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6 - Palliative and Hospice Care |

127

• What is my chance of cure?

• Will I live longer with treatment?

• What are the side effects of treatment?

• Are there other options?

• Are there any clinical trials available? Am I

eligible?

•

What are the likely things that will happen to

me with this disease?

•

How long will I live? (Ask for a range.)

• Are there things I should be doing for my

family, or ﬁnancial concerns?

•

Who is available to help me cope with this

situation?

Whereas some clinicians and family fear

that confronting end-of-life issues may cause

a newly diagnosed patient to lose hope, most

patients want to discuss their illness and wishes

as well as the advantages and disadvantages of

treatment because it results in better decisions

and a greater sense of control. Such discussions

can improve quality of life and reduce family

bereavement.

Part of the end-of-life discussion identi-

ﬁes goals of care and the wishes of the patient

and family regarding treatment. Life-prolonging

or disease-modifying treatments should be

explained, outlining the positive and negative

consequences that may occur given the patient’s

current status. Improving a patient’s quality of

life is usually an appropriate goal throughout

the disease process, whether achieved through

pharmacologic or nonpharmacologic means.

The goals of care should include a speciﬁc

discussion about pain management. Pain is a

known symptom of cancer, but many clinicians

do not realize that 50% to 85% of advanced

COPD and CHF patients also report pain symp-

toms.

Quality-of-life goals should also address

symptoms such as nausea, constipation, fatigue,

dyspnea, anxiety, and depression. Complex

psychosocial and spiritual issues should be

addressed, in goals of care.

In late stages of disease, invasive or inten-

sive therapies associated with life-prolonging

outcomes (e.g., admission to an intensive care

unit, ventilation, resuscitation, chemotherapy,

use of a feeding tube) may not necessarily

extend survival.

11,13

A major study compared

cancer patients with a 3-year prognosis who

received hospice and no chemotherapy to

patients who did not receive hospice care but

did receive chemotherapy. The study showed

survival was signiﬁcantly longer or no different

for hospice patients, depending on the type of

cancer.

Individuals admitted to hospice for

more than 1 week report an improved quality of

life compared to those not in hospice care.

late stages of disease, the goals of care should

be discussed and modiﬁed as appropriate for

the patient and his or her values. This can be a

complex task, especially if the patient or family

does not understand the prognosis. Involving

palliative care physicians and team members

at an earlier stage may enable trusting relation-

ships and improved communication with older

adults because the team members will already

be part of the individual’s care.

A second issue comprises personal

values, such as spirituality and dignity, which

may be overlooked at the end of life. As death

approaches, spiritual concerns can be as

important as physical symptoms for the patient.

Hospice services include clergy or other

bereavement counselors.

Patients may feel a

loss of dignity when they are unable to perform

familiar tasks (e.g., taking care of others, living

in an independent and self-directed manner,

being mentally alert). It is important for phar-

macists to be aware of such issues when inter-

acting with patients and their families. There is

limited evidence regarding the appropriate role

of pharmacists in spiritual assessment and care.

Nevertheless, data from nursing and physician

roles may guide pharmacists involved in direct

patient care.

One study examined 156 patients

with cancer and found that 42% wanted their

nurse to enquire about their spiritual beliefs. Of

those, 66% wanted their nurse to offer to pray

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128

| Fundamentals of Geriatric Pharmacotherapy

privately for them, and 41% wanted their nurse

to pray with them.

Some general strategies are

available to address spiritual issues and may

not require additional training.

One of the most

important strategies is to listen to and empathize

with the patient. If the patient wishes, refer to a

chaplain or invite clergy from the patient’s reli-

gious practice to meet with him or her.

16-18

KEY POINT:

Address spiritual

concerns, as well as physical symptoms, in

order to provide the patient with a better

quality of life as death approaches.

A third issue in palliative care is symptom

assessment. Although considered a nonphar-

macologic intervention, it is imperative that

assessment be done well to adequately guide

pharmacotherapy for a patient. As described in

Chapter 4, evaluating older adults (compared

to younger adults) means being on the lookout

for speciﬁc nuances. Some hospice programs

may use speciﬁc validated assessment tools to

identify the presence and intensity of symptoms;

others select tools related to the patient’s diag-

nosis. Examples of assessment tools include the

Edmonton Symptom Assessment Scale, which

addresses a variety of common symptoms at the

end of life, and the Geriatric Depression Scale.

