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4/20/2015 ETSU Internal Medicine Medicine Board Review Patrick J. Macmillan, MD, FACP Diplomate of the American Board of Psychiatry and Neurology Diplomate Hospice and Palliative Medicine East Tennessee State University Disclosures and Conflicts I, Patrick J. Macmillan MD, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. Introduction Common psychiatric mood and anxiety disorders Psychiatric Emergencies STAR D Trial (evidence based treatment for depression) Psychiatric medications: adverse reactions and drugdrug interactions Dementia Processes Somatization Disorders 1 4/20/2015 Introduction Palliative Medicine End of life care (Hospice) Psychosocial issues Medication issues Common Psychiatric Disorders You evaluate a 60 year old woman for increased irritability and anxiety. She was in a MVA 4 months ago. Since the accident she reports nightmares about the incident and is afraid to drive. She reports poor poor sleep and her husband says she has become more socially isolated. She denies any thoughts of harming herself. Physical exam is otherwise normal. What is the most likely diagnosis? Common Psychiatric Disorders er 0% om pu lsiv st e D tr au iso m ... at ic S tr es s D iso rd r rd e 0% siv e Di so ty D iso xie Ob s es siv e‐ C ep re s An ed ajo r D M Ge ne ra liz 0% rd er 0% Po A. Generalized Anxiety Disorder B. Major Depressive Disorder C. Obsessive‐ Compulsive Disorder D. Posttraumatic Stress Disorder 2 4/20/2015 Common Psychiatric Disorders Posttraumatic stress disorder Diagnostic Features---Exposure to traumatic event, intrusive thoughts (nightmares, flashbacks) Persistent avoidance of stimuli associated with the event Negative alterations in cognition/mood (diminished interest or participation in significant activities) Marked alterations in arousal and reactivity (e.g. irritable behavior and exaggerated startle response) Duration of disturbance greater than 1 month Common Psychiatric Disorders Generalized Anxiety Disorder Diagnostic Features: excessive anxiety and worry about a number of events or activities—greater than 6 months “Worry wart” Individuals find it difficult to control worry Restlessness, easy fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance Common Psychiatric Disorders 3 4/20/2015 Common Psychiatric Disorders Obsessive-Compulsive Disorder Diagnostic Features: (Obsessions) recurrent or persistent thoughts, urges or images that are intrusive and unwanted causing marked anxiety and stress. (Compulsions) repetitive behaviors such as washing hands checking, or counting that individuals feels driven to perform. “As Good As it Gets” Common Psychiatric Disorders An 84 year old man who is living in a SNF is brought to your office by his daughter who reports he has become less active in the past few months. No change in mood noted. He has multiple somatic symptoms such as headache, scalp pain and constipation. These are longstanding. No weight loss noted. His wife recently died 4 months ago. He has osteoarthritis and takes Acetaminophen. PE is unremarkable except for slow response time. He answers questions appropriately. Labs are all normal. Which diagnostic test is the most appropriate to perform next? Common Psychiatric Disorders A. Dix‐Hallpike maneuver B. Mini‐mental Status Examination (MMSE) C. PHQ‐9 depression assessment D. Timed “Up & Go” test 0% 0% 0% M Di x in i‐m en ta l ‐H al lp ik e m an eu ve r St at us PH E Q xa ‐9 m d in ep a. re .. ss io n a ss es sm Ti en m ed t “U p & G o” te st 0% 4 4/20/2015 Common Psychiatric Disorders A 28 year old man is evaluated for a 3 month history of lack of energy, hypersomnolence, and depressed mood. He is experiencing disinterest in hobbies and finding it more difficult to perform his duties as a physician. In the past he had periods where he experienced euphoric moods and needing little sleep. In those periods he found himself engaged in risky behaviors. There is a family history of alcohol abuse. Which is the most appropriate treatment? Common Psychiatric Disorders A. Duloxetine B. Lamotrigene C. Clonazepam D. Fluoxetine uo xe tin e 0% Fl on az e pa m 0% Cl tin e xe Du lo 0% La m ot rig en e 0% Common Psychiatric Disorders Mood Disorders Major Depression Depression, NOS Bereavement Bipolar Disorder 5 4/20/2015 Common Psychiatric Disorders Major Depression Diagnostic features: (1)depressed mood or (2) loss of interest or pleasure----2 weeks Weight loss, sleep disturbance, psychomotor agitation, loss of energy, feelings of worthlessness/guilt, poor concentration, recurrent thoughts of death Common Psychiatric Disorders Other Specified Depressive Disorder Recurrent brief depression: depressed mood with only 4 other symptoms lasting 2-13 days which occurs once a month Short duration depressive episode (4-13 days) Depression Scales: Beck Depression Checklist, Hamilton Depression Inventory, Patient Health Questionnaire (PHQ-9), Geriatric Depression Scale PHQ-9 is a validated tool with sensitivity of 80-90%, specificity of 90% (www.cqaimh.org/pdf/tool_phq9.pdf) Common Psychiatric Disorders Persistent Complex Bereavement Disorder Diagnostic features: Experienced the death of someone close; longing for the deceased, intense sorrow, preoccupation with the deceased, preoccupation with the circumstances of the death Normal Grief: feeling of emptiness or loss, lasts days to weeks and occurs in waves (“pangs of grief”); May be accompanied by positive emotions and humor; self esteem usually preserved. 