1. PALLIATIVE CARE Common symptoms By Dr Vanessa Kerai

2. Pain  “An unpleasant sensory and emotional experience associated with actual or potential tissue damage.”  Important to identify the cause and type of pain in order to decide on management. Different types of pain respond to different analgesics.  Psycho-social factors like anxiety and depression, which may reduce tolerance to pain or exacerbated by pain, must also be assessed and treated.

3. What causes pain? BONE NERVE COMPRESSION/ INFILTRATION SOFT TISSUE INFILTRATION VISCERAL MUSCLE SPASM LYMPHOEDEMA RAISED INTRACRANIAL PRESSURE Cancer related pain Surgery – post operative scars, adhesions Radiotherapy – fibrosis Chemotherapy - neuropathy

4. Pain classification  Nociceptive pain  Results from chemical or physical stimulation of peripheral nerve endings with the involvement of nociceptors.  Somatic pain - arises from bone, joint, muscle, skin, or connective tissue. It is usually aching or throbbing in quality and is well localized.  Visceral pain - arises from visceral organs, such as the GI tract and pancreas e.g tumour involvement of the organ capsule, obstruction of hollow viscus

5.  Neuropathic pain  Up to 40% of cancer-related pain may have a neuropathic mechanism involved.  Refers to pain arising from a primary lesion or dysfunction in the peripheral or CNS.  Central pain – usually an area of altered sensation incorporating the painful area but commonly extending beyond it with no local disease to account for the pain.  Sympathetic maintained pain: associated with dysregulation of the autonomic nervous system.

6.  Peripherally Generated Pain  Painful polyneuropathies: Pain is felt along the distribution of many peripheral nerves. Examples: diabetic neuropathy, alcohol-nutritional neuropathy, and those associated with Guillain-Barré syndrome.  Painful mononeuropathies: Usually associated with a known peripheral nerve injury, and pain is felt at least partly along the distribution of the damaged nerve. Examples: nerve root compression, nerve entrapment, trigeminal neuralgia.

7. Analgesic ladder

9. Dyspnoea  It is common in patients with advanced disease, being present in up to 70% of patients with cancer.  The causes are often multiple and are associated with both physiological and psychological factors.  May be attributable to the presence of a primary tumour in the respiratory system, metastatic spread to the lungs, a pleural effusion, or advanced respiratory disease.  The causes of breathlessness can be described as: 1. Mechanical - airway obstruction or lung compression 2. Haematological – anaemia 3. Psychological - anxiety.  Breathlessness can cause distress, fear, and disability.

10.  When managing a patient with breathlessness you should ask yourself the following questions:  Is it appropriate to treat the underlying illness?  Are there any potentially reversible causes of breathlessness, e.g heart failure, infection, anaemia, pleural or pericardial effusion, pulmonary embolus, or pneumothorax?  How best can I treat any reversible causes, for example by draining an effusion?

11. Symptomatic treatment  Keep the patient propped up  Keep the patient cool - consider using a fan  Try nebulised saline or mecysteine for tenacious respiratory secretions (mecysteine is a mucolytic)  Try bronchodilators if you suspect bronchospasm, such as nebulised salbutamol 2.5-5.0 mg four times a day.  Consider oral or subcutaneous morphine or benzodiazepines, or both, (SL lorazepam or SC midazolam)  Consider prescribing oxygen, remembering that short term oxygen therapy is not proved to confer significant benefit, unlike long term therapy in chronic respiratory conditions.

12. Supportive care  Explore the patient's fears  Encourage simple breathing exercises and relaxation techniques  Discuss drug management with the patient, for example with benzodiazepines. Lorazepam 0.5-1.0 mg as required may help patients with acute attacks of anxiety and diazepam 5.0 mg may help more chronic anxiety.  Discuss the patient's limitations and listen to the patient's and family's concerns.  Consider the need for equipment or aids and a package of community care  If the patient has severe or persistent problems consider referring them to a specialist service.

13. Cough  In up to 50% of terminally ill patients and up to 80% in lung cancer patients.  Occurs as a result of mechanical and chemical irritation of receptors in the respiratory tract.  Management depends on the cause which may or may not be reversible and the clinical condition of the patient.