Examples of tools that focus on the patient’s

diagnosis include the Functional Assessment

Staging Test (used to measure the course of

Alzheimer disease) and the New York Heart

Association Functional Classiﬁcation for patients

with heart failure.

In elderly and younger

patients, physical pain is the most common

complaint.

In older adults, symptom burden is

high and frequently under-recognized. In addi-

tion to symptom assessment, functional assess-

ment is important in the older adult. As disease

progresses, the patient may lose independence,

increasing physical and psychological needs.

Additional challenges may exist in evalu-

ation of a patient who has signiﬁcant cognitive

impairment. These patients may not remember

pain or other symptoms experienced 24 hours

prior and are only aware of current complaints. If

severe cognitive impairment is present, patients

who are nonverbal may express pain or other

symptoms through facial expressions, mental

status changes, changes in activity, interper-

sonal interactions, or speciﬁc body movements

(guarding, ﬁdgeting, pacing, or decreased

mobility).

Finally, caregiver burden should not be

underestimated. As described in Chapter 1,

informal caregivers generally have increased

responsibility as a patient grows more depen-

dent, which may lead to stress, fatigue, and poor

health outcomes. Hospice programs provide

support, with instructions on how to care for the

patient, short-term respite care, and bereave-

ment services.

C P

I  P C

A multimodal approach to symptom management

is of utmost importance, especially in the frail and

elderly patient. Elderly patients are more sensi-

tive to medications; by utilizing other members of

the interprofessional team (e.g., social workers,

chaplains, psychologists), inappropriate medi-

cations may be avoided and excessive use of

medications may be decreased. After a thor-

ough patient assessment, the choice of medica-

tion is dependent on many elements including

symptom severity, ongoing disease states, goals

of therapy, and availability and cost of therapy.

Pharmacokinetic Changes

In addition to the many pharmacokinetic and

pharmacodynamic changes occurring in older

adults that may impact response to drug therapy,

other factors include frailty and the effects of

disease in the patient who is approaching the

ﬁnal chapters of life.

22-26

It is appropriate to start

with the most basic pharmacokinetic changes.

Oral absorption may be impaired by nasogas-

tric suction. Further slowing of contractions in

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6 - Palliative and Hospice Care |

129

the gastrointestinal (GI) tract may occur due

to treatment with opioids. If the end of life is

particularly stressful physically or psychologi-

cally, an increase in acid production may occur,

increasing the risk for ulceration, especially if

nonsteroidal anti-inﬂammatory drugs (NSAIDs)

are employed.

Volume of distribution is another pharma-

cokinetic dimension that may be altered if the

patient has edema or third-space accumula-

tion of ﬂuid. Serum albumin concentrations

may decrease if hepatic function is diminished

or protein intake reduced. The resulting reduc-

tion in protein binding can signiﬁcantly increase

free drug concentrations in the blood, causing

toxicity even at normal doses.

Signiﬁcant pharmacokinetic alterations can

also alter elimination of drugs from the body.

Fever and inﬂammation may decrease cyto-

chrome P450 (CYP450) oxidative metabolism,

particularly during end-stage liver disease. The

CYP subfamilies 1A2, 2E1, and 2D6 may be

signiﬁcantly affected, either down-regulated

or up-regulated depending on the patient’s

disease and ethnicity. CYP enzyme derange-

ments can drastically increase or decrease rates

of drug elimination, with predictable harm to the

patient. Glucuronidation enzymes are gener-

ally preserved in the liver. If not preserved, then

extrahepatic glucuronidation enzymes in the

kidney and gut compensate for any decrease.

Kidney excretion can be estimated using creati-

nine clearance but has the same caveats as

found in all older adults.

Dosage Forms

When choosing a dosage form for a medica-

tion, factors to consider include best route of

administration, dosing frequency, cognitive state

of the patient, and physical impairments. Oral

administration is simplest and usually preferred;

however, if a patient is unable to swallow solids,

then oral liquid, sublingual, parenteral, rectal, or

transdermal routes must be used. As a patient

becomes unable to swallow a solid dosage form,

a rapidly dissolving or sublingual tablet may

be substituted, if available. In many instances

tablets may be crushed, or capsule contents

added to jelly or applesauce. Of course, certain

medications cannot be crushed. Compounded

oral solutions may be prepared for some medica-

tions if point-of-care preparation is not feasible.