6 4/20/2015 Common Psychiatric Disorders Bipolar Disorder Diagnostic features: abnormally, persistently elevated, expansive or irritable mood and persistently increased activity or energy that is present for most of the day, nearly every day, for a period of at least a week Major Depressive Episode Social Rhythm Therapy What is the most appropriate next step? A. Schedule the patient for a dementia evaluation. B. Reduce the patient’s Divalproex dose. C. Add Donepezil to the patent’s medication regimen. D. Check the patient’s serum ammonia level. 0% 0% ec k t h e p pe zil to Ch r a .. nt fo at ie nt he p Do ne Ad d e th e pa t ie du l uc e t Re d Sc he 0% ’s D iv a lp . E. Order a CT scan. 0% ... th e pa at te ie nt nt .. ’s s er um .. . Or de r a C T sc an . 0% Key point Hyperammonemia is an adverse effect of Valproate. Thus, a change in cognitive status should prompt a careful evaluation of liver and pancreatic function, which should include obtaining serum ammonia levels. 7 4/20/2015 Psychiatric Emergencies A 45 year old Schizophrenic male presents to the ER by EMS with rigidity, fever and confusion. On physical exam he is febrile with a temperature of 103.5. You are unable to illicit any history from the patient and EMS has left. What do you suspect is happening? Psychiatric Emergencies A. Tardive Dyskinesia B. Extra Pyramidal Symptoms C. Neuroleptic Malignant Syndrome 0% s M al ig na nt S y. Se .. ro to ni n S yn dr om e es ia 0% Ne ur ol ep tic D ys kin ra m id a l Ex tr a P y 0% Sy m pt om 0% Ta rd iv e D. Serotonin Syndrome Psychiatric Emergencies A 54-year-old female presents to the emergency room with confusion. She is noted to be on bupropion at the maximum dose, and recently was prescribed Escitalopram in a small dose. 8 4/20/2015 What is the likely cause of her confusion? A. Dissociative Episode B. Delirium C. Seizure D. Stroke os e ke 0% ru g o ve rd St ro m so d pi iriu De l e E 0% D Di ss oc ia tiv 0% e 0% e 0% Se izu r E. Drug overdose Psychiatric Emergencies A patient is being treated for depression with Sertraline 50 mg. She mentions to you that she has been taking some St. John's Wort as well, and would like to know if she could take both of them together. What adverse reaction can result with this combination? Psychiatric Emergencies A. Neuroleptic Malignant Syndrome B. Tardive Dyskinesia C. Serotonin Syndrome D. Hepatic Failure 0% 0% 0% 0% 0% Ne ur ol ep tic M al ig na nt S Ta y. rd .. iv e Dy sk Se in ro es to ia ni n S yn dr om He e pa t ic Fa ilu re Re na l F ai lu re E. Renal Failure 9 4/20/2015 Key points Neuroleptic Malignant Syndrome: muscle cramps or rigidity, fevers, autonomic instability, confusion, elevated CPK—associated with D2 blockade Serotonin Syndrome: myoclonus, sweating, shivering, hyperreflexia; Hyperthermia, elevated BP, hyperactive bowel sounds---associated with SSRI’s Tardive Dyskinesia: Grimacing, tongue movements, lip smacking, lip puckering, Pursing of the lips, excessive eye blinking EPS: akathisia or akinesia All anti-depressants can lower the seizure threshold Remember Linezolid (zyvox) and use of SSRI’s Psychiatric Emergencies The incidence of benign rash with lamotrigine is approximately: Psychiatric Emergencies A. 5% B. 10% C. 15% D. 20% E. 25% 0% 0% 0% 25 % 20 % 15 % 0% 10 % 5% 0% 10 4/20/2015 Key points Key points Key points Stevens–Johnson syndrome (SJS) usually begins with fever, sore throat, and fatigue, which is commonly misdiagnosed and therefore treated with antibiotics. Ulcers and other lesions begin to appear in the mucous membranes, almost always in the mouth and lips but also in the genital and anal regions. Those in the mouth are usually extremely painful and reduce the patient's ability to eat or drink. Associated with Lamotrigine 11 4/20/2015 Evidence Based Medicine A 38 year old female returns to your clinic for follow up. She has major depression for the past 5 months. She was started on Sertraline (Zoloft) 50 mg/day and after 6 weeks her symptoms marginally improved. The dose was increased to 100 mg/day with slight improvement. After an additional 6 weeks the dose was maximized to 200 mg/day with no additional improvement. What would you recommend? Evidence Based Medicine A. Stop Sertraline and start Fluoxetine (Prozac) B. Add Buspirone (buspar) C. Switch to Escitalopram (lexepro) D. Add Buproprione (wellbutrin) 0% .. a. e (p to N or tri p ty lin ... ut rin ex e el lb e (w pr am (l rio n Bu pr op Ad d 0% ) 0% Sw itc h u. .. ne (b to E sc ita lo st ar t F l an d B us pi ro Ad d Sw itc h Se rt ra lin e St op 0% us pa r) 0% E. Switch to Nortriptyline (pamelor) Evidence Based Medicine STAR*D Trial (Sequenced Treatment Alternatives to Relieve Depression) The NIMH-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study was conducted to determine the effectiveness of different treatments for people with major depression who have not responded to initial treatment with an antidepressant. This