14. InfectionAntibiotics Lung tumourRadiotherapy LVF/Pulmonary oedemaDiuretics Asthma/BronchospasmBronchodilators Corticosteroids Oesophageal refluxPPI Metoclopramide Post-nasal dripAntibioitic if sinusitis Nasal corticosteroid spray Nasal decongestant AspirationSpeech therapist may be able to advise Tracheo-oesophageal fistula Radiotherapy induced pulmonary fibrosis Covered metallic stent Corticosteroids

15. Dyspepsia  Gastro-oesophageal reflux/Oesophagitis  Assessment  Exclude or treat oesophageal candida  Consider oesophageal spasm  Review drugs which cause esophagitis – potassium, NSAIDs, antimuscarinics  Consider cardiac cause of pain

16.  Treatment  Raise head of bed to reduce reflux  Consider paracentesis for tense ascites  Metoclopramide if signs of gastric stasis or distension  Antacid – gaviscon (for mild symptoms)  PPI  NSAID and steroid related dyspepsia  Treatment  Consider stopping or reducing dose of NSAID/steroids  PPI for severe symptoms or proven pathology

17. Nausea and vomiting  Affects 40-70% cancer patients  Common causes  GI problems  Pharyngeal irritation – e.g Candida, difficulty in expectorating sputum  Drugs – opioids, antibiotics, NSAIDs  Metabolic – hypercalcaemia, renal failure  Radiotherapy and chemotherapy  Infection  Pain  Anxiety or fear  Brain mets

18. Anti-emetics INDICATIONDRUGDOSE Gastric StasisMetoclopramide Domperidone PO: 10mg tds SC infusion: 30-40 mg in 24hrs Drugs/biochemical upsetHaloperidolSC infusion: 1.5mg – 5mg in 24 hrs Raised ICP Distension of abdo or pelvic organs Cyclizine Dexamethasone 4-16mg PO: 50mg tds SC infusion: 50-150 mg in 24 hrs Bowel obstructionCyclizine Octreotide Hyoscine Radiotherapy Chemotherapy Haloperidol Dexamethasone Metoclopramide 1.5 mg noct/bd 4-8mg od 20mg qds

19. Constipation  Constipation is often multifactorial in origin. Causes include: A tumour within or pressing on the bowel wall A tumour damaging the lumbosacral spinal cord, cauda equina, or pelvic plexus Hypercalcaemia Dehydration Diminished food intake, low fibre diet, and immobility Drugs, such as opioids and anticholinergics Concurrent disease, such as hypothyroidism, hypokalaemia, or an anal fissure. Often patients with cancer have more than one cause of their constipation.

20. Determine and treat the cause  First diagnose the cause of the constipation.  When managing a patient with constipation you should ask yourself the following questions:  Is it appropriate to treat the underlying illness? Check with a specialist if in doubt  Are there any potentially reversible causes of constipation, for example dehydration or use of opioids?  How best can I treat any reversible causes, for example by encouraging a dehydrated patient to take more fluids?  If you cannot find a reversible cause or if your initial treatment does not work you may have to attempt symptomatic treatment.

21. Symptomatic treatment  Good fluid intake  High fibre diet  Identify and treat any hypercalcaemia  You should titrate up the dose of laxatives until constipation is controlled.  Co-danthramer is licensed only for use in terminally ill patients. It may colour the urine red and can cause a characteristic red rash over the buttocks and perineum. The risk is increased if the patient is incontinent of urine or faeces.  Generally avoid bulk forming laxatives, such as Fybogel, in patients with terminal cancer because these are not suitable for patients with a poor fluid intake, or when opioids have reduced bowel motility.

22. Recommendations for prescribing laxatives Type of constipation Mode of action Preparation/dose Acute constipation or hard impactionOsmotic Microenema - one at night Osmotic Phosphate enema - one mane Osmotic Movicol Soft impactionStimulant Senna - two tablets at night High impactionStimulant Sodium picosulphate Chronic constipationStimulant Senna - two tablets at night Osmotic Movicol - one to two sachets daily Opioid induced constipationSoftener and stimulant Co-danthramer Stimulant Senna - two tablets at night

