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Jennes DAD, Biesbrouck T, De Roo ML, Smets T, Van Den Noortgate N. Pharmacological Treatment for Terminal Agitation, Delirium and Anxiety in Frail Older Patients. Geriatrics (Basel) 2024; 9:51. [PMID: 38667518 PMCID: PMC11050185 DOI: 10.3390/geriatrics9020051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/05/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
CONTEXT Psychological distress symptoms in the last days of life often contribute to the overall symptom burden in frail older patients. Good symptom management practices are crucial to ensure high-quality end-of-life care in an aging population, though the best pharmacological approach to treat these psychological symptoms has yet to be established. OBJECTIVES To identify current evidence-based and practice-based knowledge of pharmacological interventions for the treatment of agitation, delirium, and anxiety during the last days of life in frail older patients. METHODS A systematic, mixed methods review was performed through MEDLINE via PubMed and EMBASE from inception until February 2022 and updated through March 2023. National and international guideline databases and grey literature were searched for additional studies and guidelines. RESULTS Four quantitative studies, two non-randomized and two descriptive, were identified. No randomized controlled trials met inclusion criteria. No qualitative studies were withheld. The three consensus-based protocols that were found through citation searching and screening of grey literature did not meet the standards for inclusion. Haloperidol is recommended in consensus-based guidelines for delirium and is widely used, but high-quality evidence about its efficacy is missing. Better control of agitation or refractory delirium might be achieved with the addition of a benzodiazepine. There is no evidence available about the treatment of anxiety in the last days of life in frail older patients. CONCLUSIONS This mixed methods review demonstrates the lack of good quality evidence that is needed to help clinicians with pharmacological treatment decisions when confronted with psychological symptoms in the last days of life in frail older patients. Population aging will only emphasize the need for further research in this specific population.
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Affiliation(s)
- Dine A. D. Jennes
- Department of Geriatric Medicine, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Tim Biesbrouck
- Department of Geriatric Medicine, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, 3000 Leuven, Belgium
| | - Maaike L. De Roo
- Department of Geriatric Medicine, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, 3000 Leuven, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel [VUB] and Ghent University, 1090 Brussels, Belgium
| | - Nele Van Den Noortgate
- End-of-Life Care Research Group, Vrije Universiteit Brussel [VUB] and Ghent University, 1090 Brussels, Belgium
- Department of Geriatric Medicine, Ghent University Hospital, 9000 Ghent, Belgium
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Thomas C, Alici Y, Breitbart W, Bruera E, Blackler L, Sulmasy DP. Drugs, delirium, and ethics at the end of life. J Am Geriatr Soc 2024. [PMID: 38240387 DOI: 10.1111/jgs.18766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/27/2024]
Abstract
For older persons with delirium at the end of life, treatment involves complex trade-offs and highly value-sensitive decisions. The principles of beneficence, nonmaleficence, respect for autonomy, and justice establish important parameters but lack the structure necessary to guide clinicians in the optimal management of these patients. We propose a set of ethical rules to guide therapeutics-the canons of therapy-as a toolset to help clinicians deliberate about the competing concerns involved in the management of older patients with delirium at the end of life. These canons are standards of judgment that reflect how many experienced clinicians already intuitively practice, but which are helpful to articulate and apply as basic building blocks for a relatively neglected but emerging ethics of therapy. The canons of therapy most pertinent to the care of patients with delirium at the end of life are as follows: (1) restoration, which counsels that the goal of all treatment is to restore the patient, as much as possible, to homeostatic equilibrium; (2) means-end proportionality, which holds that every treatment should be well-fitted to the intended goal or end; (3) discretion, which counsels that an awareness of the limits of medical knowledge and practice should guide all treatment decisions; and (4) parsimony, which maintains that only as much therapeutic force as is necessary should be used to achieve the therapeutic goal. Carefully weighed and applied, these canons of therapy may provide the ethical structure needed to help clinicians optimally navigate complex cases.
