Anorexia is defined as a loss of appetite that may be associated with cachexia, the latter a catabolic state characterized by severe weight loss. Either may occur in the late stages of any severe progressive illness.

Management of anorexia includes the following:

Consider treating the primary symptom (i.e., anorexia) with an appetite stimulant such as:

Note that the appetite stimulant effect of corticosteroids often decrease after several weeks. Megestrol is associated with lower limb edema and an increased risk of thromboembolism. Consider oral nutritional supplements, though subsequent decreased intake at meals can occur as a result of their use. Giving smaller amounts of a high Calorie supplement throughout the day, with medication administration, may result in less decrease of intake at meals. If used, it is preferable to use nutritional supplements that are lactose free, especially in the elderly or African Americans who have a higher prevalence of lactose intolerance. There is insufficient evidence to recommend the use of cannabinoids (dronabinol), cyproheptadine, an androgenic steroid (oxandrolone) or thalidomide, though a therapeutic trial may be worthwhile in refractory anorexia. A patient’s advance directive for health care may either request or preclude artificially administered nutrition and hydration.

Dyspnea is defined as discomfort in breathing that includes the sensation of breathlessness, shortness of breath or an increased work of breathing. Often it is not associated with tachypnea or hypoxemia. Its management includes the following:

Not infrequently a family member may request the use of oxygen for non-hypoxemic dyspnea. While there is no evidence to support this, many times it may alleviate the discomfort of breathing that patients may feel as well as the emotional distress that families may experience when observing their dyspneic family member.

The most rational approach to managing nausea and/or vomiting is to understand the four main pathophysiologic mechanisms and the neurotransmitters that mediate the emetic reflex in the brain (refer to Table 3). This will allow for a more rational and effective choice of antiemetic drugs (i.e., antihistaminic, anticholinergic, antiserotinergic, or antidopaminergic).

Management of nausea/vomiting includes:

Combination pharmacotherapy based on each medication’s different antiemetic physiologic mechanism may be necessary especially if nausea/vomiting has multiple etiologies or is refractory. Dexamethasone, metoclopramide, and low-dose antipsychotics have central antiemetic effects.

Be aware of the likely side effects of serotonin receptor antagonists such as ondansetron (headache, constipation, fatigue, xerostomia), as well as anticholinergics and antihistamines (drowsiness, fatigue, confusion, dry mouth, constipation, urinary retention, blurred vision). Metoclopramide can induce EPS, dystonia and tardive dyskinesia. Low dose haloperidol (0.5–2 mg) or olanzapine (2.5–7.5 mg) may be useful in alleviating nausea/vomiting.

Dronabinol can have an antiemetic effect though poor evidence of efficacy (start at 2.5 mg twice a day to a maximum of 20 mg/day). Common adverse effects include somnolence, asthenia, paranoia, nausea, and vomiting. Opioid-induced nausea/vomiting may require either a dose reduction of the opioid or rotation to another opioid.

Many patients who reside in a long term care setting experience constipation, especially if terminally ill. Constipation can occur because of a combination of poor fluid intake, low dietary fiber, impaired mobility and constipating drugs such as opioids, anticholinergics, iron, calcium preparations, and antihypertensives such as calcium channel blockers, diuretics, and clonidine.

Management of constipation includes the following:

Remember to prevent opioid-induced constipation: as the dose of the opioid is increased, so must the laxative regimen also be increased. Stimulant laxatives such as senna are most effective for opioid-induced constipation. In severe constipation, consider oral lubiprostone or methylnaltrexone sc, though they are expensive.

Stool softeners are considered to have poor effectiveness but can be initially prescribed in some patients when initiating their bowel regimen, i.e., the “laxative ladder ”. Remember that some patients may also require use of a rectally administered lubricating agent (glycerin) and/or stimulant (bisacodyl) to ensure adequate defecation in combination with oral agents. Noted that rectal fecal impaction can cause “paradoxical” diarrhea or urinary retention, either of which may not be evident. This often requires manual disimpaction, though a polyethylene glycol solution taken orally may be effective.

Delirium is an acute confusional state that is characterized by a fluctuating course through the day/night, inattention, and disorganized thinking and speech. Delirium can be hyperactive, hypoactive, or mixed. A good caveat to remember is that any acute illness or any medication regardless of when it was started, can precipitate delirium especially in patients with advanced illness.

Management of delirium in patients with advanced, serious illness includes the following:

Remember that opioids and steroids can cause delirium. Both haloperidol and lorazepam can cause paradoxical agitation or restlessness in which case their dose should be decreased (not increased) or discontinued. It is not uncommon to use combination therapy with both haloperidol and lorazepam. Be aware that patients with dementia are more sensitive to the adverse effects of antipsychotic medications that include sedation and EPS, and that antipsychotics have also been associated with an increased risk of sudden death and cerebrovascular events. Communication with the patient and their family about these risks and benefits must occur. Overall, judicious medication management as well as social, environmental, and practical interventions must all be implemented in an attempt to prevent and treat delirium. For further information refer to the Chap. “Dementia, Delirium, and Depression,” which discusses delirium.

Effective pain management is essential to high quality palliative care in post-acute and LTC medicine. Given that there is a high prevalence of potentially pain-producing medical conditions in this patient population. The goals of pain control include:

It is necessary for practitioners to assess each patient for the presence of pain and for “total pain”; that is, the physical, psycho-emotional, social, and spiritual components of pain and how each can affect the other. Successful pain management entails evaluation and interventions that address each component of a patient’s total pain. As with any distressful symptom, pain is more optimally managed if its cause and pathophysiologic mechanisms can be determined. Using an interdisciplinary approach with multiple treatment modalities, including both nonpharmacologic and pharmacologic treatments, will also optimize pain management. The most recent AMDA Clinical Practice Guideline on pain management [9] and the AGS publication, Geriatrics at Your Fingertips [12] are excellent up-to-date resources that provide more in depth content than permits in this chapter. Also, the AGS guidelines on the pharmacologic management of persistent pain in older persons is another noteworthy resource [13].

Key components to the evaluation of pain include the following: