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Palliative > Stroke, Dementia, etc. > Flashcards

Stroke, Dementia, etc. Flashcards

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1
Q

What are the challenges related to stroke and palliative care?

A

-trajectory is unpredictable: unexpected acute decline and low PPS that can last days to weeks
-difficult to prognosticate
-tendency to recommend palliative care only in the final days of life (pt is dysphagic and non-communicable)

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2
Q

What are the strongest predictors of outcome for stroke patients?

A

1) patient’s age
2) severity of stroke

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3
Q

What are the types of post-stroke pain?

A

1) central post-stroke pain (CPSP)
2) hemiplegic shoulder pain (HSP)
3) painful spasticity

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4
Q

Describe central post-stroke pain (CPSP)

A

-appears within weeks of a stroke
-chronic neuropathic pain in parts of the body that have lost their sensory innervation

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5
Q

What is the treatment for central post-stoke pain (CPSP)?

A

gabapentin, TCA (amitriptyline or nortriptyline for elderly), SNRI (venlafaxine)

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6
Q

Describe hemiplegic shoulder pain (HSP)

A

-develops weeks or months after a stroke
-related to sensory/motor deficits, subluxation (connecting bone is partially out of joint), limited ROM, very loose joint
-we see an internal rotation of the shoulder, adducted towards the body
-good recovery (80% of patients in 6 months)

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7
Q

What are the pharmacological interventions for hemiplegic shoulder pain?

A

-NSAIDS (ibuprofen, naproxen, Motrin)
-botox injections to relax muscles so joint can be put into proper alignment)
-intra-articular steroid injections (methylprednisolone)

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8
Q

What are the non-pharmacological interventions for hemiplegic shoulder pain?

A

-shoulder sling, avoid overhead motion, ice, heat, soft tissue massage, PT consult for exercises, ROM
-intramuscular electric stimulation

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9
Q

Describe painful spasticity

A

-when a muscle involuntary contracts when a patient moves, the muscle “freezes” in an abnormal position (ex. balled up fists)

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10
Q

What are the pharmacological interventions for painful spasticity?

A

botox injections, muscle relaxants (baclofen, dantrolene, tizanidine)
-note that muscle relaxants have CNS effects that can be problematic: confusion, dizziness, sedation, and weakness

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11
Q

What are the non-pharmacological interventions for painful spasticity?

A

consult PT (ROM and exercises), OT (splints, orthoses), electrical stimulation, massage

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12
Q

What is done for preparation for EOL due to stroke?

A

-no code
-move patients to a private room to allow family visit
-discontinue VS, IV, NG (unless to relieve distention or N/V)
-discontinue non-beneficial orders (ex. bloodwork)
-insert SC line for morphine and scopolamine

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13
Q

What are the symptoms experienced after a stroke?

A

-fatigue
-post-stroke seizures
-urinary/fecal incontinence
-depression
-anxiety
-pseudobulbar effect

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14
Q

Describe fatigue related to stroke

A
  • Caused by brain injury itself, sleep apnea, anemia,
    hypo/hyperglycemia, thyroid anomaly
  • Pharm: no research to recommend meds
  • Non Pharm: pace activities, prioritize activities, frequent rest
    periods, rest hygiene, cool environment
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15
Q

Describe post-stroke seizures

A
  • Disturbing for patients and family
  • If seizure last >2 weeks, there is ­ risk for epilepsy
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16
Q

What are the pharmacological interventions for post-stroke seizures?

A

gabapentin/neuronin (good for elderly and helps with neuropathic pain), lamotrigine (wafer)

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17
Q

Describe urinary/fecal incontinence related to stroke

A
  • 50% can experience this post-stroke
  • Rob patients of dignity and is very embarrassing
  • May be r/t immobility of patient and not stroke itself
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18
Q

What is the treatment for urinary/fecal incontinence?

