ANXIETY:

May present with mood changes, agitation, irritability or even symptom accentuation only (pain, SOB, pruritis,�)

Etiology: r/o reversible causes like hyperthyroidism, corticosteroid use and sepsis. Always exclude electrolyte/metabolic disorder and organic brain disease

Treatment:

• Benzodiazepines are the treatment of choice (dependence not an issue)
• Choice depends on desired pharmacokinetics.
• Long acting: (>24h) Diazepam 5-40 mg/d divided TID
• Intermediate acting: (12-24h) Lorazepam 0.5-2mg TID

DEPRESSION:

Patients must be allowed to be sad and grieve.

May present with vegetative signs, symptom accentuation (pain, SOB, pruritis, dizziness�)

Etiology: Iatrogenic causes - corticosteroid use and chemotherapy (misinformation). Other causes - hypothyroidism, organic brain disease, brain mets.

Treatment:

• Psychotherapy +/- Antidepressants
• i) SSRI (safer side effect profile)

• all SSRI's equivalent
• ii) TCA (proven analgesic properties)

• Amitriptyline 75-150mg qhs

Start low and titrate up q3-5days.

CNS Stimulants: (rare cases of psychomotor retardation)

• Methylphenidate 10mg OD - 60mg/d divided into BID

ANOREXIA / LACK OF APPETITE

Etiology: Depression, unrelieved pain, mouth discomfort, dysphagia, nausea, constipation, anorectic effects of radiation and chemo, compression of the stomach (by hepatomegaly, abdominal tumours, or ascites), hypercalcemia, uremia, liver failure.

Treatment:

• Control reversible etiologic factors

• Menu variation and pt. selection

• Smaller meal portions; offer supplements; increase frequency of meals

• Meals served in a room other than the bedroom; pt. should get dressed to eat

• Serve food cold or at room temperature; avoid foods with strong odours

• Sherry or wine 1/2 hour prior to meals

• Corticosteroids

• Prednisolone 5mg po tid
• Methylprednisolone 8-16mg po bid-tid
• Dexamethasone 2-4mg po bid-tid

• Megestrol 480mg, divided bid-tid; titrate from 160-1600mg/day

• Cyproheptadine Hydrochloride (Periactin) 4mg po tid, 30 mins before meals

• Antidepressants, Tranquilizers for anorexia of primarily psychogenic origin

CONFUSION / AGITATION / TERMINAL RESTLESSNESS

Etiology: always rule out reversible causes and consider inadequate analgesia. Drugs, Infection (i.e. UTI), Metabolic (Hypoxia, electrolytes), Metastases, Vascular, Endocrine, Tumour, Trauma (falls if mobile), Siezures, Stool Impaction

Treatment:

• Keep environment as familiar as possible, large clock & calendar helps with orientation to time
• Adjust narcotic doses as necessary

• Haloperidol (start low dose) 0.5 - 2mg PO/SC q12h to q8h prn
• Lorazepam 1-2mg SL/IM q4-6h prn or regularly if needed
• Chlorpromazine 50 - 100mg PR q12h to q8h may replace haloperidol if more sedation required.