Fast Fact and Concept #061: Psychostimulants in Palliative Care

Author(s): Vicki Jackson; Susan Block

Educational Objective:
Review the indications, application, and dosing of psycho-stimulants in the terminally ill patient.

Teaching Points:
More than 95% of patients experience fatigue near the end of life. Chemotherapy, radiation, and administration of opioids all tend to increase tiredness. Depression is also a common cause of suffering at the end of life; about 25% of cancer patients with early stage disease develop depression, in advanced illness more than three-quarters of all patients have symptoms of depression. Both fatigue and depression can be treated with one of the psycho-stimulants: dextroamphetamine, methylphenidate, or pemoline. Psycho-stimulants act rapidly and are well-tolerated. These medications have 6 potentially beneficial effects for patients with terminal illness:

1. Mood elevation

2. Improved energy

3. Potentiate analgesic effect of opioids

4. Counter opioid-induced sedation

5. Increase appetite

6. Improve cognition

For depression, psycho-stimulants are the drug of choice for patients with a relatively short life expectancy of weeks to months because they act quickly, usually within 24-48 hours. Psycho-stimulants are generally safe. However, they should be used with caution in patients with heart disease or cognitive disturbances (e.g. delirium). Pemoline, a milder psycho-stimulant, can rarely cause hepatotoxicity, requiring regular monitoring of hepatic function. Some patients with severe depression and a longer life expectancy benefit from starting a psycho-stimulant and then transitioning to an SSRI. Psycho-stimulants are also useful to augment the action of SSRIs in patients with severe depression.

*some patients may need a late afternoon booster dose (usually ½ the am dose)

References:

1. Block, S. Assessing and Managing Depression in the Terminally Ill Patient. Annals of Internal Medicine. 2000;132(3):209-218.
2. Roszans M, Dreisbach A, Lertora JJL, Kahn MJ. Palliative uses of methylphenidate in patients with cancer: A review. J Clin Onc 2002 ;20:335-339.

Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Fast Facts and Concepts #61 Use of psycho-stimulants in palliative care. Jackson V and Block S. February, 2002. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.

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Please e-mail suggested future topics for Fast Facts to David Weissman, MD dweissma@mail.mcw.edu. Let us know how you used this material-send an e-mail describing the educational format and the learner reaction. Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 2/2002

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Non pain symptoms & sydromes, psychiatric disorders

Specific Disease and Organ System Category(s): Psychiatric Disorders