Thursday, February 7, 2008

Symptoms in dying LTC patients; More

Too many items noted too briefly:

A few from the Journal of the American Geriatrics Society:

  • First is a paper looking at the symptom experience of dying long-term care residents. This was a multi-institutional study involving interviews of family and staff caregivers of deceased LTC residents (~670 patients, mean age 85 years, most cognitively impaired). Pain and dyspnea were significant in about half the patients prior to death: and significantly while almost all patients had meds for pain about a third had none for dyspnea. The most commonly reported symptoms were issues surrounding cleanliness. From a research perspective, this paper found pretty good agreement between staff and family caregivers about symptoms (in fact, they found generally better agreement between these groups than other research has found between patients themselves and family caregivers). (Thanks to Dr. Robert Arnold for alerting us to this article.)
  • A related article (same data set as above) is a brief report on pain, dyspnea, and perceived quality of dying in LTC residents. Caregiver related quality of dying was compared between patients with and without pain and with and without dyspnea. Presence of pain had no bearing on caregiver rated quality of dying; increasing dyspnea actually was associated with better quality. Weirdly, low dyspnea and severe dyspnea were related to better quality of dying; 'medium' dyspnea wasn't, which makes one wonder whether these results are picking up a lot of noise. One also wonders what the severely dyspneic patients themselves would say about the 'quality of their dying.' Authors' conclusion: "These findings suggest the need to look beyond physical symptoms to understand the quality of dying," which seems pretty reasonable. I still haven't figured out what QOL actually means (besides whatever a patient says it is) and don't know how to begin to conceive what the bereaved's reporting of 'QOD' actually signifies.
  • Third is another mortality follow-back study looking at the impact of palliative care consultation on many care outcomes/family satisfaction. This one involved interviewing caregivers of deceased veterans who had received care at a VA; after multiple adjustments family satisfaction/perceptions of care quality were compared between those vets who received palliative care consultation and those who didn't. PC consultation was associated with better outcomes in most domains (satisfaction with communication, pain, well-being/dignity, etc.). They also looked at the role of earlier consultation and didn't find that that seemed to make much difference in satisfaction.
  • Finally is a small but intriguing study of methylphenidate to prevent falls. It's actually a small, placebo controlled trial looking at the effect of a single dose of methylphenidate or placebo on certain fall-risk tests (e.g. the timed up and go test) in 26 elderly subjects. Methylphenidate significantly improved one (out of 4) of the 'fall-risk tests' (by a small amount) and not much else. Despite the positive spin on this in the abstract this modest finding does not seem promising that methylphenidate will have any salutary effects on fall risk in this population.
BMJ has a study providing some generic prognostic information about dementia. The data come from a large, population based study in the UK in which ~13,000 patients were interviewed every 2 years for 14 years and, among other things, were given dementia screens (mini mental state exam among others; they note that a 'validated algorithm' was used to diagnose dementia). The relative novelty of this study was that they could pick up on incident dementia (they identified 438 cases of incident dementia), in real time so to speak, and thus hopefully get a more accurate assessment of survival. Median age of onset of dementia was 84 years and survival was 4.6 years for women & 4.1 for men. As expected, age predicted survival: women less than 70 years had a median survival of 7.5 years; men over 90 had a median survival of 3.4 years. Male sex and functional status were also predictive of survival. Of note these findings probably overestimate survival (a little) as those patients who developed dementia and then died before their next interview were not counted.

A couple from the Clinical Journal of Pain:
  • A pre-clinical, proof-of-principle, trial of mirtazapine for pain. Pre-clinical insofar as it involved inflicting pain on healthy volunteers (given 30mg of mirtazapine or placebo) and then seeing if there was any difference in those who received the active drug. There was, with increased tolerance to painful stimuli in the mirtazapine group, although maybe they were just experiencing a deep sense of contentment and peace... We'll see where this leads: most of the neuropathic pain I treat is cancer-related and I'll just throw out the observation that I haven't found antidepressants (of any subclass) to be routinely or convincingly effective for most patients.
  • The second is one on geographic variations in opioid availability. It is based on a survey (60% response rate) of opioid availability in outpatient pharmacies in Washington state. Notable findings: 1) more pharmacies stocked meperidine than hydromorphone, 2) most pharmacies stocked most available opioids (unlike in similar studies in other areas), 3) however in multivariate analysis not stocking opioids was associated with being in a zip code with a higher non-white resident percentage (this was a small, but statistically significant association).
Health and Quality of Life Outcomes has a study on changes in quality of life as death approaches (free full-text here). It uses data taken from a study done in the Seattle area using complementary therapies in those with short prognoses (most in hospice) and uses some of the most maddeningly complex data manipulations I've seen for a long time. Ok, it's not the most complex, but it struck me as unnecessarily complex; this may be frank ignorance on my part and if someone smarter than me reads the article and can tell me why they did the data manipulations they did I would genuinely appreciate it. (To be fair, this was one of those articles which was as much about demonstrating the feasibility of its methods as it was about its actual results: i.e. it's written as much for biostatisticians as anyone). Anyway, their major finding, looking at QOL in the 10 weeks prior to death, is that most people rated their's good for most of those weeks, but with a rapid drop off in the last 3 prior to death, which fits my gestalt about what happens with many people. (Their QOL measure was a simple, one-item, "rate your quality of life on a 10 point scale" measure).

Supportive Care in Cancer has a systematic review on the treatment of dyspnea in cancer patients. Good one for the teaching file and a nice reference list for every trial imaginable on the topic. It downplays the results of this trial, which actually changed my practice a bit (I have begun adding benzodiazepines as adjuncts for dyspnea not immediately responding to opioids), which I found interesting (the abstract implies that there's no support for using benzos for dyspnea; my reading of this trial is that they are effective adjuncts to opioids).

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