Palliative care: Long-term solution for long-term care Part 2

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Palliative Care: Long-Term Solution for Long-Term Care Part 2 TYPES OF PAIN:

A Review Mellar P. Davis, MD, E. Duke Dickerson, MSc, PhD, Marco Pappagallo, MD, James Varga, RPh, MBA, John Shuster, Jr., MD, and Costantino Benedetti, MD

A

s outlined in Part I of this three-part series, the need for palliative care becomes more important than ever. The world population was estimated at 6.2 billion in 2000 and is expected to reach 8.9 billion by 2030. The size of the population aged 60 and older also is increasing. Representing 8.4% of the world population in 1980 and 9.3% in 1990, this subset was estimated to reach 10.6% in 2000 and 15.2% by 2030.1 In the same period, the proportion of elderly in devel-

oped countries will increase from 18% to 28%.2 With the aging population comes the inevitability of chronic disease. Many of these disease states will not respond to treatment and advance beyond cure. Palliative care will remain the only viable option of care for many with pain. Pain assessment and management are core skills in caring for this increasing population with skillful compassion and care. Editor’s note: This article, part two of three articles on palliative care, focuses on pain, its origins, and solutions for relief.

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Pain Types Nociceptive pain is defined as pain as a result of ongoing tissue damage that activates peripheral nociceptors. The nervous system is intact, and the complaints of pain are an appropriate response to ongoing tissue damage. Physiologically, nociceptive pain is the activation of somatic primary afferents that terminate in the dorsal horn. These pains typically are described as aching, squeezing, stabbing, or throbbing. Arthritis and certain types of cancer pain (eg, bone pain) exemplify somatic nociceptive pains. Pain activates primary afferent neurons that travel with sympathetic fibers. Obstructed hollow viscous is described as cramping or gnawing, having a crescendo/decrescendo temporal pattern, and referred to cutaneous sites (eg, pancreas to back, gallbladder to shoulder). When organ capsules are involved, the pain more often is described as aching, stabbing, or throbbing.3 Somatic pain is well localized, increased by weight bearing, and usually located and characterized by the patient. The pattern and pain descriptors are clues to the affected pain-sensitive structure.4 Visceral pain is the second most common form of pain. Only bone pain is more often reported. Given its noxious character, visceral pain is one of the most frequent reasons that patients seek medical attention.5 Visceral pain is not evoked from all viscera and usually occurs with obstruction of a hollow viscera or distension of organ capsules.Visceral pain is diffuse and poorly localized and may be accompanied by intense motor and autonomic response.6 In addition to spasm of the smooth muscle in hollow viscera, distention of hollow viscera, and ischemia, visceral pain also is evoked in inflammatory states, chemical stimuli, and traction, compression, and twisting of the mesentery.7 128 ■

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This pain frequently is accompanied by referred skeletal muscle contractions and spasms that last for a considerable time and contribute greatly to the patient’s discomfort. Many forms of visceral pain are accompanied by autonomic reflexes, such as tachycardia, a rise in blood pressure, and sweating.8 When the pain is treated, the heart rate slows, blood pressure decreases, and sweating ceases. Patterns of Pain Pain from pelvic organs, the retroperitoneal space, the gall bladder, and the pancreas are referred to the back. The pattern of referral is not exacerbated by movement, cough, or sneeze. It is characteristically crescendo/decrescendo in nature and improves with fetal position.3 Pancreatic cancer with regional metastases to celiac nodes produces an epigastric or diffuse abdominal pain that radiates to the back and is relieved by flexion. Pain may occur, on some occasions, in the lower abdomen and be more generalized. A significant minority of patients will have back pain only. Pain may be worsened by eating, although this occurs often with associated biliary or pancreatic duct obstruction or proximal small bowel obstruction. Patients with gallstones, peptic ulcer disease, upper abdominal abscess, hepatic venous thrombosis, or portal vein thrombosis have similar symptoms. Some patients respond favorably to nonsteroidal anti-inflammatory drugs (NSAIDs). Opioids are used for severe pain. Celiac blockade should be considered early in patients who are noncompliant, cannot return to regular appointments because of their illness, cannot afford other medications, are at risk for diverting opioids, or experience intractable constipation or other side effects to opioids for which celiac blockade would provide additional benefit. Patients with more localized

