Post on 22-Dec-2015
transcript
Rehabilitation of the Cancer Patient with a Stroke
Brendan E Conroy, MD, FAAPM&RSenior Stroke Rehabilitation Specialist
CMIOMedStar National Rehabilitation Hospital
Associate Professor Clinical Rehabilitation MedicineMedStar Georgetown University Medical Center
None
Conflicts of Interest
1. Be able to name 3 medicines that are helpful for appetite stimulation
2. Name 3 simple medical interventions that will optimize rehab outcomes (will be in PURPLE TEXT )
3. Be able to chose 3 appropriate antidepressants based on use of drug side effects
4. Be able to describe 3 accommodations that help a cancer patient succeed in inpatient Stroke Rehabilitation
Objectives
53 RHAAM, diagnosed with Pancreatic CA w/liver mets who suffered a large L MCA infarct giving R dominant HP, severe Mixed Aphasia and severe dysphagia, while mid-course in a series of chemotherapy infusions. Chemo was temporarily halted. He was placed on DVT ppx with enoxaparin (40mg daily), but needed to taken off it for Gastrostomy Tube placement, and then developed a large DVT in his involved leg. Enoxaparin was increased to therapeutic dose (1mg/kg BID). He indicated he was having pain on his involved side arm and leg, and he had been placed on Oxycontin
Recent patient
I determined his pain was not well controlled, and he indicated it was very uncomfortable, making him restless and interfering with sleep
Restlessness caused an accidental removal of the GTube Quickly tapered off Oxycontin and started on
Lyrica, which resulted in good improvement in his pain, restlessness and sleep problem
Arrival in Rehab center
SLP determined swallowing was still too impaired for safe oral intake
Gastroenterology consult: We needed him to stay on anticoagulation while having another GTube placed, due to Coagulopathy
Enoxaparin was given very early one morning and he had a new GTube placed that afternoon and received his PM dose of enoxaparin on schedule, without complications!
G-Tube replacement
Discharged to home with his devoted fiancée after an 8 week stay, still w/GTube, needing min/mod assist for ADL, modA for transfers, modA for toileting, unable to ambulate except with therapist, continent of bladder, incontinent of bowel, limited naming skills, but reliable yes/no responses, good pain control, after adding antidepressant to Lyrica, rare need for PRN narcotics
After extensive Caregiver Training of fiancée and a son from previous relationship in: GTube care, transfers, self-care, skin care, etc Equipment: hospital bed, lifting device, high backed
wheelchair, bedside commode Home therapy: Nsng, PT, OT, SLP Follow-up: OP Rehab, Oncology, ongoing
Outcome
Hypercoagulability (brain, breast, colon, lung, ovary, pancreas, prostate)
Vascular obstruction (meningioma) Mechanical obstruction internal external
Vascular aneurysm (lymphoma) Fusiform, not berry
Cardiovascular instability BP unstable arrhythmia
Intracranial mets and Primary tumors can behave like a stroke Posterior fossa
Cancer increases risk of Stroke
Lung Melanoma Kidney Breast Colon Lymphomas
Often multifocal mets Most often in posterior fossa
IT: Primary Brain Tumors (such as Astrocytoma) NEVER metastasize outside the skull
Tumors that give Intracranial Disease most commonly
Stoppage of anticoagulation for a procedure Latent Radiation Vasculitis
After neck or whole brain XRT Months or even years later
Chemotherapeutics rarely cause CVA directly , but do cause nausea, emesis, dehydration, poor nutrition, which increase risk of brain infarct.
