Palliative care for older people - World Health Organization ...

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12Symptom-specific interventionsPhysical and psychosocial symptoms are a majorburden for people in the final stages of life andcan significantly reduce their quality of life. Theassessment and management of symptoms is oneof the foremost goals of palliative care, and there ismajor evidence-based literature on how to managesymptoms (1–3). Some symptoms can be highlyprevalent across different diseases; others vary.For example, more than half the people with endstagecancer, HIV disease, heart disease, chronicobstructive pulmonary disease or kidney diseaseexperience pain, breathlessness and fatigue (4).Difficulty in swallowing is a particularly troublingsymptom in the palliative care of people whohave had strokes or have other disorders of thenervous system. People often have many symptomssimultaneously, and the presence of one symptomcan influence the intensity of others. The disease,its treatment or comorbidity may cause symptoms.The prevalence of cognitive impairment, problemswith bladder and bowel control, vision and hearingimpairment and dizziness all greatly increase withage (5). The Panel on Persistent Pain in Older Personsof the American Geriatrics Society (6) found that25–50% of older people living in the communityhave major pain problems, and 45–80% of nursinghome residents have substantial pain that isundertreated. Since older people commonly havemultiple health problems (including arthritis andother bone joint and back problems), they oftenhave several sources of pain.The most reliable reports of pain are those thatcome from the people experiencing the pain.However, older people may be reluctant to reportpain because they expect that symptoms are a“natural” part of ageing and do not believe theirpain can be alleviated. The high prevalence ofsensory and cognitive impairment among frail olderpeople makes communication and therefore theassessment of pain and other symptoms difficult.However, effective ways of assessing pain amongpeople with severe cognitive problems have beendeveloped (Box 12.1). Although older people aregenerally more susceptible to adverse drug reactions,they can use analgesic and pain-modulating drugssafely and effectively (6). A palliative approach tocontrolling distressing symptoms at the very end oflife can be used successfully with very old peopleBox 12.1. A tool for assessing discomfort among people with advanced dementiaAs dementia progresses, nonverbal cues become more important in pain assessment. A protocol for assessingdiscomfort in dementia was developed as part of a larger pain management project in long-term care facilitiesin Wisconsin, United States of America. Nurses were trained in assessing pain among cognitively impairedresidents, analgesic pharmacology and incorporating the new protocol into the procedures in their facilities.They assessed physical causes for discomfort, looked at the resident’s history and took appropriate measuresto alleviate the problem or consult with other health care providers. Non-pharmaceutical comfort interventionswere used if the source of discomfort was not physical (such as music therapy or therapeutic massage). If thesewere unsuccessful, non-opioid analgesics were used. Using the protocol reduced behavioural symptoms andincreased the use of scheduled analgesics and non-pharmaceutical comfort interventions, indicating improvedpain management.Source: Kovach et al. (10).38
(Box 12.2). Several drugs can often be discontinuedwithout significant effects on mortality, morbidityand the quality of life (Box 12.3) (7,8). A majorbarrier to improving palliative care in some countriesis the unavailability of opioids. This is a particularproblem in some countries in the eastern part of theWHO European Region (9).The use of multiple medications among olderpeople has increased the rate of drug interactionsand hospitalization secondary to drug-relatedproblems. Polypharmacy means that more drugsare prescribed than clinically indicated (8) or allprescribed medications are clinically indicated butthere are too many to take. This can potentiallycause a higher incidence of adverse drug reactions.The clinical and financial effects of this are enormousand still insufficiently studied.Increasing age among older people and advancedand terminal disease are associated with changesin pharmacokinetics and pharmacodynamics.Appropriate prescribing in this age group and/orcondition can be problematic. This is also an area inwhich interface, skills exchange and collaborationbetween specialties may be beneficial in addressingproblems and may be necessary.© Joan TenoBox 12.2. Controlling symptoms of terminal heart failure among very old peopleThe Galliera Hospital in Genoa, Italy has introduced a palliative approach to caring for people with terminalheart failure in their unit for acute care for older people. The median age of the people residing in the unitis close to 90 years, and they generally have severe comorbidity and communication problems. Most havedistressing symptoms in the terminal phase: breathlessness, agitation, death rattle, pain, nausea and vomiting.Most symptomatic patients have access to treatment on low-dose morphine (less than 20 mg per day onaverage) in combination with other medication (haloperidol, metoclopramide and scopolamine butylbromide).In the terminal phase, one third of the residents are severely distressed and agitated. They receive a slightincrease in palliative drug dosages and/or low-dose midazolam for effective relief or sedation. This approachachieves acceptable symptom control in the dying process for older people with heart failure.Source: personal communication, Vito Curiale, Galliera Hospital, Genoa, Italy.39
Page 1: PALLIATIVE CAREFOR OLDER PEOPLE:BET
Page 4 and 5: AbstractPopulations around the worl
Page 7 and 8: ForewordSocieties in the WHO Europe
Page 9 and 10: AcknowledgementsThe WHO Regional Of
Page 11 and 12: 1IntroductionPalliative care is an
Page 13 and 14: By 2050, estimates indicate that mo
Page 15 and 16: • training of health care profess
Page 17 and 18: individuals and their families. Hea
Page 20: Fig. 3.2. Factors associated with p
Page 23 and 24: (Table 4.1). After 15 years, more t
Page 25 and 26: • the last days of life and death
Page 27 and 28: Box 4.4. Gerontology Institute “1
Page 29 and 30: 5National awareness“You matter be
Page 31 and 32: 6Educational interventionsA well-pe
Page 33 and 34: Box 6.3. European Association for P
Page 35 and 36: initiated at an early stage in the
Page 37 and 38: 8Improving care for older people in
Page 39 and 40: 9Improving palliative care for olde
Page 41 and 42: Box 9.3. Training in end-of-life ca
Page 43 and 44: 10Improving palliative care for old
Page 45 and 46: References1. Higginson IJ, Sen-Gupt
Page 47: Financial help, such as the paid co
Page 51 and 52: 13Advance care planningAdvance care
Page 53 and 54: References1. Advance care planning:
Page 55 and 56: References1. Campbell H et al. Inte
Page 57 and 58: Box 15.1. Bus rounds as an educatio
Page 59 and 60: palliative care research initiative
Page 61 and 62: References1. Currow DC et al. A fra
Page 63 and 64: • Promote public awareness of pal
Page 65 and 66: 3. Invest in creative research into
Page 67 and 68: GermanyEberhard KlaschikCentre for
Page 69 and 70: United Kingdom (continued)Marilyn K
Page 71 and 72: The Maruzza Lefebvre D’Ovidio Fou

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