Palliative care in cancer patients: Palliative care in cancer patients: Neurological aspectsNeurological aspects

By By Dr Maged Abdel-NaseerDr Maged Abdel-Naseer

Prof of NeurologyProf of NeurologyCairo universityCairo university

IntroductionIntroduction

Nervous system tumours are either:Nervous system tumours are either: Primary: glioma, meningioma, medulloblastoma, Primary: glioma, meningioma, medulloblastoma,

and acoustic neuroma. and acoustic neuroma. Secondaries: Secondaries:

- direct invasion (as in cholesteatoma, - direct invasion (as in cholesteatoma, chordoma, or osteoma). chordoma, or osteoma).

- blood-borne metastases: cerebral or spinal cord- blood-borne metastases: cerebral or spinal cord

IntroductionIntroduction

Cerebral metastases:Cerebral metastases: Commonly arise from primary malignancy of Commonly arise from primary malignancy of

bronchi, breasts, kidneys, stomach, and thyroidbronchi, breasts, kidneys, stomach, and thyroid.. Headache, mental and behavioral changes, focal Headache, mental and behavioral changes, focal

weakness (hemiparesis, aphasia, and ataxia) are weakness (hemiparesis, aphasia, and ataxia) are most common complaints and signs.most common complaints and signs.

IntroductionIntroduction

Spinal cord metastases:Spinal cord metastases: Multiple myeloma, lymphoma, and cancer Multiple myeloma, lymphoma, and cancer

breast, lung and prostate are common primary breast, lung and prostate are common primary sources. sources.

Clinically, there is back pain without Clinically, there is back pain without neurological deficits at early stage, then, subtle neurological deficits at early stage, then, subtle weakness and/or numbness in both legs which weakness and/or numbness in both legs which progresses rapidly to complete paraplegia in few progresses rapidly to complete paraplegia in few days. days.

Paraneoplastic neurological Paraneoplastic neurological syndromes syndromes

These are stereotyped syndromes through These are stereotyped syndromes through remote effects of primary cancer especially from remote effects of primary cancer especially from breast, lung, and ovaries. breast, lung, and ovaries.

They are not the result of tumour invasion or They are not the result of tumour invasion or metastases, treatment by chemotherapy or metastases, treatment by chemotherapy or radiotherapy, malnutrition, or infection.radiotherapy, malnutrition, or infection.

Paraneoplastic neurological Paraneoplastic neurological syndromessyndromes

These syndromes are immune-mediated and These syndromes are immune-mediated and include: progressive cerebellar degeneration, include: progressive cerebellar degeneration, limbic encephalitis, optic neuritis, opsoclonus, limbic encephalitis, optic neuritis, opsoclonus, spinal cord syndromes, pure sensory neuropathy, spinal cord syndromes, pure sensory neuropathy, and disorder of myoneural junction.and disorder of myoneural junction.

Disturbed conscious level is a common neurological Disturbed conscious level is a common neurological manifestation of cancer patientsmanifestation of cancer patients

CausesCauses Primary or secondary brain tumours.Primary or secondary brain tumours. Paraneoplastic syndrome. Paraneoplastic syndrome. Metabolic encephalopathy: organ failure, Metabolic encephalopathy: organ failure,

hypercalcemia, electrolyte imbalance, drug, or sepsis. hypercalcemia, electrolyte imbalance, drug, or sepsis. Complication of chemotherapy or radiotherapy. Complication of chemotherapy or radiotherapy.

** Confusion: inability to maintain a coherent stream of Confusion: inability to maintain a coherent stream of thoughts or action.thoughts or action.

** Drowsiness: ready arousal, ability to respond verbally, Drowsiness: ready arousal, ability to respond verbally, and by movement induced by verbal stimuli.and by movement induced by verbal stimuli.

** Stupor: incomplete arousal to noxious stimuli. No or Stupor: incomplete arousal to noxious stimuli. No or little response to verbal commands, no verbal response little response to verbal commands, no verbal response is elicited. The motor responses are still of purposeful is elicited. The motor responses are still of purposeful type.type.

** Coma: motor responses to noxious stimuli are either Coma: motor responses to noxious stimuli are either primitive or totally absent.primitive or totally absent.

Management of comatose patient

1- Care of circulation: fluids to maintain blood 1- Care of circulation: fluids to maintain blood pressure and cardiac monitoring.pressure and cardiac monitoring.

Management of comatose patient

2- Care of respiration: adequate oxygenation and avoid 2- Care of respiration: adequate oxygenation and avoid infection: infection: a-a- remove dentures. remove dentures.

b-b- short oropharyngeal airway to prevent the tongue short oropharyngeal airway to prevent the tongue from obstructing airflow.from obstructing airflow.

c-c- prevent aspiration by suction of secretions and lateral prevent aspiration by suction of secretions and lateral decubitus position.decubitus position.

d-d- endotracheal intubation. endotracheal intubation. e-e- nasogastric tube to evacuate gastric contents and nasogastric tube to evacuate gastric contents and

prevent aspiration.prevent aspiration.

Management of comatose patient

3- Management of increased intracranial tension and brain 3- Management of increased intracranial tension and brain oedema:oedema:

a-a- avoid hypotonic IV solutions or fluids containing avoid hypotonic IV solutions or fluids containing large amounts of free water e.g. glucose 5%.large amounts of free water e.g. glucose 5%.

b-b- hyperosmolar agents: mannitol 20% may be given IV hyperosmolar agents: mannitol 20% may be given IV in a dose of 1 gm/kg over 10-30 minutes according to in a dose of 1 gm/kg over 10-30 minutes according to the severity of the condition. the severity of the condition.

c-c- steroids: dexamethasone (decadron) 10 mg by rapid steroids: dexamethasone (decadron) 10 mg by rapid IV infusion followed by 4-6 mg IV/6 hours.IV infusion followed by 4-6 mg IV/6 hours.