pancreatic cancers are more likely to respond. Pain Related to Hepatomegaly The distention of gleason capsule produces a noxious, nauseating, epigastric pain. A sharp component can occur subcostal because of extension to the abdominal or chest wall or may radiate to the right shoulder with diaphramatic irritation. Opioids are the treatment of choice for painful livers. Dexamethasone or NSAIDs are helpful in significantly relieving pain. A celiac block or short course of liver radiation (usually < 2000 rads) also can be beneficial. The choice of therapy depends on the patient’s performance score and prognosis. Neuropathic Pain Neuropathic pain emanates from aberrant somatosensory processing in the peripheral or central nervous system from direct nerve damage. Broad subtypes have been defined, derived from clinical experience, and do not reflect the true complexity of neuropathic pain. These subgroups include deafferent pains, sympathetically maintained pains, and a group that can be termed painful peripheral neuropathic pains—nononeuropathy, polyneuropathy, radiculopathy, etc.9 Neuropathic cancer pain comes from direct tumor infiltration of neural structures or, in some patients with diabetic crisis. Pain in an area of an abnormal or absent sensation is always neuropathic.10 Many patients with neuropathic pain exhibit persistent or paroxysmal pain independent of a stimulus (paroxysimal pains). This stimulus-independent pain can be shooting, lancinating, or burning (dysethesia) and may depend on ongoing activity of the sympathetic nervous system.11 Patients with neuropathic pain from tumor infiltration clinically resemble neuropathic pain arising from nonmalignant causes, but important differ-

ences exist. Neuropathic cancer pain almost always is accompanied by other pain syndromes, such as bone and visceral pain.12 Tumor infiltration is from progressive incurable disease, inevitably leading to loss of motor, sensory, and autonomic function. Relentless disability, combined with the knowledge that the disease process is ultimately life-limiting, adds a major suffering component to the pain syndrome.9 Finally, the dynamics of progressive nerve injury differs from monophasic (traumatic) nerve injury that has implications for treatment.13 Neuropathic pain syndromes are difficult to treat.14 Currently, even the most effective treatment produces satisfactory pain relief in only 50% to 60% of patients. Overall, a goal of “complete” relief from monotherapy probably is achieved in only 10% to 20% of patients with chronic neuropathic pain. Therefore, polypharmacy for patient relief is the rule, not the exception.15 Bone Pain Bone pain may be attributed to vascular injury, infection complication, neoplastic desctruction. or metabolic processes.16 Bone pain is the most prevalent type of chronic cancer pain associated with metastatic solid tumors.17 Cancer affects bone by three mechanisms: primary bone tumors, regional (paraspinal) invasion from primary tumors, and hematogenous spread. Hematogenous spread to the thoracic spine are the most common sites.18 Metastatic cancer invades bone in 60% to 84% of cases.19 An associated neuropathic radicular component indicates extraosseous extension. Back pain with neurologic deficits occurs with lumbar or brachial plexopathies or leptomenin-geal metastases. A myelophthistic process and pulmonary hypertrophic osteoarthropathy will produce a lower extremity pain. Degenerative disc disease mimics vertebral metastases, except pain usually

does not worsen in a recumbent position, unlike cancer-associated back pain. Osteoporosis with fractures and Paget’s disease also must be kept in mind when assessing and caring for these patients. In addition, pathologic fractures have been reported in 10% to 30% of patients with bone metastases.20,21 Continuous pain is the most frequent presentation of bone pain and usually is well localized to one or more specific bone areas. It develops gradually over a period of weeks or months, often becoming more severe. The pain is dull in character and constant in presentation.18 NSAIDs are the initial treatment of choice for patients with mild to moderate pain. Corticosteroids are alternatives. Moderate to severe pain also should be treated with opioids. Radiation and surgery for bone stabilization may be more effective in the long-term palliation of pain than opioids alone and may be used in conjunction with medical management. Bisphosphonates, initially used for hypercalcemia, are also effective analgesics. Bisphosphonates reduce adverse skeletal events, such as fractures. Pamidronate at 60 to 90 mg IV over 1 to 4 hours monthly is effective with skeletal metastases from multiple myeloma or breast cancer and other solid tumors. Radioisotopes for osteoblastic metastases will produce analgesia several weeks after administration but are associated with myelosuppression, which may be quite prolonged. Acute painful bony metastases associated with severe incidence pain may signal a pathologic fracture. If surgery is not an option, the pain should respond to appropriately placed epidural or plexus blockades, with local anesthetics or by long-term intratheacal or epidural morphine. Bupivacaine may be added for patients not responding to opioids or experiencing opioid toxicity. This approach is