A

Treatment: early removal of foley, bladder training (restriction,
toilet/fluid time), bowel training program – amounts of food, warm
beverage in the morning

Pharm tx: treat constipation with laxatives; stimulant laxative at
night with osmotic laxative, then access toilet in a timely fashion

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19
Q

Describe depression related to stroke

A
  • We can directly ask pt if they are sad or depressed, does not have
    to be a MH professional who asks
  • Do not normalize or over medicalize
  • Say, “what do you mean by that” = can uncover untreated physical
    symptoms of psychological distress
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20
Q

What is the treatment for depression related to stroke?

A

Pharm: SSRI (citalopram)

Non-pharm: cognitive behaviour therapy and interpersonal therapy

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21
Q

What is the treatment for anxiety related to stroke?

A

Pharm: SSRI – citalopram for generalized anxiety, depression,
panic symptoms (takes 6 weeks to take effect); in the meantime,
use short-acting anxiety meds: benzodiazepines (lorazepam)

Non pharm: CBT

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22
Q

Describe the pseudobulbar effect

A
  • Occurs in the first 6 months post stroke, often mistaken for
    depression, “short circuit” of brain.
  • May be uncontrolled laughing, anger, bursts of crying that is out of
    proportion to a situation
  • Important to educate patient and family
  • Once stroke effects subside, so should PBA
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23
Q

What is the treatment for pseudobulbar effect?

A

Pharm: SSRI (citalopram)

Non-pharm: distraction

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24
Q

Describe Alzheimer’s disease

A

most common form of dementia.
- Considered a terminal illness, an “illness of the family”

Behavioural and psychological symptoms (BPSD)
- Alteration in abstract thought
- Inability to reason

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25
Describe advanced dementia
patient loses all verbal capabilities (speaks in grunts and monosyllables), is incontinent, loses basic psychomotor skills, loses walking and posture control, and can have nutritional/eating problems, skin problems and pressure ulcers.
26
When is the best time for an advanced care directive?
discuss "what ifs" early so the patient does no lose out on being a participant in decision-making about what EOL should be
26
What is the primary cause of death for a patient with dementia?
pneumonia, cardiovascular disease
27
Why are antibiotics not considered appropriate in the terminal stages of dementia?
because they may increase survival but they do not increase comfort
28
Why is enteral nutrition (feeding tubes) not used for terminal dementia?
-do not prevent aspiration pneumonia, malnutrition, pressure ulcers, etc -do not increase survival, performance status, comfort, QOL -pts with feeding tubes need more physical restraints and medications for sedation d/t behavioural problems
29
What are some interventions to encourage pts with dementia to eat?
-get food the patient wants -change taste/texture of foods to be more favourable -check for ill-fitting dentures, lesions, infections -check for constipation, pain, nausea, diarrhea
30
Describe the dysphagia diet
semi-thick foods and fluids that the pt can swallow safely
31
What are some behavioural signs of pain?
facial grimacing, guarding, disturbed sleep patterns, mental status change, etc.
32
What are the assessment scales for pain?
PAINAD-- for advanced dementia, looks at breathing, negative vocalization, facial expression, body language, consolability NOPPAIN-- for non-communication pts, has body map to indicate where pt identifies pain PASLAC-- for limited ability to communicate, looks at facial expression, activity, body movement, social/personality/mood
33
What are the pharm interventions for pain for pts with dementia?
acetaminophen hydromorphone fentanyl methadone gabapentin (for neuropathic)
34
What is acetylcholine prescribed for?
memory enhancement
35
Which drugs should be avoided for dementia pts?
morphine and TCAs
36
What is the treatment for behavioural and psychological symptoms r/t dementia?
begin with non-pharm approach-- assess triggers/underlying issues (pain or infection), behaviour mapping to link stimuli, provide a calm approach (music or companion), warn pt before providing care (especially if providing massage, touch, giving care)
37
What is the first line pharmacological therapy for behavioural and psychological symptoms r/t dementia?
1st line therapy: atypical antipsychotics (quetiapine, olanzapine, risperidone) – has risk for a cardiovascular event, start low & go slow
38
What is the second line pharmacological therapy for behavioural and psychological symptoms r/t dementia?
2nd line therapy: typical antipsychotics (haloperidol) - Acetylcholinesterase inhibitors are used in early dementia but will not work in late-stage dementia.
39
Which pharmacological treatments should be avoided for behavioural and psychological symptoms r/t dementia?
anti-platelet agents, lipid-lowering agents, warfarin, chemotherapy agents
40
Describe Reality Orientation
what we do when we try to manage delirium, we reorient the patient using clocks, calendars, signs, etc. Use the patient’s name frequently and discuss current events. More factual and not focused on feelings.
41
Describe validation therapy
Emotional and subjective, we do not focus on reorienting them. Talk to them about where they are and be in the moment, do not argue or correct. Can be very beneficial to patients
42
Describe reminisce therapy
very much like validation therapy. Trying to meet each person in their current reality and not trying to get them to meet ours.
43
Describe deprescribing
a critical review of medications to stop those that have lost their original indication, have no clear efficacy for the pt or do not fit with the pts GOC -can increase QOL and decrease adverse effects
44
What is Multiple Sclerosis?
immune-mediated inflammation attacks myelinated axons in the brain and spinal cord leading to meline eroding -this impairs signals from the brain to spinal cord -affects both motor and seonsory neurons; unpredicted disease course -average onset is 31 years old and more common in women
45
What are the 3 types of MS?
1) relapsing-remitting MS 2) secondary-progressive MS 3) primary-progressive MS
46
Describe relapsing-remitting MS
most common, attacks/relapses with partial or complete recovery
47
Describe secondary-progressive MS
relapses and remissions that are steadily worsening, there is increasing disability -relapsing-remitting MS progresses into SPMS in around 10 years
48
Describe primary-progressive MS
a continuous progression of MS with no relapse/remissions, slow disability; estimated 25% of those severely disabled are still alive at 10 years
49
What are the symptoms of MS?
- Varies, no 2 individuals may present the same symptoms - Visual disturbances, loss of sensation, limb weakness (loss of coordination/balance), bladder/bowel dysfunction, labile moods (PBA), mental changes, and muscle spasms. No two patients have the same manifestations
50
What are the symptoms of MS at EOL?
pain, fatigue, nausea, constipation, breathlessness
51
What are the common causes of death for pts with MS?
aspiration pneumonia, UTI, chest infection, pressure sores
52
Describe Parkinson's disease
Deficiency of dopamine. There is an imbalance of acetylcholine and dopamine that is required for coordinated movement and semi-automatic functions. Hallmark is Lewy bodies. No cause or cure for PD.
53
Too much dopamine causes..
involuntary movement, dyskinesia (bobbing, pill rolling, contorted movements)
54
Too little dopamine causes...
akinesia (loss of ability to move muscles voluntarily), rigidity. tremor
55
What are the 3 cardinal signs of parkinson's disease?
1. Tremor at rest (pill-rolling) and subsides with movement = first sign of disease 2. Cogwell Rigidity: increase in muscle tone and stiffness of arms = short, shuffling gait 3. Bradykinesia: slow movement, blinking decreases, natural arm swing stops, pts may “freeze” need 2 of 3 to get diagnosis
56
Describe the on/off phase of parkinson's disease
- ON: medication is working and patient is able to move - OFF: medication has not taken effect, is wearing off, or stopped working. Patient cannot move
57
What is the gold standard for Parkinson's Disease?
Sinemet (Levodopa-Carbidopa) -levodopa converts to dopamine in the brain and is given with carbidopa to prevent peripheral breakdown because we need it to cross the BBB and work in the brain
58
What are some add-on therapies (things to do with levodopa) for Parkinson's disease?
Dopamine agonists MAO-B inhibitors COMT inhibitors Amantadine (Symmetryl)
59
What medications should be used during on/off periods?
Safinamide Apomorphine Inbrija (inhaled levodopa)
60
Safinamide
61
Apomorphine
62
Inbrija

Palliative (12 decks)

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