Hiv/aids palliative care module

HIV/AIDS Palliative Care Module
Chapter 7
NEURO-PSYCHIATRIC PROBLEMS
DEMENTIA
The term dementia is used interchangeably with HIV encephalopathy. It is also known as AIDS dementiacomplex (ADC).
Chapter 2
Dementia may be related to HIV (direct cause) or it may be the result of another infection, a spaceoccupying lesion or a metabolic imbalance (indirect cause).
PRESENTATIONS
Early dementia
Late dementia
Very late dementia
Chapter 7
• loss of balance• night time delusions• psychomotor retardation• sundown syndrome Chapter 4
• tremors• vacant stare• wandering• withdrawal Infectious:
Chapter 5
APPROACHES AND
INTERVENTIONS
• a trial of methylphenidate 5-20 mg po qam has cleared mild Examination, investigation and treatment of underlying causes should be appropriate to the presentation, stageand context of the person and illness.
• manage associated agitation (see Delirium)• provide a protective, safe, structured environment• keep familiar objects in visible proximity• establish daily routines including regular activity and sleep Chapter 6
• reduce external stimuli, i.e. noise, conversations not specifically • consider competency (see Legal Issues)• provide as much control as possible• make instructions clear, simple• minimize number of caregivers• monitor finances, spending habits• occupational therapy Chapter 7
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PROBLEMS
INTERVENTIONS
orientation
have caregivers and visitors identify themselves regularly raise side rails (caution: may increase agitation. May lead to anaccident if person attempts to climb over them) psychomotor retardation/
methylphenidate 5-20 mg po q4h. Avoid late afternoon and evening somnolence
doses as these can interfere with sleep at night time. Occasionally,doses late in the day can keep the person alert for visitors or pleasur-able activities (Do not use if person is delirious or agitated) HIV encephalopathy
anti-retrovirals (AZT, ddI, ddC) may protect against or reverse HIV-related dementia COMPLEMENTARY
THERAPIES
• art therapy• massage therapy• music therapy• therapeutic touch DELIRIUM, DECREASED LEVEL OF CONSCIOUSNESS, TERMINAL DELIRIUM
PRESENTATIONS
May include:• agitation• bad dreams, nightmares• decreased level of consciousness, somnolence (often fluctuating)• disorientation• hallucinations or other perceptual disturbances• hypervigilance• moaning, groaning• reduced concentration• restlessness• short term memory difficulties• sleep/wake cycle reversal Moaning and groaning may be the result of partial closure of the vocalcords due to stress during the dying process. They are rarely the result ofpain, unless they have been present prior to the onset of delirium.
May be related to psycho-social or spiritual distress. Pain, even inthe unconscious person, is usually associated with furrowing of thebrows and/or signs of tension across the forehead Mount Sinai Hospital/Casey House Hospice HIV/AIDS Palliative Care Module
Chapter 7
Depression:
(some are associated with agitation, delusions, hallucinations,
memory impairment)
Hypomania/mania:
Psychosis:
Chapter 2
Other:
• HIV encephalopathy
• opportunistic infections, sepsis
• increased intracranial pressure
• medications: side effects and/or withdrawal, including
– benzodiazepines– opioids– anti-cholinergics • metabolic abnormalities including hepatic or renal failure Chapter 7
• hypoxia• environmental changes, i.e. hospitalization, ICU• fecal impaction• urinary retention APPROACHES AND
• continue only essential medications. Discontinue any that could INTERVENTIONS
Examination, investigation and treatment of underlying • provide familiar environment, orient frequently, enhance safety causes should be appropriate to the presentation, stageand context of the person and illness.
Chapter 4
PROBLEMS
INTERVENTIONS
agitation, restlessness,
neuroleptics may help to re-organize thought patterns as well as psychosis
choice of drug depends largely on familiarity start with smallest possible doses:– haloperidol 0.5 mg po, im, sc; thioridazine 10 mg po; loxapine 2.5 Chapter 5
mg po, im; chlorpromazine 10 mg po, pr, im – adjust upward as necessary. Frequent dosing may be necessary – once under control, reduce total daily acute dose by 25-33% and divide daily maintenance dose into 2-3 doses/24 hrs higher potency, i.e. haloperidol, perphenazine, are associated
with extrapyramidal side-effects
lower potency, i.e. thioridazine, chlorpromazine, are associated
with more sedation and anti-cholinergic side-effects
Chapter 6
mid potency, i.e. loxapine, trifluoperazine, provide a balance
in severe agitation, iv haldol can provide rapid relief with few side-effects:– haloperidol 0.5-2 mg iv, infuse at 1 mg/min, repeat q30min until – if agitation is particularly severe, may add lorazepam 1-2 mg iv use anti-cholinergics as necessary for side-effects i.e. Benztropine Chapter 7
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COMPLEMENTARY
• homeopathy: arsenicum 30 ch bid to decrease anxiety and THERAPIES
• massage therapy• music therapy• therapeutic touch THE TWO ROADS
In the dying, coma and death may ensue along 2 different TO COMA18
The low road is a hypo-active state where the person slips quietlyinto a coma and dies peacefully. The high road is a hyper-activestate consistent with terminal delirium.