is the largest and longest study ever conducted to evaluate depression treatment. http://www.nimh.nih.gov/health/trials/practical/stard/index.shtm l 12 4/20/2015 Key points Level 1: SSRI (Citalopram) Level 2: SSRI + bupropion or CBT Level 3: SSRI or Other + Lithium or triiodothyronine (T3) Level 4: MAOI’s (tranylcypromine) Psychiatric medications You are evaluating a 55 year old male patient in the ER for mental status changes. He is unable to provide a history but you check the EHR and find he has multiple admissions to Woodridge Hospital for bipolar disorder. You astutely note that he was started on an ACE inhibitor on his last admission to Woodridge several weeks ago. You note tremors bilaterally in his hands along with hyperreflexia. The psychiatry tech with him notes that his balance has gotten worse over the past day or so. Otherwise PE is normal aside from obvious disorientation. BUN and creatinine are 40 and 2.6, respectively. Other labs and tests are normal. Which of the following drugs is the most likely the cause of this man’s symptoms? Psychiatric medications A. Amitriptyline (Elavil) B. Paroxetine (Paxil) C. Aripiprazole (Abilify) D. Lithium 0% Lit hi um c A cid (D ep ak ot e) 0% Va lp ro i l) ax i Ab ili ra z ol e ( e (P 0% fy ) 0% Ar ip ip Pa ro xe tin El av il) 0% Am itr ip ty lin e ( E. Valproic Acid (Depakote) 13 4/20/2015 Key points Lithium: Commonly used for Bipolar Disorder and occasionally refractory depression Renal Execretion (urine 95%); half life 24 hr Watch for toxicity when used with NSAIDs, ACE or dehydration Diabetes insipidus Ebstein’s Anomaly Psychiatric medications A 50 year old female comes to your office for severe hot flushes limiting her quality of life and causing vaginal dryness. Her history is significant for stage II, estrogen and progesterone receptor positive, HER2-negative, invasive right breast cancer for which she received chemotherapy and radiation. She was diagnosed 1 year ago and has been taking tamoxifen for 3 months. She has been amenorheic since her 4th cycle of chemotherapy. Attempts to control the hot flushes by non-pharmacologic means has failed. Further exam and history is otherwise unremarkable. Which of the following is the most appropriate therapy? Psychiatric medications A. Fluoxetine B. Low-dose estrogenprogesterone in e os h fa x oh 0% Ve n la ck C e ro ge s.. . ‐p uo xe tin se e st ro ge n 0% ‐d o Fl 0% Lo w D. Venlafaxine 0% Bl a C. Black Cohosh 14 4/20/2015 Key points SSRI’s (e.g. Fluoxetine, Paroxetine, Sertraline): Potent CYP2D6 inhibitors SNRI’s (e.g. Venlafaxine, Duloxetine) Others (bupropion, mirtazipine) Avoid in seizure disorders or eating disorders--bupropion Metabolic syndrome—Mirtazipine Psychiatric medications A 26 year old male who you treat for seasonal allergies and occasional GERD symptoms comes to your office. He has a history of schizoaffective disorder and comes to your office for his annual physical exam. You note he has gained 30 lbs. in the past year (BMI of 28), and his blood pressure is 148/95. Lipid panel reveals triglycerides of 256. He tells you “Dr. Mac” has placed him on a new medicine 6 months ago. Which new medicine is the patient likely taking that has caused the changes noted. Psychiatric medications A. Haloperidol B. Lithium C. Olanzapine D. Bupropion E. Aripiprazole ip on ro pi 0% ra zo le 0% Ar ip 0% Bu p Lit h iu m 0% Ol an za pin e Ha l op er id ol 0% 15 4/20/2015 Key points Typical and Atypical Antipsychotics (e.g Haloperidol, Olanzapine) Atypicals: Metabolic Syndrome Aripiprazole and ziprazidone are less likely to cause Metabolic Syndrome 3 of 5 criteria: abdominal (central) obesity, elevated blood pressure, elevated fasting plasma glucose, high serum triglycerides, and low high-density cholesterol (HDL) levels. Psychiatric medications An 80 year old female had a hip fracture repaired 3 days ago and has developed a UTI and episodes of atrial fibrillation with RVR. She is experiencing a delirium and her medications include digoxin, diltiazem, bactrim, haloperidol, and enoxaparin, which have been started while in the hospital. Her past medical history includes PAF. Vitals are stable. EKG is performed and shows a QTc of 520 (baseline QTc of 420). Which of the following medications is most likely the cause of the EKG changes? Psychiatric medications A. Diltiazem B. Enoxaparen C. Haloperidol D. Bactrim 0% Ba ct rim er id Ha lo p m xa En o Di lti az e 0% ol 0% pa re n 0% 16 4/20/2015 Key points Haloperidol and other psychiatric medications can prolong QT interval thereby lengthening cardiac repolarization If QTc is greater than 500 msec or has increased by 60 msec or more than the offending agent should be stopped because of the risk of torsades de pointes Dementia Processes Why should TCA’s be avoided in elderly patients with Alzheimer's Disease? Dementia Processes A. They worsen cognition B. They cause weight gain C. They cause sedation D. They cause dry mouth 0% 0% 0% 0% n c og Th nit ey io ca n us e w ei gh Th t g ey ai ca n us e s Th ed ey at io ca n Th us ey e d ca ry us m e ou ur th in ar y re te nt io n 0% Th ey w or se E. They cause urinary retention 17 4/20/2015 Dementia Processes Which SSRI is most likely to worsen