Commercially available transdermal prod-

ucts offer another convenient method to admin-

ister medications, and this route often provides

a sustained release so dosing intervals can

be extended. Another option in palliative and

hospice care is to have topical dosage forms

compounded for administration; however,

this should be limited to medications with

proven transdermal absorption. For example, a

compounded formulation of lorazepam, diphen-

hydramine, and haloperidol was a common

choice by many centers for treatment of nausea

and vomiting.

Nevertheless, a pharmacoki-

netic evaluation showed absorption insufﬁcient

to cause any effect, and a trial demonstrated

anti-nausea effects to be similar to placebo.

30,31

Localized neuropathic pain that will not respond

to topical application of commercially available

products (e.g., lidocaine patch) may respond

to compounded N-methyl D-aspartate (NMDA)

antagonists, clonidine, or doxepin for topical

use.

Tailoring Medication

Appropriateness in Palliative

and Hospice Care

Hospice care originated with the need for more

effective pain and symptom control in cancer

patients at the end of life. In the past, too few

medications were being used to sufﬁciently ease

suffering. Only recently have providers begun to

recognize that for patients at the end of life medi-

cation appropriateness should be assessed to

reduce pill burden and exposure to medications

that are unlikely to provide clinical beneﬁt to

patients with limited life expectancy. Prescribing

has been traditionally guided by evidence from

randomized controlled clinical trials, on which

guidelines are based. However, most clinical

trials for medications used in chronic progres-

sive disease would exclude individuals who

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130

| Fundamentals of Geriatric Pharmacotherapy

are nearing the end of life. Medication use in

a patient with reduced life expectancy should

incorporate an added layer of scrutiny.

Efﬁcacy and safety are still paramount in identi-

fying appropriate medications for use in an older

adult near the end of life. The clinician must

also consider whether the expected therapeutic

outcomes can reasonably be achieved within the

patient’s estimated life expectancy. The difﬁculty

in discontinuation of medication is illustrated by

several statistics. Insurance claims for poten-

tially inappropriate medications used during the

last year of life revealed that 44% of Medicare

Advantage members received one such drug.

Statins were continued in over half of Veterans

Administration patients during the last 6 months

of life.

Among patients enrolled in hospice

for end-stage dementia, 21% were prescribed

cholinesterase inhibitors and memantine.

KEY POINT:

e goals of care change

for patients closer to the end of life and

no longer follow treatment guidelines

for prevention or cure of illness.

A model has been proposed for evaluating

the appropriateness of medication use in older

adults. The patient’s life expectancy is estimated

using life tables or multidimensional models

designed for use with speciﬁc illnesses or func-

tional states.

Next, the likely time until the beneﬁt

of the medication is achieved is compared to

life expectancy. For example, opioids for pain

management tend to have a rapid onset of

action, within minutes to hours. This compares to

preventive medications (i.e., antihypertensives)

which may require months or years for clinical

beneﬁt to occur. Should a patient have a rela-

tively short life expectancy, preventive medica-

tions may not have time to achieve expected

outcomes. Other components of the model are

goals of care and treatment targets, which are

paramount in determining a treatment plan and

may negate any practice guidelines. When goals

of care are established, treatment targets can be

identiﬁed. These targets become the elements

of the plan of care, with goals of care, life expec-

tancy, and time to beneﬁt used to tailor the

choice and implementation of treatment.

Re-evaluating Potentially

Inappropriate Medications

Often, medications that would normally be

considered inappropriate in older adults may

be suitable for geriatric patients in the palliative

care setting. What may customarily be consid-

ered a side effect of a medication becomes a

therapeutic beneﬁt. Some agents have worri-

some effects in patients who are expected to live

months to years more but may not be an issue

in those who only have days or weeks left to

live.

For example, dry mouth from scopolamine

patches, usually an undesirable effect, is helpful

to reduce secretions at the end of life. Long-

acting benzodiazepines may be preferred in a

patient who is bed-bound and unlikely to fall.