LAST HOURS
INTERVENTIONS
irreversible, cannot treat the underlying causes, so focus on terminal delirium
goals in managing terminal delirium include:– muscle relaxation, including reduction of moaning/groaning– reduction of anxiety– reduction of risk of seizures– inhibition of the perception of the last hours of living benzodiazepines may settle terminal delirium and/or induce sedation:– lorazepam 1-4 mg against buccal mucosa q1h prn (pre-dissolved in 0.5-1.0 mls of water) even in the personwho is unconscious and/or unable to swallow.
Doses of 20-50 mg per 24 hours may be required in individualswho are very restless – midazolam 1-5 mg sc, im, iv q3h prn or by continuous infusion haloperidol, chlorpromazine and methotrimeprazine may alsobe useful, but im injections may be too painful in the cachecticperson (haloperidol, methotrimeprazine could be administered sc) Mount Sinai Hospital/Casey House Hospice HIV/AIDS Palliative Care Module
Chapter 7
where terminal delirium is extreme or sedation is difficult toachieve with benzodiazepines, phenobarbital or sodium thiopental(Pentothal®), may be required to settle the person. This should bediscussed in detail with the family prior to initiating therapy:– phenobarbital 100-130 mg iv, im q6h or by continuous infusion 1-5 mg/hr (starting with lowest dose and titrating Chapter 2
– sodium thiopental, consult with an anesthetist educate the family about the causes and significance of terminaldelirium, particularly the distressing features, i.e. moaning/groaning maintain good mucous membrane and skin care (see Dehydration,Skin care/problems) do not measure blood pressure, heart or respiratory rateunnecessarily Chapter 7
measure oxygen saturation only if necessary, no blood gases COMPLEMENTARY
THERAPIES
DEPRESSION
Chapter 4
PRESENTATIONS
May also include neuro-vegetative symptoms (less helpful in the Chapter 5
severely medically ill):• decreased appetite Other:
• dementia
Note:• attempt to distinguish dysphoria associated with losses from a Chapter 6
more severe clinical depression. Even a “reactive” depressioncan become a major depression and warrant pharmacologicaltreatment:– index of suspicion will be high if guilty ruminations, apathy, • diagnosis is difficult due to diagnostic criteria (refer to DSM-IV) which rely on neuro-vegetative symptoms that are invariablydisrupted in severe medical illness • diagnosis is important as appropriate intervention may Chapter 7
Mount Sinai Hospital/Casey House Hospice Symptom Management
APPROACHES AND
• reduce doses of medication if possible INTERVENTIONS
Examination, investigation and treatment of underlying • provide a familiar, safe, protective environment (see Dementia) causes should be appropriate to the presentation, stageand context of the person and illness.
• consider supportive and/or insight oriented psychotherapy PROBLEMS
INTERVENTIONS
clinical depression
choice of medication depends on presentation and side-effect profiles:– early tricyclic anti-depressants, i.e. doxepine, imipramine, are sedating and have risk of anticholinergic side effects includingconstipation, xerostomia – newer tricyclic anti-depressants, i.e. nortriptyline, desipramine, have fewer side effects than other older antidepressants, and offeradvantage of monitoring blood levels – newer anti-depressants, i.e. sertraline, fluvoxamine, can be stimu- lating and have risk of agitation/restlessness, GI upset or sleepdisturbance – trazadone can be sedating with less risk of other side effects– avoid fluoxetine due to long half life start with half usual adult starting dose, increase slowly, expectresponse only after two or more weeks on a therapeutic dose:1. tricyclic anti-depressants including desipramine, doxepine, imi- pramine, nortriptyline:– start with 10–25 mg po od-tid and increase in 25 mg increments, if no side-effects, up to a max of 100–200 mg in 1–3 doses/24hrs (max 100 mg/24 hrs for nortriptyline only) 2. serotonin re-uptake inhibitors including sertraline and fluvoxamine: – start with 50 mg po od and increase if no side-effects up to 150– 200 mg/24 hrs (wait at least 7 days between increments) – start with 50 mg po od and increase if no side-effects up to 150– 200 mg/24 hrs (wait at least 7 days between increments) methylphenidate 5–20 mg po q4h, avoid late afternoon and evening psychomotor retardation/
somnolence
– helpful in the medically ill. Rapid but likely a limited response COMPLEMENTARY
THERAPIES
– nat mur 30 ch bid for deep sadness, with blocked emotions, – iamara (ignatia amara) 30 ch bid for emotions PRESENTATIONS
Other:
• delirium
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Chapter 7
APPROACHES AND
provide a familiar, safe, environment (see Dementia) INTERVENTIONS
Examination, investigation and treatment of underlyingcauses should be appropriate to the presentation, stageand context of the person and illness.
