General Principles of Symptom Management
Cardiomyopathies are diseases that impair cardiac function and can be caused by ischemic as well as nonischemic injuries to the heart. There are many etiologies that lead to impairment in the pumping function of the heart, and most of those listed here lead to a dilatation of the heart. But, regardless of etiology, symptomatic management is often the same.1 Etiologies of cardiomyopathy include coronary artery disease leading to ischemic cardiomyopathy, peripartum cardiomyopathy, hypertrophic cardiomyopathy, amyloid cardiomyopathy, alcohol-induced cardiomyopathy, HIV-associated cardiomyopathy, and trypanosomiasis.2 The primary focus of symptomatic treatment is on reducing symptoms of volume overload and optimizing cardiac output to alleviate dyspnea and fatigue.
Nonpharmacological Symptom Management
Volume overload in patients with cardiomyopathy can cause dyspnea, orthopnea, and generalized fatigue. A limit of 2 g sodium daily is appropriate, but this can be difficult to quantify for many patients. The patient should also be educated about other sources of salt, such as prepackaged food, sauces, and canned foods. Exertion is often limited in these patients because of fatigue and dyspnea.3
Pharmacological Symptom Management
Volume overload in patients with cardiomyopathies can initially be treated with a loop diuretic such as furosemide, bumetanide, or torsemide, in combination with dietary salt restriction.4 A pharmacological regimen for cardiomyopathy includes a beta blocker and aspirin for all patients without contraindications, in addition to management of volume overload in appropriate patients.5 Other therapies that may be appropriate in some patients are the combination of hydralazine and a nitrate and mineralocorticoid receptor antagonists such as spironolactone or eplerenone.6
General Principles of Symptom Management
Mental health is an often neglected area of noncommunicable diseases (see Chapters 7 and 16 in this book for coverage of adjustment disorder, anxiety, trauma, and delirium), and chronic and acute psychotic illness may be missed in a humanitarian setting. Patients with these symptoms may be subjected to stigma and cultural misinterpretation. People living with learning difficulties may also be vulnerable. It is thus important to work closely with mental health workers for patients’ wider needs.
Dementia is a general term that encompasses a number of pathological processes and refers to the loss of cognitive functioning and behavior that results in an inability to carry out one’s activities of daily living. Affected patients have trouble with thinking, memory, language, reasoning, and problem-solving, in addition to emotional dysregulation that can cause personality changes.7 As the severity of dementia increases, people become unable to carry out basic activities of daily living. Dementia has become increasingly common in resource-limited settings; life expectancy in these regions has increased, and dementia accompanies primarily diseases of aging.8 Dementia treatment is mainly symptomatic and involves manipulation of the physical environment to support patient safety and functioning.
Nonpharmacological Symptom Management
In patients with dementia, it is important to consider the sociocultural situation and to determine who the surrogate decision-makers are. In advanced dementia, the patient’s next of kin or closest friends will have to serve as surrogate decision-makers. It is important to make them aware of this and ensure that ethical and legal implications are addressed for decision-making, management of assets, and other responsibilities. Open discussion with decision-makers will be important as the patient’s illness progresses. The patient and caregivers should be aware that as the illness progresses, the patient will not be able to report side effects to therapy and fully participate in treatment decisions, so these issues should be discussed at the outset of diagnosis. The patient and caregiver should discuss whether the patient is interested in focusing on comfort only or also seeks interventions that may be uncomfortable but could prolong life. This discussion should factor in the patient’s culture and personal values, what is available, and the place of preferred care.9
Impaired eating is a common issue in patients with dementia. Patients with dementia often have a decreased sense of smell, which leads to decreased appetite. Sometimes altering the texture or flavor of the meal can help overcome this issue. Offering small meals high in caloric intake is one approach to maintain nutrition in patients with dementia. Patients with advanced dementia often cannot feed themselves and require hand-feeding. In resource-limited regions, artificial feeding may not be available, but if it is available, it is important to discuss with patients that artificial feeding may impair quality of life and that there is no evidence that it can actually prolong length of life.10
Impaired sleep is another issue that patients with dementia can encounter. Nonpharmacological approaches to insomnia are recommended. These include sleep hygiene techniques, such as avoiding caffeine later in the day, using the bed only for sleep, sleeping in a quiet and dark area, and avoiding alcohol intake.11
General Principles of Symptom Management
Cirrhosis refers to irreversible end-stage fibrosis of the liver and is the result of a number of pathological processes, including chronic hepatitis B infection, chronic hepatitis C infection, alcohol use, and nonalcoholic steatohepatitis.12 Cirrhosis can cause a number of debilitating symptoms and complications that themselves produce much morbidity. The general goals of symptomatic treatment of cirrhosis are to address the symptom burden while preventing and treating complications of cirrhosis.13 Some areas are rolling out vaccinations programs for hepatitis B and antiviral agents, so it is important to be aware of the local resources.
