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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
  • More About:

  • Hospice Care
  • Clergy and Faith Communities
  • Additional Links
    Site Index
    Back to Module 10: Common Physical Symptoms
    Specific Symptoms

    Breathlessness (Dyspnea)
    Nausea and Vomiting
    Fluid Balance/Edema


    Case Example

    GE is a 92-year-old seamstress with progressive dementia. Her daughter, who lives with her but works during the day, indicates the patient isn’t sleeping well. The caregiver during the day indicates she spends most of the day in a chair in front of the television, and naps frequently.


    • Many patients (and their families) complain that they cannot sleep



    • Usual and current sleep patterns
    • Do they have difficulty falling asleep or are they waking?
    • Are they awakened by nightmares?
    • Are they experiencing early morning awakening or nighttime restlessness?
    • What do they think about when they are awake?
    • Are they afraid?
    • Are they experiencing day-night reversal of sleep patterns?
    • What are the associated symptoms (e.g., anxiety, pain, nausea and vomiting, breathlessness, medication effects), psychosocial or spiritual issues, or practical concerns that may be interfering with sleep?
    • Family and other team members will often be needed to find answers


    General Management of Insomnia

    • Encourage patient:
      • Maintain a regular sleep schedule
      • If possible, avoid staying in bed when awake
      • Avoid caffeine, including analgesics with caffeine, especially late in the day
    • Assess alcohol
      • Many patients use alcohol as a soporific or "toddy" at bedtime
      • Can cause a paradoxical awakening several hours after falling asleep
    • Plan for cognitive/physical stimulation during the day
    • Suggest that the patient avoid overstimulation in the period before going to sleep
    • Control pain during the night with long-acting medication
    • Relaxation and imagery interventions may be helpful


    Specific Management of Insomnia

    • Pharmacological measures may be adjuncts to the general measures indicated above
    • Antihistamines are frequently used
      • Examples include:
        • diphenhydramine 25–50 mg po q hs
        • meclizine 25–50 mg po q hs

      • However, tolerance may develop quickly, and some patients find the anticholinergic adverse effects troubling
    • Benzodiazepines (e.g., lorazepam 0.5–2 mg po q hs) are frequently used
      • However, dementia and delirium may be worsened, particularly in the frail or elderly
    • Imidazopyridines (e.g., zolpidem 5–10 mg po q hs) may have fewer adverse effects
    • Neuroleptic medications may be required

      • Risperidone or haloperidol 1 mg q hs (less sedating)

      • chlorpromazine 10–25 mg q hs (more sedating)
    • Debilitated and frail patients require careful titration and attention to undesired effects of medications
      • Commonly used medications may be associated with excessive daytime sedation

      • Trazodone 25 mg po q hs (titrating to up to 200 mg q hs) may be particularly useful in the frail and/or elderly
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