palliative care in neurological disease

Palliative care in Neurological

DiseaseSurat Tanprawate, MD, FRCPT

Division of Neurology, Department of MedicineChiang Mai University

04-10-2011, Chaing Mai, ThailandThursday, October 6, 2011

“Palliative care”

Thursday, October 6, 2011

End of Life CareThursday, October 6, 2011

Patients with terminal cancer


Patients with terminal cancer

So many neurologic illness are progressive and incurable

It should be recognized as an important concept in the

management of any patient with a progressive, incurable illness


Who do the neurologists see?

}Thursday, October 6, 2011


Worried well, headache/migraine, numbness,

dizziness, etc




dizziness, etc

Chronic neurological disorder: MS, spinal

cord, dementia




dizziness, etc

Chronic neurological disorder: MS, spinal

cord, dementia

Acutely ill patients }


ART > SCIENCEThursday, October 6, 2011

What we have to learn?



• Learning process, not just knowledge




• Different diseases have different problems >> the same goal





• Humanity diversity





• Humanity diversity

• Knowing your function, and connect with others


The different viewNeurologist view

Palliative care team view


The different view• Holistic approach(physical,

psychological, cultural, spiritual)

• Experience in symptoms control

• End of life decision

• Community center

• In-patient facilities for terminal care/respite

• Day hospice facilities

• Complementary therapies

• Bereavement counselling

Neurologist view

Palliative care team view


Neurologist

ยกตัวอย่างการดูแลผู้ป่วยโรคอัลไซเมอร์

Palliative care


Neurologist

รู้จักโรคอัลไซเมอร์


Palliative care


Neurologist



เข้าใจผู้ป่วย ญาต ิสิ่งแวดล้อม สังคม

Palliative care


Neurologist



เข้าใจผู้ป่วย ญาต ิสิ่งแวดล้อม สังคม

Palliative care

รู้จักและเข้าใจผู้ป่วยโรคอัลไซเมอร์Thursday, October 6, 2011

Distress physical symptoms

Feeling and psychological

symptoms

Patient Health care

Family member

Social

Intervention

- Pharmacological

-Non-pharmacological

Improve QOL


Common neurological problems

• Cognitive dysfunction, dementia> Alzheimer’s disease, other dementia

• Physical disability >stroke, motor neuron disease, Parkinson’s disease, spinal cord disease, neuromuscular weakness


Dementia and Alzheimer’s disease

“แม้ความจําจะเลือนลาง แต่ความสุขไม่ลางเลือน”


Dementia(โรคสมองเสื่อม)

• Decline of cognitive function (พุทธิปัญญา)

• Cognitive function: memory, language, motor ability, calculation

• It’s also involved psychological and behavioral symptoms: depression, anxiety, hallucination, sleep problem, pain


Alzheimer’s disease

• Most common cause of dementia

• AD is a neurodegenerative disorder presented with progressive dementia

0

5

10

15

20

25

30

35

40

Percent of Age Group

30-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85-8

9

90-9

4

95-9

9

Years

Female

Male


Alzheimer’s disease

Cognitive impairment

Psychiatric and behavioral symptoms

Activity daily living

Physical disability-late stage


Stage of AD


Management strategies

• Prognostication, and dying from dementia

• Cognitive and communication ability decline

• Behavioral and psychological problems

• Challenging caregiver stress and bereavement issues


Prognostication questions in dementia

• Patient’s question: “How long do I have before my mind is shot?”

• Health professional’s question: “Is s/he eligible for palliative care?”

• Family’s question: “How long does s/he have to live ?”

• Caregiver’s question: “ I am exhausted. How much longer can I do this?”