The most common debilitating symptom of cirrhosis is ascites. Patients with discomfort associated with the ascites should be given a diuretic regimen with furosemide and spironolactone. It is also important for patients with cirrhosis to limit their daily sodium intake to 2000 mg daily.14 Caution should be exercised with this regimen, as overdiuresis can cause renal insufficiency and place the patient at risk for hepatorenal syndrome. It may also make the patient hypotensive and liable to falls. If the patient is not able to achieve sufficient comfort through diuresis, paracentesis may be indicated to help alleviate ascites symptoms. Paracentesis involves inserting a needle into the peritoneum to drain ascitic liquid. The procedure is relatively safe, even in patients with coagulopathies. As much as 5 to 8 L fluid may be removed during paracentesis, leading to decreased intra-abdominal pressure. Patients with greater than 5 L of fluid removed should be given 6 to 8 g albumin per liter of fluid removed, but, more commonly, smaller amounts are removed, to avoid the need for very expensive albumin.15
Management of Complications of Cirrhosis
Muscle cramping is a common symptom of cirrhosis. Other causes of muscle cramps should be excluded and electrolytes should be repleted. If the cramping is severe, quinine sulfate may be administered for symptomatic relief. If quinine is not available, branched-chain amino acids, taurine, or vitamin E can be used.16
Another complication of cirrhosis is umbilical hernia. If the hernia is not incarcerated or ruptured, watchful waiting is a reasonable approach, given the high complication rate of surgical repair. Abdominal binders can help alleviate symptoms of the hernia. Chronic hyponatremia is also common and may be caused by treatment with diuretics. Fluid restriction is recommended in patients with sodium levels less than 120 mmol/L.
Esophageal varices caused by pressure building up through the portal venous system are a serious complication, leading to dangerous upper gastrointestinal bleeding. Beta blockers are indicated in patients with cirrhosis for primary and secondary prophylaxis of variceal hemorrhage but should be used with caution in patients with refractory ascites or current spontaneous bacterial peritonitis. If there is access to endoscopy, this should be sought early as part of disease management.
Spontaneous bacterial peritonitis is an infection in the ascitic fluid that can cause abdominal pain and fevers. Management involves treatment with an antibiotic. Hepatic encephalopathy is another complication of cirrhosis that can be life-threatening. Management includes use of lactulose and rifaximin.17
Chronic Kidney Disease (CKD)
General Principles of Symptom Management
There is an estimated overall prevalence of 8–16% of CKD around the world.18 This corresponds to nearly 500 million affected individuals, of whom 78% (387.5 million) reside in low-income to middle-income countries (LMICs). The rate of CKD progression is variable and dependent on the underlying etiology. There are many etiologies which cause CKD, with the largest prevalence being diabetes and high blood pressure. Other etiologies include HIV and other infectious diseases. As CKD is caused by other large groups of medical comorbidities and exposures, there is a three-pronged approach that may be helpful in LMIC:
(1) Treat noncommunicable diseases, including hypertension and diabetes mellitus.
(2) Reduce exposure to environmental toxins, including, pesticides and environmental heavy metals, and provide safe drinking water.
(3) Address and treat infectious diseases including malaria, HIV, hepatitis B and C.19
CKD stages 1–3 are largely asymptomatic. In CKD stages 4 and 5, patients generally begin to develop symptoms. Fluid management for volume overload can be addressed with decreased salt intake. Malnutrition in CKD is a challenge, and providing enough protein with a low potassium focus is beneficial. Characterizing and avoiding foods that have high potassium are also important. Patients should take less calcium and less phosphate as their kidney failure progresses. Inorganic phosphate has much higher bioavailability than does organic phosphate, therefore, sources rich in inorganic phosphate, such as highly processed foods, should be avoided as much as possible. Protein should be restricted slightly, to a level of 0.8 g/kg/day, in non-nephrotic patients.20
Glomerular diseases should be suspected early when patients present with typical clinical and urinary features, such as body swelling, rash, proteinuria, and hematuria.
Blood pressure control to a goal of 140/80 is important. Angiotensin-converting enzyme (ACE) inhibitors are recommended, though some increase in creatinine or hyperkalemia can occur. Diuretics should be used to manage volume status.21 Correction of metabolic acidosis with bicarbonate is useful, as is using a statin to reduce vascular events.22 Caution is warranted regarding prescribing medications, as many require a dose reduction in the setting of renal impairment.
Access to renal replacement therapies including dialysis is very limited in most low-resource settings. The decision to start such therapy should be done with care in CKD and working with experts in renal disease.
In crisis areas, there is often no available medical treatment other than trauma management and infection control. For patients with malignancies, this usually means no access to chemotherapy, immunotherapy, radiation, disease-modifying surgeries, or even symptom management. If patients with cancer are unable to travel to other settings for treatment, the best approach is to focus on good palliative care with a holistic approach, including symptom support and excellent communication. The following cancer-related symptoms are explored in these chapters:
Chapter 4: pain
Chapter 5: dyspnea
Chapter 6: nausea and constipation
Chapter 7: delirium and anxiety
Chapter 8: skin care (including pruritus and care of fungating tumors)
Chapter 9: care of the dying patient
Chapter 11: palliative care emergencies (including bleeding, effusions, seizures, SVC syndrome, and spinal cord compression)
Chapter 14: communicating difficult news
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