1. Review of Palliative Care for Non-Malignant Conditions Dr Michal Boyd, RN, NP, ND, FCNA (NZ), FAANP Sr. Lecturer and Gerontology Nurse Practitioner University of Auckland School of Nursing and Freemasons’ Dept. of Geriatric Medicine Waitemata District Health Board

2. Rates per 100,000 population, age-standardised to WHO World Standard Population. Five major causes of mortality NZ 1980–2009 2011 New Zealand Dementia Mortality 67/100,000 people Alzheimers New Zealand, Updated Dementia Economic Impact Report, 2011, New Zealand 2

3. Specialist Palliative Care Services > 60% of deaths are from non-cancer causes Almost 80% of hospice patience are dying from cancer 3

4. National Health Needs Assessment for Palliative Care Part 1: 2011 National Palliative Care Council Place of Death by Age Group 4

5. National Palliative Care Needs Assessment for Palliative Care: Phase II 2013 5

6. % Survival After Residential Aged Care Admission Connolly, Broad, Boyd, Gott, Australasian J Ageing, in press. 6

7. Variables associated with time to death in residents with length-of-stay under 1 month as at survey date (n=380): Proportional Hazards Model Hazard ratio95%CI Acute hospital into long-term hospital care (vs other pathway)2.021.24 to 3.31 Unable to manage personal care at all (vs some or no assistance)1.891.67 to 3.07 Unscheduled GP visit during prior 2 weeks (vs none)1.921.16 to 3.17 Number of admissions in 2 years prior to survey (vs none) One4.621.35 to15.74 Two4.501.30 to15.51 Three or more5.371.64 to17.63 Residential Aged Care ‘De Facto Hospice for Older People’? Connolly, Broad, Boyd, Gott et al. Australasian J Ageing (in press) 7

8. Chronic Illness Prognosis Determination Increases difficulty in providing ‘traditional’ models of palliative care delivery Several studies looking at frail older people are right about 70% of the time (AUC.67-.77) InterRAI Changes in Health, End-Stage Disease, Signs, and Symptoms Scale (CHESS) CHESS Index – Sex, age, co-morbidity, and CHESS Frailty Criteria for assisted living residents (.68 AUC) Hirdes JP, Frijters D, Teare G. 2003.Journal of the American Geriatrics Society 51(1): 96–100. Hogan, D., Freiheit, E., Strain, L., Patten, S., Schmaltz, H., Rolfson, D., & Maxwell, C. (2012). BMC Geriatrics, 12(1), 56. Kruse, R.L., Parker-Oliver, D., Mehr, D.R., et al., Medical Sciences 2010; 65A: 1235-1241. Mitchell, S.L., Miller, S.C., Teno, J.M., et al., Journal of the American Medical Association 2010; 304: 1929-1935. Porock, D., Parker-Oliver, D., Petroski, G.F., et al., BMC Research Notes 2010; 3: 200-208. 8

9. PALLIATIVE APPROACH TO CARE Lynn and Adamson, 2003 The transition to a palliative approach to care is not a “transition” from one form of care to another but is the last phase in the continuum of good care for patients with multimorbidity (Burge & Mitchell, BMJ, 2012:345) 9

10. Common End of Life Issues Weight Loss Pain Shortness of Breath Depression, Fear, Anxiety Functional Impairment Mobility Malignancy COPD Congestive Heart Failure End Stage Renal Disease Dementia General frailty – Comprehensive geriatric assessment 10

11. Cachexia versus Starvation Starvation: pure protein/energy deficiency (under- nutrition) Cachexia: cytokine-induced wasting of protein and energy stores, caused by effects of disease – Malignancy, COPD, End Stage Renal Disease (ESRD), Congestive Heart Failure (CHF) – Remarkably resistant to hyper-caloric feeding 11 Thomas, D. “Distinguishing Starvation from Cachexia.” Clinics in Geriatric Medicine. 2002; 18: 883-891

12. Cachexia versus Starvation StarvationCachexia AppetiteLate suppressionEarly suppression BMINot predictive of mortalityPredictive of mortality AlbuminLow in late phaseLow in early phase CholesterolMay remain normalLow Total lymphocyte count Low, responds to re-feeding Low, no response to re-feeding CytokinesLittle dataElevated InflammationUsually absentPresent With re-feedingReversibleResistant Thomas, D. “Distinguishing Starvation from Cachexia.” Clinics in Geriatric Medicine. 2002; 18: 883-891 12

13. MNA Mini Nutritional Assessment 13 Huffman, Am Fam Physician. 2002 Feb 15;65(4):640-651

14. Prognostic indicators of Chronic Obstructive Pulmonary Disease mortality Very severe airflow obstruction – FEV1 < 30 per cent of predicted. 2 or more severe exacerbations and hospital admission in the preceding year. Housebound by disability – Reduced activities of daily living. BMI <20 and weight loss. Established respiratory failure or previous ventilation for respiratory failure Receiving long-term oxygen therapy Evidence of cor pulmonale Scullion J, Holmes S (2011)Nursing Older People. 23, 4, 32-39. 14

15. COPD vs Terminal Lung Cancer COPD More Short of breath More physical, social functional disability – 90% tested as depressed Less acceptance of impending death Less access to services – None offered palliative services Lungs Cancer More pain Less depressed – 52% tested as depressed 52% had been offered specialist palliative care and knew where to get it 30% were receiving palliative care Gore, Brophy, Greenstone. Thorax 2000;55:1000–6 15

