Page 65 Guide to Pain Management in Low-Resource Settings

Principles of Palliative Care 53

off ers a selective and eff ective option for treatment of However, these symptoms may overburden the patient
opioid-induced constipation, but high costs will prevent and will then require treatment to restore quality of life
its use in resource-poor settings. Nondrug interventions for the remainder of the lifespan.
such as increased activity, more fl uid intake, or change Anxiety may be most pronounced at night, pre-
of diet usually are very eff ective, if appropriate for the venting sleep and adding to tiredness during the day.
patient’s condition. Benzodiazepines at night provide a good night’s rest
and prevent endless brooding. Lorazepam off ers a pro-
How should you treat fatigue? fi le with rapid onset and little hangover the next day, but
Fatigue has been named as the most frequent symp- other sedatives will do as well. Treatment with benzo-
tom of cancer patients, and it is a predominant feature diazepines will also help with the treatment of dyspnea
in noncancer palliative care patients as well. As the and other symptoms, as these symptoms may have been
concept of fatigue is often not clearly understood by augmented by anxiety.
patients or by all health care professionals, it is recom- Some patients with advanced disease suff er
mended to consider the symptoms tiredness and weak- from major depression and require treatment with an-
ness instead of fatigue. However, there are only a few tidepressants. Mirtazapine is included in the IAHPC list
medical interventions for these symptoms. Treatment of essential drugs for palliative care. Mirtazapine is also
with erythropoietin, where available, has been used with indicated for anxiety and panic attacks, and has been
good eff ect in cancer patients, but in the palliative care reported to alleviate pruritus. However, for treatment
setting with reduced life expectancy there seems to be of depression, other antidepressants will do as well. Se-
no indication for erythropoietin. Drugs such as methyl- lective serotonin reuptake inhibitors (SSRIs) should be
phenidate and modafi nil are under investigation. How- preferred as they produce less side eff ects compared to
ever, the most eff ective medication seems to be dexa- older tricyclic antidepressants. Eff ect of antidepressant
methasone or other steroids. Th eir eff ect tends to wear therapy usually will take 2–3 weeks, and as treatment
off within a few days or weeks, and often is accompa- should be started at a low dose with stepwise titration
nied by adverse events, so steroids should be reserved until eff ective, many patients with reduced life expec-
for situations where a clear goal is visible within a short tancy will not live long enough to benefi t from antide-
time frame, such as a family celebration. pressants. For these patients methylphenidate is an al-
Reduction of other medications may alleviate ternative, as the onset of action takes only a few hours.
tiredness dramatically, and a review of the drug regi- However, many patients will suff er not from
men is advocated in patients with reduced performance major depression, but from feeling depressed, which
status, as many medications may not be required any is not the same. A feeling of sadness and grief may be
more. In selected patients with severe anemia, blood completely appropriate and may even help with coping
transfusions are an option to reduce tiredness and with the disease. Treatment with antidepressants for
weakness, with repeated transfusions even over a pro- these patients may impede coping and add burdensome
longed period of time. side eff ects such as dry mouth or constipation. Th e de-
However, for most patients, nondrug interven- cision to treat depression therefore requires careful bal-
tions will be eff ective, such as counseling, energy con- ancing of eff ectiveness and side eff ects.
serving and restoration strategies, and keeping a diary
of daily activities. Physical training has been shown to How should you treat agitation and confusion?
reduce fatigue eff ectively. Physical activity is possible In the fi nal phase of life, agitation and confusion are
even for patients with advanced disease, although it has frequent symptoms that can cause considerable stress
to be adapted to reduced performance status and cogni- not only on the patient, but also on caregivers and staff .
tive function. Neurological causes may include focal seizures, isch-
emic insult, cerebral bleeding, or brain metastases.
How should you treat anxiety and depression? Many drugs as well as withdrawal of drugs or more fre-
Anxiety and depression are among the major psycho- quently of alcohol may lead to delirium, typically with
logical problems in palliative care. Patients facing the fl uctuating symptomatology after sudden onset. Fever,
diagnosis of an incurable disease and limited progno- infection, electrolyte disturbance such as hypercalcemia,
sis may have every right to feel anxious and depressed. or dehydration also may trigger or aggravate delirium.