Friday, July 20, 2007

Changing treatment preferences over time; Neuropathy review

The most recent Journal of the American Geriatrics Society has a few articles I wanted to mention.

First is one on changing treatment preferences over time in older adults with life-limiting illnesses. It looked at ~180 community dwelling, cognitively intact, older adults with chronic illnesses (CHF, COPD, cancer) and at least one dependency in IADL's. They were interviewed at least every 4 months for up to 3 years. The subjects were asked questions along the lines of the following and then given different survival/recovery scenario/statistics:

"Think again about if you were suddenly to get sick with an illness that would require you to be in the hospital for a few days to a week. It would either be that your (CHF, COPD, cancer) worsened or you got sick with a different illness. In the hospital you would need to have minor tests, such as x-rays and blood draws, and therapies such as intravenous antibiotics and oxygen. However, this time, imagine that, at the end of the treatment, you would be in a state where you would be bedbound. You would not be able to get up out of bed to the bathroom by yourself, and you would need help with all of your daily activities. Without the treatment, you would not survive. Would you want the treatment?"

They found that (depending on the scenario) 35-50% of subjects, over time, reported inconsistent treatment preferences (their answers changed). They controlled for demographics, self-rated health status and quality of life, etc. and none of these predicted 'inconsistent' responses other than cancer subjects being generally more consistent than non-cancer subjects. The one thing that was predictable was that people who initially endorsed a desire for life-prolonging treatment in the most extreme circumstances (99% chance of death or permanent cognitive disability for example) were the most consistent - they didn't tend to change their minds. While not entirely clear to me after reading the article the authors imply there wasn't a consistent direction of the inconsistencies either (for example, across the cohort people didn't tend to change their mind toward wanting more 'aggressive' treatment as time went on).

As a practical matter this doesn't mean much other than a reminder to never stop talking with our patients about goals & the future - it's an ongoing process and not a static 'decision.' What is interesting here is that their findings suggest that the flux in decision making doesn't seem to be related in change in health status. Why else it would be happening I'm not sure and this finding could just be a limitation of the study design as opposed to anything profound. I'm intrigued by these patients who consistently said they'd want everything even with a 1% chance of recovery - seems like a population worthy of further study.

The other two I'll only mention in passing. One is a randomized trial of a Kaiser in-home palliative care program (it reduced costs, emergency room visits, hospitalizations). The other is about using an electronic medical record to improve advance directive and code status documentation in nursing homes.

BMJ has a metaanalysis of therapies for painful diabetic neuropathy. It looked at controlled trials of agents for PDN and used a 50% reduction in pain as its primary outcome (& calculated odds ratios for this outcome compared to placebo). Using the magnitude of calculated OR's they conclude:

"Our systematic review shows that tricyclic antidepressants, traditional anticonvulsants, and opioids have better efficacy than newer generation anticonvulsants, a selective serotonin reuptake inhibitor, and a serotonin noradrenaline reuptake inhibitor for relieving the pain of diabetic neuropathy."

They then propose a treatment algorithm for PDN based on their findings which places opioids as the last line treatment (behind the apparently less efficacious newer generation anticonvulsants and duloxetine). And they do this without comment. While I don't necessarily disagree with them (due to, among other things, opioid side effects - I'd try duloxetine first too) I found it notable that they down-graded opioids against their own findings without even bothering to discuss it, because, of course opioids are our last-line therapy....

This is a little off topic but I thought it might be of interest to some of Pallimed's readers: JAMA has a fascinating review on emotional distress causing cardiac arrhythmias.

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