Hospice eligibility for dementia requires stage 7C or below according to the FAST scale (this means the patient is unable to ambulate without assistance, unable to dress or bathe without assistance, has urinary and fecal incontinence, and cognitive function has declined to the point where the patient can speak fewer than 6 words), as well as one or more qualifiers such as aspiration pneumonia. A decline in memory has to be substantiated by a demonstration of cognitive ability, such as verbal articulation. Inappropriate behavior such as hitting or acting out, does not neccessarily mean the patient has less than 6 months to live, nor do repeated UTIs.
Brain atrophy is part of normal aging, but the rate of atrophy is accelerated in individuals with Alzheimer’s disease. Studies have found patients with Alzheimer’s disease can have 3 to 4 % brain loss in a year, whereas loss of brain tissue secondary to atrophy with normal aging was < 1% a year.
Hospice eligibility for liver disease includes a PT>5 sec, or an INR > 1.5, serum albumin < 2.5gm/dl, and one or more qualifiers such as refractory ascites or hepatorenal syndrome.
Hospice eligibility for a cancer diagnosis includes a PPS score less than or equal to 70%, and hypercalcemia > 12. Regardless of the stage pancreatic cancer is diagnosed at, the 1-year survival rate is 20%, and the 5-year survival rate is 7%. Pancreatic cancer is still largely considered incurable, and colon, breast, and prostate cancer have much higher survival rates.
When cancer spreads to the bone and erodes bone tissue, calcium is released into the blood causing hypercalcemia. Bisphosphates prevent osteoclast-mediated bone loss in the occurrence of hypercalcemia in malignancies.
Kyphoplasty is very simple surgical procedure that can be done with local and mild general anesthesia. It is done using fluoroscopy and a cement-like material that hardens very quickly called polymethylmethacrylate, and is injected into the fractured area of the vertebrae. This stabilizes the fracture and reduces pain.
Any type of cancer can spread to the spine, but it is more commonly associated with breast cancer, lung cancer, prostate cancer, kidney cancer, lymphoma, and mutiple-myeloma. Up to 70% of spinal cord compression, secondary to the spread of malignancies, occurs in the thoracic spine area, particularly between T4-T7. The most common symptom is back pain.
Radiation therapy is first-line treatment for spinal cord compression and should be initiated within 24 hours of diagnosis. Radiation quickly relieves pressure on the spinal cord by shrinking the tumor.
Pleural effusions are common in patients with lung cancer and is often the first presenting symptom. Patient’s usually present with dyspnea and a non-productive cough. A CT scan is typically ordered.
Hospice eligibility for HIV includes CD4+ < 25 cells/mcl, or a viral load > 100,000 and a PPS score of < 50%.
Opioid-induced hyperalgesia (OIH) is a paradoxical response to opioids, where the patient encountes a more intense pain response affecting areas outside of the initial area of pain. For example, a continual increase in opioids is given to a patient for left femur pain. The pain escalates with increasing opioid dosages to the point that even a light back rub cause the patient severe discomfort. OIH involves the activation of N-methyl D-aspartate (NMDA) receptors, therefore pharmacological approaches work to block these receptors with antagonists such as ketamine, in addition to opioid reduction.
Opioid overdose presents with a decrease in arousal and respiration, not an increase in hypersensitivity.
Allodynia is characterized as pain caused by a stimulus that normally does not produce pain such as light touch. Most people describe allodynia as feeling like pinpricks or a burning sensation. Although allodynia occurs in areas other than the original source of pain, it is not considered “radiating,” such as pain associated with cardiac issues, nor is it considered “refered,” such as pain related to an appendicitis.
Superior vena cava syndrome commonly occurs in the presence of chest cancer’s that have grown, causing compression of the superior vena cava. Typical signs include facial edema, dyspnea, and vein distention.
For refractory dyspnea, low-dose opioids have been shown to reduce symptoms when optimal therapy for the underlying condition have been exhausted.
Cachexia is known as wasting syndrome, and is a condition in which the body can no longer adequately use food sources to maintain sustenance due to alterations in metabolism, (which often increases with cancer), and a chronic inflammatory response secondary to the disease process. This is seen in the late stages of a disease and is not reversible and does not respond to supplementation. Despite giving the patient a high-protein diet secondary to muscle atrophy, supplementation primarily turns to fat instead of muscle, and the patient continues to lose lean muscle mass and bone. Therefore, a low-protein diet is optimal for patients with cachexia.
First-line management for addressing excessive secretions in actively dying patients is to reposition the patient’s head to allow for secretions to drain naturally. A washcloth can be placed for absorption. Aggressive suctioning is ineffective and has been found to produce even more secretions. Anticholinergics such as glycopyrrolate are given when other management methods have failed, but anticholinergics are not always effective.
Anticholinergics block the neurotransmitter acetylcholine, and inhibit the transmission of parasympathetic nerve impulses, which reduces spasms of smooth muscles. This class of medications has considerable side effects such as dry mouth, urinary retention, delirium, dilated pupils, tachycardia, flushing of skin, and constipation.
Mirtazapine (Remeron) is often given for insomnia and depression. It is best to give one pill that can treat several issues and is cost-effective.