Palliative care – 14 – Delirium, Insomnia, Advance Directives

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)

Question:  Last time we covered few more common symptoms in cancer patients that can be managed by family doctors, physicians. For cancer patients in any stage, from diagnosis to end of life. 1. Constipation. Role of prevention especially with painkillers like morphine and antiemetics like ondansetron palonosetron. Role of different classes of laxatives and their right doses. Identify treatable causes of constipation. 2. Diarrhea. Diagnose reason for diarrhea. Role of loperamide, and other medicines. Antibiotics do not work in chemotherapy induced diarrhea. Role of pancreatic enzymes. Risk of underestimation of diarrhea in colostomy patients.

What are some of the other common issues that you face, especially where non oncologist doctors can play a role?                          

Ans: Let us discuss other common issues i.e. insomnia, delirium, and then briefly touch upon advance care directives like DNR. With significant input from NCCN guidelines.

1. Insomnia or Sedation (Sleep/Wake Disturbances): Sleep related issues are seen in about 75% of cancer patients as per one study. Difficulty sleeping can be due to anxiety, depression, delirium, pain, nausea. Also assess for medicines or withdrawal induced insomnia such as steroids, tricyclic antidepressants, benzodiazepines, opioids, hormones, herbal medicines, anticonvulsants, caffeine, barbiturates, alcohol. Underlying obstructive sleep apnea, restless leg syndrome etc may also be the reason for insomnia. In addition, poor sleep hygiene is a common issue. In fact, good sleep hygiene should be advised to all patients even before medication use i.e. sleep and wake up at same time, no screen time (television, mobile, computer) at least 30 minutes before bedtime, no caffeine after evening, evening walk or light exercise, no heavy food 3 hours before bedtime, reduce liquids 3 hours before bedtime, if unable to sleep within 20 minutes come out of bed and do light activity or reading etc but no electronics use, use bed only to sleep.

For those who do need medicine, depending upon their diagnosis various options are available. For example, lorazepam, olanzapine, zolpidem, chlorpromazine. We mainly use first two options in our practice.

Some patients have issue of Sedation in day time. Once again, underlying cause is to be identified and treated. Those without underlying treatable cause may need medicine. Such as Caffeine, methylphenidate, dextroamphetamine, and in some cases modafinil. We mainly use methylphenidate in our practice. However sedation, requiring medicine use, is much less common compared with insomnia. Those patients who are having life expectancy in days are generally not treated with stimulants, unless there is a very specific request.

2. Delirium: Delirium is a serious condition where patient is confused, disoriented. Patients may have one of three types of delirium:

Hyperactive – most easy to recognize. Restless, agitated, too much speech, stuck on one topic. Also frequently noticed as patient who does not cooperate with treatment – such as refusing medicines, not allowing measurements of vital signs, removing iv canula etc.

Hypoactive – low activity, not typically drowsy but seems like so, confused look.

Mixed – episodes of hyper and hypo activity. With quick switching between the two forms.

Delirium generally develops rapidly over hours to few days. Diagnosis is important since many underlying reasons are of serious nature e.g. metabolic (severe low sodium, low glucose etc), sepsis, hypoxia, urinary obstruction, bowel obstruction, dehydration, CNS event, brain metastases. Additionally uncontrolled severe pain, use of too much alcohol or drugs. Medicines or their withdrawal such as steroids, opioids, benzodiazepines, anticholinergics. Steroids are especially important cause in elderly who sometimes do not tolerate standard doses used in several aspects of cancer management. Most elderly however tolerate steroids fairly well. Treatment includes reducing or removing likely medicines, and management of other conditions listed above. In addition, some patients need medicines to treat delirium such as Haloperidol, Risperidone, Olanzapine, Chlorpromazine. For patients in last days of life with severe agitation, may need frequent injections of lorazepam or midazolam. Sometimes even need continuous infusion. Propofol may also be required in occasional patients for infusion in severe refractory delirium. Since delirium is difficult not only for patient but also for family members to see or manage in severe cases. And instead of restraining patient, it is more humane to use medicines to calm the patient.

3. ADVANCE CARE Planning: LAST but very important step in palliative care where role of family doctor is most important. It is important to discuss this topic with patient and family. We do not have very advance planning in India. However DNR – do not resuscitate i.e. no CPR is what most patients would like. But this needs to be documented. Similarly, most patients would like to die at home rather than in hospital. And with proper planning and understanding, they would avoid hospitalization in last few months to days of life. Additionally, patients may want to avoid some aspects of care such as dialysis, ICU stay, ventilator, any surgery etc. Preparing a “Will” is important. Above noted steps can reduce a lot of expense and suffering both.

December 14, 2021 Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 9998084001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com