___________________________________________ Palliative Care and Pain Management at the End of Life
When pharmacologic management is deemed necessary, ben- zodiazepines are generally preferred, and administration on an as-needed basis is usually sufficient [67]. Neuroleptics and tricyclic antidepressants may also be effective ( Table 22 ). For all medications, the initial dose should be low and subsequently titrated to produce the desired effect within the level of toler- ance. Benzodiazepines should be given with caution in older patients, as these drugs may harm memory or cause confusion and agitation in patients who have cognitive impairment [409]. DEPRESSION Depression is linked to many other symptoms, especially pain, and is a primary source of suffering. Depression in patients with life-limiting disease is a challenge to identify, as feelings of sadness, helplessness, and hopelessness are a typical reaction to the situation [206; 408]. Depression is more likely when sad-
ness and/or hopelessness is overwhelming or pervasive and is accompanied by a sense of despair [408; 411]. Early diagnosis is essential for effective treatment and relief of other symptoms. Prevalence The prevalence of depression varies widely among adults with life-limiting diseases, ranging from 3% to 82%, with the high- est rate among patients with HIV/AIDS and end-stage liver disease [201; 211]. Etiology Unrelieved pain is one of the primary risk factors for depres- sion. Other causes within the physical domain include metabolic disorders (hyponatremia or hypercalcemia), lesions in the brain, insomnia, or side effects of medications (corti- costeroids or opioids). Many patients with heart failure have
PHARMACOLOGIC MANAGEMENT OF ANXIETY AND DEPRESSION
Typical Starting Oral Dose a
Condition
Drug Class, Drugs
Titration Recommended
Maximum Daily Dose
Comments
Benzodiazepines Lorazepam 0.5–2 mg, every 1 to 6 hours May titrate upward —
Anxiety
First choice
Diazepam 2.5–10 mg, every 3 to 6 hours Midazolam 2–10 mg/day (SC)
May titrate upward —
May titrate upward — Clonazepam 0.5–1.0 mg, 3 times per day May titrate upward 4 mg —
Neuroleptics Haloperidol
0.5–4.0 mg, every 4 to 6 hours
May titrate upward —
—
Thioridazine 10 mg, 3 times per day
May titrate upward —
—
Tricyclic Antidepressant Imipramine
10–25 mg, 3 times per day May titrate upward —
—
Selective Serotonin Reuptake Inhibitors Fluoxetine 20 mg/day
Depression
Increase by 10 mg every 1 to 2 weeks Increase by 10 mg every 1 week Increase by 25 mg every 1 week
20–60 mg
First choice when immediate onset not needed (onset at 4 to 6 weeks)
Paroxetine
10 mg/day
10–50 mg
Sertraline
50 mg/day
50–150 mg
Escitalopram 10 mg/day
—
20 mg
Venlafaxine
18.75 mg/day
Increase by 75 mg every 1 week
75–225 mg
Tricyclic Antidepressants Amitriptyline 25 mg/day Nortriptyline 25 mg/day Desipramine 25 mg/day
Increase by 25 mg every 1 to 2 days
50–150 mg Less useful because of side effects; slow onset of action (3 to 6 weeks) 50–150 mg 50–150 mg
Doxepin
25 mg/day
50–200 mg
a Doses are given as guidelines; actual doses should be determined on an individual basis. Source: [67; 206; 227; 410]
Table 22
53
MDCA1525
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