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The Royal Marsden
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Symptom control, essentials: delirium, dyspnoea and
recurrent ascites
Dr Jayne Wood
Consultant Palliative Medicine, Clinical Lead
The Royal Marsden NHS Foundation Trust, London
ESMO Preceptorship Supportive and Palliative
Care programme, April 2018
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DISCLOSURE OF INTEREST
Nil to disclose
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Objectives
• Symptom control of:
• Delirium
• Dyspnoea
• Recurrent ascites
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DELIRIUM
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Cardinal features
– Acute onset and fluctuating course
– Inattention
– Disorganized thinking
– Altered level of consciousness
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Epidemiology
– Incidence in advanced cancer varies: reported to be up to 88% in terminal phase
– Underdiagnosed
– Hypoactive subtype commonest (drowsiness/inactivity)
– Combined physician/nurse assessment best
– Majority of studies: admissions to PCU
– Limited published information on frequency in oncology out-patients
– Mismatch with caregivers’ reports
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Outcomes
– Increased:
– Post discharge mortality
– Institutionalisation
– Rehabilitation needs
– Pressure sores
– Aspiration pneumonia
– Higher rates of:
– Care home admission
– Functional decline
– Readmission
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The Royal Marsden
Risk factors
– Baseline vulnerability:
– Visual impairment, severity of illness, pre-existing cognitive impairment, dehydration
– Precipitating factors or insults:
– Direct or indirect
– Cancer related factors, treatment toxicities, physical complications, medications
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Assessment
– Diagnostic tools
– Reference standard DSM/ICD: requires expertise and time
– Confusion assessment method (CAM):
– Most widely used standardized delirium instrument but evidence limited for use in cancer patients
– Requires the presence of “Acute onset and fluctuating course” & “Inattention” and either “Disorganized thinking” or “Altered level of consciousness”
– Routine:
– Screening
– Insufficient evidence in cancer patients but recommend daily observation:
– Monitoring
– Collateral history
9 DSM: Diagnostic and Statistical Manual of Mental Disorders (American Psychiatrist Association)ICD-10: Classification of Mental and Behavioural Disorders: WHO
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Management
– 20-50% delirium episodes are reversible in advanced cancer
– Medication vs organ failure/hepatic encephalopathy
– Assess capacity nb fluctuating nature
– Advance care directives
– Surrogate decision maker
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Common scenarios
– Polypharmacy
– Opioid toxicity: rotation/switching
– Dehydration: limited evidence to support artifical hydration – case by case basis
– Potentially reversible infections
– Hypercalcaemia: hydration, bisphosphonates, denosumab
– SIADH: review medications, restrict fluid intake, vasopressin receptor antagonists
– Hypomagnesaemia
– Anticancer treatments
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Non-pharmacological interventions
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Pharmacological interventions
– Cerebral imbalance between excess of dopaminergic and deficiency of cholinergic transmission
– Opioid rotation/switching
– 2nd generation anti-psychotics (less EPSEs):
– Olanzapine
– Aripiprazole
– Quetiapine
– Benzodiazepines: sedation/anxiolysis nb terminal phase
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Other considerations
– Experiential impact
– Informational and support needs of family
– Educational needs of healthcare professionals
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DYSPNOEA
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The Royal Marsden
Introduction
– Frequent symptom
– Up to 74% Ca lung
– Increases in terminal phase
– Impacts on quality of life
– “suffocating” “choking” “tightness of breath”
– Descriptions:
– Air hunger
– Effort of breathing
– Chest tightness
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The Royal Marsden
Introduction
– Definitions:
– Perceived breathlessness
– Difficult breathing
– Shortness of breath
– “Total dyspnoea”:
– Physical
– Psychological
– Social
– Spiritual
– …requires an MDT approach
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The Royal Marsden
Assessment
– Acknowledge subjective nature
– Patient reported outcome (or caregiver)
– Differentiate between:
– Continuous
– Episodic
– Breakthrough
– Crisis
– Evaluate:
– Onset
– Exacerbating/relieving factors
– Associated anxiety incl psychosocial/ environmental domains
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Management
– Treatment options:
– Disease modifying
– Causative
– Symptomatic
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Treating reversible causes
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Consider performance status and goals of care!
