Dec 21, 2015
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