23. Diarrhoea  Occurs in up to 10% of cancer patients on admission to hospice.  Common causes: 1) Imbalance of laxative therapy (should settle within 24 hrs if laxatives stopped and reintroduced at a lower dose). 2) Drugs (antibiotics, NSAIDs, iron, antacids) 3) Malignant partial intestinal obstruction and faecal impaction 4) Radiotherapy 5) Malabsorption (associated with ca pancreas, gastrectomy, ileal resection, colectomy). 6) Colonic or rectal tumour 7) Rare endocrine tumours (e.g carcinoid)

24.  Investigations  Faecal impaction needs to be excluded by abdominal and rectal examination.  Persistent watery diarrhoea with systemic upset which might indicate an infective cause my requite investigation.  Treatment  Look for cause before using antidiarrhoeals  General measures – increase fluids  Non specific drug treatment  Opioids – such as codeine or loperamide act via gut opioid receptors to reduce peristalsis and increase anal sphincter tone.

25. Specific measures CausesTreatment Fat MalabsorptionPancreatin Radiation diarrhoeaOndansetron 4mg tds Pseudomembranous Colitis1 st line metronidazole 400mg tds 2 nd line vancomycin 125mg tds Profuse secretory diarrhoeaSomatostatin analogues (best given via syringe driver)

26. Ascites  Malignant ascites accounts for 10% of all cases of ascites and in up to 50% of all patient with ovarian cancer.  May be the presenting feature of the malignancy or be indicative of recurrence or metastatic spread.  It is caused by malignant peritoneal deposits irritating the serosa, blockage of subdiaphragmatic lymphatics and secondary sodium retention. Symptoms:  Abdominal distension, discomfort and pain  Dyspnoea  Nausea & vomiting  Oesophageal reflux

27.  Treatment options:  Chemotherapy  Paracentesis – poor prognosis  Diuretics – if prognosis >4 wks, paracentesis unsuccessful or unacceptable or leg oedema. Spironolactone is the drug of choice.  Peritoneovenous shunt – considered if persistent recurring ascites. Complications: shunt obstruction, sepsis.

28. Intestinal obstruction  Most commonly occurs with carcinoma of the ovary or bowel.  Not uncommonly partial or subacute and often precipitated by constipation.  Severe constipation with faecal impaction can mimic obstruction.  Initial drug management:  The optimum treatment is surgery, but often inappropriate in advanced cancer. 1) Relieve nausea and reduce vomiting as much as possible: metoclopramide (may increase colic or vomiting in complete obstruction, but may resolve partial upper GI tract obstruction). Cyclizine 150mg + haloperidol 2.5mg/24 hrs. If nausea persists replace with levomepromazine. 2) Ensure constant pain is adequately relieved with diamorphine. 3) Stop any stimulant laxatives

29. Anorexia/Cachexia/Asthenia  Anorexia – absence or loss of appetite  Cachexia – profound weight loss and catabolic loss of muscle and adipose tissue.  Asthenia – encompasses fatigue or easy tiring and reduced sustainability of performance. Generalised weaknesss, poor concentration, impaired memory and emotional lability.  Occur in about 70% of patients with advanced cancer particularly pancreatic and gastric cancer.  Reversible causes must be excluded such as dysphagia (due to thrush, mucositis, ulceration), nausea and vomiting, constipation, pain, anxiety and depression.  If no reversible factors consider dexamethasone (continue if response after a few days).

30. Pruritus  Generalised pruritus in the absence of a rash may be due to:  Cholestatic jaundice (commonest cause in advanced malignancy)  Renal failure  Opioids  Anaemia  Thyroid disease  Myeloma, lymphoma  Paraneoplastic syndrome: breast, colon, lung, stomach ca  Diabetes  Treat the underlying cause

31. Lymphoedema  Excess accumulation of fluid in the body tissues caused by inadequate lymphatic drainage.  Treatment  Explanation and information about lymphoedema  Skin care to avoid dryness, cracking and infection  Avoidance of trauma, including sunburn, venepuncture, or vaccinations on the affected limb in order to minimise the chance of infection.  Massage  Compression bandaging  Compression garments  Exercise

32. References  European Journal of Palliative Care, 1998; 5(2):39-45  Adult palliative care guidance 2006  Palliative care handbook 3 rd edition  BMJ learning module – palliative care in the community  Palliative care, symptom control handbook for health professionals

33. Thanks for listening