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The Project to Educate Physicians on End-of-life Care
Supported by the American Medical Association and
the Robert Wood Johnson Foundation
Module 6
Depression,
Anxiety, Delirium
Objectives

Identify depression, anxiety, delirium
near end of life

Describe management plans
Depression, anxiety,
delirium

Highly prevalent, under-diagnosed

May prevent quality dying

Effective management is possible
Depression

25%–77% of patients

Intense suffering

Not inevitable

Treatable in most cases

Early treatment is better
Risk factors . . .

Pain, other symptoms

Progressive physical impairment

Advanced disease

Medications
steroids
benzodiazepines
. . . Risk factors

Particular diseases
pancreatic cancer
stroke

Spiritual pain

Preexisting risk factors
prior Hx, family Hx, social stress
suicide attempts, substance use
Diagnosing depression in
advanced illness

Somatic symptoms always present

Look for psychological, cognitive
symptoms
pain not responding as expected
sad mood / flat affect, anxious, irritable
worthlessness, hopelessness,
helplessness, guilt, despair
anhedonia, lost self-esteem
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
Management of
depression

Psychotherapeutic interventions
cognitive approaches
behavioral interventions

Medications

Combination of psychotherapy,
medication
Counseling goals . . .

Weave counseling into routine
interventions
include family when possible

Improve patient understanding

Create a different perspective

Identify strengths, coping strategies
. . . Counseling goals

Reestablish self-worth

New coping strategies

Educate about modifiable factors
Pharmacologic
management . . .

Psychostimulants

SSRIs

Tricyclic and atypical
antidepressants
. . . Pharmacologic
management

Choose by time to effect
days – psychostimulants
weeks / months – SSRIs, tricyclic /
atypical antidepressants

Start dosing low, titrate slowly

Consider consultation
Psychostimulants . . .

Rapid effect

Methylphenidate, 5 mg q am + q
noon, titrate to effect

Alone or in combination

Continue indefinitely
. . . Psychostimulants

Diminish opioid sedation

Not usually an appetite suppressant

May exacerbate
tremulousness
anxiety
anorexia
insomnia
SSRIs

Latency 2–4 weeks

Highly effective (70%)

Well tolerated

Once-daily dosing

Low doses may be effective in
advanced illness
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
Anxiety . . .

Fear, uncertainty about future

Physical, psychological, social,
spiritual, practical issues

Presentation
agitation, insomnia, restlessness,
sweating, tachycardia, hyperventilation,
panic disorder, worry, tension
. . . Anxiety

Assessment complex

Differentiate from
delirium, depression
bipolar disorder
medication effects
insomnia
alcohol, caffeine
Management of anxiety

Counseling, supportive therapy

Benzodiazepines
short vs long half-life
diazepam
lorazepam
alprazolam, oxazepam

Atypical antidepressants
Delirium

Global change in cognition,
awareness, acute onset

Presentation
fluctuating level of consciousness
cognitive impairment
distinguish from dementia, depression,
anxiety
Causes to consider . . .

Infections, sepsis

Medications, street drugs (including
withdrawal)

Hypoxemia

Metabolic
. . . Causes to consider

Vitamin deficiencies

Fecal impaction, urinary retention

Renal, hepatic failure

Tumor burden, secretions

Changes in environment
Medical management

Neuroleptics
haloperidol
chlorpromazine

Atypical neuroleptics
risperidone
olanzepine

Benzodiazepines for acute agitation
Terminal delirium

Day-night reversal

Agitation, restlessness

Moaning, groaning
Evaluate treatment

Monitor carefully

If negligible or partial response
reevaluate diagnosis
inquire about adherence to medication
consider dosage adjustment
consider a different medication
refer to a specialist
E
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Depression,
Anxiety, Delirium
Summary