• Stage 7 or beyond according to the FAST scale

• Unable to ambulate without assistance

• Unable to dress without assistance

• Unable to bathe without assistance

• Urinary or fecal incontinence, intermittent or constant

• No meaningful verbal communication, stereotypical phrases only, or ability to speak limited to six or fewer intelligible words

• Plus one of the following within the past 12 months:

• Aspiration pneumonia

• Pyelonephritis or other upper UTI

• Septicemia

• Multiple stage 3 or 4 decubitus ulcers

• Fever that recurs after antibiotic therapy

• Inability to maintain sufficient fluid and calorie intake, with 10 percent weight loss during the previous six months or serum albumin level less than 2.5 g per dL (25 g per L)

Dementia hospice eligibility


Cognition and ability decline-1

• Unrecognized symptoms-pain, physical illness

• to find the hidden problem: patient report, caregiver report, and direct observation

• change in behavior or mental status

• OA, peripheral neuropathy, other pain are common


Cognition and ability decline-II

• Loss of functional ability

• unable to ambulate

• unable to bath, dress, or feed independently

• incontinent of bowel and bladder

• unable to communicate meaningfully

• (presence of medical complication)


What does dying look like

• Decline in functional status

• Lack of desire to eat or drink

• Withdrawn

• Sleep- wake state

• Mottling of limbs

• Jaw movement

• Death rattle

• Co-morbid symptoms


Tube feed or not tube feed? That’s the question

• The facts:

• Effect on life span is an open question

• Increases suffering

• Need for better pt/family education

• Discussing benefits and burdens of therapy

• Use neutral language

• Separate facts from your opinion

• Please offer your opinion

• Make allowances for special circumstances.


Palliative care in stroke patient


Stroke

• Stroke is one of the three biggest killers in Thailand.

• Two types:

• Infarction

• Hemorrhage

• Death range from 8-20% in first 30 days (higher for hemorrhage)


Stroke care: palliative care aspect

• Palliative care’s role in stroke care

• Acute stroke: end of life care

• Long term care in stoke with severe disability

• Death is mainly from cardiac (AMI, arrhythmias) or respiratory (aspiration, pneumonia embolism)

• Brain swelling


End of life care in acute stroke

• Ethical aspects of care - end of life issues including withdrawal of treatment

• Early decisions about withholding cardiopulmonary resuscitation are avoided.

• There is full discussion with the patient (if possible) and family/carer about reasons for withdrawal/futility of treatment to allow all concerned to understand treatment goals.

• There is accurate documentation of plans of care and discussions between the multidisciplinary team, the patient and family/carer.


Various case of stroke with disability


Various case of stroke with

disability


Various case of stroke with disability


Palliative care in motor neuron disease


--Motor Neuron Disease--Amyotrophic Lateral Sclerosis (ALS)

• Progressive, degenerative neurologic disease of unknown etiology

• Involve: upper and lower motor neurons

==: LMN: weakness, atrophy, fasciculation

==: UMN: hyperreflexia, spasticity due to lateral corticospinal tract degeneration


--Motor Neuron Disease--Amyotrophic Lateral Sclerosis (ALS)

• Progressive, degenerative neurologic disease of unknown etiology

• Involve: upper and lower motor neurons

==: LMN: weakness, atrophy, fasciculation

==: UMN: hyperreflexia, spasticity due to lateral corticospinal tract degeneration

:Symptoms:Weakness of body muscles

causing:: limb weakness

:: dysphagia:: respiratory failure:: speech difficulty

Memory and Cognitive function are spared...


Signs and symptoms


Secretion management : decrease saliva production Medication use>>Benztropine, amitriptyline, artane : remove saliva>>increase fluid intake, humidified air



Dysarthria : speech therapyDysphagia : Decreased caloric and fluid intake may lead to worsening of symptoms, such as weakness, muscle atrophy, fatigue : Initially management includes the modification of food and liquid consistency : Discussion for PEG



Muscle spasm & weakness : Early PT/OTCramps : Quinine sulfate 200 mg twice daily, Tizanidine 2-4 mg twice daily




Muscle spasm & weakness : Early PT/OTCramps : Quinine sulfate 200 mg twice daily, Tizanidine 2-4 mg twice daily


Respiratory care : initiate discussion regarding the patients’s goals and how the goal can be best achieved : respect the right of patients to refuse or withdraw treatment


To cure sometimes


To cure sometimes

To relieve often


To cure sometimes

To relieve often

To comfort always


Thank You for Your Kind Attention

Dr.Surat Tanprawate, MD, MSc(Lond.), FRCP(T)Division of Neurology, Department of Medicine,

CMU

My Deep Gratitude to Ass. Prof. Siwaporn

Chankrachang

WWW.OPENNEURONS.COMThursday, October 6, 2011

http://WWW.OPENNEURONS.COM

http://WWW.OPENNEURONS.COM

palliative care in neurological disease

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