cognition in a patient with Alzheimer's Dementia? Dementia Processes A. Paroxetine B. Sertraline. C. Fluoxetine D. Fluvoxamine E. Citalopram 0% pr am 0% ta lo Ci Fl uv ox am in e e . in e 0% uo xe tin Fl xe tin e Pa ro 0% Se rtr al 0% Dementia Processes The head CT scan of a 68-year-old female patient experiencing memory difficulty is interpreted by the radiologist as showing "mild age-appropriate generalized atrophy with signs of periventricular white matter disease." Also, neuropsychological testing reveals borderline functioning in the area of orientation and memory, without any other abnormalities. You set up a meeting with the patient and her family to discuss the meaning of these findings and the course of treatment. What would be LEAST appropriate to tell them at this meeting? 18 4/20/2015 Dementia Processes The patient may be at an early stage of a dementing process. The patient should start thinking about legal processes such as designating powers of attorney, advance directives, and establishing a will. D. The patient should have a neurological consultation. E. At this stage, the patient can continue independent functioning. 0% 0% 0% 0% ul sh o ea rl. . Th e p e a t a n as A lzh h at ie nt Th e p m ay b at ie nt at ie nt Th e p 0% ei m er ’ .. . The patient has Alzheimer’s Dementia. C. . d s at ta ie rt nt th sh At in ou ... th ld is s h av ta e ge a , t n. he .. p at ie nt ca n. .. B. Th e p A. Key points Alzheimer’s Dementia: linier cognitive decline; early onset Vascular dementia: step-wise decline; later onset Lew body dementia: visual hallucinations (seroquel) Parkinson’s dementia: prior history Frontal lobe Dementia: inappropriate behavior; early onset BLACK BOX Warning: Long term use (greater than 30 days) Antipsychotic medications and Dementia---Cerebrovascular and cardiovascular events Somatoform Disorders A patient presents with his family to the emergency room. He complains of leg paralysis that begun a week after his father died. The doctor tests the patient for the Hoover sign by asking the patient to lift the normal leg while placing his hand under the heel of the paretic leg. The results of this test are a possible indication of which disorder? 19 4/20/2015 Somatoform Disorders A. Body Dysmorphic Disorder B. Conversion Disorder C. Dissociative Disorder NOS. D. Hypochondriasis iso r ia sis de r 0% n D So m at iza tio rd e iso e D tiv dr r N OS . 0% oc ho n r de r rd e iso r n D nv er sio Di so 0% Di ss oc ia ys m or ph ic Co y D Bo d 0% Hy p 0% E. Somatization Disorder Key points Body Dysmorphic Disorder: Michal Jackson Conversion Disorder: Unexplained neurological issue Hypochondriasis: Medical students. “I think I have a brain tumor” for tension headache Somatization Disorder: Female, under 30, GI, GU, pain, neurological “symptoms” Malingering: secondary gain Factitious disorder: look for someone in the medical field intentionally producing illnesses “munchausen by proxy” Factitious disorder 20 4/20/2015 Palliative Medicine A 78-year-old man with metastatic colon cancer is admitted with dehydration and anorexia. Upon discussion with the patient, he tearfully reveals that he feels fatigued, has a poor appetite, has lost 5 lbs over the past month, and remains in bed for a majority of the day. His wife reports that on some days he is tearful and spends a great deal of time talking about his death. Both are in agreement that he still looks forward to spending time with his grandchildren. Which one of the following options is the most appropriate diagnosis of the patient’s mood disorder? Palliative Medicine A. Major depressive disorder B. Anticipatory grief C. Cancer-induced failure to thrive 0% 0% 0% Ca nc ep ajo r d M 0% re ss ive d iso rd An er tic ip er at ‐in or du y g ce rie d f fa ilu re to t. .. 0% E. Hypoactive delirium Sa Hy dn po es ac s t iv e d el ir iu m D. Sadness Palliative Medicine An 88-year-old man with advanced dementia is admitted to the hospital for his third episode of pneumonia over the past 5 months. He has lost 5 lbs over this time period. He is unable to participate in discussions about his care, although his adult daughter is his documented health care proxy and has taken over making decisions for him. A speech and swallowing evaluation clearly demonstrates that he is aspirating thin and thick liquids. The patient’s daughter asks about the possibility of a feeding tube. Which one of the following responses to her questions is the most appropriate? 