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Symptom Management

When people think of discomfort, pain is the first symptom that comes to mind. There are a myriad of symptoms that require effective symptom management in order to improve quality of life and function, as well as reduce suffering.

Anxiety

Anxiety is a state of apprehension resulting from the perception of a current or future threat to oneself.  The term is used to describe a symptom as well as a variety of psychiatric disorders in which anxiety is a salient symptom.

Anxiety is characterized by an unpleasant state of inner turmoil, often accompanied by nervous behavior, such as pacing back and forth, somatic complaints, and rumination. It is the subjectively unpleasant feelings of dread over anticipated events, for example, the feeling of imminent death.

Anxiety is not the same as fear, which is a response to a real or perceived immediate threat, whereas anxiety is the expectation of future threat. Anxiety is a feeling of uneasiness and worry, usually generalized and unfocused as an overreaction to a situation that is only subjectively seen as menacing. It is often accompanied by muscular tension, restlessness, fatigue and problems in concentration. Anxiety can be appropriate, but when experienced regularly the individual may suffer from an anxiety disorder.

Anxiety is commonly reported by patients with serious illness. At least 25% of cancer patients and 50% of CHF and COPD patients experience significant anxiety.

Potential causes in seriously ill patients include an underlying psychiatric disorder, undesirable drug effects, drug withdrawal, and metabolic causes like an overactive thyroid.  Anxiety may be a prominent component of acute or chronic pain, shortness of breath, nausea, or cardiac irregular rhythm (arrhythmias).  Anxiety may also arise from existential and psychosocial concerns about dying, disability, loss, legacy, family, finances, religion and spirituality.

Treatment is available once the underlying cause of the anxiety is identified.

Confusion (Delirium)

Delirium, also referred to as acute confusional state, is common in patients with serious medical illness.  Delirium is an acute change in a person’s mental status from a previous baseline. It often varies in severity over a short period of time.  Typically, the patient has difficulty paying attention, disorganized behavior, deficits in perception, altered sleep-wake cycle, and may show signs of psychosis such as hallucinations and delusions.

Delirium itself is not a disease, but rather a set of symptoms that is categorized as hyperactive (agitated), hypoactive, or mixed.

Hyperactive delirium is a type of delirium that is commonly characterized by restlessness, agitation, hallucinations, and delusions. Patients are highly sensitive to sensory stimuli, constant scanning of the environment for perceived threats and have increased anxiety that can lead to exhaustion. Hyperactive delirium is associated with alcohol and drug withdrawal, drug intoxication, or adverse reactions to medications.

Hypoactive delirium presents with sluggishness, slowness and drowsiness.  Patients respond slowly to questioning, and show little spontaneous movement. The type of delirium occurs most frequently in elderly patients. These patients are frequently overlooked or misdiagnosed as having depression or a form of dementia.

Several common causes are reversible. These include constipation, urinary retention, medications, electrolyte imbalance, and sleep deprivation. As with other symptoms, it’s important to start by identifying and treating the underlying cause, as well as non-pharmacological treatment.  When these approaches are not effective, medication may be needed.

Constipation

Constipation is a condition in which there is difficulty in emptying the bowels, usually associated with hardened feces. As with other symptoms, rational therapy should be based on a sound understanding of the underlying cause. The goal in treating constipation is generally to help the patient return to the best possible balance that will allow a normal bowel movement to be passed.

Four major components affect the production of a normal BM:

Solid waste, either too much or too little, is a problem. The intestine is most efficient pushing intermediate volumes. Patients on low fiber diets may improve if fiber is added.

Water content of stool depends on how much water we drink, our general hydration status, how much water is absorbed from and secreted into the intestine and how fast stool moves through the bowel. Any of these variables can be manipulated with treatment.

Slow movement of the bowels are a problem for patients with low-activity levels (for example, patients who are bed-ridden, dying, or have advanced neurodegenerative disorders.) Use of certain drugs can also lead to the bowel slowing down.

Lubrication simply eases passage and minimizes pain that can interfere with excretion.

Many medications can cause or exacerbate constipation. Review your medications carefully with your doctor, nurse practitioner or pharmacist.

Depression

Depression is a common but serious mood disorder. It causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working.

Depression is a significant symptom for approximately 1 in 4 seriously ill patients and is especially common in patients with metastatic cancer.  Up to 80% of the psychological symptoms that occur in cancer patients go unrecognized and untreated.  One reason for this is the difficulty in diagnosing depression in seriously ill patients.  The symptoms associated with depression in patients without other serious illnesses (weight loss, loss of energy, fatigue, insomnia) also occur in patients without depression who have a serious illness.

It is important to consider the diagnosis of depression in seriously ill patients who exhibit feelings of hopelessness, worthlessness, guilt, loss of pleasure or joy, sustained periods of feeling sad, and suicidal ideation and/or suicidal plans.

Once identified, depression should be treated.  Consultation with a psychiatrist is indicated when the diagnosis is uncertain, and/or when patients present with profound depression and/or are overtly suicidal.

Dyspnea (Shortness of Breath)

Shortness of breath or dyspnea is defined as a subjective sensation of difficulty breathing. The causes of shortness of breath include a wide spectrum of serious lung or heart conditions, anemia, anxiety, chest wall pathology, electrolyte imbalance, retaining urine or constipation.

It is important to know and treat the underlying cause of the shortness of breath in order to improve quality of life and reduce suffering.  In addition, it is important to know the person’s health status, prognosis (life expectancy) and what matters most to the individual in order to provide treatment than meets their personal goals for care.

Some general measures including positioning by helping a person to sit up, increasing air movement via a fan or open window, and use of bedside relaxation techniques are all helpful. If the patient is expected to die imminently, stopping IV fluids is appropriate.

For patients who are not receiving enough oxygen in their blood stream, oxygen is helpful to treat the underlying disease and the symptom. When patients are seriously ill and dying, oxygen is often, but not universally, helpful.  When in doubt, it is helpful to try a therapeutic trial and base treatment on symptom relief, not the oxygen measurement.

Opioids like morphine are the drugs of choice for shortness of breath at the end-of-life as well as shortness of breath that does not respond to the treatment of the underlying cause.

Nausea and Vomiting

It is important to understand the different types of causes of nausea in order to treat nausea effectively.  Treatment can be optimized and side effects minimized by using specific anti-nausea medications that work on the reason for the nausea.

Special receptors in the body’s tissues react differently to specific medicines depending on the cause of the nausea. Thus, certain medicines work better than others in certain circumstances.  There are five different causes for nausea:

Infection or inflammation

Obstruction of Bowel by Constipation

Dysmotility of the upper gut is a condition where muscles of the digestive system become impaired leading to changes in the speed, strength or coordination of digestive organs

Toxins that stimulate the chemoreceptor trigger-zone (CTZ), an area of the brain that receives inputs from blood-borne drugs or hormones, and communicates with other structures in the vomiting center to initiate vomiting.  Examples are medicine like opioids or chemotherapy

Vestibular system is the sensory system that provides the leading contribution to the sense of balance and orientation in space to help coordinate movement with balance. Together with the cochlea, a part of the auditory or hearing system, it constitutes the labyrinth of the inner ear, situated in the vestibulum in the inner ear.

Pain

While all patients should be screened for pain, identifying a specific etiology for pain is challenging. A complete assessment, including physical, mental, emotional, and spiritual components is helpful in determining the appropriate course of management.  Pain Guidelines help guide appropriate therapy.

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