SYMPTOM POTPOURRI
Symptom Potpourri Eric Widera, MD University of California, San Francisco San Francisco, CA
[email protected] Twitter:@ewidera
Disclosure I have no relevant financial relationships.
Topics Covered • Hiccups • Behavioral and psychological symptoms of dementia • Dysphagia
SYMPTOM POTPOURRI
Hiccups
ARS Question 1 72 year old with advanced Parkinson's disease developed persistent hiccups since a stroke two weeks ago. Work-up included a normal chest radiograph, electrocardiogram, and baseline laboratory blood results. Non-pharmacologic treatments have not improved symptoms. What would be the best next pharmacological treatment A. Haloperidol B. Dexamethasone C. Chlorpromazine D. Baclofen E. Metoclopramide
Definitions • Hiccup: – An involuntary, intermittent, spasmodic contraction of the diaphragm and intercostal muscles accompanied by sudden inspiration that ends with abrupt closure of the glottis, making the classic hiccup sound. – Derives from the sound of the event
• Singultus • Originated from the Latin, singult, "the act of catching one's breath while sobbing.”
• Persistent or protracted hiccups – lasting more than 48 hours but < 1 month
• Intractable hiccups – lasting more than one month
SYMPTOM POTPOURRI
Mechanism • Purpose of hiccups – We don’t know (a couple theories out there include vestige from our time as amphibians to preparing us for suckling)
• Frequency decreases with age – common in fetus then less so overtime
• Neural Pathway – Afferent limb • Phrenic, vagus, sympathetic chain
– Central mediator – Efferent limb • Phrenic and accessory connections to glottis and intercostal muscles
Benign Hiccups - Causes • Gastric distention – – – – – – – –
Overeating Carbonated beverages Aerophagia Gastric insufflation (endoscopy) Sudden changes in ambient or stomach temperature Alcohol ingestion Tobacco use Sudden stress
Persistent/Intractable Hiccups - Causes • Vagus and Phrenic nerve irritation – – – – –
Pharyngeal branches – pharygitis, laryngitis Thoracic branches – pneumonia/bronchitis, esophagitis Auricular branches – foreign body irritation Recurrent laryngeal nerve – goiter / tumor Abdominal branches – gastric distention, gastritis, PUD, pancreatitis, IBS – Diaphragmatic branches – GERD, subphrenic abscess
SYMPTOM POTPOURRI
Persistent/Intractable Hiccups - Causes • “Hiccup-genic” medications – Opioids, BDZs, steroids (dexamethasone)
• CNS disorders – Head trauma, CVA, AVM – Encephalitis, neoplasm, etc
• Toxic-metabolic disorders – ETOH, uremia – Hyponatremia, hypocalcemia
• Psychogenic factors – Stress
• Post-op – anesthesia, intubation
Helpful Questions • History – Duration – MPH – Medications – ETOH use • Labs: CBC, Electrolytes, renal function, LFTs
Treatments • • • •
Not great evidence out there Try to treat underlying illness (PPI for GERD) Stop “Hiccup-genic” medications Empiric therapy – Non-pharm aimed at interrupting vagal afferent limb • Breath holding • Sugar or sipping cold water • Breathing into bag • Fright • Digital Rectal massage
SYMPTOM POTPOURRI
Pharmacologic • Dopamine antagonists – Chlorpromazine (Thorazine) - central dopamine antagonist • • • • •
Previously FDA approved for treating hiccups Blocks dopaminergic neurotransmission Bad stuff: hypotension, EPS Oral/ IV/IM Recommended dose: 25-50 mg PO/IM q6-8 hours
Pharmacologic • Dopamine antagonists – Haloperidol - central dopamine antagonist • Dopamine antagonist • PO/IM/SL (use IV cautiously. Increased chance of QT interval prolongation) • Recommended: 1-4mg PO/SL q8hour
– Metoclopramide (Reglan) • Dopamine antagonist • Helps with gastric distension • Recommended: 5-10mg po/IV q8hours
Pharmacologic Baclofen – GABA(B) receptor agonist – Acts primarily at the spinal cord level by inhibiting spinal afferent pathways – Studied in a small randomized controlled study of poststroke patients showing effectiveness compared to placebo (1) – Cautious use in elderly, renal failure 1. Zhang C, Zhang R, Zhang S, et al.. Trials 2014;15:295.
