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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