To review the use of medications in patients

approaching the end of life, especially in the

elderly, the questions in Table 6-2 can be

considered, which help with the effort to opti-

mize therapy and decrease adverse effects.

has been shown that when patients are initially

referred to palliative care, as many as 20% are

already receiving at least eight other medica-

tions, usually for comorbid conditions.

40-42

The

risk for adverse drug reactions and medication

interactions increases when more medications

are taken. It is estimated that the risk of adverse

drug interactions is more than 80% when more

than seven medications are taken on a regular

basis.

Because many pathophysiologic

changes may affect metabolism, excretion, and

volume of distribution of the chronic medications

for comorbid conditions in the setting of a life-

limiting illness, it is important to review a patient’s

medications to ensure appropriateness of each

medication.

New medications will usually be

introduced for symptom control as the patient’s

life-limiting illness progresses, and these addi-

tions all increase the risk for medication inter-

actions and adverse drug events. At the end

of life, priority shifts from prolonging a patient’s

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6 - Palliative and Hospice Care |

131

life to improving quality. If a patient is receiving

medication that offers no beneﬁt in quality of life,

consider discontinuing the agent.

Discontinuation of medication in patients

near death is a process similar to initiating drug

therapy. First, an indication to discontinue medi-

cation must be identiﬁed. As goals of care change

and patients become more frail, an increased risk

for harm from a medication may develop. In addi-

tion, the drug may be identiﬁed as providing no

clinical beneﬁt. Communication with the patient

and/or family must occur to ascertain their under-

standing of the medication’s beneﬁts and harms,

and to address what objections they may have

toward discontinuation.

Empirically, it is best to

stop one drug at a time, in a manner that will mini-

mize any adverse drug withdrawal events. For

some agents, such as aspirin or warfarin, there

may be no physiologic withdrawal symptoms. For

others, such as digoxin or diuretics, there may be

risk for exacerbation of an underlying condition.

A third category would be medications such as

beta blockers or antidepressants, which cause

rebound or withdrawal symptoms. Whatever type

of agent is discontinued, the patient should be

monitored for adverse effects. With drugs that

cause physiologic withdrawal, or where exac-

erbation of an underlying condition may cause

additional symptoms, it is best to taper to the

lowest doses before discontinuation, to minimize

the risk to the patient.

KEY POINT:

At the end of life, priority

shifts from prolonging a patient’s life to

improving the quality of it. If a patient

is receiving medication that oers no

benet in quality of life, discontinuing

the medication may be benecial.

P

M  S

Many symptoms and signs may occur in the

actively dying patient.

They vary depending

on the patient and the length of time before

death occurs. Symptoms that may be present

earlier in the dying process (i.e., months left to

live) include pain, constipation, and anxiety and

depression. In the weeks before death, patients

may experience nausea and vomiting, anorexia,

and fatigue. In the actively dying patient (i.e.,

days left to live), dyspnea, agitation, decreased

levels of consciousness, changes in breathing,

and other symptoms listed in Table 6-3 may be

present. The sections below will discuss many

of these symptoms and their pharmacologic

management; however, evidence is sparse

for effective management of symptoms in the

elderly. Nonpharmacologic measures are not

speciﬁcally addressed in this chapter, although

the best care for elderly patients at the end of life

is a combination of pharmacologic and nonphar-

macologic measures.

Symptom Management

Pain Management

Pain can be one of the most difﬁcult and

distressing symptoms to manage in the elderly.

For elderly patients at the end of life, it is impor-

tant to remember the concept of “start low and

Table 6-2. Questions to Consider When

Optimizing Medications in the End-of-Life

Patient

Is the symptom due to a reversible underlying

cause?

Is the patient undertreated and is additional

medication indicated?

Is the patient able to adhere to his or her medica

tion schedule?

Which drugs can be withdrawn?

Which drugs are inappropriate for this patient?

Which adverse effects are present?

What clinically relevant interactions are to be

expected?

Should the dose, dose frequency, and/or form of

drug be adjusted?

For additional information, see reference 39.

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132

| Fundamentals of Geriatric Pharmacotherapy

go slow.” It is equally important to “get there”

(i.e., adequately relieve pain). Although there

is a higher rate of adverse effects with opioids

in this patient group, there is also a higher rate

of undertreated individuals.