particulary effective with lower extremity fractures. Pain Relief Barriers Pain therapy often is suboptimal in the United States. Health care professionals sometimes do not receive the appropriate training in pain therapy and may not appreciate the importance or recognize that a patient is in pain.22 Cancer pain is a very complex symptom and continues to haunt health care as one of the most difficult symptoms to treat. However, 90% of all cancer pain can be controlled through relatively simple means. So why do so many people continue to needlessly suffer in pain? The reason is threefold. First are the problems related to health care professionals, including inadequate knowledge, poor assessment, regulatory concerns regarding opioids, fear of patient addiction, side effects of therapy, and concerns about patients becoming tolerant to analgesics. The second problem is patient perception. Many patients are reluctant to report pain because it may distract physicians from treating the underlying disease, or they may fear the disease is worsening. Sometimes they think pain is a reflection of not being a “good” patient. Patients also are often reluctant to take pain medications for fear of addiction, unmanageable side effects, or becoming tolerant to analgesics. Finally, we must focus on the problems as they relate to the health care system. Until recently, low priority has been given to cancer pain therapy. Reimbursement has been inadequate— the most appropriate treatment may not be reimbursed in favor of more costly and invasive alternatives. Many times, the appropriate pain therapy is not economically feasible for patients and families. Other problems with the health care system include restrictive regulation of controlled substances and problems of access to therapy. August 2001 ■ 129

Symptom Management Delirium

because of depression may be misdiagnosed as having Definition: Delirium (synonym: acute confusional state) is assodementia. ciated with mental clouding, which leads to a disturbance of Delirium, dementia, anxiety, and depression may present consciousness and comprehension. Estimates of prevalence as a mixed syndrome. The aim of evaluation is to identify the range from 20% to 70%; however, as the patient nears death, presence and underlying causes of delirium and dementia and the incidence approaches 90% to 95%. the presence and severity of anxiety and depression. Manifestations: poor concentration, misinterpretations, rambling Inappropriate treatment may be harmful or even danor incoherent speech, impaired consciousness, impaired shortgerous. For example, if early delirium is misdiagnosed and term memory, paranoid ideas, restlessness, fluctuating course, distreated with an antidepressant, the patient may deteriorate orientation, hallucinations, noisy or aggressive behavior dramatically. A patient with anxiety and dementia who is Precipitating factors: change of environment, disorientation to given a benzodiazepine may experience further decline in day/night cycles (eg, no windows, clocks in room), anxiety, depresability to respond appropriately to environmental stimuli. sion, unfamiliar excessive stimuli (eg, too hot, too cold, wet bed, A standard approach for managing delirium in the crumbs in bed, creases in sheets), pain, urinary retention, dehydracancer patient includes a search for underlying causes, cortion, vitamin deficiency, sepsis, constipation, infection, fatigue, rection of those factors, and management of the symptoms. withdrawal state (eg, alcohol, nicotine, psychotropic drug use). When a cause is found, many times it is reversible (eg, Causes: Direct central nervous system causes—primary brain hepatic failure, brain metastases). tumor, metastatic spread to the central nervous system, seizures Therapeutic recommendations: When the diagnosis and treatment Indirect causes—metabolic encephalopathy as a result of organ of all underlying conditions have been addressed, haloperidol is the failure, electrolyte imbalance, treatment side effects (eg, drug of choice to treat delirium in medically ill patients. Haloperidol chemotherapy, corticosteroids, radiation, opioids, anticholinerin low doses (1-3 mg) usually is effective in targeting agitation, gics, antiemetics, antivirals), infection, hematologic abnormaliparanoia, and fear. A common strategy to manage symptoms ties, nutritional deficiencies, paraneoplastic syndromes related to delirium is to add parenteral lorazepam (0.5-1 mg q Additional information: the main aim of evaluation of the patient 1-2 h) to a regimen of haloperidol. This strategy is effective in with cognitive impairrapidly sedating the ment is to exclude agitated or delirious reversible causes patient. Lorazepam DISTINGUISHING DELIRIUM FROM DEMENTIA of stressful situaalone is ineffective in tions (eg, fecal the treatment of Feature Delirium Dementia impaction or a disdelirium and actuOnset Sudden, over hours to days Gradual, over months or tended bladder). ally may exaceryears Dementia bate delirium and Diurnal course Usually gets worse at night Usually stable for 24 commonly presents cognitive impairhours with anxiety or ment. However, a Sleep-wake cycle Severely disordered May be normal depression rather combination of Level of consciousness Impaired; fluctuates over Normal than with overt lorazepam and 24 hours cognitive impairhaloperidol in low Hallucinations Frequent; often vivid and Rare ment. Conversely, doses is highly frightening an older patient effective in controlOrientation Disoriented to time and place May be impaired with physical and ling delirium Level of activity Abnormally reduced or Usually normal mental slowing symptoms. increased agitation is common

