Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + DEMENTIA, FEEDING TUBES Download Section PDF Listen +++ +++ Population ++ –Patients with advanced dementia. +++ Recommendations ++ American Geriatrics Society 2013 ++ –Percutaneous feeding tubes are not recommended for older adults with advanced dementia. –Careful hand-feeding should be offered. ++ Source ++ –http://americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/ +++ Comment ++ Careful hand-feedings and tube-feedings have identical outcomes of death, aspiration pneumonia, functional status, and patient comfort. In addition, tube-feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers. + DEMENTIA, ALZHEIMER DISEASE Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ NICE 2011 ++ –Donepezil, galantamine, and rivastigmine are recommended as options for mild-to-moderate Alzheimer disease. –Memantine is recommended as an option for managing moderate Alzheimer disease in patients who cannot tolerate acetylcholinesterase inhibitors. ++ Source ++ –http://www.nice.org.uk/nicemedia/live/13419/53619/53619.pdf +++ Comments ++ Common adverse effects of acetylcholinesterase inhibitors include diarrhea, nausea, vomiting, muscle cramps, bradycardia, and insomnia. Common adverse effects of memantine are dizziness, headache, constipation, somnolence, and hypertension. Reassess the efficacy of the pharmacological intervention. If the desired clinical effect (eg, stabilization of cognition) is not achieved, discontinue the medication (AGS, 2015). + DELIRIUM, POSTOPERATIVE Download Section PDF Listen +++ +++ Population ++ –Older adults at risk for or who have postoperative delirium. +++ Recommendations ++ AGS 2015 ++ –Institutions should enact multi-component intervention programs to manage delirium. –Consider regional anesthesia at the time of surgery to improve postoperative pain control. –Avoid inappropriate medications postoperatively in older adults. –Use antipsychotics at the lowest effective dose and for the shortest duration possible to treat severe agitated delirium. –Avoid benzodiazepines for postoperative delirium. –Avoid pharmacologic therapy for hypoactive delirium. –Avoid use of physical restraints. ++ Source ++ –https://guidelines.gov/summaries/summary/49932 + DEMENTIA Download Section PDF Listen +++ +++ Population ++ –Adults with dementia. +++ Recommendations ++ ACP 2008, AAFP 2008, AGS 2015 ++ –Recommend a trial of therapy with a cholinesterase inhibitor or memantine based on individual assessment of relative risks vs. benefits. –Reassess for clinically significant effect or adverse effects after 3-mo trial. –The choice of medication is based on tolerability, side-effect profile, ease of use, and medication cost. –The evidence is insufficient to compare the relative efficacy of different medications for dementia. –Evidence is insufficient to determine the optimal duration of therapy. ++ Source ++ –http://www.annals.org/content/148/5/370.full.pdf +++ Comments ++ A beneficial effect of cholinesterase inhibitors or memantine is generally observed within 3 mo. Good-quality data in mild-to-moderate Alzheimer disease and vascular dementia show that cholinesterase inhibitors provide a modest improvement in global assessment, but no clinically important cognitive improvement. Subsets of patients may have significant cognitive improvement. Five high-quality studies evaluated memantine use in moderate-to-severe Alzheimer disease and vascular dementia and showed statistically significant improvement in global assessment, but no clinically important cognitive improvement. + PALLIATIVE CARE OF DYING ADULTS Download Section PDF Listen +++ +++ Population ++ –Dying adults. +++ Recommendations ++ NICE 2015 ++ –Care of the dying patient should be aligned with the patient’s goals and wishes and cultural values. –Symptom management should address physical, emotional, social, and spiritual needs. –Determine who should be the surrogate decision maker if they cannot make their own decisions. –Establish if the patient has a preferred care setting. –Medical management of symptoms: Pain is typically managed with opioids. Breathlessness can be managed with opioids or benzodiazepines +/– oxygen. Nausea can be managed with sublingual ondansetron or promethazine suppositories. Anxiety can be managed with benzodiazepines. Delirium or agitation can be managed with antipsychotics. Secretions can be managed with a scopolamine patch. ++ Source ++ – https://guidelines.gov/summaries/summary/49956 ++ Table Graphic Jump Location | Download (.pdf) | Print PALLIATIVE AND END-OF-LIFE CARE: PAIN MANAGEMENT Principles of Analgesic Use By the mouth The oral route is the preferred route for analgesics, including morphine. By the clock Persistent pain requires round-the-clock treatment to prevent further pain. As-needed (PRN) dosing is irrational and inhumane; it requires patients to experience pain before becoming eligible for relief. Relief is accomplished with long-acting delayed-release preparations (fentanyl patch, slow-release morphine, or oxycodone). By the WHO ladder If a maximum dose of medication fails to adequately relieve pain, move up the ladder, not laterally to a different drug in the same efficiency group. Severe pain requires immediate use of an opioid recommended for controlling severe pain, without progressing sequentially through Steps 1 and 2. When using a long-acting opioid, the dose for breakthrough pain should be 10% of the 24-h opioid dose (ie, if a patient is on 100 mg/d of an extended-release morphine preparation, their breakthrough dose is 10 mg of morphine or equivalent every 1–2 h until pain relief is achieved). Individualize treatment The right dose of an analgesic is the dose that relieves pain with acceptable side effects for a specific patient. Monitor Monitoring is required to ensure the benefits of treatment are maximized while adverse effects are minimized. Use adjuvant drugs For example, a nonsteroidal anti-inflammatory drug (NSAID) is often helpful in controlling bone pain. Nonopioid analgesics, such as NSAIDs or acetaminophen, can be used at any step of the ladder. Adjuvant medications also can be used at any step to enhance pain relief or counteract the adverse effects of medications. Neuropathic pain should be treated with gabapentin, duloxetine, nortriptyline, or pregabalin. Moderate- to high-dose dexamethasone is effective as an adjunct to opioids in a pain crisis situation. Source: Adapted from Pocket Guide to Hospice/Palliative Medicine.