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Non-pharmacological interventions
– Little evidence but sufficient clinical consensus
– Technical support:
– Cool face
– Open window
– Handheld fans
– Positioning
– Respiratory training
– Walking aids
– Psychological training:
– Relaxation
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Oxygen
– Not unless hypoxaemia/chronic obstructive pulmonary disease
– Consider short period before physical effort/eating
– Disadvantages:
– Tubes and tanks
– Nosebleeds
– Psychological addiction to ‘umbilical cord’
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Pharmacological treatment: Opioids
– Use without causing breath depression, impaired oxygenation or increased CO2 concentration
– Stimulation of opioid receptors in cardio-respiratory and central nervous systems
– Nb side effects, renal impairment
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Pharmacological treatment: Benzodiazepines
– If non- or insufficient response to opioids
– Reduce unpleasantness of dyspnoea and anxiolytic
– Nb tolerability of muscle relaxation in context of cachexia and sarcopenia
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Pharmacological treatment: Other drugs
– Neuroleptics: anxiolytics and sedatives NO EVIDENCE
– Antidepressants and buspirone: mood enhancers NO EVIDENCE
– Steroids: effective if lynphangitis carcinomatosa, radiation pneumonitis, superior vena cava syndrome, inflammatory component, obstruction of airways
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Terminal phase
– Increased need for sedation
– Management of secretions:
– Reduction of artificial hydration
– Antisecretory drugs
– Glycopyrronium
– Hyoscine
– Positioning
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Keys to success
– Teach techniques early
– Listen to their story
– Engage patients and agree goals
– Support carers
– Remember, dyspnoea is about the brain not the lungs!
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RECURRENT ASCITES
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Accumulation of fluid
Obstruction of lymphatic drainage
Cytokine release eg. VEGF, VPF, IL-6, TNF
Activation of renin-angiotensin-aldosterone system
Ascites
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– Evidence:
– Diuretic use inconsistent
– Weak assessing efficacy
– Interval between initiation and response poorly defined
– Response may depend upon plasma renin/aldosterone concentration
Diuretic therapy
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– Temporary relief for 90% patients (Smith et al, 2003)
– Complications:
– Hypovolaemia
– Hypoproteinaemia
– Bowel perforation
– Infection
– Formation of drainage nodules
– Peritoneocutaneous fistulae
– Pain
Paracentesis
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Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007794. Management of drainage for malignant ascites in gynaecological cancer. Keen, A. et al
– Benefit and harms of different practices in the management of drains for malignant ascites in advanced or recurrent gynaecological cancer.
– Evidence re:
– How long should the drain stay in place?
– Should the volume of fluid drained be replaced intravenously?
– Should the drain be clamped to regulate the drainage of fluid?
– Should any particular vital observations be regularly recorded?
– No relevant studies were identifed
– Unable to make recommendations
– Large, multi-centre RCTs are required to evaluate the efficacy and safety of the management of ascitic drains when in situ and their impact on QOL.
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Paracentesis [2]
– Stephenson et al (2002)
– Variation in practice between local hospice and hospital, in relation to:
– Prior USS
– Use of IV fluids
– Length of time drains left in (hospital>hospice)
– Length of inpatient stay (hospital<hospice)
….ALL hospital > hospice
– Clinical guidelines drawn up:
– Prior USS only if ascites not easily clinically identified or signs of bowel obstruction present
– IV fluids only if patient at risk of hypovolaemia
– Free drainage of 5L or for 5 hours – whichever is sooner
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Paracentesis [3]
– Findings:
– Procedure repeated more frequently in post-guidelines group, BUT
– No significant difference in mean volumes drained
– No cases of symptomatic hypotension in post-guidelines group
– Significant reduction in:
– number of prior USS
– Mean time drain left in
– Mean duration of patient stay
– BUT are hospital patients more at risk of complications…
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Indwelling peritoneal catheters
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PleurX Peritoneal Catheter Drainage System
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Encourages tissue growth to secure catheterPrevents air entering and
fluid leaking
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PleurX drain in management of malignant ascites: safety,
complications, long-term patency, factors predictive of success.
Br J Radiol. 2012 May;85(1013):623-8. Epub 2011 Mar 22. Tapping,
CR et al.
– 28 consecutive patients (4y period, 32 drain insertions, mean age 61y)
– 4 inserted with combination of fluoroscopic and ultrasound guidance and 28 under ultrasound guidance alone
– 100% technical success rate
– No procedure-related deaths/major complications
– Minor complications were reported:
– Three (10%) immediate; three (10%) early; and two (7%) late.
– Factors associated: chemo, low Hb/albumin, high WBC, high c-reactive protein
– Length of time the drains in situ: 5 to 365 days (mean, 113 days)
– 24 (86%) in situ and functioning until the patients' death
– 4 (14%) drains dislodged but drains remained patent until the patient's death
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Review of objectives
– Symptom control of:
– Delirium
– Dyspnoea
– Recurrent ascites
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