Conclusion As problems exist, however, so do answers. The fact remains that, in accordance with a complete and comprehensive assessment, pain can be relieved through relatively simple 130 ■

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means. Palliative care strives to meet this need. The Italian poet Primo Levi, witnessing his mother’s death from cancer in excruciating pain, said,“If we know that pain and suffering can be

alleviated, and we do nothing about it, then we ourselves become the tormentors.” We know the problems, and we know the answers. Now is time to do something about it, and palliative care may help.

Midazolam (30-100 mg q 24 h), given by subcutaneous or intravenous infusion, also may be used to control agitation related to delirium in the terminal stages. Although neuroleptic drugs, such as haloperidol, are most effective in diminishing agitation, clearing the sensorium, and improving cognition in the delirious patient, this goal is not always possible in the dying patient. Depression Definition: Depression is recognized as the most common mental health problem that arises in palliative care, yet it is widely misunderstood. The term depression is such a colloquial expression that its specific clinical definition as a diagnostic term identifying a discrete and treatable syndrome often is obscured. The diagnosis of a major depressive syndrome in a terminally ill patient often relies more on the psychologic or cognitive symptoms of major depression (eg, worthlessness, hopelessness, excessive guilt, and suicidal ideation) rather than somatic signs and symptoms of major depression. The usual signs and symptoms of depression (eg, fatigue and other somatic symptoms) often are not helpful in establishing a diagnosis of depression in terminally ill people. Terminal illness itself can produce many of these physical symptoms so characteristic of major depression in physically healthy populations. Diagnostic criteria: low mood that the patient recognizes as being qualitatively and quantitatively different from normal variations in mood and previous periods of unhappiness, depression of mood that persists for at least 2 weeks and occupies more than 50% of each day, patient not able to banish the depression or be distracted from it, and other symptoms of depression that cannot be attributed to the physical disease (eg, sleep disturbance, weight or appetite loss, impaired concentration, psychomotor retardation, guilt, fatigue, suicidal ideations or thoughts of death) Distinguishing depression from sadness: Sadness requires counseling and social contact rather than medication. This mood may be part of a normal adjustment reaction. Depression is associated with low self-esteem and an inability to enjoy life. Features of both: depressed mood, tearfulness, anxiety, suicidal ideas, decreased sleep, fatigue, decreased concentration, loss of interest, anorexia

Features suggesting depression: distinct low mood, loss of all emotion, not distractible but diurnal variation, irritability, physical anxiety (eg, sweating, tremor, panic attacks), hopelessness (particularly with regard to family and friends), guilt, intractable pain, suicide attempts, requests for euthanasia Additional information: It is particularly important to identify depression because conventional treatment leads to a good response in more than 80% of cases. Evidence suggests many cases are not diagnosed; the reasons for this include low mood ignored by health professionals because it is considered understandable or reactive, diurnal variation (when seen by the physician the patient may be feeling better than earlier in the day), smiling depression (social skills mask the depressed mood), somatization (the depression is expressed through one or more physical symptoms, such as pain). Depression masked by concomitant symptoms of anxiety and depression manifests as a worsening of a personality trait (eg, egomania). Therapeutic recommendations: life expectancy is a key criteria in determining what pharmacotherapeutic agent will be used to treat depression. Therapeutic options include tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and psychostimulants. TCAs and SSRIs generally take a minimum of 2 weeks to provide therapeutic benefit for depression and thus are not appropriate for patients with a life-expectancy of 4 weeks or less. For patients with a life expectancy longer than 4 weeks, the choice of antidepressant depends on their medical profiles. A TCA is the appropriate first-line therapy for those who present peripheral symptoms (eg, insomnia, urinary incontinence, neuropathic pain, drooling). The choice of TCA depends on the nature of the depressive symptoms, medical problems, and side effects. The depressed patient who is agitated and has insomnia will benefit from a TCA that has sedating effects, such as amitriptyline. Start amitriptyline (10-25 mg qhs), increasing 10-25 mg every 3 days until the desired effect or maximum dose of 150 mg is reached. Patients with psychomotor slowdown or retardation will benefit from the use of compounds with less sedative effects (eg, desipramine). The patient who has stomatitis as a result of chemotherapy or radiotherapy or who has slow intestinal motility or uri-

