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
Clergy and Faith Communities
Nausea and Vomiting
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 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
- Maintain a regular sleep schedule
- If possible, avoid staying in bed when awake
- Avoid caffeine, including analgesics with caffeine, especially late in the day
- 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
- 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