21 4/20/2015 Palliative Medicine Feeding tubes have been shown to reduce aspiration pneumonia in patients with dementia C. Video swallowing studies are very sensitive and specific to predict who will develop aspiration pneumonia D. There is no evidence that a feeding tube will either prolong life or reduce aspiration risk in patients with advanced dementia E. Feeding tubes will not help him gain weight or remain at a stable weight 0% 0% 0% 0% Fe ed He i 0% ot a ca nd id at in e f g t or ub a es fe Vi h ... de av o e b sw ee al n lo s. w Th . . in er g s e i tu s n di o e es ar v id Fe ... e ed nc in e t g t ha ub t a es .. w . ill n ot h elp ... He is not a candidate for a feeding tube B. s n A. Palliative Medicine A 65-year-old man with NSCLC is admitted to the hospital after his wife found him tachypneic and with impaired speech at home. She reports that this is new, as of 12 hours ago. His medications include fentanyl patch and hydromorphone for pain, and metoclopramide for nausea; he was recently started on haloperidol for increasing confusion on a previous hospital admission. On exam, he is tachypneic and restless in bed with continuous movements of his hands and feet. He is unable to appropriately answer complex questions. Which one of the following steps in management is the most appropriate to ensue with this patient? Palliative Medicine D. Add olanzapine 5 mg PO every 12 hours E. Rotate his fentanyl as this is a true allergic reaction to additives in the patch 0% 0% 0% 0% 0% Di sc f h on al op tin er ue id A S h ol al TA op T er he id ad ol C a Ad T t .. d o ola ev a lu nz ap at in e f Ro e .. ta 5 m te h g i s PO fe e nt ve an .. yl a s t hi s is .. . A STAT head CT to evaluate for possible CNS metastasis os e o C. is d Discontinue haloperidol and metoclopramide h B. ble Double his dose of haloperidol Do u A. 22 4/20/2015 Key points Anticipatory Grief No evidence to support Feeding Tubes Remember EPS: “continuous movements of hands and feet”---Akathesia Palliative Medicine A 20-year-old female was in a motor vehicle accident and had prolonged resuscitation in the field prior to regaining a pulse 72 hours ago. She remains intubated and nonresponsive with no sedatives in the ICU. Her core body temperature is 36.5 °C (97.7 °F). Her pupils are 3 mm, equal, and nonreactive to light bilaterally. She has no corneal, oculocephalic, or oculovestibular reflexes and cannot be stimulated to gag. She has no motor responses to painful stimuli. The neurointensivist performed a 10 minute apnea test in which her PC02 rose by >10 mmHg on arterial blood gas; she had no spontaneous respirations. Which one of the following steps in management should ensue with this patient’s care? Palliative Medicine Perform an EEG E. Correct all electrolyte abnormalities 0% 0% 0% 0% 0% RI b ra ng in to fu lo rt he ok r ... is rfo n rm ee a de se d. co .. nd e xa m in at Co i .. Pe rr ec rfo t a rm ll e a le n E ct EG ro ly te a bn o. .. D. Pe Perform a second examination to assess her brainstem reflexes, body temperature, and presence of apnea rm a n M C. th i Nothing further is needed—she qualifies for brain death rfo B. No Perform an MRI brain to look for cerebral blood flow Pe A. 23 4/20/2015 Key point a second exam is needed to declare brain death. If a patient has a core temperature above 32 °C, she has no brainstem reflexes as evidenced by gag, corneal, oculocephalic, and oculovestibular, and a positive apnea test (a 10 mmHg rise in CO2 within 10 minutes and no spontaneous respirations), and this is verified by a repeated exam, the patient meets brain death criteria. Any doctor can perform a brain death test SOURCE: Morenski JD. Determination of death by neurological criteria. J Intensive Care Med. 2003; 18(4): 211-221. Palliative Medicine Which one of the following factors is the most important predictive factor in cancer survival? Palliative Medicine A. Age B. Sex C. Symptom burden D. Performance status di ic a l c o m or bi ed M Pe 0% tie s 0% rfo rm an om b ur Se x de n 0% ce st at us 0% Sy m pt 0% Ag e E. Medical co morbidities 24 4/20/2015 Key points A patient’s functional ability is a measure of how much a patient can do for themselves, their activity, and energy level. Patients with solid tumors typically lose ~70% of their functional ability in the last 3 months of life. The most common scales used to measure functional ability are the Karnofsky Index and the ECOG scale (Eastern Cooperative Oncology Group). Age, sex, symptom burden, and co morbidities have not been shown to be a reliable predictor of survival. SOURCE: Lamont EB, Christakis NA.. Complexities in prognostication in advanced cancer. JAMA. 2003; 290:98-104. Palliative Medicine A 47-year-old male with severe COPD is admitted to the ICU with hypercapnic respiratory failure requiring intubation. After 48 hours on a ventilator, he is successfully extubated and remains on high-flow oxygen via nasal cannula. He is frustrated with his recurrent hospitalizations and experiences dyspnea with minimal exertion. Palliative care is consulted to discuss advance care planning with him and his wife. Which one of the following variables is most predictive of poor one year survival? Palliative Medicine A. Age B. Smoking status C. Oxygen requirement D. Percent predicted FEV1 Ag e 0% 0% 0% 0% in g Ox st at yg us en re qu Pe ire rc m en en t p t re di ct To ed ta FE l l un V1 g c ap ac it y (T LC ) 0% Sm ok E. Total lung capacity (TLC) 25 4/20/2015 Key points An FEV1 <35% predicted is indicative of severe COPD and using the BODE index to calculate 1 and 2 year survival is indicative of worse survival. Although COPD is difficult to prognosticate for shorter-term survival, studies have shown that FEV1 percent predicted, BMI, 6 minute walk distance, and a dyspnea scale (0 = no dyspnea, to 4 = dyspneic when dressing) are helpful in predicting 1 year and 2 year mortality. Elevated pCO2 >50 mmHg and mechanical ventilation >72 hours have also purported