SYMPTOM POTPOURRI
Pharmacologic • Other Drugs – Gabapentin – Phenytoin • reportedly effective in patients with a CNS etiology of their hiccups – Valproic Acid – Carbamazepine
Behavioral and Psychological Symptoms of Dementia
ARS Question 2 Stem A 84-year-old man who lives at home has Lewy Body Dementia. He recently has become agitated and aggressive at night. He has a Mini-Mental State Examination score of 14/30 and has exhibited cogwheel rigidity for the past year. Efforts to address comfort, assess for infection, redirect, and structure activities have failed to reduce his agitation.
SYMPTOM POTPOURRI
ARS Question 2 Options In addition to continued non-pharmacological measures, which pharmacologic treatment is the best next intervention to manage his behaviors? A. Quetiapine B. Clozapine C. Chlorpromazine D. Lorazepam E. Levodopa/carbidopa
Behavioral symptoms arise from a complex interaction between patient, caregiver, and the environment
Workup D: Describe the behavior (“A-B-C’s) I: Investigate possible underlying causes – Patient: unmet need, untreated symptom (pain, constipation), medication side effect – Caregiver: stress, burden, lack of training, poor communication techniques – Environment: over or under-stimulating, changing environment, routines not aligned with preferences
C: Create a care plan that matches the identified precipitants of the behaviors E: Evaluate the effectiveness
SYMPTOM POTPOURRI
Pharmacologic Therapy • Non-pharm treatment (i.e. based on DICE) should always be first line • Medications are generally recommended only after non-pharmacologic interventions have been tried • All drug therapies carry risk and are at best modestly effective and at worst, not effective at all
Pharmacologic Treatments - All have significant side effects •
Antipsychotics – All have FDA black box warning –
Mixed evidence with at best a modest short-term improvement in behaviors such as aggression or psychosis
• Antidepressents (Sertraline, Citalopram, Escitalopram) – Modest benefit with agitation behavior in randomized control trials
•
Mood Stabilizers
•
Dextramethorphan-Quinadine
•
Cholinesterase Inhibitors and memantine
– RCTs and meta-analyses have not supported the use for agitation, aggression, or other behavioral symptoms – Increased risk for falls – Modest effect maybe bigger in Lewy Body Dementia
Pain and Behaviors • Pain is a common and important source of behavioral disturbances in patients with dementia. • Empiric treatment of pain can should also be considered in individuals with behavioral disturbances without a clear cause • An empiric stepwise protocol starting with a trial of scheduled acetaminophen then moving to scheduled opioids has been shown to decrease agitation and aggression in individuals with dementia
SYMPTOM POTPOURRI
Board Pearls • Do not use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia. • Do not use benzodiazepines or other sedativehypnotics in older adults as first-choice for insomnia, agitation, or delirium. • Do not use strong antidopaminergic antipsychotics in Lewy Body dementia or Parkinson's with dementia • Empiric treatment of pain a good option in a field of bad options
Dysphagia
ARS Question 3 Stem You are consulted in the hospital on a 81-year-old Veteran with advanced dementia who is currently living in a long term care facility. He is admitted for a pneumonia thought secondary to aspiration and progressive weight loss (>15 lbs in the last 6 months). He is made NPO and bedside swallow assessment shows significant oropharyngeal dysphagia. He is currently taking donepezil 10mg, oxybutynin, simvastatin, and aspirin. On exam he is cachexic, has a dry oropharynx, and decreased breath sounds right base of lung.