Accurate pain

assessment is vital in determining the best

treatment plan for the patient (see Chapter 4).

For patients who cannot verbally describe their

Table 6-3. Signs Present when Death Is Imminent

Clinical Sign Additional Information Management

Weakness and fatigue Monitor for pressure ulcers. Reposition the patient to prevent pres-

sure ulcers.

Decreased food and

ﬂuid intake

May occur earlier in the terminal

disease; however, when death is

imminent, patient is usually not

hungry. Forcing food and ﬂuids

may cause discomfort. Dehydration

occurs naturally in the dying.

Moisten and care for the mouth, nose,

and eyes by moistening and cleaning

the mouth, coating the lips and anterior

nasal mucosa with petroleum jelly, and

moistening the conjunctiva with an

ophthalmic lubricant if the eyes are not

closed.

Decreased ability to

swallow and cough

May lead to noisy breathing (gurgling,

crackling, and rattling).

Refer to the section Terminal Secretions.

Reduced circulation

and renal function

Occur due to dehydration and

decreased cardiac output. May

cause the extremities to look

cyanotic and feel cool when touched.

None. Intravenous ﬂuids will not reverse

the decreases in organ function at the

end of life and may cause other prob

lems (e.g., ﬂuid overload).

Decreased levels of

consciousness

Encourage family and friends to talk to

the patient, who may still hear and

sense their presence.

None.

Agitation Mild symptoms may respond to soft

music or calming, comforting words.

Refer to the sections Agitation and

Delirium and Proportionate Palliative

Sedation for management of more

complicated symptoms.

Incontinence Educate family members regarding

loss of bladder and bowel function,

and demonstrate how to address it.

Manage based on symptom (e.g., urinary

incontinence vs. bowel incontinence)

Changes in breathing May present as periods of apnea,

irregular patterns of respiration, or

Cheyne-Stokes–pattern tachypnea

Refer to the section Dyspnea for

management of breathlessness.

Loss of ability to close

eyes

Explain to family members that this is

common.

Continue to moisten the conjunctiva with

ophthalmic lubricants or artiﬁcial tears.

Near-death awareness Patients may appear to describe what

dying is like; it may be difﬁcult to

distinguish between a near-death

awareness and delirium.

Involve a multidisciplinary team to offer

support for the family.

For additional information, see reference 16.

symptoms, nonverbal pain scales and attentive

patient assessment are important.

Some medications are speciﬁc to the end of

life and palliative care. Non-opioid pain manage-

ment is commonly used for mild to moderate

pain as well as in speciﬁc types of pain (e.g.,

bone pain). Classes of medications or agents in

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6 - Palliative and Hospice Care |

133

neuropathic pain. The most common adjuvant

analgesic classes for the treatment of neuro-

pathic pain are the anticonvulsants, tricyclic

antidepressants (TCAs), serotonin norepineph-

rine reuptake inhibitors (SNRIs), and topical

local anesthetics.

These medications must

be started at low doses and titrated slowly to

avoid potential side effects. Therefore, it may

take up to 2–3 weeks for onset of the full effect.

Estimating the amount of time a patient has left

before death may help decide whether an adju-

vant analgesic would beneﬁt the patient. Table

6-4 lists speciﬁc adjuvant analgesics to consider

for these patients.

Angina is another type of disease-speciﬁc pain.

Medications used to treat and/or manage it should

be considered, including nitrates, beta blockers,

calcium-channel blockers, and ranolazine.

KEY POINT:

Pain can be one

of the most dicult and distressing

symptoms to manage in the elderly.

Constipation

Constipation is an inability to pass stools. In

palliative care patients, prevention is the best

therapy. For opioid-induced constipation, recom-

mended agents are stimulant laxatives such as

bisacodyl or senna, with or without a stool soft-

ener. Other agents such as the osmotic laxatives

(e.g., lactulose or polyethylene glycol) may be

added to the patient’s bowel regimen if needed.

Counsel the patient to drink plenty of ﬂuids so

the laxative can be effective. A third-line option

is methylnaltrexone, an injectable opioid antago-

nist. It works to inhibit opioid-induced decreased

GI motility and delayed GI transit time; it does

not cross the blood-brain barrier and, there-

fore, will not reverse the analgesic effect of the

opioids.