16. COPD Pain Chest pain is often reported by people with COPD May be caused by respiratory muscle hypoxia and/or musculoskeletal problems which are common in inactive older populations Kelly, C. (2009) An overview of acute exacerbations of COPD. Nursing Times; 105: 13 16

17. COPD Anxiety and Depression Anxiety and depression are common for people with COPD and carers Should be recognised and treated Some Antidepressant Considerations: – Tricyclics have some anticholinergic effect and can cause sedation – Buspirone can help reduce anxiety in COPD (Runo and Ely 2001) Antidepressants and anxiolytics are underused in severe COPD, despite the high levels of anxiety and depression Scullion J, Holmes S (2011)Nursing Older People. 23, 4, 32-39. 17

18. Breathlessness Inhalers Bronchodilators Positioning Fans Anxiolytics Opiates – Codeine 30 mg TID (cough suppressant) – Morphine 5 mg q 4 hours - should be low dose Managing breathlessness in palliative care. BPJ 47 October 2012 18

19. COPD Dyspnoea Treatment Inhaled morphine – review of 9 small studies – Heterogeneous samples, diseases, doses – 3 positive results – 6 not positive results – Individual variation – Brown, Eichner, and Jones, Ann Pharmacother June 2005 39:1088-1092 Oxygen? – should only be considered for patients with established hypoxaemia (PaO 2 ≤ 55 mmHg) Managing breathlessness in palliative care. BPJ 47 October 2012 19

20. Heart Failure (CHF) Disease Course Grade 1 and 2 – median survival 5 years Grade 3 and 4 – median survival 1 year 5-year mortality rate 75% after 1 st hospital admission 20

21. 21 The last six months of life for patients with congestive heart failure Levenson JW et al. J Am Geriatric Soc 45(5 Suppl):S101, 2000 p<0.001 % n=539 21

22. Barriers to Palliative Care Although mortality high, increasing number of patients living longer due to improvements in pharmacological, device, and cardiac surgical interventions Pacemakers/AICDs – Resuscitation difficult subject – DNR written on 5% only (47% Cancer pts) – 23% wanted DNR 22

23. Heart Failure Pain Pain inadequately dealt with in 90% of people with CHF Angina 41-77% – Treated with anti-anginals, stenting Abdominal pain due to liver capsule stretching – Treated with diuretics Opioids first-line agents for moderate to severe pain No NSAIDS Methadone prolongs QT interval Ward C. The need for palliative care in the management of heart failure. Heart 2002;87:294–8 23

24. CHF and Depression Prevalence of depression is > 30%, mortality rates increased Treat underlying factors such as pain, dyspnoea – SSRIs and psychotherapy are both helpful – Avoid drugs with high risk of drug-drug interaction, such as fluoxetine – Avoid TCAs. – Citalopram preferred Spiritual well-being and reinforcement 24

25. CHF and Fatigue Treat underlying causes Anaemia, infection, dehydration, electrolyte abnormalities, low nutritional intake, thyroid dysfunction, depression, sleep apnoea Non-pharmacological techniques physical therapy/exercise (esp. for muscle wasting) training in aerobic exercise energy conservation 25

26. CHF Nausea, Taste disturbance, Anorexia Reduced perfusion of intestines Medications Stretching of liver capsule, Small, frequent, easily digested, appetizing meals Pro-motility agents Vitamin supplements 26

27. 27 Cardiac Advanced Care Planning Palliative Care Approach Consideration 27

28. National End of Life Care Programme Improving end of life care; End of Life Care in Heart Failure. http://www.improvement.nhs.uk/LinkClick.aspx?fileticket=KBUUEsR0mms%3D&tabid=57 28

29. ESRD - Withdrawal of Dialysis Catalano C et al, Withdrawal of renal replacement therapy in Newcastle upon Tyne: 1964-1993., Nephrol Dial Transplant. 1996 Jan;11(1):133-9. Up to 20% of people actively decide to discontinue dialysis n = 88 Median survival = 8 days 29

30. Withdrawal of Dialysis – Palliative Issues in Ensuring Comfort Anticipating symptoms, aggressive response –Pain (generally due to co-morbidity) Neuropathic (diabetic neuropathy) Ischemic Renal insufficiency and opioid choice – morphine and hydromorphone active metabolites accumulate –Nausea –Restlessness, confusion –Dyspnea – fluid balance, pneumonia –Pruritus –Myoclonus, twitching Anticipating need for non-oral medication routes Communication 30

31. Barriers to Dementia Palliative Care (Ouldred and Bryant, (2008). 17(10), 308, British Journal of Nursing) Dementia is not recognized as terminal disease Difficult recognising when care becomes palliative Symptom management is difficult because of communication difficulties Lack of advanced care planning Lack of skills and knowledge re palliative care for advanced dementia Lack of access to specialist palliative care consultation Limited treatment options encourages loved ones to request admission to hospital and aggressive interventions (Koopmans et al, 2003) 31

32. Dementia Care Planning  Communication and collaboration with loved ones is the most important Mitchell, et al., 2009  Pneumonia, febrile episodes, and eating problems are frequent complications in patients with advanced dementia  complications are associated with high 6-month mortality rates  Residents with Families that understood likely complications had less hospitalisations 32

33. Pneumonia Treatment Givens, (2010), Arch of Internal Med.170(13), 1102 People with severe dementia treated with antibiotics live >200 days longer Comfort measures were less for those treated with antibiotics than those not treated. 33

34. Summary End of Life symptoms are similar for cancer and chronic diseases Comprehensive assessment and care planning can alleviate pain and suffering for those dying of chronic diseases Integration of a palliative approach with chronic illness care is key 34