Abstract
Elsayem A, Bush SH, Munsell MF, Curry E 3rd, Calderon BB, Paraskevopoulos T, Fadul N, Bruera E: Subcutaneous olanzepine for hyperactive or mixed delirium in patients with advanced cancer: A preliminary study. J Pain Symptom Manage 2010;40:774–782.
Olanzepine is efficacious in the management of delirium, but often via oral administration. Unfortunately, parenteral administration (intramuscular, IM) is often necessary, but IM olanzepine is inappropriate for terminally ill patients. The authors attempted to determine the safety and tolerability of subcutaneous (SC) olanzepine in the management of hyperactive or mixed delirium in patients with advanced cancer. A prospective open-label study in patients with advanced cancer and agitated delirium who had not responded to a 10 mg or higher dose of parenteral haloperidol over 24 hours was performed. Patients received olanzapine 5 mg SC every 8 hours for 3 days and continued haloperidol for breakthrough agitation.
For patients requiring more than 8 mg of rescue haloperidol daily, the olanzapine dose was increased to 10 mg SC every 8 hours. Injection site, systemic toxicity, and efficacy were evaluated. Twenty patients received at least one olanzapine injection and 15 (63%) completed the study. Median age of evaluable patients was 58 years, and 67% were males. No injection site toxicity was observed after 167 injections. Probable systemic toxic effects were observed in four patients (severe hypotension [blood pressure < 90/50 mm Hg], paradoxical agitation, diabetes insipidus, and seizure). Efficacy was achieved in nine (37.5%) patients. The authors conclude that IM olanzapine is well tolerated subcutaneously, however, further research is needed to evaluate its efficacy in controlling agitated delirium.
Miller SC, Lima JC, Mitchell SL: Hospice care for persons with dementia: The growth of access in US nursing homes. Am J Alzheimers Dis Other Demen 2010;25:666–673.
Patients with dementia often die in nursing homes (NHs), however, concerns exist about their low use of the Medicare Hospice Benefit. From1999 through 2006, NH resident resident assessment and Medicare claims and enrollment data to identify NH decedents with dementia and hospice use were merged from all states, including Washington, D.C. The authors' two groups, those with advanced dementia and those with mild-to-moderately severe dementia. Results demonstrated that across the study years, 22.2% of all NH decedents had mild-to-moderately severe dementia and 19.6% had advanced dementia. In 1999, 14.5% of decedents with advanced and 13.2% with mild-to-moderately severe dementia accessed hospice, increasing to 42.5% and 37.9%, respectively, in 2006. Between 1999 and 2006, mean days of hospice stays increased from 46 to 118 for advanced dementia and from 39 to 79 for mild-to-moderately severe dementia. These mean length of stay differences resulted from a relatively lower proportion of short hospice stays together with higher proportions of longer stays among advanced versus mild-to-moderately severe dementia decedents. Hospice access and lengths of stay among U.S. states varied widely. The authors conclude that over 40% of U.S. NH decedents have mild-to-moderately severe or advanced dementia. For these NH decedents, access to and duration of Medicare hospice has increased; however, there is considerable variation in hospice use across U.S. states.
Adenis A, Panel N, Horn S, Horn S, Dominguez S, Vanhuyse M, Mirabel X: Palliative chemotherapy does not improve survival in metastatic esophageal cancer. Oncology 2010;79:46–54.
The role of chemotherapy in metastatic esophageal carcinoma (MEC) remains a matter of debate. In this retrospective study, the authors attempted to analyze the survival of chemotherapy after stratification for prognostic factors. Consecutive patients with MEC (from the years 1995 to 2008) were randomly assigned to a development (n = 171) and a validation cohort (n = 113). The authors had first identified prognostic factors using the Kaplan-Meier and Cox methods in the development cohort and then validated them in the validation cohort. Then, they analyzed the impact of chemotherapy after stratification for these prognostic factors. The majority of patients had squamous cell carcinoma (80%). Results demonstrated that the Cox model retained two prognostic factors only: associated cancers (hazard ratio = 2.77, range 1.39–5.54, p = 0.004) and grade 3-4 dysphagia (hazard ratio = 1.44, range 1.08-2.14, p = 0.007). Median survival was 10.9 in patients with 0 (n = 77), 6.2 in those with 1 (n = 65) and 1.8 months in those with 2 prognostic factors (n = 11/171; p = 0.025). The median survival times of the patients with 0, 1, and 2 prognostic factors were 13 versus 9 months (nonsignificant, NS), 6 versus 5 months (NS) and 5 versus 1.3 months (NS) in patients with and without chemotherapy, respectively. The authors conclude that their data suggest that chemotherapy has no significant effect on survival for unselected MEC patients, regardless of the prognostic factors we identified.