Cancer therapeutics can lead to Stroke
Take good care of typical CVA Risk Factors BP Diabetes Hyperlipidemia Atrial Fibrillation Monitor for Hypercoagulability
Monitor D-dimer Maintain hydration
CRITICAL Maintain nutrition
CRITICAL
Prevention of CVA in Cancer patients
Fatigue Pain Need to undergo XRT and/or chemo
If these can be delayed until inpatient rehab phase completed, it facilitates rehab
If no delay is possible, schedule therapy sessions prior to Oncology Tx each day
Risk of pathological fracture Bone scan most helpful in predicting this risk
Depression, +/- anxiety Anorexia Insomnia
Problems during Rehab of Cancer/Stroke patient
Alter therapy schedule, w/at least 1 hour break between Tx sessions
Make sure they are sleeping Make sure they are hydrated Make sure they are eating Treat depression Encourage napping Make sure XRT and/or Chemo sessions are in late
afternoons, after therapy sessions for that day
Fatigue
Helpful Meds: Trazodone Mirtazepine (Remeron) Melatonin
Zolpidem (Ambien)
Problematic meds: Benzodiazepines Anti-psychotics
Amnesogenic, decrease respiratory drive, depressing, cause confusion
Poor Sleep
Psychology consultation! Helpful Meds:
Buspirone Fluoxetine Escitalopram, not citalopram Mirtazepine Bupropion (clonazepam)
Problematic meds: Most other benzodiazepines narcotics
Anxiety
Give in the early evening, 7-8PM May cause some lethargy first couple days Not helpful for learning capacity in general I use olanzepine, quetiapine for agitation I use very small dose of clonazepam (0.25mg)
for severe anxiety I will NOT use haloperidol, thorazine,
diazepam, alprazolam (too sedating, reduce learning capacity)
Use of Psychotropic meds
Good medications for bone and deep tissue, aching pain, and post-op pain
Cause less interference with rehab if given in long acting formulations Oxycontin, MSContin
With breakthrough Pain PRNs Oxycodone, Morphine IR
Try to use the same active ingredient for LA and IR formulations
Pain - Narcotics
Great for localized pain, minimize side effects Diclofenac gel/ Diclofenac patch Lidoderm patch Myoflex gel (counter-irritant) Hot/Cold modalities
Moist heat Quick onset and offset Very comforting and very effective
Icing Takes 15-20 minutes to kick in and uncomfortable but effects last longer
Topical Pain treatments
Burning, tingling, lancinating pain Central Post-Stroke Pain Syndrome
A.k.a. Thalamic Pain; or, Syndrome of Dejerine-Roussy Complex Regional Pain syndromes Gabalins are highly effective
Gabapentin has more side-effects Pregabalin has much less side effects, but is less often covered
by insurance TCAs Fluoxetine Vascular Surgical wound neuropathies
Lidoderm great if limited painful area Can’t be used on damaged skin
Narcotics much less effective
Neuropathic pain
NSAIDs highly effective Joint injections also very helpful Always check for pathological fractures
Bone and Joint Pain
Adequate nutrition and fluid intake for good rehab is essential
Appetite stimulants Megestrol Tetrahydrocannabinol (THC)(“Weed”) Dronabinol (THC derivative) Mirtazepine
Gastrostomy Tube Doesn’t prevent the patient from pleasure eating Assures adequate nutrition, fluids and medication Can be temporary
Anorexia/Cachexia
Typically under-treated in cancer Psychology/Psychiatry interventions very helpful Most antidepressants are useful
Try to use the side effects to patient’s advantage E.g.:
trazodone for poor sleep mirtazepine for depressed patient with anorexia and
poor sleep fluoxetine for lethargic patient with neuropathic pain
and/or anxiety
Depression
Rehab during End of Life therapy Can decrease helplessness Optimize sense of self-worth Minimize burden on caregivers Minimize depression improve the quality of final weeks/days
Treatable Cancer Rehab is just as effective for people with cancer as
those without Although progress is somewhat slower
Applications of Rehab
Rehabilitation therapies improve quality of life Discharge to home Minimize burden of care on caregivers Although slower rate of improvement, CVA
survivors with Cancer can have similar outcomes to CVA survivors without cancer (US figures) 65-70% discharge to home 80% ambulate within one year 60% return to living independently
Outcomes
“DNR” does not mean “Do Not Rehabilitate”
REMEMBER!
2005 Management of Adult Stroke Rehabilitation Care: A Clinical Practice Guideline; Stroke, 2005; 36: e100-e143; Duncan, Zorowitz, et al (entire contents available online)
Important Cancer Rehabilitation authors Lynn Gerber Michael Stubblefield Andrea Cheville
References
Thank-you very much!
Any questions?