COMMON END-OF- LIFE PHYSICAL SYMPTOMS: WEAKNESS, FALLS, AND SKIN PROBLEMS SKIN PROBLEMS By Dr. Mike Marschke

WEAKNESS  #1 Symptom – 80%  Multi-factorial: Cachexia; muscle atrophy Cachexia; muscle atrophy Effect of underlying disease – CA, CHF, COPD, infections Effect of underlying disease – CA, CHF, COPD, infections Anemia Anemia Drug effect – including chemo and narcotics Drug effect – including chemo and narcotics Radiation therapy effect Radiation therapy effect Dehydration; electrolyte imbalance (Na, K, Ca, Magnesium) Dehydration; electrolyte imbalance (Na, K, Ca, Magnesium) Depression Depression Poor sleep – pain, sleep apnea, anxiety Poor sleep – pain, sleep apnea, anxiety Neurologic impairment – stroke, tumor, cord paralysis, neuropathies Neurologic impairment – stroke, tumor, cord paralysis, neuropathies Endocrine problem – hypothyroid, hypercortisol, syndrome of inappropriate ADH secretion Endocrine problem – hypothyroid, hypercortisol, syndrome of inappropriate ADH secretion

TREATABLE CAUSES AT THE END OF LIFE  Dehydration may be treatable with IV fluids (but usually only if symptomatic orthostasis)  Anemia – symptoms may improve with transfusions or erythropoietin  Depression may be treatable; stimulants like Ritalin may work faster and can also help other drug-related fatigue  Poor sleep can be improved by treating cause, like pain- control, CPAP (continuous positive airway pressure) for apnea, but also with sleepers  Endocrine or electrolyte abnormalities may be treatable

COMPLICATIONS FROM FATIGUE/WEAKNESS  Decreased quality of life  Increased burden on others  Increased risk of suicide  Increased risk of falls  Impaired skin integrity  Aspiration, increased infections, increased thrombosis formation

EFFECTS ON QUALITY OF LIFE  Inability to do Activities of Daily Living – including cooking, dressing, bathing, even toiletry  Unable to work or be “useful”  Unable to enjoy social function activities  Strain on finances  Unable to enjoy sexual intimacy  Imposes on emotional well-being

Increased burden on others  Family, caregivers need to take up slack  Need for rest, respite  Need for assistance, especially for caregivers to continue their lives  Need for education on caring  Caregiver stress, grief and anxiety over dying relative

SUICIDE VULNERABILITY FACTORS IN ADVANCED DISEASE  Pain; physical suffering  Advanced illness with poor prognosis  Depression; hopelessness  Delirium  Helplessness; lack of control  Substance/alcohol abuse  Suicide history; family history  Fatigue; exhaustion  Lack of social support

FALLS - Risk factors -  Sedative use  Cognitive impairment  Disability of lower extremities  Palmomental reflex present (a signof significant frontal lobe problems)  Abnormal balance or gait  Foot problems  Others – poor vision, depression, anxiety, poor vision, poor hearing

FALLS - Consequences -  Serious injuries – fractures, hematomas, concussions, even death – from intracranial bleeds, consequences of hip fractures  Long lies – dehydration, pressure sores, pneumonia, rhabdomyolysis  Fear of falling – can lead to inactivity, poor life satisfaction, depression  Hospitalization, nursing home placement

FALLS - Risk factors for serious injury -  Falling on stairs  Activities that displaced center of gravity (pulling something, being pushed, carrying a heavy object, assuming an unusual position)  When height of fall is at least body height  Cognitive impairment  Presence of at least 2 chronic conditions  Balance and gait problems  Low body mass  Females  Other minor risks – hard surfaces, while walking, older age, osteoporosis, mechanical restraints

FALLS - Risk factors for inability to get up -  age over 80  depression  poor balance and gait  other minor risks – previous stroke and sedative use  Fallers who could not get up were more likely to have long-lasting decline in ADLs, more likely to die soon, and to be hospitalized

FALLS - Physical Assessments -  Orthostasis with drop of 20mm of systolic BP when standing  “Get up and go test” – arise from sitting without help, stand still 10 sec, walk 10 ft, turn, walk back than sit  Other balance tests – while standing – withstand a gentle nudge on chest, stand with eyes closed  Knee strength, LE strength – timed chair stand (poor if > 10 sec repeating standing 3 times)  Decreased neck or back flexibility; dizziness with neck extension  Visual check

FALLS - Risk modification - Balance problems – PT strength exercises, transfer training, neck exercises, appropriate walking aids (canes for one weak extr, walkers for poor balance and bilat weak extr) Balance problems – PT strength exercises, transfer training, neck exercises, appropriate walking aids (canes for one weak extr, walkers for poor balance and bilat weak extr) Gait/strength problems – gait training and exercises, walking aids Gait/strength problems – gait training and exercises, walking aids Orthostasis – change meds, hydrate, pressure stockings, arise slowly Orthostasis – change meds, hydrate, pressure stockings, arise slowly Foot disorders – podiatry eval to shave calluses, nails, bunions Foot disorders – podiatry eval to shave calluses, nails, bunions Reduced vision/ hearing – assistive devices Reduced vision/ hearing – assistive devices Medications – attempt reductions of sedatives, anti- hypertensives, diabetic agents, diuretics, psychotropics Medications – attempt reductions of sedatives, anti- hypertensives, diabetic agents, diuretics, psychotropics