Smith AK, Cenzer IS, Knight SJ, Puntillo KA, Widera E, Williams BA, Boscardin WJ, Covinsky KE: The epidemiology of pain during the last 2 years of life. Ann Intern Med 2010;153:563–569.
Pain affects quality of life, and its epidemiology during the last years of life has not been well described. In this observational study of 4703 decedents, the authors attempted to describe the prevalence and correlates of pain during the last 2 years of life. Data from participants who died while enrolled in the Health and Retirement Study (a nationally representative survey of community-living older adults) were analyzed. The survey interview closest to death was used. Each participant or proxy was interviewed once in the last 24 months of life and was classified into 1 of 24 cohorts on the basis of the number of months between the interview and death. The relationship between time before death and pain was modeled and was adjusted for age, sex, race or ethnicity, education level, net worth, income, terminal diagnosis category, presence of arthritis, and proxy status. Measurements were clinically significant pain, as indicated by a report that the participant was “often troubled” by pain of at least moderate severity. Results demonstrated that the mean age (standard deviation [SD]) of participants was 75.7 years (SD, 10.8); 83.1% were white, 10.7% were black, 4.7% were Hispanic; and 52.3% were men. The adjusted prevalence of pain 24 months before death was 26% (95% CI, 23% to 30%). The prevalence remained flat until 4 months before death (28% [confidence interval {CI}, 25% to 32%]), then it increased, reaching 46% (CI, 38% to 55%) in the last month of life. The prevalence of pain in the last month of life was 60% among patients with arthritis versus 26% among patients without arthritis and did not differ by terminal diagnosis category (cancer [45%], heart disease [48%], frailty [50%], sudden death [42%], or other causes [47%]. The authors noted the limitations of the study: data were cross-sectional; 19% of responses were from proxies; and information about cause, location, and treatment of pain was not available. The authors conclude that although the prevalence of pain increases in the last 4 months of life, pain is present in more than one quarter of elderly persons during the last 2 years of life, and that arthritis is strongly associated with pain at the end of life.
Amin AP, Spertus JA, Reid KJ, Lan X, Buchanan DM, Decker C, Masoudi FA: The prognostic importance of worsening renal function during an acute myocardial infarction on long-term mortality. Am Heart J 2010;160:1065–1071.
Although an acute worsening in renal function (WRF) commonly occurs among patients hospitalized for acute myocardial infarction (AMI), its long-term prognostic significance is unknown. In this study, the authors examined predictors of WRF and its association with 4-year mortality. Participants were acute myocardial infarction patients from the multicenter PREMIER study (N = 2098) who survived to hospital discharge who were followed for at least 4 years. Worsening in renal function was defined as an increase in creatinine during hospitalization of ≥ 0.3 mg/dL above the admission value. Correlates of WRF were determined with multivariable logistic regression models and used, along with other important clinical covariates, in Cox proportional hazards models to define the independent association between WRF and mortality.
Results demonstrated that worsening renal function was observed in 393 (18.7%) of AMI survivors. Diabetes, left ventricular systolic dysfunction, and a history of chronic kidney disease (documented history of renal failure with baseline creatinine N 2.5 mg/dL) were independently associated with WRF. During 4-year follow-up, 386 (18.6%) patients died; mortality was significantly higher in the WRF group (36.6% versus 14.4% in those without WRF). After adjusting for other factors associated with WRF and long-term mortality, including baseline creatinine, WRF was independently associated with a higher risk of death (hazard ratio = 1.64, 95% CI 1.23–2.19). The authors conclude that worsening renal function occurs in approximately 1 of 6 AMI survivors and is independently associated with an adverse long-term prognosis, and that further studies on interventions to minimize WRF or to more aggressively treat patients developing WRF should be tested.