poor survival. SOURCE: Celli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Eng J Med. 2004; 350(10):1005-12 Palliative Medicine An 86-year-old man, with end stage renal disease on hemodialysis, is admitted to the hospital for hypertensive emergency. His blood pressure is controlled via IV mediations and an emergent session of dialysis. Because of concern for cardiac arrest necessitating CPR, a codestatus discussion is initiated with him and his adult children. His son asks if his heart would stop and he needed prolonged CPR, what his chance of survival is. Which one of the following options is the most associated with poor survival to discharge post-CPR? Palliative Medicine A. Asystole or pulseless electrical activity (PEA) as the etiology of the arrest B. Myocardial infarction C. Hypertension .. Ra ce 0% Ve nt ric ul ar fib r il ar di ul r p M yo c e o As ys to l 0% s t he . 0% se le ss e le ct ric .. al in fa rc tio n Hy pe rt en sio n 0% n a 0% E. Ventricular fibrillation as the etiology of the arrest la tio D. Race 26 4/20/2015 Key points In hospital cardiac arrests with prolonged resuscitation, there is a poor survival to discharge for all patients, with only approximately one-quarter of these patients surviving to discharge. If asystole or pulseless electrical activity occurs, 10% or less of these patients survive to discharge. Of patients surviving to discharge post resuscitation, only one-half of these will be able to return home. Factors shown to increase likelihood of survival to discharge are MI, HTN, and ventricular fibrillation or pulseless ventricular tachycardia on arrest. SOURCE: Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: A report of 14,720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003; 58 297-308 Palliative Medicine A 72-year-old Chinese-speaking woman with advanced gastric cancer is admitted with nausea and vomiting. She speaks minimal English; however, she has a son who speaks fluent English with her in her hospital room who has offered to translate for his mother. You are asked to help with management of her nausea and vomiting, and discuss goals of care. Which one of the following steps in assessment is the most appropriate to ensue with this patient? Palliative Medicine Allow the son to interpret as long as the patient is in agreement with this C. Ask the patient’s nurse to translate, as she is also Chinese-speaking D. Begin the conversation in English, as she is able to answer many “yes/no” questions; get an interpreter for more detailed discussion after she is feeling better E. Allow the son to interpret for his mother—a family member is an accepted form of translation 0% 0% 0% 0% 0% r a C hi ne se in w th te rp e so re te n As to r.. k in . th te e rp pa re tie t a nt Be s.. ’s n gi . n t ur he se to c o tr nv Al ... er lo w sa th tio e n so in n E to n. .. in te rp re t f o. .. B. Al lo Ask for a Chinese interpreter prior to proceeding any further with the consult As k fo A. 27 4/20/2015 Key point you must use a certified medical interpreter for all interactions to ensure that you are effectively communicating with your patient. It is not acceptable for a family or staff member to serve as an interpreter. Professional interpreters ensure that the patient is hearing exactly what you say and vice versa. Has been shown to improve communication between language discordant patients and clinicians. Palliative Medicine A 22-year-old male with testicular cancer is started on immediate-release morphine for pain control. Which one of the following options is the most appropriate indicator of potential opioid abuse problems? Palliative Medicine 0% 0% 0% 0% d d os e es ca la ... dr a st w s t a l o m sy . Ar .. ul ou tip nd le p ‐th hy e‐ sic Di clo ... ffic ck n ult ee y c d f on or ce t. nt . ra tin g af te r .. . 0% w ith ue Difficulty concentrating after taking a dose Re q E. r r ap i Around-the-clock need for the immediate-release morphine in g D. fo Requests to multiple physicians for prescriptions and regular need for early refills ee d C. er ie nc Experiencing withdrawal symptoms with cessation of the drug A n A need for rapid dose escalation B. Ex p A. 28 4/20/2015 Key point Requests for more than one physician to write prescriptions for pain medications and regular need for early refills. Signs of opioid abuse or misuse include use causing adverse life events, need for early refills or “lost” prescriptions, asking for specific medications by name, or asking multiple physicians for opioid prescriptions. The definition of addiction is primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. Although rare, some patients develop problems with opioid abuse and addiction; everyone on chronic opioids should be monitored for these signs. Rapid dose escalation and need for around-the-clock dosing are often related to pseudoaddiction, which occurs from under-treated pain. Remember Pseudoaddiction Palliative Medicine A 62-year-old man with advanced head and neck cancer is admitted to the hospital with local wound breakdown and pain. He notes that over the past 24 hours he had a small amount of hematemesis that spontaneously resolved. On physical exam, the patient has a large tumor on the left