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Section IV: Psychosocial Issues Depression Anxiety Post-Traumatic Stress Disorder (PTSD) Delirium/agitation/confusion Core Depression Ranges from sadness to suicidal Often unrecognized and undertreated Occurs in 25-77% of terminally ill Distinguish normal vs. abnormal Should not be dismissed Cluster Fulcher, 2014; Pasacreta et al., 2015 Core Causes of Depression Disease-related Psychological Medication-related Treatment-related Social issues Core Assessment of Depression Situational factors/symptoms Previous psychiatric history Other factors (e.g., lack of support system, pain) Pasacreta et al., 2015 Core Suicide Assessment Risk factors for suicide History of declining functionality Psychiatric evaluation Core Pharmacologic Interventions for Depression Goal: Focus on symptom control Antidepressants (e.g. Amitryptiline- may take 4-6 weeks to be effective) Steroids (e.g. Dexmethasone) Pasacreta et al., 2015 Core Non-Pharmacologic Interventions for Depression Promote autonomy Grief counseling Draw on strengths Use cognitive strategies Core Anxiety Subjective feeling of apprehension Often without specific cause Categories of mild, moderate, severe Core Causes of Anxiety Physiological changes Medications and substances Pre-existing anxiety pre-diagnosis Uncertainty Pasacreta et al., 2015 Core Assessment of Anxiety Physical symptoms Cognitive symptoms Questions for assessment APA, 2013 Core Pharmacologic Interventions for Anxiety Benzodiazepines (e.g. Diazepan) Anticonvulsants (e.g. Carbamazepine) Core Non-pharmacologic Interventions for Anxiety Empathetic listening Assurance and support Concrete information/warning Relaxation/imagery Core Post-Traumatic Stress Disorder (PTSD) PTSD is characterized by persistent/severe reaction to a traumatic event Combat Terrorist attacks Sexual or physical assault Accidents National/natural disasters Symptom clusters Avoidance Re-experiencing the event Hyperarousal Implications for EOL Core PTSD and End-of-Life Care Illness/death can be a PTSD activator Challenges social ties Delirium or flashbacks? Medication GOAL: Reduce PTSD symptoms and create an emotionally safe environment Grassman, 2015 Core Delirium/Agitation/Confusion Delirium - Acute change in cognition/awareness Agitation or withdrawal - Accompanies delirium Confusion - Disorientation, inappropriate behavior, hallucinations Heidrich & English, 2015 Core Delirium/Agitation/Confusion: Causes Medications Infection Hypoxemia Bladder distention Unrelieved pain Other Core Delirium/Agitation/Confusion: Assessment Physical exam History Spiritual distress Other symptoms Heidrich & English, 2015 Core Delirium/Agitation/Confusion: Treatment Maintain Safety Pharmacologic Neuroleptics – Monitor for side effects, withdrawal – Eliminate non-essential/contributing medications – Reorientation Relaxation/distraction Hydration Core