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Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC, USA
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Thomas B, Barclay G, Barbato M. Dexmedetomidine for end of life sedation: retrospective cohort comparison study. BMJ Support Palliat Care 2024; 13:e898-e901. [PMID: 37402543 DOI: 10.1136/spcare-2023-004252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/12/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVES Infused sedatives are often utilised to alleviate distress at the end of life. Which sedative best achieves this is unknown. This study compares breakthrough medication requirements of patients treated with the novel agent dexmedetomidine compared with patients treated with standard-care sedatives. METHODS A retrospective cross-cohort comparison. Two studies of patients at the end of life under sedation at the same palliative care unit, one utilising novel sedatives, and the other standard care were compared. Breakthrough medication requirements were compared using paired t-tests, including opioids, benzodiazepines and anticholinergics. Changes in background infusions were compared. RESULTS The dexmedetomidine cohort required less breakthrough interventions per day compared with the standard care group, the reduction was significant (2.2 vs 3.9, p=0.003). There was a significant difference in benzodiazepine requirements, with the dexmedetomidine cohort requiring fewer doses per day than the standard care cohort (1.1 vs 0.6, p=0.03). Anticholinergics were more commonly utilised in the standard care cohort but there was no significant difference (p=0.22). Opioid requirements were similar across cohorts with comparable rates of breakthrough use and infusion increases. CONCLUSIONS This study demonstrates a reduction in breakthrough medication requirements, particularly benzodiazepines, for patients sedated with dexmedetomidine at end of life.
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Affiliation(s)
- Benjamin Thomas
- Palliative Medicine, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Gregory Barclay
- Palliative Medicine, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Michael Barbato
- Palliative Care Unit, Port Kembla Hospital, Port Kembla, New South Wales, Australia
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Sato J, Tanaka R. Effects of Opioids, Steroids, Benzodiazepines, Anticholinergics, and Antihistamines on the Efficacy of Antipsychotics for Treating Delirium in End-of-Life Adult Patients Undergoing Palliative Care. J Pain Palliat Care Pharmacother 2023; 37:298-307. [PMID: 37702451 DOI: 10.1080/15360288.2023.2253241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 08/17/2023] [Indexed: 09/14/2023]
Abstract
The purpose of the study was to determine the effect of combination therapy involving opioids, steroids, benzodiazepines, anticholinergics, and antihistamines on antipsychotics efficacy for delirium. The study included adult inpatients receiving end-of-life palliative care and diagnosed with hyperactive delirium. Changes in delirium symptoms were assessed using the Intensive Care Delirium Screening Checklist (ICDSC). A retrospective analysis was conducted on 97 patients with ICDSC scores of ≥4, comparing the scores before and after antipsychotic administration. A mean score <4 sustained for 3 days after antipsychotics administration was considered effective. The mean days with ICDSC <4 within a 3-day period were evaluated as well. The efficacy of antipsychotics was compared between cases with and without the use of opioids, steroids, benzodiazepines, anticholinergics, and antihistamines. The results revealed no significant differences in the efficacy of antipsychotics for delirium when used in conjunction with opioids (odds ratio 0.614, 95% CI [0.179-2.105]), benzodiazepines (0.387, [0.108-1.390]), steroids (1.258, [0.276-5.746]), or anticholinergics (2.085, [0. 148-29.458]). Additionally, no significant differences were observed in the mean days with ICDSC <4 within 3-day period. Although opioids, benzodiazepines, steroids, anticholinergics, and antihistamines are recognized as delirium risk factors, their use for symptom relief in patients with delirium may not affect antipsychotic efficacy.
