Hospice clinicians are well-versed in treating major symptoms such as pain, dyspnea, nausea and delirium, but what about the minor ones? They can negatively impact comfort and patient/caregiver satisfaction too. Enclara pharmacists have assembled the top five everyday annoyances that can sometimes become severe and unremitting for hospice patients. Effective management can include treating both the symptoms themselves and their underlying causes through pharmacologic and nonpharmacologic interventions. Treatments and assessments mentioned below are a broad overview intended for educational purposes and do not constitute medical advice.
Pruritus is the medical term for irritated, itchy skin due to a variety of causes. It can be localized to one area or diffuse – occurring all over the body. Treatment depends on cause and severity. Causes include drug side effects, allergies, infections, environmental factors and psychological issues. Several diseases can trigger specific types of pruritis, including liver disorders (cholestatic), kidney disease (uremic) and malignancy (paraneoplastic).
Specific treatment protocols exist for certain types of pruritis or underlying causes, but general symptom management recommendations will apply to most cases. Corticosteroids and antihistamines are common treatments, either orally for diffuse cases or topically for localized irritation. Other topical options include anesthetics (e.g., lidocaine and camphor) and emollients/protectants (e.g., calamine lotion and zinc oxide).
Several of the most common terminal diagnoses in hospice trigger coughing, including COPD, congestive heart failure and certain cancers. Other causes include allergies, infections, asthma and gastroesophageal reflux. Cough can also be a side effect of several medications, particularly ACE inhibitors (e.g., lisinopril) which often cause a dry cough and bronchospasm.
Qualities of sputum or its absence can aid in assessing cause, severity and management. Clinicians should treat the underlying cause of cough when possible. Symptom management often includes opioids and anticonvulsants. Bronchospasm symptoms (e.g., wheezing and chest tightness) may benefit from bronchodilators and corticosteroids. Cases with thick sputum production may also benefit from medications such as guaifenesin or nebulized saline. Note that multiple medications are often combined in over-the-counter products, which can complicate dosing and documentation. Nonpharmacologic therapy may include breathing exercises, air filtration, and oral anesthetics (e.g., menthol cough drop or throat spray).
Hiccups, medically known as singultus, are involuntary spasms of the diaphragm. For most people they resolve in minutes or hours, but occasionally they become persistent (lasting longer than 48 hours) and even intractable (lasting more than a month). Longer-term cases are often associated with conditions which impinge or irritate the diaphragm, particularly gastrointestinal disorders such as reflux. Hiccups can also be a side effect of certain medications, including corticosteroids and benzodiazepines. Uremia, alcohol intoxication and electrolyte imbalances may also contribute to hiccups.
Management of hiccups can require some trial and error. There are several non-pharmacologic remedies for hiccups, most involving some variation of breath holding, drinking water, or consuming very sweet or sour liquids. One more structured breathing exercise, supra-supramaximal inspiration, has shown promise. If these prove ineffective, explore underlying causes and treatments. For example, hiccups triggered by reflux may respond to a proton pump inhibitor. In palliative care, common pharmacological treatments include chlorpromazine, gabapentin and baclofen.
Muscle Spasms (Cramps)
Muscle spasms are involuntary, painful contractions of a muscle or muscle group. They can affect the skeletal muscles used for movement as well as the smooth visceral muscles of organs, including those of the digestive and respiratory systems. Skeletal muscle spasms are usually persistent, tender to the touch, worse upon movement and may be precipitated by trauma or exertion. Smooth muscle spasms, including colic, are more likely to be episodic, felt deeper within the body and often stem from underlying conditions.
Management of smooth muscle spasms may include addressing the underlying condition responsible and/or prescribing anticholinergic/antispasmodic medications. Skeletal muscle spasms may respond to nonpharmacological interventions such as heat, massage and topical anesthetics. Skeletal muscle relaxants may also be effective but be cautious of side effects such as dizziness and fatigue.
Xerostomia (Dry Mouth)
Xerostomia, also known as dry mouth, refers to decreased saliva production. It can also cause bad breath and tooth decay and make it harder to talk and swallow food. Risk factors include radiation from cancer treatments directed at the head and mouth, polypharmacy, dehydration and autoimmune conditions, notably Sjogren’s syndrome. Dry mouth can also be a natural part of aging and disease progression.
Over 500 medications are associated with dry mouth, including tricyclic antidepressants, bronchodilators, urinary incontinence drugs, antihypertensives, diuretics, antihistamines, sedatives and muscle relaxants. Any drug with anticholinergic effects can contribute to dry mouth. Pharmacist review can help determine a patient’s overall anticholinergic burden and guide deprescribing decisions to reduce dry mouth and improve overall quality of life.
There are a variety of treatments to consider for managing persistent dry mouth. Two cholinergic agonists, pilocarpine and cevimeline, are sometimes used to increase saliva production, but be mindful of their many drug interactions and contraindications. Artificial saliva products can provide short-term relief. Many contain xylitol, which can also be found in some sugarless chewing gums, lozenges, and candies. Sour drinks and candies can also increase salivary production.
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