References 1. Stjernswôrd J, Pampallona S. Palliative medicine—a global perspective. In: Doyle D, Hanks GWC, MacDonald N, editors. Oxford textbook of palliative medicine. Oxford: Oxford University Pres; 1998. p. 1228-45. 2. World Bank. World development report

1993. New York: Oxford University Press; 1993. 3. Portenoy RK, Kanner RM. Definition and assessment of pain. In: Portenoy RK, Kanner RM, editors. Pain management: theory and practice. Philadelphia: F.A. Davis; 1996. p. 11.

4. Kanner RM. Low back pain. In: Portenoy RK, Kanner RM, editors. Pain management: theory and practice. Philadelphia: F.A. Davis; 1996. p. 135. 5. Cervero F, Laird JMA. Visceral pain. Lancet 1999;353:2145-8. 6. Cervero F. Visceral pain. In: Dubner R,

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Symptom Management (continued) nary retention should receive a TCA with the least anticholinergic effects, such as nortriptyline. Amitriptyline, desipramine, and nortriptyline also are used frequently to manage neuropathic pain in cancer patients. SSRIs (setraline, paroxatine, etc.) provide therapeutic benefit with fewer side effects than TCAs for patients with a life expectancy more than 4 weeks. The most common side effects are mild nausea, headache, somnolence or insomnia, and perhaps a brief period of anxiety. SSRIs also can suppress appetite for several weeks. For patients with a life expectancy of 4 weeks or less, a psychostimulant (eg, methylphenidate) is recommended. The main advantage of psychostimulants is a rapid onset of action compared with TCAs and SSRIs. Low incidence of side effects, augmented opioid analgesia, reversed opioidinduced sedation, and enhanced appetite in cachexic patients all add to the usefulness of psychostimulants in palliative care. Occasionally, side effects can produce nightmares, insomnia, and even psychosis. An effective starting dose of methylphenidate is 5 mg in the morning. If no adverse reaction occurs, an additional dose of 5 mg may be administered 4 hours later. A therapeutic effect may be apparent within 2 days. Maximum doses are 40-60 mg per day. Given methylphenidates’ psychostimulant properties, every effort should be made to avoid administration in the late afternoon or evening hours. Occasionally, it may be appropriate to start patients on a psychostimulant while TCA or SSRI therapy is started. Once the latency period for effectiveness for the TCA or SSRI is reached, the psychostimulant can be progressively discontinued. Dyspnea Definition: shortness of breath or a subjective difficulty or distress in breathing, usually associated with disease of the

Gebhart FG, Bond MR, editors. Proceedings of the 5th World Congress on Pain. Amsterdam: Elsevier Science Publishers; 1988. p. 216-26. 7. Ayala M. Douleur sympathique et douleur viscerale. Revue Neurologique 1937;68:222-42. 8. Twycross R. Pain relief in advanced cancer. Edinburgh: Churchill-Livingstone; 1994. p. 55-78. 9. Portenoy RK. Issues in the management of neuropathic pain. In: Basbaum A, Besson JM, editors. Towards a new pharmacotherapy of pain. New York: John Wiley and Sons; 1991. 10. Glynn C. An approach to the management of the patient with deafferentation pain. Palliat Med 1989;3:13-21.

