How to manage a patient with anxiety, dyspnea (shortness of breath) at rest, constipation for 4 days, back pain, and disturbed sleep, with a possible history of cardiovascular disease and Chronic Obstructive Pulmonary Disease (COPD)?

Management of Anxiety, Dyspnea at Rest, Constipation, Back Pain, and Sleep Disturbance in a Patient with Possible COPD

Avoid benzodiazepines entirely in this patient—instead, initiate non-pharmacological interventions for dyspnea and anxiety as first-line treatment, address constipation with osmotic laxatives, manage back pain with acetaminophen or topical NSAIDs, and consider low-dose SSRIs for ongoing anxiety management. 1

Immediate Management of Dyspnea and Anxiety

Non-Pharmacological Interventions (First-Line)

• Use a hand-held fan directed at the patient's face to provide immediate relief of dyspnea through stimulation of facial trigeminal receptors 2, 1
• Position the patient for comfort (typically upright or leaning forward) to optimize respiratory mechanics 1
• Initiate breathing-relaxation training techniques including pursed-lip breathing and diaphragmatic breathing to reduce respiratory rate and anxiety 2, 1
• Assess oxygen saturation immediately—if hypoxemic (SpO2 <90%), provide supplemental oxygen as this prevents cognitive dysfunction from disordered gas exchange 1

Critical Safety Warning About Benzodiazepines

• Benzodiazepines are contraindicated in this patient population due to lack of evidence for breathlessness management and association with increased all-cause mortality in severe COPD 1
• In elderly patients (especially with possible dementia given the sleep disturbance), benzodiazepines cause CNS impairment including delirium, slowed comprehension, sedation, and falls—all significantly worsening quality of life and mortality risk 1
• Benzodiazepines should only be considered as second- or third-line therapy in acute episodes when other measures have failed and anxiety significantly aggravates distress 1

Pharmacological Management of Anxiety

SSRIs as Preferred Anxiolytic

• Initiate a low-dose SSRI (sertraline 25-50 mg daily or escitalopram 5-10 mg daily) for ongoing anxiety management as these have better safety profiles than benzodiazepines in elderly patients with COPD 1
• Counsel the patient that anxiety and disturbed sleep may occur during the first 10 days and benefits may not appear for 3-4 weeks 3
• SSRIs are particularly appropriate for this patient given the constipation, as they may have mild prokinetic effects unlike tricyclic antidepressants which worsen constipation 3

Opioids for Refractory Dyspnea

• Consider low-dose oral morphine (2.5-5 mg every 4 hours as needed) if dyspnea remains severe despite non-pharmacological measures, as opioids are the primary pharmacologic treatment for dyspnea in advanced respiratory disease 2
• Use a dyspnea scale to guide dose adjustment with dual goals of providing adequate relief while minimizing sedative effects 2
• Avoid nebulized opioids as systematic reviews show they are no more effective than nebulized placebo 2

Management of Constipation (4 Days)

Immediate Laxative Therapy

• Initiate polyethylene glycol (MiraLAX) 17 grams daily as first-line osmotic laxative for this duration of constipation
• Add docusate sodium 100 mg twice daily as stool softener if stools are hard
• Consider bisacodyl 10 mg suppository or enema if no bowel movement within 24 hours of oral laxative initiation
• Avoid anticholinergic medications (including certain antispasmodics) as they worsen constipation and cause CNS impairment in elderly patients 1

Addressing Opioid-Related Constipation

• If morphine is initiated for dyspnea, start prophylactic bowel regimen immediately with scheduled osmotic laxative and stimulant laxative (senna 8.6 mg twice daily)

Management of Back Pain

Analgesic Approach

• Start with acetaminophen 650 mg three times daily as first-line for musculoskeletal back pain given better safety profile in elderly patients
• Consider topical NSAIDs (diclofenac gel) to affected area if acetaminophen insufficient, avoiding systemic NSAID exposure
• Avoid systemic NSAIDs if possible due to cardiovascular and renal risks in patients with potential cardiovascular disease
• Avoid muscle relaxants as they cause sedation and falls in elderly patients

Management of Sleep Disturbance

Non-Pharmacological Sleep Hygiene

• Address nocturnal dyspnea first as this is likely the primary driver of sleep disturbance in COPD patients 2
• Elevate head of bed 30-45 degrees to reduce nocturnal dyspnea
• Screen for obstructive sleep apnea given the constellation of COPD, obesity (if present), and sleep disturbance 2

Pharmacological Sleep Management

• The SSRI initiated for anxiety will likely improve sleep quality over 3-4 weeks 3
• Avoid benzodiazepines and "Z-drugs" (zolpidem, eszopiclone) due to fall risk and respiratory depression
• Consider low-dose trazodone 25-50 mg at bedtime if sleep remains severely disturbed after addressing dyspnea and anxiety

Comprehensive Pulmonary Rehabilitation Referral

Evidence-Based Rehabilitation Program

• Refer immediately to pulmonary rehabilitation as this is the cornerstone treatment for COPD patients with anxiety and breathlessness, providing Level A evidence for reducing both symptoms while improving exercise capacity and quality of life 1
• Pulmonary rehabilitation should include minimum 6-12 weeks duration with twice-weekly supervised sessions of 2 hours each, as longer programs produce greater sustained benefits 1
• Program must include psychosocial interventions such as relaxation techniques and stress management training integrated into comprehensive rehabilitation to significantly reduce anxiety and depression 1
• Exercise training should include both endurance training (walking, cycling) and strength training for upper and lower extremities 1

Long-Term Maintenance

• Exercise programs must be maintained indefinitely as benefits disappear rapidly upon discontinuation 1
• Encourage ongoing home-based exercise programs with periodic supervised sessions 1

Screening for Depression

• Screen for depression using Hospital Anxiety and Depression Questionnaire or Beck Depression Inventory as depression is significantly undertreated in elderly COPD patients with 45% prevalence of depressive symptoms 1
• Up to 40% of COPD patients have symptoms of depression or anxiety, with higher prevalence in advanced disease and those using supplemental oxygen 2

Key Clinical Pitfalls to Avoid

• Do not reflexively prescribe benzodiazepines for acute dyspnea in elderly patients with COPD—the risks far outweigh benefits 1
• Do not assume all breathlessness requires pharmacological intervention—non-pharmacological approaches are most appropriate for anxiety-driven dyspnea 1
• Do not use anticholinergic medications as they cause CNS impairment, delirium, and sedation in elderly patients 1
• Do not ignore the dyspnea-anxiety cycle as patients experience fear and anxiety in anticipation of dyspnea episodes, which creates heightened physiologic arousal that precipitates or exacerbates dyspnea 1
• Many elderly patients refuse psychiatric medications due to fear of side effects, embarrassment, denial, addiction concerns, or frustration with polypharmacy—address these concerns proactively 1

Follow-Up Assessment

• Reassess symptoms within 48-72 hours to evaluate response to non-pharmacological interventions and laxative therapy
• Continual reassessment is required for optimal symptom control 2
• If constipation persists beyond 7 days total, consider digital rectal examination to rule out fecal impaction