Management of comatose patient

4- Care of skin: change patient position every 2 4- Care of skin: change patient position every 2 hours and use airmatress.hours and use airmatress.

5- Care of nutrition: initial IV fluids then 5- Care of nutrition: initial IV fluids then nasogastric tube feeding.nasogastric tube feeding.

6- Care of bladder: condom catheter for male 6- Care of bladder: condom catheter for male patients. Indwelling catheter may be necessary. patients. Indwelling catheter may be necessary. Clamp the catheter and release every 3-4 hours Clamp the catheter and release every 3-4 hours to maintain the bladder tone.to maintain the bladder tone.

Management of comatose patient

7- Care of bowel: enema for fecal impaction.7- Care of bowel: enema for fecal impaction.

8- Care of eyes: avoid corneal injury by using eye 8- Care of eyes: avoid corneal injury by using eye drops and ointment.drops and ointment.

9- Management of restlessness and agitation: avoid 9- Management of restlessness and agitation: avoid unnecessary sedation. In case of excessive unnecessary sedation. In case of excessive severity or duration of agitation, a short-acting severity or duration of agitation, a short-acting benzodiazepine (e.g. dormicum) may be benzodiazepine (e.g. dormicum) may be indicated.indicated.

Paraplegia is another neurological problem that Paraplegia is another neurological problem that may be:may be:

- presentation of primary or secondary spinal - presentation of primary or secondary spinal cord tumours. cord tumours.

- represent a complication of radiotherapy as - represent a complication of radiotherapy as radiation-induced myelopathy.radiation-induced myelopathy.

Management of paraplegic patients

1- Bladder care: 1- Bladder care:

** The hyperreflexive bladder: many uninhibited The hyperreflexive bladder: many uninhibited detrusor contractions, reduced capacity, and detrusor contractions, reduced capacity, and spontaneous voiding with a strong stream. spontaneous voiding with a strong stream.

** The hyporeflexive bladder: very low pressure, The hyporeflexive bladder: very low pressure, no contractions, high capacity, high residual no contractions, high capacity, high residual volume, and poor streamvolume, and poor stream

Bladder care: Drug TherapyBladder care: Drug Therapy

a- Bethanechol (urecholine) may increase detrusor activity and a- Bethanechol (urecholine) may increase detrusor activity and facilitate reflex voiding. The dosage is 10-50 mg/6 hours.facilitate reflex voiding. The dosage is 10-50 mg/6 hours.

b- Oxybutynin chloride (ditropan) has an atropine-like effect on b- Oxybutynin chloride (ditropan) has an atropine-like effect on smooth muscle and causes relaxation of detrusor muscle. The smooth muscle and causes relaxation of detrusor muscle. The dose is 5 mg b.i.d. or t.i.d.dose is 5 mg b.i.d. or t.i.d.

c- Baclofen has been reported to reduce residual urine volume.c- Baclofen has been reported to reduce residual urine volume.d- Alpha-adrenergic blocking agents may reduce urethral pressure. d- Alpha-adrenergic blocking agents may reduce urethral pressure.

Residual volume may be reduced and voiding is more complete.Residual volume may be reduced and voiding is more complete.e- Beta-adrenergic blockers increase urethral resistance and may be e- Beta-adrenergic blockers increase urethral resistance and may be

helpful when incontinence is caused by uninhibited contractions helpful when incontinence is caused by uninhibited contractions that overcome the urethral pressure.that overcome the urethral pressure.

Management of paraplegic patientsManagement of paraplegic patients

2- Bowel care: the initial stage of bowel distension is 2- Bowel care: the initial stage of bowel distension is treated by enemas. Later, stool softeners are used. As treated by enemas. Later, stool softeners are used. As the bowel becomes more active, suppositories replace the bowel becomes more active, suppositories replace enemas. enemas.

3- Skin care.3- Skin care.

4- Nutrition: high-calorie, high protein diet is essential. 4- Nutrition: high-calorie, high protein diet is essential. Fluid and electrolyte balance should be watched closely.Fluid and electrolyte balance should be watched closely.

5- Pain control: aspirin for acute pain, carbamazepine and 5- Pain control: aspirin for acute pain, carbamazepine and amitriptyline for neuropathic pain.amitriptyline for neuropathic pain.

Management of paraplegic patientsManagement of paraplegic patients

6- Psychiatric care and therapy are essential for 6- Psychiatric care and therapy are essential for suicidal or excessively depressed patients: suicidal or excessively depressed patients: - Although tricyclic and tetracyclic - Although tricyclic and tetracyclic antidepressant drugs are very effective against antidepressant drugs are very effective against depression, side effects limit their use especially depression, side effects limit their use especially in elderly patients. in elderly patients. - The new group of selective serotonin-reuptake - The new group of selective serotonin-reuptake inhibitors (SSRI) as prozac, cipralex, lustral, or inhibitors (SSRI) as prozac, cipralex, lustral, or seroxat have better safety profile. seroxat have better safety profile.

Management of paraplegic patientsManagement of paraplegic patients

7- Avoid complications: decubitus ulcer, muscle 7- Avoid complications: decubitus ulcer, muscle spasm, deep vein thrombosis, pneumoniaspasm, deep vein thrombosis, pneumonia

8- Physiotherapy8- Physiotherapy

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