Dyspnea Dyspnea is common among patients at the end of life and is associated with many diseases or conditions including end-stage pulmonary and cardiac disease, cancers, cerebrovascular disease, and dementia. A number of mechanisms can be involved in dyspnea including pneumonia, airway hyperreactivity, pulmonary edema, pleural effusions, and simple deconditioning. Assessing the severity of dyspnea can be challenging because most dyspnea scales rely on patient self-report, although the Respiratory Distress Observation Scale (eight variables, 0-16 score) is based solely on observers’ clinical assessments. 91 Regardless of a patient’s measured oxygen saturation, tachypnea, increased difficulty breathing, restlessness, and grunting are clinical signs of dyspnea. Opioids are first-line agents for treating dyspnea at the end of life. 36 Opioids help reduce the sense of “air hunger” and, when administered at appropriate doses, do not compromise respiratory status or hasten dying. 92 Opioids should be selected and administered based on patient’s comorbidities, previous opioid exposure, and ease of administration (see Table 8 for initial doses). Morphine and oxycodone are available in concentrated forms and sublingual formulations, which allow rapid administration regardless of a patient’s level of wakefulness or swallowing ability. Delirium and agitation Delirium and agitation are commonly associated with dementia, but may also occur in patients without diagnosed dementia due to physiological or psychological changes at the end of life. Manifestations can include calling out, screaming, verbal and physical aggression, agitation, apathy, hostility, sexual disinhibition, defiance, wandering, intrusiveness, repetitive behavior and/ or vocalizations, hoarding, nocturnal restlessness, psychosis (hallucinations or delusions), emotional lability, and paranoid behaviors. 93,94 When a patient presents with delirium or agitation, the first course of action should be to perform a comprehensive assessment of the symptom(s): • Antecedents: What are the triggers for the behavior(s)? • Behavior: Which behavior, or behaviors, are targets for intervention? • Consequences: What are the consequences of the behavior(s) for the patient and others? Family, caregivers, and nurses are often in the best position to answer these questions. Understanding these factors may reveal simple and effective interventions.
Complex, expensive management strategies and interventions may not be required. A patient’s medical condition or a medication the patient is taking may be the primary trigger for delirium or agitation. Although identifying a trigger through patient history and/or physical examination can be challenging if the patient’s cognitive impairment is severe, clinicians should persist and include family and caregivers in the process, if possible. Treatment of a reversible medical problem can be much more effective and safe than deploying either non-pharmacologic or pharmacologic interventions. Reversible causes of new-onset behavioral disorders in the elderly include: • Acute infection (e.g., urinary tract infection, sepsis) • Delirium (an acute state of confusion which itself can be the result of a new-onset medical condition) • Depression • Dehydration • Hypoxia (e.g., congestive heart failure, pneumonia, anemia due to gastrointestinal hemorrhage) • Pain (e.g., vertebral or hip fracture, or acute abdominal pain) • Medication side effect • Emotional stress • Reactions to changes in care, caregivers, or caregiver behaviors • Boredom Many medications routinely used by older adults can cause or worsen behavioral and psychological problems. For example, anticholinergic agents increase the risk of visual hallucinations, agitation, irritability, delirium, and aggressiveness. Psychotropics, such as benzodiazepines, can impair cognition, be disinhibiting, and may contribute to falls. Adverse drug effects are one of the most common reversible conditions in geriatric medicine. They present an opportunity to effect a cure by stopping the offending drug or lowering the dose. This has led to the recommendation that “any new symptom in an older patient should be considered a possible drug side effect until proven otherwise.” 95 Non-pharmacologic management options for delirium and agitation Evidence suggests that non-pharmacologic approaches to delirium or agitation can produce equivalent outcomes, in a much shorter time and at less overall risk and cost, than pharmacologic therapies. 96,97
A meta-analysis of community-based non- pharmacologic interventions for delirium or agitation found significant reductions in symptoms as well as improvements in caregiver’s reactions to these symptoms. 97 Behaviors more likely to respond to such interventions are: agitation, aggression, disruption, shadowing, depression, and repetitive behaviors. Non-pharmacologic interventions should always be matched to the specific needs and capabilities of the patient, and they can be used concurrently with any pharmacologic therapies that might be employed. 71,72,98 Behavioral and psychological symptoms often arise in response to a wide range of factors that can make life uncomfortable, frightening, worrisome, irritating, or boring for people with dementia. Paying close attention to such environmental factors, and eliminating or correcting them, should be the first priority for caregivers. 93 This may require patience, diligence, and a willingness to see the world through the eyes and other senses of the person whose behaviors are challenging. Because sensory deficits are common in older adults, and because vision and hearing deficits, in particular, can increase fearfulness, anxiety, and agitation, any patient displaying delirium or agitation should be assessed for these deficits, and, if any are found, they should be corrected promptly with glasses, improved lighting, magnifying devices, hearing aids, or other techniques. Other environmental factors that can increase agitation include: temperature (too hot or too cold), noise (in or outside the room or dwelling unit), lighting (too much, too little, or quality), unfamiliarity (new people, new furniture, new surroundings), disrupted routines, needing assistance but not knowing how to ask, being uncomfortable from sitting or lying on one position for too long, or inability to communicate easily because of language difficulties. Dietary and eating-related issues should be carefully assessed. An inability to chew properly or swallow easily can increase agitation, hence a patient’s dental integrity, use of false teeth or other orthodontia, and swallowing ability should be considered. If a patient’s appetite or cycle of hunger/satiety is not synchronized with the timing of meals provided by an institution, consider options to individualize the availability of food and/ or food choice. Difficulty preparing or eating meals, confusion about mealtimes, apathy, agitation, and paranoid ideation about food and fluids may all contribute to weight loss, which is common in patients with dementia. Avoidance of alcohol and caffeine can promote good sleep hygiene and may help stabilize mood. 99 Pharmacologic management options Although pharmacologic interventions may be necessary in some circumstances, they should only be considered if the patient is not responding to appropriate, sustained, patient-tailored non- pharmacologic interventions. Two classes of medications should be used very cautiously: benzodiazepines and antipsychotics.
Table 8. Initial opioid doses for dyspnea or pain in opioid-naïve EOL patients 36 Medication Oral dose IV or subcutaneous dose Initial dosing frequency Fentanyl Transmucosal 100-200 mcg 25-100 mcg Every 2-3 hrs. Hydromorphone 2-4 mg 0.5-2 mg Every 3-4 hrs. Morphine 2.5-10 mg 2-10 mg Every 3-4 hrs. Oxycodone 2.5-10 mg NA Every 3-4 hrs.
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