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Osteopathic EPEC
Education for Osteopathic Physicians on End-of-Life Care
Based on The EPEC Project, created by the American Medical
Association and supported by the Robert Wood Johnson Foundation.
Adapted by the American Osteopathic Association for educational use.
American
Osteopathic
Association
American
Osteopathic
Association
AOA: Treating
Family
Yours
D.O.s: Physicians
TreatingOur
People,
Notand
Just
Symptoms
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Module 6
Depression, Anxiety
and Delirium
American Osteopathic Association
AOA: Treating Our Family and Yours
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Objectives
• Identify depression, anxiety,
delirium near end of life
• Describe management plans
• Application of osteopathic
principles, philosophy and
techniques in management of
anxiety, depression and delirium
American Osteopathic Association
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Depression, anxiety,
delirium
• Highly prevalent, under-diagnosed
• May prevent quality dying
• Effective management is possible
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Depression
• 25%–77% of patients
• 28%-60% of caregivers
• Intense suffering
• Not inevitable
• Treatable in most cases
• Early treatment is better
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Risk factors . . .
• Pain, other symptoms
• Progressive physical impairment
• Advanced disease
• Advanced age 70 yo
• Social Isolation
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. . . Risk factors
• Particular diseases
• Pancreatic cancer
• Stroke
• Medication
• Steroids
• Benzodiazepines
• Chemotherapy
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. . . Risk factors
• Spiritual pain
• Bereavement
• Pre-existing risk factors
• Prior Hx, family Hx, social stress
• Suicide attempts, substance use
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Depression…diagnosis
• Physical Symptoms
• Anorexia / Insomnia / Fatigue / Weight Loss
• Psychological Symptoms
• Dysphoric Mood / Despair / Guilt
• Worthlessness / Suicidal Ideation
• Social Withdrawal / Apathy
• Pain not responding as expected
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Barriers to Treatment
• Fear of side-effects of medication
• Comorbidities
• Renal/Hepatic Insufficiency
• Cardiovascular Disease
• Gastrointestinal Disease
• Polypharmacy
• Cognitive Impairment
• Psychosocial Factors
American Osteopathic Association
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Barriers to Treatment
• 50% rule of depression
• Only 50% of patients with depression are
diagnosed
• Only 50% of the patients diagnosed are treated
• 50% of the patients with depression are
inadequately treated
- Full effects of antidepressants in older patients
may require 12 weeks or more
American Osteopathic Association
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Caregiver Impact
• 27.6 million family caregivers
• Average time devoted
• 20.5 hours/wk
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Caregivers Responsibilities
• Critical Medical Decisions
• Assistance with activities of daily living
• Administer Medication
• Provide physical, emotional and spiritual
support
• Transportation
• Homemaking
• Finance
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Impact on Caregivers
•
Spousal caregiver → mortality of 63%
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53% Worried
•
37% Frustrated
• 28-60% Depressed
•
22% Overwhelmed
•
10-38% Isolation
American Osteopathic Association
D.O.s: Physicians Treating People, Not Just Symptoms
Be Sensitive to the
Caregiver
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Who is involved in care?
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Are there problems?
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How are they coping?
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Sensitive to the caregiver
•
•
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Their needs and experience
Stressors and Ill-effects
Understand the cost and implications
American Osteopathic Association
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Suicide
•
Assess all depressed patients for risk
•
Discussion of thoughts of suicide may
reduce the risk
•
Suicidal thoughts a sign of depression
•
High risk if recurrent thoughts, plans
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Management of
Depression
•
Proactive
•
Identify Risk Factors
•
Early intervention
•
•
•
Improves symptoms
Restores function
Reduces treatment resistance
American Osteopathic Association
D.O.s: Physicians Treating People, Not Just Symptoms
…..Management of
Depression
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Psychotherapeutic interventions
•
Cognitive approaches
•
Behavioral interventions
•
Medications
•
Combination of psychotherapy,
medication and possible osteopathic
manipulation, if indicated
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Counseling goals . . .
• Weave counseling into routine
interventions
• Include family when possible
• Improve patient understanding
• Create a different perspective
• Identify strengths, coping strategies
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. . . Counseling goals
• Reestablish self-worth
• New coping strategies
• Educate about modifiable factors
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Pharmacologic
management . . .
• Psychostimulants
• SSRIs
• Tricyclic and atypical
antidepressants
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. . . Pharmacologic
management
• Choose by time to effect
• Days – psychostimulants
• Weeks / months – SSRIs, tricyclic /
atypical antidepressants
• Start dosing low, titrate slowly
• Consider consultation
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Psychostimulants . . .
• Rapid effect
• Methylphenidate, 5 mg q am +
q noon, titrate to effect
• Alone or in combination
• Continue indefinitely
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. . . Psychostimulants
•
Diminish opioid sedation
•
Not usually an appetite suppressant
•
May exacerbate
•
Tremulousness
•
Anxiety
•
Anorexia
•
Insomnia
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SSRIs
• Latency 2–4 weeks
• Highly effective (70%)
• Well tolerated
• Once-daily dosing
• Low doses may be effective in
advanced illness
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Tricyclic antidepressants
•
Not recommended as first-line therapy
•
Latency 3–6 weeks
•
Adverse effects are common
•
•
Nortriptyline, desipramine have fewer
adverse effects
Atypical antidepressants still being
studied
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Anxiety . . .
•
Fear, uncertainty about future
•
Physical, psychological, social, spiritual,
practical issues
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Presentation
•
Agitation, insomnia, restlessness,
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Sweating, tachycardia, hyperventilation,
•
Panic disorder, worry, tension
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Management of anxiety
•
Counseling, supportive therapy
•
Benzodiazepines
• Short vs. long half-life
- Diazepam
- Lorazepam
- Alprazolam, oxazepam
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…Management of Anxiety
•
Assessment complex
•
Differentiate from
•
•
•
•
•
Delirium, depression
Bipolar disorder
Medication effects
Insomnia
Alcohol, caffeine
-
Lorazepam
Alprazolam. oxazepam
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…Management of Anxiety
• Atypical antidepressants
• Osteopathic manipulative
techniques as clinically indicated
American Osteopathic Association
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Delirium
• Global change in cognition,
awareness, acute onset
• Presentation
• Fluctuating level of consciousness
• Cognitive impairment
• Distinguish from dementia,
depression, anxiety
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Causes to consider . . .
• Infections, sepsis
• Medications, street drugs (including
withdrawal)
• Hypoxemia
• Metabolic
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. . . Causes to consider
• Vitamin deficiencies
• Fecal impaction, urinary retention
• Renal, hepatic failure
• Tumor burden, secretions
• Changes in environment
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Medical management
• Neuroleptics
• Haloperidol
• Chlorpromazine
• Atypical neuroleptics
• Risperidone
• Olanzepine
• Benzodiazepines for acute agitation
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Terminal delirium
• Day-night reversal
• Agitation, restlessness
• Moaning, groaning
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Evaluate treatment
•
Monitor carefully
•
If negligible or partial response
•
Re-evaluate diagnosis
•
Inquire about adherence to medication
•
Consider dosage adjustment
•
Consider a different medication
•
Refer to a specialist
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Depression, Anxiety and
Delirium
Summary
American Osteopathic Association
AOA: Treating Our Family and Yours