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heart or lungs. Dyspnea may be the most distressing symptom for both patient and family. It is always associated with some degree of anxiety, which in turn aggravates dyspnea. Patients with severe dyspnea may feel they are about to die from suffocation or choking and may show signs of fear and panic. Core features: Physiological—the result of the demands on the lungs being out of proportion to their capacity to respond Etiological—should be viewed first as a warning of disease, a call to investigate and treat the underlying medical condition Functional—undue awareness of a discomfort that is not commensurate with the level of physical activity Quality of life—suffering caused by difficulty in breathing that significantly impairs enjoyment Causes: Cancer—pleural effusion(s), obstruction of main bronchus, replacement of lung by cancer, lymphangitis carcinomatosa, mediastinal obstruction, pericardial effusion, massive ascites, abdominal distension, cachexia-anorexia syndrome Treatment—pneumonectomy, radiation-induced fibrosis, chemotherapy (eg, bleomycin, doxorubicin) Cancer and/or debility—anemia, ateectasis, pulmonary embolism, pneumonia, empyema, weakness Concurrent causes—COPD, asthma, heart failure, acidosis Additional information: Dyspnea is a sensation of shortness of breath in which tachypnea is an increased respiratory rate, but patients can be dyspneic without tachypnea. Dyspnea usually occurs with cardiopulmonary disease and most frequently is found in advanced lung cancer. A significant minority of advanced cancer patients have dyspnea as a result of intercostal muscle weakening or diaphragmatic fatigue. Stridor, when it occurs with inspiration, is a result of airway obstruction outside of the thoracic cavity, and expiratory stridor usually is a result of a narrowing of the intrathoracic trachea. Wheezing may occur as a result of asthma, congestive heart failure, pleural effusions, pneumonia, pulmonary embolism, and superior vena cava syndrome.

11. Woolf CJ, Mannion RJ. Neuropathic pain: aetiology, symptoms, mechanisms, and management. Lancet 1999;353:1959-64. 12. Banning A, Sjogren P, Kenriksen H. Pain causes in 200 patients referred to a multidisciplinary cancer pain clinic. Pain 1991;45:45-8. 13. Moulin DE. Neuropathic cancer pain: syndromes and clinical controversies. In: Bruera E, Portenoy RK, editors. Topics in palliative care. Vol 2. Oxford: Oxford University Press; 1998. p. 7-29. 14. Bennett GF. Neuropathic pain. In: Wall PD, Melzack R, editors. Textbook of pain. Edinburgh: Churchill Livingstone; 1994. p. 201-24. 15. Rowbotham MC. Recent developments in the treatment of neuropathic pain

[abstract]. 9th World Congress on Pain. Seattle: IASP Press; 1999. p. 374. 16. Cohen ML, Brooks PM. Chronic arthritis and painful diseases of bone. In: Portenoy RK, Kanner PM, editors. Pain management: theory and practice. Philadelphia: F.A. Davis; 1996. p. 170-90. 17. Portenoy RK. Bone pain: defining the need for new approaches. In: Bruera E, Portenoy RK, editors. Topics in palliative care. Vol. 3. Oxford: Oxford University Press; 1998. p. 73-7. 18. Pereira J. Management of bone pain. In: Bruera E, Portenoy RK, editors. Topics in palliative care. Vol. 3. Oxford: Oxford University Press; 1998. p. 79-116. 19. Lote K, Walloe A, Bjersand A. Bone metastases: prognosis, diagnosis and treatment.

Therapeutic recommendations: Step 1 consists of taking general measures, including exhalation through pursed lips, deep breathing with cough, proper posturing, cool air or breeze across the face and humidified oxygen, and reassurance with a calm environment. Certainly patients may benefit from pleurodesis, pleural effusion, congestive heart failure, treatment for diastolic and systolic dysfunction, chest radiation for superior vena cava syndrome, and heparin for pulmonary embolism. Step 2 consists of a trial of bronchodilators for patients with dyspnea but without a defined specific etiology and may include corticosteroids. Many patients in palliative medicine programs have occult chronic obstructive lung disease. Step 3 includes initiating opioids for rest dyspnea. Step 4 calls for chlorpromazine for respiratory panic. Although benzodiazepines are an alternative for respiratory panic, they are not as effective in treating rest dyspnea. Anemia requires treatment. Ascites associated with dyspnea will respond to judicial paracentesis. Heart failure responds to diuretics, digoxin and ACE inhibitors with hydralazine, and nitrates as an alternative. In patients who have intractable cough with ACE inhibitors, angiotensinII-receptor blocker lorsartan inotropic agents may be helpful. Insomnia Definition: I5 Causes: Physiological—wakeful stimuli (eg, light, noise, urinary frequency), sleep during daytime (long naps, catnaps, sedative drugs) Psychologic causes—anxiety, depression, fear of dying in sleep Unrelieved symptoms—pain, dyspnea, vomiting, incontinence, diarrhea, pruritus, restless legs Drugs—diuretics, corticosteroids, caffeine, sympathominmetics, night sedative withdrawal, benzodiazepines (short-acting may lead to rebound anxiety), alcohol (may cause rebound wakefulness)