side on his neck with erosion through the skin and areas of oozing that cause significant pain with neck rotation. The patient wishes to focus on comfort and is hopeful to go home although he lives alone. Which one of the following steps in management is the most appropriate to ensue with this patient? Palliative Medicine Assess his swallowing function for safety to continue pills by mouth B. Discuss the possibility of carotid blowout syndrome C. Increase his long-acting pain medication by 25% D. Ask for a wound care nurse evaluation and plan for dressing changes E. Explain to the patient that he is not able to leave the hospital 0% 0% 0% 0% 0% As se ss h is s w a ll Di sc ow us in s t g he fu nc p os In ti. sib cr . ea i li se ty h o is f c lo a As r .. ng k . ‐a fo ct r a in w g p ou a i. Ex nd .. pl ca ai n t re n o t ur he se p .. at . ie nt th at h e. .. A. 29 4/20/2015 Key point Discuss possible carotid blowout as this patient is at very high risk for a catastrophic bleed. Carotid blowout is the rupture of any portion or branch of the extracranial artery. Risk factors for this include prior radiation, extensive surgery, skin breakdown, or infection. A sentinel bleed—orally or transcervical— indicates a higher likelihood of impending rupture. Careful discussion about goals of care and symptom management are necessary, including use of dark colored towels, acute medication strategies, and what home support is available. Although an increase in his pain medication or change in wound care may be warranted, this is not nearly as important as recognizing the signs of impending carotid blowout SOURCE: Harris DG, Noble SI. Management of terminal hemorrhage in patients with advanced cancer: a systematic literature review. J Pain Sympt Manage. 2009; 38:913-27. Palliative Medicine An 85-year-old man, with colon cancer and a large metastatic burden in his liver, has continued to have a poor appetite and early satiety. He remains at home with hospice, but is now mostly bedbound and eats a few bites at a time from large meals his wife continues to cook for him. He denies any nausea or constipation as well as any sensation of hunger. His family is concerned that he is not taking in enough calories to maintain his strength. Which one of the following steps in management is the most appropriate to ensue with this patient? Palliative Medicine 0% St ti. ar . ily t m t h et at hy h lp e he i.. . ni da te 5 m g. .. 0% va lu a ni st e la in t o h ut rit io Ex p 0% is fa m rie o ra ... 0% n e 1 ig h‐ ca lo 5 m g. .. 0% r a Start methylphenidate 5 mg with meals az ap in E. h Explain to his family that he is not experiencing any discomfort or hunger and that anorexia is a common side effect of advanced cancer As k fo Ask for a nutritionist evaluation and consultation D. e m irt C. m en d Recommend high-calorie oral supplements Re co m Prescribe mirtazapine 15 mg daily B. Pr es cr ib A. 30 4/20/2015 Key points discuss with the family the nature of cancer, cachexia, and the frequency of anorexia with advanced disease. Although patients are not troubled by their lack of PO intake, many family experience distress around poor feeding and nutrition. Given his short life expectancy and progression of disease, no medications are effective in treating the expected cachexia and anorexia seen at the end of life. Oral supplements for forced oral intake can cause significant nausea and vomiting and is not recommended. While helpful in early-stage cancers, nutritionists do not have a role in the end stage cancer cachexia. SOURCE: Strasser F, Bruera E, Update on anorexia and cachexia. Hematol Oncol Clin North Am 2002; 16:589-617. Palliative Medicine A 52-year-old woman, with metastatic ovarian cancer, is admitted with nausea, vomiting, and 48 hours of acute abdominal pain. A CT scan of her abdomen and pelvis reveals a single site of complete bowel obstruction in her descending colon, likely from a new metastatic lesion. An NG tube is placed with a large amount of bilious output, and her nausea and vomiting subside. Prior to admission, she was working part-time in the business she owns with her husband. On physical exam, she appears comfortable with diffuse abdominal tenderness and hypoactive, high-pitched bowel sounds. Which one of the following steps in the management of her bowel obstruction is the most appropriate to ensue with this patient? Palliative Medicine Consult interventional radiology for possible stent placement D. Keep the patient NPO and reassess her physical exam in 48 hours E. Start metoclopramide 10 mg IV every 6 hours 0% 0% 0% 0% 0% t o th e p at ie t s nt ur a ge nd Co ry h fo ns .. r p ul t i os nt s i er ble ve Ke .. nt . ep io th na l r e p ad at io ie St ... nt ar N t m PO et a oc nd lo r. pr .. am id e 1 0 m g . . C. la in Consult surgery for possible surgical interventions ns ul B. Ex p Explain to the patient and her husband that there is nothing more to offer her and hospice would be helpful in keeping her comfortable at home Co A. 31 4/20/2015 Key points Consult surgery for possible surgical interventions. Malignant bowel obstruction is a common complication of ovarian cancer. Decision making in management of bowel obstruction relies on