SYMPTOM POTPOURRI
ARS Question 3 Options Which is the best next step in the care of this Veteran? A. Discontinue oxybutynin B. Place a feeding tube C. Start honey thickened liquids D. Order videofluoroscopic swallowing study
Dysphagia • Definition – difficulty swallowing food or liquid
• May occur in the: – Oral phase – Pharyngeal phase – Esophageal phase
Causes of Oropharyngeal Dysphagia •
• •
Iatrogenic • Medications!!! • NSAIDS/antibiotics • Anticholinergics • Radiation and other antitumor treatments Infection • Candidiasis/Bacterial/Viral Structural • Head and neck and Esophageal cancers • Poor dentition
• Myopathic • Myasthenia gravis • Sarcoidosis • Paraneoplastic • Neurologic • Dementia • Stroke • ALS • Parkinson • Delirium
SYMPTOM POTPOURRI
Dysphagia in Advanced Dementia • 86% will develop eating Problems – Refusal to eat (disinterest, lack of hunger, depression) – Apraxia (difficulty with motor movement) – Oropharyngeal dysphagia
Medications, weight loss, and dysphagia • Anorexia – Digoxin – SSRI
• Dysgeusia – Statins – Phenytoin – Anything that dries the mouth
• Cholinesterase Inhibitors
• Dysphagia – Bisphosphonates – Anti-cholinergics
• Nausea – – – –
SSRIs Digoxin Opioids Vitamins (ie Zinc, Iron)
• Just Plain Bad Taste
Evidence Base for Feeding Tubes in Dementia • No RCTs • 7 observational controlled studies showed no evidence of: – – – – – –
Increased survival Decreased mortality Improved quality of life Improved nutritional parameters (weight, albumen) Physical functioning Improvement or reduced incidence of pressure ulcers Sampson EL, Candy B, Jones L. Cochrane Database of Systematic Reviews 2009
SYMPTOM POTPOURRI
High expectations are often based on faulty information • 2001 survey of 195 primary care physicians of tube feeding in advanced dementia – 76% believed it reduced aspiration pneumonia – 61% believed it prolonged survival – 94% believed it improved nutrition
• Shega JW, Hougham GW, Stocking CB, et al. J Palliat Med. 2003;6(6):885-893.
Risks of Tube Feeding • Up to one-third experience transient gastrointestinal adverse effects (ie, vomiting, diarrhea) • Bowel perforations is rare (1%). • Tube dislodgement, blockage, and leakage are common (4%-11%) • Patients with dementia may require physical or chemical restraints to prevent tube dislodgment – 26% were physically restrained after feeding tube placement. – 29% needed sedating medications to prevent them from pulling out the feeding tube J Am Geriatr Soc. 2011 May;59(5):881-6
PEARL: What to do if the feeding tube falls out • 1 in 5 will need feeding tube replaced or repositioned • If PEG tube falls out in the first 7 days after the primary insertion – Do not insert anything into stoma but seek advice from the on-call surgeon.
• After 7 days – Safe to carefully insert a Foley catheter into stoma until a replacement gastrostomy tube can be inserted. – Foley catheter needs to be inserted straight away or stoma site will close in a few hours.
SYMPTOM POTPOURRI
Alternative: Careful Hand feeding • Pros – Maintains pleasure of tasting food – Participation in meal times – Increases interactions with patients
• Cons – Labor Intensive – Lower reimbursement than tube feeding – Food consumption will inevitably decrease with time due to disease progression
Oral Care • RCT of NH patients • Intervention: oral care (nurses or caregivers cleaned the teeth of residents after every meal with an applicator of povidone iodine) • Outcomes – Pneumonia was noted in 21 of 184 (11%) patients assigned to oral hygiene versus 34 of 182 (19%) patients who received no oral care – (OR 1.74, P=0.052)
SYMPTOM POTPOURRI
What about Thickened Liquids?
Aspiration and Dysphagia • 515 patients with dementia or Parkinson’s disease with aspiration on videofluoroscopic swallowing study – Randomized to chin-down position, nectar-thick liquids, or honey-thick liquids – Followed for 3 months
• No difference in pneumonia or death • Increased risk of dehydration Robbins J et al. (2008). Ann Intern Med , 148 (7), 509518.
Feeding Tubes in Populations other than Advanced Dementia • • • • •
ALS Stroke Metastatic Cancer Head & Neck Cancer PVS
SYMPTOM POTPOURRI
Other treatment options for espophageal dysphagia secondary to cancer • Surgical resection or laser ablation • Palliative radiation therapy • Esophageal stenet
Feeding Tubes in Eyes of the Law • Nancy Cruzan Case – Tube feedings do not differ from other medical therapies and could be started and stopped based on a person’s wishes and values – Individual states could define the level of evidence required to substantiate that a patient would not want artificial feeding • “Clear and Convincing” vs “Reasonable Evidence” Orentlicher D. JAMA. 1989;262(20):2928-2930
Questions? Please fill out a card for a response during the question and answer session at the end of the day.
SYMPTOM POTPOURRI
Further Questions after the course? Eric Widera, M.D.
[email protected] Twitter: @ewidera