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Affiliation(s)
- Junya Sato
- Department of Pharmacy, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi Prefecture, Japan
- School of Pharmacy, International University of Health and Welfare, Ohtawara City, Tochigi Prefecture, Japan
| | - Rei Tanaka
- Department of Pharmacy, Shizuoka Cancer Center, Sunto-gun, Shizuoka Prefecture, Japan
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, Noda City, Chiba Prefecture, Japan
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Ijaopo EO, Zaw KM, Ijaopo RO, Khawand-Azoulai M. A Review of Clinical Signs and Symptoms of Imminent End-of-Life in Individuals With Advanced Illness. Gerontol Geriatr Med 2023; 9:23337214231183243. [PMID: 37426771 PMCID: PMC10327414 DOI: 10.1177/23337214231183243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/23/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Background: World population is not only aging but suffering from serious chronic illnesses, requiring an increasing need for end-of-life care. However, studies show that many healthcare providers involved in the care of dying patients sometimes express challenges in knowing when to stop non-beneficial investigations and futile treatments that tend to prolong undue suffering for the dying person. Objective: To evaluate the clinical signs and symptoms that show end-of-life is imminent in individuals with advanced illness. Design: Narrative review. Methods: Computerized databases, including PubMed, Embase, Medline,CINAHL, PsycInfo, and Google Scholar were searched from 1992 to 2022 for relevant original papers written in or translated into English language that investigated clinical signs and symptoms of imminent death in individuals with advanced illness. Results: 185 articles identified were carefully reviewed and only those that met the inclusion criteria were included for review. Conclusion: While it is often difficult to predict the timing of death, the ability of healthcare providers to recognize the clinical signs and symptoms of imminent death in terminally-ill individuals may lead to earlier anticipation of care needs and better planning to provide care that is tailored to individual's needs, and ultimately results in better end-of-life care, as well as a better bereavement adjustment experience for the families.
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Affiliation(s)
| | - Khin Maung Zaw
- University of Miami Miller School of Medicine, FL, USA
- Miami VA Medical Center, FL, USA
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Stoevelaar R, Juffermans CCM, Roorda IMM, de Nijs EJM, Hoornweg J, Cannegieter SC, van der Linden YM. A simple risk score list can be used to predict the occurrence of delirium in patients admitted to inpatient hospice care: A medical record study. Eur J Cancer Care (Engl) 2022; 31:e13658. [PMID: 35840543 PMCID: PMC9787666 DOI: 10.1111/ecc.13658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/25/2022] [Accepted: 06/24/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This study aimed to examine whether the 10-item Risk Score List (RSL) accurately predicts delirium in patients admitted to inpatient hospice care and whether this instrument can be simplified. Determining the risk for developing delirium can help to treat these patients in a timely manner. METHODS This was a retrospective medical record study in patients who died in 2019 or 2020 in three hospices. Predictive values were examined using Cox regression analysis, crosstabs, and C-statistic. RESULTS In total, 240 patients were included. Median age at admission was 78 (IQR 70-84) years. Primary diagnosis most often was cancer (n = 186, 78%); 173 (72%) patients had an increased risk of delirium according to RSL, of whom 120 (69%) developed delirium. Overall, 147 (61%) patients developed delirium. The RSL significantly predicted future delirium (HR 3.25, CI 1.87-5.65, p < 0.01) and had a sensitivity of 85%, a specificity of 43%, positive predictive value of 62%, negative predictive value of 73%, and a C-statistic of 0.64. Simplifying the RSL to four items still significantly predicted future delirium, with similar predictive values. CONCLUSION Delirium occurs in more than half of patients admitted to hospice care. The RSL can be simplified to four items, without compromising on predictive accuracy.
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Affiliation(s)
- Rik Stoevelaar
- Center of Expertise in Palliative CareLeiden University Medical CenterLeidenThe Netherlands,Department of Public Health and Primary CareLeiden University Medical CenterLeidenThe Netherlands
| | - Carla C. M. Juffermans
- Center of Expertise in Palliative CareLeiden University Medical CenterLeidenThe Netherlands,Department of Public Health and Primary CareLeiden University Medical CenterLeidenThe Netherlands
| | | | - