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COMMON END-OF-LIFE PHYSICAL SYMPTOMS:

COMMON END-OF-LIFE PHYSICAL SYMPTOMS:. WEAKNESS, FALLS, AND SKIN PROBLEMS By Dr. Mike Marschke. WEAKNESS. #1 Symptom – 80% Multi-factorial: Cachexia; muscle atrophy Effect of underlying disease – CA, CHF, COPD, infections Anemia Drug effect – including chemo and narcotics

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COMMON END-OF-LIFE PHYSICAL SYMPTOMS:

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

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

  3. TREATABLE CAUSESAT 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

  4. COMPLICATIONS FROMFATIGUE/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

  5. EFFECTS ONQUALITY 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

  6. Increased burdenon 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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) • Gait/strength problems – gait training and exercises, walking aids • Orthostasis – change meds, hydrate, pressure stockings, arise slowly • Foot disorders – podiatry eval to shave calluses, nails, bunions • Reduced vision/ hearing – assistive devices • Medications – attempt reductions of sedatives, anti- hypertensives, diabetic agents, diuretics, psychotropics

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

  15. PRESSURE ULCERS- Pathogenesis - • Pressure – exposure to 60-70 mmHg for 1-2 hrs can breakdown muscle and skin by occluding blood vessels (can get pressures of 100-150 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

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

  17. 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

  18. 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?

  19. 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) - CLEAN – moist clean dressing that absorbs exudate (calcium alginate packings, silvadene guaze, wet dressings)

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

  21. 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) • Increased intra-abdomenal pressure (tumor, ascites) • Cirrhosis, nephrosis, heart failure • Malnutrition

  22. COMPLICATIONS FROM EDEMA • Pain/discomfort from the pressure • Immobility • Stasis vasculitis • Stasis ulcers

  23. 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)

  24. 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 • DEEP VEIN THROMBOSIS – usually acute swollen, unilateral limb with redness, pain, calf tenderness. • 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

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