Palliative Care in Neurological Disease

Palliative care in Neurological Disease
Surat Tanprawate, MD, FRCPT Division of Neurology, Department of Medicine Chiang Mai University
04-10-2011, Chaing Mai,Thailand

Thursday, October 6, 2011
Palliative care
End of Life Care

Patients with terminal cancer
Patients with terminal cancer
It should be recognized as an important concept in the management of any patient with a progressive, incurable illness
So many neurologic illness are progressive and incurable

Who do the neurologists see?
Worried well, headache/ migraine, numbness, dizziness, etc

Chronic neurological disorder: MS, spinal cord, dementia


Acutely ill patients Chronic neurological disorder: MS, spinal cord, dementia

ART > SCIENCE

What we have to learn?

Learning process, not just knowledge

Learning process, not just knowledge Different diseases have different problems
>> the same goal

>> the same goal
Humanity diversity

>> the same goal
Humanity diversity Knowing your function, and connect with

others
The different view

Neurologist view
Palliative care team view
The different view

Neurologist view
Holistic approach(physical, psychological, cultural, spiritual) Experience in symptoms control End of life decision Community center In-patient facilities for terminal care/respite Day hospice facilities Complementary therapies Bereavement counselling
Palliative care team view
Neurologist
Palliative care
Neurologist
Palliative care
Neurologist
Palliative care

Neurologist
Palliative care

Improve QOL
Distress physical symptoms Feeling and psychological symptoms
Intervention
- Pharmacological -Nonpharmacological
Patient Family member

Health care
Social
Common neurological problems

Cognitive dysfunction, dementia> Alzheimers disease, other dementia Physical disability >stroke, motor neuron disease, Parkinsons disease, spinal cord disease, neuromuscular weakness
Dementia and Alzheimers disease

Dementia()
Decline of cognitive function () Cognitive function: memory, language,

motor ability, calculation
Its also involved psychological and
behavioral symptoms: depression, anxiety, hallucination, sleep problem, pain
Alzheimers disease
Most common cause of dementia AD is a neurodegenerative disorder

40 35 30
Female Male
presented with progressive dementia
Percent of 20 Age Group

15 10 5 0
25
-64
-69
-74
-79
-84
-89
-94 90
30
65
70
75
80
85
Years
95
-99
Alzheimers disease
Cognitive impairment
Physical disabilitylate stage
Psychiatric and behavioral symptoms

Activity daily living
Stage of AD
Management strategies
Prognostication, and dying from dementia Cognitive and communication ability
decline
Behavioral and psychological problems Challenging caregiver stress and

bereavement issues
Prognostication questions in dementia
Patients question: How long do I have

before my mind is shot?
Health professionals question: Is s/he

eligible for palliative care? have to live ?
Familys question: How long does s/he Caregivers question: I am exhausted.

How much longer can I do this?
Dementia hospice eligibility
Stage 7 or beyond according to the FAST scale
Unable to ambulate without assistance Unable to dress without assistance Unable to bathe without assistance Urinary or fecal incontinence, intermittent or constant No meaningful verbal communication, stereotypical phrases only, or ability to speak limited to six or fewer intelligible words Aspiration pneumonia Pyelonephritis or other upper UTI Septicemia Multiple stage 3 or 4 decubitus ulcers Fever that recurs after antibiotic therapy Inability to maintain sufcient uid and calorie intake, with 10 percent weight loss during the previous six months or serum albumin level less than 2.5 g per dL (25 g per L)
Plus one of the following within the past 12 months:
Cognition and ability decline-1

Unrecognized symptoms-pain, physical illness to nd the hidden problem: patient
report, caregiver report, and direct observation
OA, peripheral neuropathy, other pain are

common
change in behavior or mental status
Cognition and ability decline-II

Loss of functional ability unable to ambulate unable to bath, dress, or feed
independently
incontinent of bowel and bladder unable to communicate meaningfully (presence of medical complication)
What does dying look like

Decline in functional status Lack of desire to eat or drink Withdrawn Sleep- wake state Mottling of limbs Jaw movement Death rattle Co-morbid symptoms
Tube feed or not tube feed? Thats the question
The facts:
Effect on life span is an open question Increases suffering
Need for better pt/family education

Discussing benets and burdens of therapy Use neutral language Separate facts from your opinion Please offer your opinion Make allowances for special circumstances.
Palliative care in stroke patient

Stroke

Stroke is one of the three biggest killers in Thailand. Two types:
Infarction Hemorrhage
Death range from 8-20% in rst 30 days (higher for hemorrhage)
Stroke care: palliative care aspect

