___________________________________________ Palliative Care and Pain Management at the End of Life
The antidepressant trazodone (Desyrel) is the preferred anti- depressant for insomnia (although it is not FDA approved for this indication) [252; 366]. It is the drug of choice among tricyclic antidepressants because of its shorter half-life and its milder anticholinergic side effects [366]. Antidepressants are especially useful for people who have anxiety or depression. The most recently (2019) FDA-approved drug for insomnia is lemborexant (DayVigo), an orexin receptor antagonist [252]. The first approved drug of this class, suvorexant (Belsomra), received FDA approval in 2014 [252]. These agents support sleep through inhibition of orexin A and B, which are neuro- peptides that promote wakefulness [252; 375]. Another drug is ramelteon (Rozerem), a melatonin receptor agonist. This drug is short acting and used primarily for sleep-onset insomnia [252; 373]. Ramelteon is FDA approved for long-term use [365]. For insomnia related to restless legs, a systematic review showed that dopamine agonists are effective, with cabergoline (Dostinex) and pramipexole (Mirapex) often having a greater efficacy than levodopa (L-Dopa) [376]. Barbiturates are not recommended for insomnia because of the rapid development of tolerance [366]. Two supplements promoted for sleep enhancement—melatonin and valerian— have not been shown to be effective for managing insomnia [366; 377]. Several factors must be considered when treating older patients with insomnia. For example, it has been recommended that benzodiazepines be avoided in older individuals because of side effects such as increased risk for falls, confusion, and “hang- over” [373]. However, these side effects must be considered in light of an individual’s particular situation and weighed against the benefits [366; 373]. Eszopiclone and ramelteon have been studied in older individuals and have a favorable side-effect profile for that population [373]. Lower doses are often recommended for older individuals [365]. DELIRIUM Delirium is a disturbance of attention and awareness with reduced ability to direct, focus, sustain, or shift attention, as well as changes in cognition (e.g., disorientation, memory deficit, language impairment) [378]. Patients may seem con- fused or be restless, agitated, or combative. Delirium is often difficult to recognize because it shares diagnostic features with other symptoms, especially dementia and depression. As a result, delirium is often unrecognized or misdiagnosed and consequently inappropriately treated or not treated [379]. Delirium is classified into three clinical subtypes: hypoactive, hyperactive, and mixed [380]. Hypoactive delirium is character- ized by lethargy, reduced awareness of surroundings, sedation, and psychomotor retardation, whereas hyperactive delirium is characterized by agitation, restlessness, hallucinations, hyper- vigilance, and delusions [380]. In the palliative care setting, about half of patients with delirium will have the hypoactive subtype [380; 381].
Delirium can be extremely distressful for the patient and even more so for family members. The healthcare team can help alleviate family members’ distress by educating them about the nature and cause of the syndrome and the potential for reversal. Encouraging them to participate in nonpharmacologic interventions may also help to provide a positive experience. Prevalence The prevalence of delirium among adults in hospice or receiv- ing palliative care ranges from 28% to 80%, occurring most frequently among patients with cancer [382; 383]. Terminal delirium is a distinct entity that occurs within the last days or hours of life, and it is estimated to occur in 80% of dying patients [384]. Etiology Many factors may cause delirium, and although the cause is usually multifactorial, often no cause is found [385]. In one comprehensive review, the primary contributor to delirium was unrelieved pain [386]. Delirium is also often caused by medications, including several that are used in the end-of-life setting, such as opioids, corticosteroids, benzodiazepines, and NSAIDs, or the sudden withdrawal from alcohol or drugs (particularly benzodiazepines) upon admittance to a hospital or hospice [310; 383; 384]. In addition, age, cognitive deficits, impaired vision/hearing, emotional stress, depression, and comorbidities are predisposing factors of delirium [381; 384]. Prevention Because of the substantial influence of unrelieved pain, adequate pain management can help prevent delirium. Preven- tion strategies are directed at minimizing precipitating factors, which include a high number of medications (more than six), dehydration, decreased sensory input, psychotropic medica- tions, and a change in environment. Assessment The diagnosis of delirium relies on identifying its two features: cognitive impairment and deficits in attention; these features can be assessed with the Mini-Mental State Examination [384]. The Confusion Assessment Method (CAM) is considered to be the gold standard for distinguishing between delirium from other causes of altered mental status, and other tools to evalu- ate delirium include the Delirium Rating Scale, the Delirium Symptom Interview, and the Memorial Delirium Assessment Scale [384]. Communication with the healthcare team and family is vital in assessing the patient to help determine the onset and course of delirium as well as signs indicative of the syndrome. Some specific ways to help determine if a patient has delirium include [380]: • Ask the patient “Do you feel 100% awake?” If they do not, ask “How awake do you feel?” • Evaluate whether the patient is easily distracted. • Test registration and immediate recall.
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MDCA1525
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