PROBLEMS/APPROACHES
INTERVENTIONS
Chapter 2
medication choice depends on desired half-life:– longer half-life: more sustained effect, but may accumulate– shorter half-life: risk of withdrawal and rebound anxiety lorazepam and oxazepam are not metabolized in the liver and are abetter choice in presence of hepatic failure consider possibilities of withdrawal if stopped abruptly, i.e. agitation,rebound anxiety, delirium:– long half-life: Chapter 7
alprazolam 0.25–0.5 mg po bid-tid, max 3 mg/24 hrs (particularlyfor panic attacks and nightmares) diphenhydramine 25–50 mg po, iv tid-qid Chapter 4
homeopathy:– anxiety attacks, aconitum 6 ch tid, if recurrent or acute 30 ch prn– generalized anxiety, arsenicum 30 ch bid– high anxiety, argentum nitricum 30 ch bid anti-depressants
anti-depressants may be very helpful, i.e. trazodone COMPLEMENTARY
• acupuncture: raises endorphin levels, sedates Chapter 5
THERAPIES
• aromatherapy: general calming effect, see practitioner for appropriate aromatherapy oils (melissa, bergamot, lavender, neroli):– warm baths and oils • biofeedback• chiropractic: specific cervical and thoracic manipulation to • hypnosis• imagery• massage therapy Chapter 6
• relaxation therapy• therapeutic touch: general calming effect INSOMNIA
PRESENTATIONS
May include:• difficulty falling asleep Chapter 7
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Other:
• anxiety disorder
APPROACHES AND
• give corticosteroids in the morning to reduce interference with INTERVENTIONS
Examination, investigation and treatment of underlying • look for reversible symptoms which cause discomfort at night causes should be appropriate to the presentation, stageand context of the person and illness.
APPROACHES
INTERVENTIONS
enhance environment
provide comforting objects i.e. teddy bears establish sleep routines
reduce stimulation 2 hours before sleeping remove dietary stimulants
avoid caffeinated medications and beverages, i.e. coffee, tea, softdrinks anxiolytics
choice depends on half-life:– short: may lead to withdrawal, arousal– long: may result in daytime sleepiness, hangover or impaired cognition. However, may provide anxiolytic effect during the day do not use nightly:– avoids attenuation effect– reduces potential for dependency abrupt stoppage may lead to rebound insomnia effective doses may be very small in the elderly dosing:– lorazepam 0.5–2 mg po, sl qhs prn– oxazepam 15–30 mg po qhs prn– diazepam 2–5 mg po qhs prn– alprazolam 0.25–0.5 mg po qhs prn anti-depressants
low doses of sedating anti-depressants may be very helpful over longterm:– amitriptyline, desipramine, doxepin 10–25 mg po qhs– trazodone 25–50 mg po qhs other sedatives
COMPLEMENTARY
• aromatherapy: see practitioner for specific oils THERAPIES
• guided meditations, imaging• herbal treatments, soothing teas Mount Sinai Hospital/Casey House Hospice HIV/AIDS Palliative Care Module
Chapter 7
• homeopathy: coffea 12 ch bid in evening spaced 3 hrs apart before bedtime, allow 4 days to assess, increase to 30 ch, ifneeded – progressive muscle relaxation– self hypnosis– focused muscle relaxation Chapter 2
• therapeutic touch• warm milk, Ovaltine™ CARDIO-RESPIRATORY PROBLEMS
CHEST PAIN
Chapter 7
PRESENTATIONS
May occur at rest, on movement, on exertion, on inspiration.
May be generalized or localized and may be specific to one ormore dermatomes.
Infectious:
Chapter 4
• pneumocystis carinii• pyogenic bacteria• TB Malignant:
• Kaposi’s sarcoma
• lymphoma
Chapter 5
APPROACHES AND
• distinguish between non-esophageal and esophageal pain (see INTERVENTIONS
Examination, investigation and treatment of underlying • pain on inspiration, exertion may indicate rib subluxation causes should be appropriate to the presentation, stageand context of the person and illness.
PROBLEMS
INTERVENTIONS
chest wall inflammation,
provide stepwise analgesia, especially NSAID’s (see Pain) Chapter 6
trauma, pericarditis, pleurisy
if costochondritis, consider local steroid/xylocaine injections for extreme, chest wall pain consider nerve block herpes zoster
acute - provide stepwise analgesia (see Pain) ischemia
use appropriate cardiac medications - nitroglycerin, nitrates, calciumchannel blockers, beta blockers Chapter 7
pneumothorax
manage acutely with chest tube and suction, if appropriate Mount Sinai Hospital/Casey House Hospice

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