Acta Radiol Oncol 1986;25:227-32. 20. Harrington KD. Orthopedic management of metastatic bone disease. St. Louis: Mosby; 1988. p. 7-14. 21. Fidler MW. Incidence of fracture through metastases in long bones. Acta Orthop Scand 1981;52:623-7. 22. U.S. Department of Health and Human Services. Management of cancer pain. Clinical practice guideline number 9. AHCPR Publication No. 94-0592. Washington (DC): U.S. Department of Health and Human Services; 1994. Mellar P. Davis, MD, is director of the Harry R. Horvitz Center of Palliative

Additional information: If the patient is not sleeping for most of the night, the situation needs to be assessed and evaluated. Many times the cause is easily reversible. Therapeutic recommendations: Insomnia should not be managed simply by prescribing sedatives and hypnotics. Step 1 considers the physical factors related to the disease that may be preventing or disturbing sleep; they, particularly pain, need to be assessed and treated. The patient’s medications and caffeine consumption are assessed and note made of any drugs recently ceased. Step 2 involves assessing and treating psychologic and psychiatric factors appropriately. Some patients with advanced cancer have a great fear of dying in their sleep and need to discuss these fears and anxieties and be reassured. Good psychologic support and relaxation training can be of great benefit. Step 3 should consider environmental factors that prevent or disturb sleep, such as noise, the need for a nightlight, comfortable bed, and appropriately managed hospital routines. If nighttime sedation is required, a benzodiazepine should be the first choice for Step 4. Short-acting benzodiazepines are safe and effective, and any possible physical dependence is not a concern in patients with advanced cancer. Temazepam has an intermediate half-life (8-10 hours); because it does not produce active metabolites that may cause cumulative toxicity, it is preferred to both short- and longer-acting drugs. The usual dose of temazepam is 15-30 mg. The drug may be given rectally if the oral capsule is pierced with a needle. Patients unable to take temazepam either orally or rectally can be treated with sublingual lorazepam or subcutaneous midazolam. Step 5 is recommended for patients with insomnia and acute confusion or delirium, who are best treated with chlorpromazine or haloperidol. Chlorpromazine can be given at 6 PM and bedtime. Amitriptyline 25-150 mg at bedtime is useful if a sedative antidepressant is warranted.

Medicine at the Cleveland Clinic Foundation in Cleveland, Ohio. E. Duke Dickerson, MSc, PhD, is a fellow in health sciences and systems (fellowship funded by Boehringer Ingelheim GmbH) at Oxford International Centre for Palliative Care in the United Kingdom. Marco Pappagallo, MD, is director of pain services at New York University. James Varga, RPh, MBA, is in pharmacoeconomics at the Pain and Palliative Care Association in Orlando, Fla. John Shuster, Jr., MD, is director of hospice at the University of Alabama in Birmingham. Costantino Benedetti, MD,

teaches anesthesiology at Ohio State University in Columbus. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 69/1/117490 doi:10.1067/mhc.2001.117490

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TEST YOUR KNOWLEDGE CONTINUING EDUCATION TEST INSTRUCTIONS To receive continuing education (CE) credit for home study of the article after you have read it, darken the appropriate circles on the answer page. Each question has only one correct answer. A passing score for this test is 7 correct answers (70%). You may photocopy the page if you do not want to cut it out or if others also want to take the test. Complete the registration information on the coupon and send it with your $9 registration fee to Buchanan and Associates, 1666 Garnet Ave., PMB102, San Diego, CA 92109. Answer forms for this test must be received by August 1, 2002. Within 4 weeks after Buchanan and Associates receives your answer form, you will be notified of your test results. If you pass, Buchanan and Associates will send you a CE certificate indicating the number of contact hours you have earned. If you fail, Buchanan and Associates gives you the option of taking the test again for an additional registration fee. Buchanan and Associates is an approved provider of continuing education in nursing by the American Nurses Credentialing Center Commission on Accreditation: California—No. CEP9473; Florida—No. FBN2159.