Palliative cares role in stroke care
Acute stroke: end of life care Long term care in stoke with severe disability
Death is mainly from cardiac (AMI, arrhythmias) or respiratory (aspiration, pneumonia embolism) Brain swelling
End of life care in acute stroke
Ethical aspects of care - end of life issues including withdrawal of treatment
Early decisions about withholding cardiopulmonary resuscitation are avoided. There is full discussion with the patient (if possible) and family/carer about reasons for withdrawal/ futility of treatment to allow all concerned to understand treatment goals. There is accurate documentation of plans of care and discussions between the multidisciplinary team, the patient and family/carer.
Various case of stroke with disability
Palliative care in motor neuron disease
--Motor Neuron Disease-Amyotrophic Lateral Sclerosis (ALS)
Progressive, degenerative neurologic disease

of unknown etiology
Involve: upper and lower motor neurons

==: LMN: weakness, atrophy, fasciculation ==: UMN: hyperreexia, spasticity due to lateral corticospinal tract degeneration
--Motor Neuron Disease-:Symptoms: Amyotrophic Lateral Sclerosis (ALS)
Weakness of body muscles causing :: limb weakness Progressive, degenerative neurologic disease :: dysphagia of unknown etiology :: respiratory failure Involve: upper and lower motor neurons :: speech difculty
==: LMN: weakness, atrophy, fasciculation ==: UMN: hyperreexia, Memory and Cognitive spasticity due to lateral corticospinal tract function are spared... degeneration
Signs and symptoms
Signs and symptoms
Signs and symptoms
Signs and symptoms
Secretion management
: decrease saliva production Medication use>>Benztropine, amitriptyline, artane : remove saliva>>increase uid intake, humidied air
Dysarthria Dysphagia
: speech therapy
: Decreased caloric and uid intake may lead to worsening of symptoms, such as weakness, muscle atrophy, fatigue : Initially management includes the modication of food and liquid consistency : Discussion for PEG
Muscle spasm & weakness

: Early PT/OT
Cramps
: Quinine sulfate 200 mg twice daily, Tizanidine 2-4 mg twice daily
: speech therapy
Muscle spasm & weakness

: Early PT/OT
Cramps
: Quinine sulfate 200 mg twice daily, Tizanidine 2-4 mg twice daily
: speech therapy
Respiratory care
: initiate discussion regarding the patientss goals and how the goal can be best achieved : respect the right of patients to refuse or withdraw treatment
To cure sometimes
To cure sometimes To relieve often
To cure sometimes To relieve often To comfort always
Dr.Surat Tanprawate, MD, MSc(Lond.), FRCP(T)

Division of Neurology, Department of Medicine, CMU
My Deep Gratitude to
Ass. Prof. Siwaporn Chankrachang
Thank You for Your Kind Attention
WWW.OPENNEURONS.COM

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Palliative care in Neurological Disease

04-10-2011, Chaing Mai,Thailand

End of Life Care

Patients with terminal cancer

Thursday, October 6, 2011

Patients with terminal cancer

So many neurologic illness are progressive and incurable

Who do the neurologists see?

Thursday, October 6, 2011

Who do the neurologists see?

Worried well, headache/ migraine, numbness, dizziness, etc

Who do the neurologists see?

Chronic neurological disorder: MS, spinal cord, dementia

Worried well, headache/ migraine, numbness, dizziness, etc

Who do the neurologists see?

Worried well, headache/ migraine, numbness, dizziness, etc

Thursday, October 6, 2011

ART > SCIENCE

What we have to learn?

Thursday, October 6, 2011

What we have to learn?

Thursday, October 6, 2011

What we have to learn?

Thursday, October 6, 2011

What we have to learn?

Thursday, October 6, 2011

What we have to learn?

Humanity diversity Knowing your function, and connect with

The different view

Palliative care team view

Thursday, October 6, 2011

The different view

Palliative care team view

Thursday, October 6, 2011

Thursday, October 6, 2011

Thursday, October 6, 2011

Thursday, October 6, 2011

Thursday, October 6, 2011

Distress physical symptoms Feeling and psychological symptoms

Patient Family member

Thursday, October 6, 2011

Common neurological problems

Thursday, October 6, 2011

Dementia and Alzheimers disease

Thursday, October 6, 2011

Decline of cognitive function () Cognitive function: memory, language,

Its also involved psychological and

behavioral symptoms: depression, anxiety, hallucination, sleep problem, pain

Thursday, October 6, 2011

Most common cause of dementia AD is a neurodegenerative disorder

presented with progressive dementia

Percent of 20 Age Group

Psychiatric and behavioral symptoms

Activity daily living

Thursday, October 6, 2011

Thursday, October 6, 2011

Thursday, October 6, 2011

Behavioral and psychological problems Challenging caregiver stress and

Prognostication questions in dementia

Patients question: How long do I have

Health professionals question: Is s/he

Familys question: How long does s/he Caregivers question: I am exhausted.

Dementia hospice eligibility

Stage 7 or beyond according to the FAST scale