FALLS - Environmental modification - Lighting – well lit everywhere, night lights, accessible switches Lighting – well lit everywhere, night lights, accessible switches Floors – tacked down thin-pile carpeting, paths clear Floors – tacked down thin-pile carpeting, paths clear Stairs – try to avoid Stairs – try to avoid Bathroom – grab bars, raised toilet seats, shower chair Bathroom – grab bars, raised toilet seats, shower chair High firm chairs with arms, hospital beds, beds on floor High firm chairs with arms, hospital beds, beds on floor Increase accessibility of things needed around bed Increase accessibility of things needed around bed Footwear – shoes with nonskid low soles Footwear – shoes with nonskid low soles Alarms – monitors, bed alarms to alert others that patient wants to get out of bed or has fallen Alarms – monitors, bed alarms to alert others that patient wants to get out of bed or has fallen

PRESSURE ULCERS - Pathogenesis -  Pressure – exposure to mmHg for 1-2 hrs can breakdown muscle and skin by occluding blood vessels (can get pressures of mmHg over bony prominences on a regular mattress)  Shearing – sliding over mattress pulls skin over subcutaneous tissue also occluding blood supply  Friction can cause intrapidermal blisters  Moisture can increase the friction and produce maceration of skin

PRESSURE ULCERS - Risk factors -  Immobility, decreased spontaneous movements  Hypoalbuminemia  Incontinence  Pressure of a fracture

PRESSURE ULCERS - Stages -  STAGE 1 – nonblanchable erythema of intact skin (the first sign of underlying ischemia)  STAGE 2 – superficial ulcer involving epidermis or dermis  STAGE 3 – ulcer with full thickness skin loss to the fascia  STAGE 4 – ulcer extending to muscle or bone

PRESSURE ULCERS - Prevention -  Reposition at least every 2 hrs., avoiding on side at 90 degrees  Low pressure mattresses – reducing pressures to < 32 mmHg – low-air-loss mattresses if have ulcers, egg crates with frequent turning can help prevent new ones  Keep clean, avoid excessive dryness  Turning and transferring techniques to avoid friction, shear  Avoid massaging over boney prominences  Nutrition?

PRESSURE ULCERS - Treatment -  STAGE 1 & 2 – keep pressure off, keep clean, vapor- permeable protective dressings that promote healing (i.e. – duoderm, polymem, vigilon….)  STAGE 3 & 4 – will need low-air-loss mattress - DIRTY – remove devitalized tissue (debride surgically or with wet-to-dry, enzymatic debriders like elase, collagenase), clean infected areas (irrigation, short-term cleansers like peroxide or Dakin’s solution, or antibiotic creams like silvadene, flagyl) - DIRTY – remove devitalized tissue (debride surgically or with wet-to-dry, enzymatic debriders like elase, collagenase), clean infected areas (irrigation, short-term cleansers like peroxide or Dakin’s solution, or antibiotic creams like silvadene, flagyl) - CLEAN – moist clean dressing that absorbs exudate (calcium alginate packings, silvadene guaze, wet dressings)

PRESSURE ULCERS - Goal at end-of-life -  Prevent ulcers from worsening  Prevent pain, especially with frequent dressing changes  Minimize dressing changes  Keep comfortable

EDEMA CAUSES – From decreased venous return increasing permeability of interstitial fluid into extravascular space, or from under nutrition with low albumin states increasing capillary permeability Venous obstruction (extravascular compression or intravascular clots/tumor) Venous obstruction (extravascular compression or intravascular clots/tumor) Increased intra-abdomenal pressure (tumor, ascites) Increased intra-abdomenal pressure (tumor, ascites) Cirrhosis, nephrosis, heart failure Cirrhosis, nephrosis, heart failure Malnutrition Malnutrition

COMPLICATIONS FROM EDEMA  Pain/discomfort from the pressure  Immobility  Stasis vasculitis  Stasis ulcers

TREATMENT OF EDEMA  Elevation of limb  Relieve pressure on the vein (i.e. – RT for tumor, remove ascites, anti-coagulation of clots)  Compression stockings, gentle massage (if no clots)  Increase nutrition (hard to do in terminal patients)

POTENTIAL HOSPICE EMERGENCIES  SPINAL CORD COMPRESSION – back pain usually precedes neurologic compromise by 1-2 wks, see bilat leg weakness and numbness from the level of compression down. Needs aggressive treatment to prevent permanent paralysis – RT, steroids, surgery Needs aggressive treatment to prevent permanent paralysis – RT, steroids, surgery  DEEP VEIN THROMBOSIS – usually acute swollen, unilateral limb with redness, pain, calf tenderness. Needs aggressive anti-coagulation to prevent life-threatening pulmonary emboli Needs aggressive anti-coagulation to prevent life-threatening pulmonary emboli  SUBDURAL HEMATOMA – usually from fall with head contusion (may appear minor), then see mental status changes usually within 24 hrs, potential coma with respiratory suppression May need aggressive surgical intervention May need aggressive surgical intervention