Other agents may be useful for non-

opioid induced constipation (see Chapter 11).

Remember that the best way to treat and manage

constipation in the palliative care patient is to

identify the underlying causes.

this category include NSAIDs, acetaminophen,

steroids, and bisphosphonates (see Table 6-4).

Corticosteroids are often used in those who are

terminally ill for symptoms such as bone pain and

visceral pain (e.g., obstruction), among others.

is common to encounter corticosteroid treatment

at the end of life. Dexamethasone is the most

frequently used corticosteroid and is considered

the drug of choice. It causes less sodium and

ﬂuid retention than other agents in the class. It

has a long half life (>36 hours) and, therefore, can

be given once a day. Short-term courses of corti-

costeroids rarely cause the side effects associ-

ated with long-term use. Still, a reversible delirium

known as steroid psychosis may develop, espe-

cially in elderly patients.

Bisphosphonates and

other bone modifying agents (denosumab) may

be used for relief of bone pain.

These have

also been shown to decrease the time to skel-

etal-related events (e.g., fractures) in patients

with bone metastases.

These are unlikely to

be covered under the patient’s insurance in the

hospice setting, even though they may be beneﬁ-

cial in palliative care.

Opioids are the most useful and ﬂex-

ible agents for treatment of pain in patients at

the end of life. They are recommended by the

American Geriatrics Panel on the Pharmaco-

logical Management of Persistent Pain in Older

Persons, regardless of whether patients are at

the end of life. Opioids should always be consid-

ered in patients with moderate to severe pain.

In the palliative care setting, immediate-release

opioids may be prescribed based on the peak

effect of the medication, rather than the dura-

tion of action. For example, morphine immediate

release may be prescribed every 1–2 hours as

needed for pain instead of every 4 hours, which

is the duration of action of immediate-release

morphine.

If a patient is unable to swallow,

some alternatives include sublingual admin-

istration of concentrated morphine solution,

oxycodone immediate-release solution, off-label

administration of sustained-release morphine, or

oxycodone given rectally.

Adjuvant analgesics may be beneﬁcial in

some patients, especially those experiencing

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134

| Fundamentals of Geriatric Pharmacotherapy

Table 6-4. Selected Agents Used in Hospice and Palliative Care in the Geriatric Population

Medication

Use in

Palliative Care

Geriatric Starting

Dosing (po or

transdermal unless

otherwise noted) Special Considerations

Opioid Analgesics

Fentanyl transdermal Nociceptive pain 12.5 mcg/hr; titrate based

on response

Do not use in opioid-naive

patients; absorption may be

variable in the elderly

Hydrocodone/acetamino-

phen

Nociceptive pain,

cough

2.5/325–5/325 mg every

6 hours prn; titrate

based on response

MDD of acetaminophen = 3 g

Hydromorphone Nociceptive pain 1–2 mg every 4 hours

prn; titrate based on

response

Not the best ﬁrst-line opioid

for opioid-naive patients

Methadone Nociceptive pain

Neuropathic pain

2.5 mg every 12 hr Do not use in opioid-naive

patients

Morphine extended release Nociceptive pain

Dyspnea

15 mg every 12 hr Do not crush; active metabo

lites accumulate in renal

insufﬁciency

Morphine immediate

release

Nociceptive pain

Dyspnea

2.5–5 mg every 1 hr prn Active metabolites accumulate

in renal insufﬁciency

Oxycodone extended

release

Nociceptive pain

Dyspnea

10 mg every 12 hr Opioid of choice in the elderly;

do not crush

Oxycodone immediate

release

Nociceptive pain

Dyspnea

2.5–5 mg every 1 hr prn Opioid of choice in the elderly

Tapentadol Nociceptive pain

Neuropathic pain

25–50 mg every 6 hr MDD = 600 mg; adjust dose

in hepatic and renal failure;

serotonin syndrome can

occur if taken with SSRIs/

SNRIs and MAOIs

Tramadol Nociceptive pain

Neuropathic pain

25–50 mg every 8 hr MDD = 600 mg; adjust dose

in hepatic and renal failure;

serotonin syndrome can

occur if taken with SSRIs/

SNRIs and MAOIs

Non-Opioid Analgesics

Acetaminophen Mild to moderate

pain

325–650 mg every 6 hr

Ibuprofen Bone pain

Inﬂammatory

nociceptive

pain

400 mg every 8 hr MDD = 3200 mg; give with

PPI to prevent GI problems

Meloxicam Bone pain

Inﬂammatory

nociceptive

pain

7.5 mg daily MDD = 15 mg, less GI side

effects than other NSAIDs

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6 - Palliative and Hospice Care |