several factors: site of obstruction; single vs. multiple sites of obstruction; clinical assessment; patient’s age; functional status; and functional vs. mechanical obstruction. Presence of carcinomatosis, failed chemo trials, ascites: Unlikely to benefit from surgery (ascites= NO PEG) A surgical intervention is preferred when a patient has a good performance status, there is a single site of mechanical obstruction, and distal bowel affected Metoclopramide must be avoided in complete obstructions, as it could cause an exacerbation of her pain. SOURCE: Ripamontia C, Eassonc M, Gerdesd H. Management of malignant bowel obstruction. European Journal of Cancer 2008; 44: 1105-1115. Palliative Medicine A 48-year-old female, with head and neck cancer undergoing concurrent chemotherapy and radiation, is admitted to the hospital with failure to thrive. She has lost a significant amount of weight (>20 lbs) since beginning treatment. She denies significant nausea, vomiting, or odynophagia limiting her intake, but notes that she does not have any appetite. On physical exam she is cachetic with dry mucus membranes and no oral lesions or evidence of thrush. Abdominal exam is unremarkable. Her oncologist talked with her about use of megestrol acetate during an outpatient visit and she asks if this would be helpful. Which one of the following options would make use of megestrol acetate contraindicated? Palliative Medicine A. History of gastrointestinal bleeding B. History of arrhythmia C. Current use of dexamethasone D. Renal insufficiency 0% 0% 0% Cu as tro i Hi st or y o f g Hi st or 0% nt es tin al b ... y o rr en f a t u rrh se yt o hm f d ia ex am et ha Re so Hi na st ne or l in y o su f t f fi hr cie om nc bo y em bo lic .. . 0% E. History of thromboembolic events 32 4/20/2015 Key points Megestrol acetate, a synthetic progestin, is useful in some patients with cachexia and severe anorexia to aid in weight gain. Although the results are modest (less than 30% of patients will have a significant response), the medication is extremely helpful for selected patients. The side effects are generally mild and the only strong contraindication is a history of thromboembolic events. SOURCE: McQuellon RP. Supportive use of megestrol acetate with head/neck and lung cancer patients receiving radiation therapy. Int J Radiat Oncol Biol Phys. 2002; 52:11805. Disease Prognosis: Impending Death Last hours Prognostic signs: Death Rattle, jaw movement with breathing, Acrocyanosis (mottling), radial pulselessness Feeding Tubes: DO NOT prevent aspiration, NO evidence of benefit Respiratory Congestion (Death Rattle): reposition, stop IVF, meds (robinol), DO NOT suction. Remember: IVF DO NOT treat sensation of thirst Psychosocial Aspects of Palliative Medicine Substituted Judgement: Family attempts to discern what patient would say if they were able Futility Principle: only approach this strategy after establishing rapport with family Thoughts of hastening death: Common, may be call for “help” don’t call Woodridge so fast... Pseudoaddiction: occurs when patients pain is under treated Family Meeting: satisfaction correlates with increased proportion of time that family members speak Breaking bad news: ALWAYS start by asking the patient of her understanding of the current situation 33 4/20/2015 Psychosocial Aspects of Palliative Medicine You are asked to do a consult on a 29-year-old man in a persistent vegetative state who was transferred from a nursing home with his fourth episode of urosepsis. He has a stage 4 pressure ulcer on his coccyx and severe contractures. During each hospitalization, he has had to be admitted to the intensive care unit (ICU) and put on vasopressors and a mechanical ventilator for 1 to 2 weeks. The ICU team feels that they have tried everything to convince the family that this care is futile. Still, the family persists in their hope for a miracle. When you sit down with the patient’s mother, she tells you that she is frustrated by the endless meetings and that she wants “everything done to help him.” She says that she feels like the ICU doctors do not care about her son, and she resents having to talk to you (“Do they make you talk to everyone?”). She says, “I cannot give up. I have faith that God will give me a miracle and bring my son back.” Which of the following would be the most appropriate response? Psychosocial Aspects of Palliative Medicine “Given how long your son has been asleep, it is very unlikely he will ever awaken.” B. “Maybe God has a different plan for your son.” C. “Have you thought about what we should do if you do not get a miracle?” D. “Why do you think your son will be the one to get a miracle?” E. “I can see how important a miracle is to you.” 0% 0% 0% 0% 0% “G iv en h ow lo “M ng ay yo be ur G so od h n h “H as .. av a e y di ffe ou re th nt “W ou . .. gh hy d t a o y bo ou ut w th “I ... in ca k y n s ou ee r s h on ow .. im . po rt an t a .. . A. Key points Developing a relationship is a critical first step when stepping into a previously conflicted relationship. Simple reflections that allow the family to be heard are better options than convincing statements or interrogative questions. 34 4/20/2015 THE END Good Luck 35