3. EPECEPECEPECEPEC EPECEPECEPECEPEC Depression, Anxiety, Delirium Depression, Anxiety, Delirium Module 6 The Project to Educate Physicians on End-of-life Care Supported by the American Medical Association and the Robert Wood Johnson Foundation

4. Objectives l Identify depression, anxiety, delirium near end of life l Describe management plans l Identify depression, anxiety, delirium near end of life l Describe management plans

5. Depression, anxiety, delirium l Highly prevalent, under-diagnosed l May prevent quality dying l Effective management is possible l Highly prevalent, under-diagnosed l May prevent quality dying l Effective management is possible

6. Depression l 25%–77% of patients l Intense suffering l Not inevitable l Treatable in most cases l Early treatment is better l 25%–77% of patients l Intense suffering l Not inevitable l Treatable in most cases l Early treatment is better

7. Risk factors... l Pain, other symptoms l Progressive physical impairment l Advanced disease l Medications steroidsbenzodiazepines l Pain, other symptoms l Progressive physical impairment l Advanced disease l Medications steroidsbenzodiazepines

8. ... Risk factors l Particular diseases pancreatic cancer stroke l Spiritual pain l Preexisting risk factors prior Hx, family Hx, social stress suicide attempts, substance use l Particular diseases pancreatic cancer stroke l Spiritual pain l Preexisting risk factors prior Hx, family Hx, social stress suicide attempts, substance use

9. Diagnosing depression in advanced illness l Somatic symptoms always present l Look for psychological, cognitive symptoms pain not responding as expected sad mood / flat affect, anxious, irritable worthlessness, hopelessness, helplessness, guilt, despair anhedonia, lost self-esteem l Somatic symptoms always present l Look for psychological, cognitive symptoms pain not responding as expected sad mood / flat affect, anxious, irritable worthlessness, hopelessness, helplessness, guilt, despair anhedonia, lost self-esteem

10. Suicide l Assess all depressed patients for risk l Discussion of thoughts of suicide may reduce the risk l Suicidal thoughts a sign of depression l High risk if recurrent thoughts, plans l Assess all depressed patients for risk l Discussion of thoughts of suicide may reduce the risk l Suicidal thoughts a sign of depression l High risk if recurrent thoughts, plans

11. Management of depression l Psychotherapeutic interventions cognitive approaches behavioral interventions l Medications l Combination of psychotherapy, medication l Psychotherapeutic interventions cognitive approaches behavioral interventions l Medications l Combination of psychotherapy, medication

12. Counseling goals... l Weave counseling into routine interventions include family when possible l Improve patient understanding l Create a different perspective l Identify strengths, coping strategies l Weave counseling into routine interventions include family when possible l Improve patient understanding l Create a different perspective l Identify strengths, coping strategies

13. ... Counseling goals l Reestablish self-worth l New coping strategies l Educate about modifiable factors l Reestablish self-worth l New coping strategies l Educate about modifiable factors

14. Pharmacologic management... l Psychostimulants l SSRIs l Tricyclic and atypical antidepressants l Psychostimulants l SSRIs l Tricyclic and atypical antidepressants

15. ... Pharmacologic management l Choose by time to effect days – psychostimulants weeks / months – SSRIs, tricyclic / atypical antidepressants l Start dosing low, titrate slowly l Consider consultation l Choose by time to effect days – psychostimulants weeks / months – SSRIs, tricyclic / atypical antidepressants l Start dosing low, titrate slowly l Consider consultation

16. Psychostimulants... l Rapid effect l Methylphenidate, 5 mg q am + q noon, titrate to effect l Alone or in combination l Continue indefinitely l Rapid effect l Methylphenidate, 5 mg q am + q noon, titrate to effect l Alone or in combination l Continue indefinitely

17. ... Psychostimulants l Diminish opioid sedation l Not usually an appetite suppressant l May exacerbate tremulousnessanxietyanorexiainsomnia l Diminish opioid sedation l Not usually an appetite suppressant l May exacerbate tremulousnessanxietyanorexiainsomnia

18. SSRIs l Latency 2–4 weeks l Highly effective (70%) l Well tolerated l Once-daily dosing l Low doses may be effective in advanced illness l Latency 2–4 weeks l Highly effective (70%) l Well tolerated l Once-daily dosing l Low doses may be effective in advanced illness

19. Tricyclic antidepressants l Not recommended as first-line therapy l Latency 3–6 weeks l Adverse effects are common nortriptyline, desipramine have fewer adverse effects l Atypical antidepressants still being studied l Not recommended as first-line therapy l Latency 3–6 weeks l Adverse effects are common nortriptyline, desipramine have fewer adverse effects l Atypical antidepressants still being studied

20. Anxiety... l Fear, uncertainty about future l Physical, psychological, social, spiritual, practical issues l Presentation agitation, insomnia, restlessness, sweating, tachycardia, hyperventilation, panic disorder, worry, tension l Fear, uncertainty about future l Physical, psychological, social, spiritual, practical issues l Presentation agitation, insomnia, restlessness, sweating, tachycardia, hyperventilation, panic disorder, worry, tension

21. ... Anxiety l Assessment complex l Differentiate from delirium, depression bipolar disorder medication effects insomnia alcohol, caffeine l Assessment complex l Differentiate from delirium, depression bipolar disorder medication effects insomnia alcohol, caffeine

22. Management of anxiety l Counseling, supportive therapy l Benzodiazepines short vs long half-life diazepamlorazepam alprazolam, oxazepam l Atypical antidepressants l Counseling, supportive therapy l Benzodiazepines short vs long half-life diazepamlorazepam alprazolam, oxazepam l Atypical antidepressants

23. Delirium l Global change in cognition, awareness, acute onset l Presentation fluctuating level of consciousness cognitive impairment distinguish from dementia, depression, anxiety l Global change in cognition, awareness, acute onset l Presentation fluctuating level of consciousness cognitive impairment distinguish from dementia, depression, anxiety

24. Causes to consider... l Infections, sepsis l Medications, street drugs (including withdrawal) l Hypoxemia l Metabolic l Infections, sepsis l Medications, street drugs (including withdrawal) l Hypoxemia l Metabolic

25. ... Causes to consider l Vitamin deficiencies l Fecal impaction, urinary retention l Renal, hepatic failure l Tumor burden, secretions l Changes in environment l Vitamin deficiencies l Fecal impaction, urinary retention l Renal, hepatic failure l Tumor burden, secretions l Changes in environment

26. Medical management l Neuroleptics haloperidolchlorpromazine l Atypical neuroleptics risperidoneolanzepine l Benzodiazepines for acute agitation l Neuroleptics haloperidolchlorpromazine l Atypical neuroleptics risperidoneolanzepine l Benzodiazepines for acute agitation

27. Terminal delirium l Day-night reversal l Agitation, restlessness l Moaning, groaning l Day-night reversal l Agitation, restlessness l Moaning, groaning

28. Evaluate treatment l Monitor carefully l If negligible or partial response reevaluate diagnosis inquire about adherence to medication consider dosage adjustment consider a different medication refer to a specialist l Monitor carefully l If negligible or partial response reevaluate diagnosis inquire about adherence to medication consider dosage adjustment consider a different medication refer to a specialist

29. EPECEPECEPECEPEC EPECEPECEPECEPEC Depression, Anxiety, Delirium Summary Summary