TEST ITEMS 1. Pain as a result of ongoing tissue damage but an intact nervous system is called: A. Visceral B. Somatic C. Nociceptive D. Neuroleptic 2 . Localized pain that increases with weight bearing is called: A. Visceral B. Somatic C. Nociceptive D. Neuroleptic

6. Dysethetic pain is NOT described as: A. Gnawing B. Shooting C. Lancinating D. Burning 7. What is the most common type of pain experienced in someone with chronic cancer pain of metastatic solid tumors? A. Visceral B. Somatic C. Neuroleptic D. Bone

3. Pain described as diffuse and poorly localized that can be accompanied by spasm is called: A. Visceral B. Somatic C. Nociceptive D. Neuroleptic

8. How frequently does metastatic cancer involve bones? A. 10%-14% B. 25%-32% C. 35%-44% D. 60%-84%

4. Pain that involves organ capsules is NOT usually described as: A. Aching B. Stabbing C. Throbbing D. Cramping

9. Poor control of cancer pain is related to all of the following EXCEPT: A. Misperceptions from health care professionals B. Reluctance from patients C. Lack of effective medications D. Health care economics

5. Pain that refers to the back includes the following EXCEPT:

10. By the year 2030, what percentage of the world population is projected to be 60 or older? A. 9.3% B. 10.6% C. 15.2% D. 28%

A. Pelvic organs B. Pancreas C. Bladder D. Neuropathic

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CE ANSWER/ENROLLMENT FORM Home study title: Palliative Care: Long-Term Solution for Long-Term Care Part 2 Test ID: HCP0801 Expiration date: August 1, 2002 Fee: $9 (payable by U.S. check or money order) Contact hours: 1.0 Minimum passing score: 70% (seven correct answers) To receive continuing education credit for this issue, simply do the following: 1. Read the article on pages 126-33. 2. Take the test and record your answers on the form below. (You may send photocopies of the answer form.) 3. Mail the completed answer form and enrollment page with a check or money order for $9 per test. Payment must be included. Please do not send cash. The deadline for submitting your enrollment/answer form is August 1, 2002. Instructions: Darken only one circle for your answer to each question. This is a standard form; use only the number of spaces required for the test you are taking. 1. ❍ a ❍b ❍c ❍d

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5. ❍ a ❍b ❍c ❍d

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8. ❍ a ❍b ❍c ❍d

9. ❍ a ❍b ❍c ❍d

10. ❍ a ❍b ❍c ❍d

11. ❍ a ❍b ❍c ❍d

12. ❍ a ❍b ❍c ❍d

13. ❍ a ❍b ❍c ❍d

14. ❍ a ❍b ❍c ❍d

15. ❍ a ❍b ❍c ❍d

16. ❍ a ❍b ❍c ❍d

17. ❍ a ❍b ❍c ❍d

18. ❍ a ❍b ❍c ❍d

19. ❍ a ❍b ❍c ❍d

20. ❍ a ❍b ❍c ❍d

Program evaluation: Please rate this CE material by darkening the appropriate circles below. 1. The following objectives of the program have been accomplished: 1. Describe the different types of pain 2. Identify pain patterns 3. Discuss pain relief barriers 2. My expectations have been met: ❍ Yes ❍ No 3. This method of CE is effective for the content provided:

❍ Yes

❍ No

4. The level of difficulty of this program was —————————————. 5. It took —— hours to complete this program. PLEASE PRINT CLEARLY

Last name—————————————First name————————————— Middle name ——————— Address ———————————————————————————————————————————— City——————————————————————————State————————ZIP———————— Phone ————————————————Social Security number——————————————————— State(s) of licensure and license number(s)—————————————————————————————— Position/title——————————————————————————————————————————— Specialty area—————————————————————————————————————————— MAKE CHECK OR MONEY ORDER PAYABLE TO: Buchanan and Associates

MAIL TO: Buchanan and Associates

1666 Garnet Ave., PMB102 San Diego, CA 92109

August 2001 ■ 135