TAMPA — Physicians caring for older adults at the end of life commonly have to treat these patients for urinary incontinence and delirium and often must decide whether the use of feeding tubes would be helpful.
Several experts offered their tips on dealing with these challenges at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.
Urinary Incontinence
Urinary incontinence is a troubling and common concern among older patients and is an independent predictor of nursing home placement. Urinary incontinence erodes a patient's quality of life through social withdrawal, body image distortion, and depression, said Dr. Lynn Bunch of Mount Sinai Medical Center in New York. This condition also increases caregiver burden because of the need for frequent changes of undergarments and the extra work involved in preventing and treating skin breakdown.
All palliative care patients should routinely be assessed for urinary incontinence, Dr. Bunch said. If the onset is acute, do a medical evaluation to look for a reversible cause, she said. Reversible causes include urinary tract infection, volume overload, stool impaction, hyperglycemia, hypercalcemia, vaginitis, and urethritis. A review of medications also is important, looking in particular for diuretics (which can increase urinary output), sedatives (which impair mobility and cognition), anticholinergics (which decrease bladder contractility), and α-adrenergics (which alter sphincter tone).
Functional incontinence—an inability to reach the toilet in time and/or coordinate the movements necessary to use the toilet—is common in the palliative care setting because many of these patients have functional decline and loss of mobility. Interventions for functional incontinence include physical rehabilitation, use of assistive devices, space planning/furniture rearrangement, use of a bedside commode, assistance with transfers, elimination of chemical/physical restraints, treatment of depression, scheduled voiding times, decreased intake of fluids at night, and discontinuation of or change of dosing time for diuretics.
It's important to talk with families of palliative care patients about functional urinary incontinence, Dr. Bunch said. Advise caregivers that all patients with life-limiting disease, especially those with dementia, will eventually develop functional urinary incontinence. Provide families with support and resources for this eventuality.
Chronic indwelling catheters have the advantages of protecting skin from moisture, making patient care easier, and decreasing the need for linen and clothing changes. However, they may be uncomfortable for patients, and because they limit patient mobility, they may contribute to delirium and agitation, which is a symptom of delirium. The decision to catheterize at the end of life should be individualized, Dr. Bunch said.
Delirium
The mortality rate of hospitalized patients with delirium ranges from 22% to 76%, and the 1-year mortality rate associated with delirium is roughly 35%–40%. The diagnosis of delirium is primarily clinical, and the condition often goes unrecognized. “Often, we fail to do a formal cognitive assessment,” said Dr. Elise C. Carey, an internal medicine physician who specializes in geriatrics at the Mayo Clinic in Rochester, Minn.
When a patient becomes agitated, determine if it represents an acute change in mental status, and perform a cognitive assessment and an evaluation for delirium using a tool like the Confusion Assessment Method. Identify and address any predisposing or precipitating factors. It's important to remember that delirium is often the sole manifestation of underlying disease. “I can't emphasize this enough,” Dr. Carey said.
Evaluate the patient for new or intercurrent illness: Take a history, do a physical exam, run selected lab tests, and get an ECG. Also look for infection, low blood volume, pressure sores, and poor nutrition. Review the patient's medications, looking for potential troublemakers—such as anticholinergic effects, narcotic pain medications, and benzo-diazepines—and replacing them with alternatives that are less likely to cause delirium. Evaluate environmental factors that may be contributing to the patient's agitation—such as recently performed surgery or multiple procedures, a room change, an ICU stay, sleep deprivation, the use of restraints or bladder catheters, and pain. Then take the necessary steps to treat any identified causes, provide supportive care, and prevent complications.
In terms of treating behavioral symptoms, “primarily we're going to try to rely on nonpharmacologic therapies,” Dr. Carey said. Such an approach includes reorienting patients to their surroundings, encouraging family involvement, having people sit with the patient, avoiding the use of indwelling catheters and of restraints, working to maintain the patient's mobility and self-care ability, and normalizing the patient's sleep-wake cycle.
In cases of severe agitation, pharmacologic treatment may be necessary. The first-line therapy is low-dose haloperidol (Haldol), at 0.5–1.0 mg twice daily plus every 4 hours as needed, Dr. Carey said.