1. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Osteopathic EPEC Osteopathic EPEC Education for Osteopathic Physicians on End-of-Life Care Based on The EPEC Project, created by the American Medical Association and supported by the Robert Wood Johnson Foundation. Adapted by the American Osteopathic Association for educational use. American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms

2. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Module 6 Depression, Anxiety and Delirium

3. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Objectives Identify depression, anxiety, delirium near end of life Describe management plans Application of osteopathic principles, philosophy and techniques in management of anxiety, depression and delirium

4. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Depression, anxiety, delirium Highly prevalent, under-diagnosed May prevent quality dying Effective management is possible

5. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Depression 25%–77% of patients 28%-60% of caregivers Intense suffering Not inevitable Treatable in most cases Early treatment is better

6. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Risk factors... Pain, other symptoms Progressive physical impairment Advanced disease Advanced age  70 yo Social Isolation

7. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms... Risk factors Particular diseases Pancreatic cancer Stroke Medication Steroids Benzodiazepines Chemotherapy

8. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms... Risk factors Spiritual pain Bereavement Pre-existing risk factors Prior Hx, family Hx, social stress Suicide attempts, substance use

9. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Depression …diagnosis Physical Symptoms Anorexia / Insomnia / Fatigue / Weight Loss Psychological Symptoms Dysphoric Mood / Despair / Guilt Worthlessness / Suicidal Ideation Social Withdrawal / Apathy Pain not responding as expected

10. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Barriers to Treatment Fear of side-effects of medication Comorbidities Renal/Hepatic Insufficiency Cardiovascular Disease Gastrointestinal Disease Polypharmacy Cognitive Impairment Psychosocial Factors

11. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Barriers to Treatment 50% rule of depression Only 50% of patients with depression are diagnosed Only 50% of the patients diagnosed are treated 50% of the patients with depression are inadequately treated ­Full effects of antidepressants in older patients may require 12 weeks or more

12. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Caregiver Impact 27.6 million family caregivers Average time devoted 20.5 hours/wk

13. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Caregivers Responsibilities Critical Medical Decisions Assistance with activities of daily living Administer Medication Provide physical, emotional and spiritual support Transportation Homemaking Finance

14. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Impact on Caregivers Spousal caregiver → mortality of 63% 53% Worried 37% Frustrated 28-60% Depressed 22% Overwhelmed 10-38% Isolation

15. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Be Sensitive to the Caregiver Who is involved in care? Are there problems? How are they coping? Sensitive to the caregiver Their needs and experience Stressors and Ill-effects Understand the cost and implications

16. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Suicide Assess all depressed patients for risk Discussion of thoughts of suicide may reduce the risk Suicidal thoughts a sign of depression High risk if recurrent thoughts, plans

17. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Management of Depression Proactive Identify Risk Factors Early intervention Improves symptoms Restores function Reduces treatment resistance

18. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms …..Management of Depression Psychotherapeutic interventions Cognitive approaches Behavioral interventions Medications Combination of psychotherapy, medication and possible osteopathic manipulation, if indicated

19. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Counseling goals... Weave counseling into routine interventions Include family when possible Improve patient understanding Create a different perspective Identify strengths, coping strategies

20. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms... Counseling goals Reestablish self-worth New coping strategies Educate about modifiable factors

21. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Pharmacologic management... Psychostimulants SSRIs Tricyclic and atypical antidepressants

22. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms... Pharmacologic management Choose by time to effect Days – psychostimulants Weeks / months – SSRIs, tricyclic / atypical antidepressants Start dosing low, titrate slowly Consider consultation

23. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Psychostimulants... Rapid effect Methylphenidate, 5 mg q am + q noon, titrate to effect Alone or in combination Continue indefinitely

24. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms... Psychostimulants Diminish opioid sedation Not usually an appetite suppressant May exacerbate Tremulousness Anxiety Anorexia Insomnia

25. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms SSRIs Latency 2–4 weeks Highly effective (70%) Well tolerated Once-daily dosing Low doses may be effective in advanced illness

26. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Tricyclic antidepressants Not recommended as first-line therapy Latency 3–6 weeks Adverse effects are common Nortriptyline, desipramine have fewer adverse effects Atypical antidepressants still being studied

27. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Anxiety... Fear, uncertainty about future Physical, psychological, social, spiritual, practical issues Presentation Agitation, insomnia, restlessness, Sweating, tachycardia, hyperventilation, Panic disorder, worry, tension

28. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Management of anxiety Counseling, supportive therapy Benzodiazepines Short vs. long half-life ­Diazepam ­Lorazepam ­Alprazolam, oxazepam

29. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms …Management of Anxiety Assessment complex Differentiate from Delirium, depression Bipolar disorder Medication effects Insomnia Alcohol, caffeine ­Lorazepam ­Alprazolam. oxazepam

30. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms …Management of Anxiety Atypical antidepressants Osteopathic manipulative techniques as clinically indicated

31. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Delirium Global change in cognition, awareness, acute onset Presentation Fluctuating level of consciousness Cognitive impairment Distinguish from dementia, depression, anxiety

32. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Causes to consider... Infections, sepsis Medications, street drugs (including withdrawal) Hypoxemia Metabolic

33. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms... Causes to consider Vitamin deficiencies Fecal impaction, urinary retention Renal, hepatic failure Tumor burden, secretions Changes in environment

34. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Medical management Neuroleptics Haloperidol Chlorpromazine Atypical neuroleptics Risperidone Olanzepine Benzodiazepines for acute agitation

35. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Terminal delirium Day-night reversal Agitation, restlessness Moaning, groaning

36. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Evaluate treatment Monitor carefully If negligible or partial response Re-evaluate diagnosis Inquire about adherence to medication Consider dosage adjustment Consider a different medication Refer to a specialist

37. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Depression, Anxiety and Delirium Summary