Elevation of limbElevation of limb Relieve pressure on the vein (i.e. – Relieve pressure on the vein (i.e. –

RT for tumor, remove ascites, anti-RT for tumor, remove ascites, anti-coagulation of clots)coagulation of clots)

Compression stockings, gentle Compression stockings, gentle massage (if no clots)massage (if no clots)

Increase nutrition (hard to do in Increase nutrition (hard to do in terminal patients)terminal patients)

POTENTIAL HOSPICE POTENTIAL HOSPICE EMERGENCIESEMERGENCIES

SPINAL CORD COMPRESSION – back pain usually SPINAL CORD COMPRESSION – back pain usually precedes neurologic compromise by 1-2 wks, see precedes neurologic compromise by 1-2 wks, see bilat leg weakness and numbness from the level bilat leg weakness and numbness from the level of compression down.of compression down.

Needs aggressive treatment to prevent permanent paralysis – Needs aggressive treatment to prevent permanent paralysis – RT, steroids, surgeryRT, steroids, surgery

DEEP VEIN THROMBOSIS – usually acute swollen, DEEP VEIN THROMBOSIS – usually acute swollen, unilateral limb with redness, pain, calf unilateral limb with redness, pain, calf tenderness.tenderness.

Needs aggressive anti-coagulation to prevent life-threatening Needs aggressive anti-coagulation to prevent life-threatening pulmonary embolipulmonary emboli

SUBDURAL HEMATOMA – usually from fall with SUBDURAL HEMATOMA – usually from fall with head contusion (may appear minor), then see head contusion (may appear minor), then see mental status changes usually within 24 hrs, mental status changes usually within 24 hrs, potential coma with respiratory suppressionpotential coma with respiratory suppression

May need aggressive surgical interventionMay need aggressive surgical intervention