135

Naproxen Bone pain

Inﬂammatory

nociceptive

pain

250 mg every 12 hr MDD = 1500 mg; give with

PPI to prevent GI problems

Adjuvant Analgesics

Desipramine Neuropathic pain

Depression

10–25 mg at bedtime Less anticholinergic side

effects when compared to

amitriptyline and doxepin

Duloxetine Neuropathic pain

Depression

20 mg daily MDD = 60 mg; not recom

mended in hepatic failure or

if CrCl <30 mL/min

Gaba

pentin Neuropathic pain 100 mg twice daily MDD = 3600 mg; often better

tolerated than pregabalin,

adjust dose in renal insuf

ﬁciency

Lidocaine patch Neuropathic pain On 12 hr, off 12 hr MDD = 3 patches per 12 of 24

hr; few side effects; caution

in liver failure (reduced

clearance)

Nortriptyline Neuropathic pain

Depression

10–25 mg at bedtime Tricyclic antidepressant of

choice in the elderly; less

anticholinergic effect when

compared with amitriptyline

or doxepin

Pregabalin Neuropathic pain 25 mg three times per day MDD = 600 mg (doses greater

than 300 mg/day may offer

no additional beneﬁt); adjust

dose based on CrCl

Venlafaxine Neuropathic pain

Depression

25–50 mg twice daily

(immediate release)

or 37.5 mg once daily

(extended release)

MDD = 225 mg; reduce dose

in renal and hepatic failure

Bisphosphonates

Zoledronic acid Bone pain and

prevention

of skeleton-

related events

(e.g., fractures)

4 mg IV once every 3–4

weeks

Adjust dose when CrCl

<60 mL/min; do not use

when CrCl <30 mL/min

Pamidronate Bone pain and

prevention

of skeletal-

related events

(e.g., fractures)

90 mg IV over 2.5 hr once

every 3–4 weeks

Use not recommended with

severe renal impairment

https://t.me/medicina_free

136

| Fundamentals of Geriatric Pharmacotherapy

Bone-Modifying Agents

Denosumab Bone pain and

prevention

of skeletal-

related events

(e.g., fractures)

120 mg SC every 4 weeks

Corticosteroids

Dexamethasone Bone pain

Inﬂammatory

nociceptive

pain

Visceral pain

(obstruction,

etc.)

Anorexia

Nausea (espe

cially intracra-

nial pressure-

induced)

2–6 mg; use smallest

effective dose

Take earlier in the day to

decrease sleeping

impairment

Antipsychotic Agents

Chlorpromazine Delirium

Agitation

10 mg every 8–12 hr May be given sublingually or

rectally

Haloperidol Delirium

Agitation

Severe nausea

and vomiting

0.25–0.5 mg every 12 hr Preferred medication; may be

given po, IV, SC, sublingually,

or rectally

Benzodiazepines

Lorazepam Anxiety 0.25–0.5 mg every 12 hr Benzodiazepine of choice in

the elderly; avoid doses >3

mg daily in the elderly

Midazolam Palliative seda

tion

Bolus:

0.5–2.5 mg IV

push over 2 minutes;

maintenance: 0.02 mg–

0.2 mg/kg/hr

May be given IV or SC

Oxazepam Anxiety 10 mg 3 times daily MDD = 45 mg; titrate dose

slowly

Antidepressants

Citalopram Depression

Anxiety

Panic disorder

Pruritus

10–20 mg daily MDD = 40 mg

Mirtazapine Depression

Insomnia

Anorexia

Pruritus

7.5 mg daily MDD = 45 mg; adjust dose in

renal and hepatic impair

ment

Sertraline Depression

Anxiety

Panic disorder

Pruritus

25 mg daily MDD = 200 mg

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