One of the most common complaints in very elderly patients in need of care is dyspnea. Pharmacological as well as non-pharmacological options are available to provide relief to sufferers. However, it is often much more important than therapeutic measures to provide both patients in their final phase of life and their relatives with comprehensive information and to leave no questions unanswered.
Typical characteristics of geriatric patients and, in particular, nursing home residents include multimorbidity and disease chains, symptom change or atypical presentations, negation of disease (deficit model), tendency toward chronification, and polyetiologic syndromes. The common final stretch in the very elderly, multimorbid patient is often failure to thrive: cachexia, frailty, and sarcopenia are the issues that geriatric palliative care physicians regularly face.
In the care of these very old patients, there are a number of aspects which, for Christoph Fuchs, specialist in geriatrics and home physician at Zofingen Hospital, are part of successful advance care planning [1]. In March 2020, in a nursing home he manages, 90 of 94 residents were asked about and documented living wills and advance directives, including clarification of hospitalization wishes and wishes for ventilation. “The data were there before, of course, but we specified it again in terms of hospitalization and the current issue of COVID-19 prognosis,” the geriatrician said. His conclusion from the survey: Discussions with patients and relatives are very important for all parties involved in order to clarify factors such as values, spirituality and the (presumed) will in advance. Subsequently, medically appropriate measures should be defined in a transparent documentation (electronic medical record). For those affected, the accessibility of the responsible therapists is also of great importance in terms of trust.
Dyspnea in the very elderly
When treating respiratory distress, the first step is to rule out possible differential diagnoses: Aspiration pneumonia in neurodegenerative diseases (e.g., dementia, post apoplexy, Parkinson’s disease) is a topic that concerns every geriatrician and also every family physician with a patient clientele of advanced age. Malignant processes and acute bacterial or viral diseases such as e.g. COVID-10 must be distinguished.
Non-pharmacological interventions with the highest evidence for dyspnea include the use of a rollator, chest wall vibration and neuro-electric muscle stimulation, as well as nursing interventions (counseling, relaxation, breathing exercises) ( Fig. 1). Various options are available for drug treatment; opioids are still considered the drug of choice. The data situation is relatively poor, and the expert criticized the frequent lack of randomization and placebo control. Nevertheless, high significance has been shown with parenteral and oral administration. In addition, it has long been known that an adequate opioid dose does not result in a significant decrease in O2 saturation but helps the patient via economization of respiratory rate.
Oral, subcutaneous and intravenous administration are recommended as forms of administration. According to Christoph Fuchs, the opioids to be administered nasally and buccally are not very useful for geriatric patients due to the rapid onset and possible serotonergic side effects. For younger palliative patients, however, these fentanyl sprays or devices are certainly an option, he said. Dose titration of opioids for respiratory distress is similar to that for analgesia: in opioid-naive patients, start with morphine 2.5-5 mg orally every 4 hours (as drops) if necessary; alternatively, the sustained-release form is available (10-30 mg). In non-opioid-naïve patients, baseline medication should be increased by 25-50%, depending on the severity of dyspnea.
Benzodiazepines are readily given by non-specialist colleagues in the acute situation because the anxiety component always plays a role. Geriatricians, however, are not particularly enthusiastic about these agents because of the sedating effect and possible tendency of patients to fall. Studies are also scarce, so benzodiazepines should be considered only as second- or third-choice agents.
Explain rattle breathing
Rales are a very common symptom in terminal respiratory failure. In the dying phase, this symptom occurs in 30 to 50 percent of patients, which is perceived as unpleasant especially by the relatives and raises the question among them whether this is associated with burdens for the person affected.
As a basic therapeutic measure, the expert recommended reducing fluid intake (if any) and possibly changing positioning. If anticholinergics are to be used as a means of medicinal inhibition of secretion, the colleague advised a rapid start of therapy. The drug of choice is butylscopolamine, which can be given s.c. and as a bolus. It has no CNS side effects but has poor oral absorption. Alternative is glycopyrronium bromide, which is much more potent (2-5 times potency of scopolamine). Again, no CNS adverse effects, but cardiac adverse effects may occur. There is no difference in efficacy between the two substances in terms of secretion reduction.
Christoph Fuchs emphasized the unpleasant meaning and consequence that terminal rales have for the affected person, but above all also for the relatives. Therefore, he said, it is important to explain to the family exactly why the patient is “seething” and to make it clear that the rattling represents a phase of the dying process and that the patient is entering a comatose state. “If we insufflate oxygen in high doses, then we prolong the entry phase into what is called CO2-narcosis, we prolong suffering by doing so, and thus we are not actually good doctors. But communicating that is sometimes not easy.” Many relatives would not understand that oxygen insufflation can still be useful in an awake patient, but is no longer indicated in a comatose or dying patient.
Congress: DGIM 2021 (online)
Source:
- Session “Palliative medicine in geriatrics – the old patient between early rehabilitation and palliation” at the 127. Congress of the German Society of Internal Medicine (DGIM), April 20, 2021.
InFo PAIN & GERIATRY 2021; 3(1): 20-21 (published 2/7/21, ahead of print).
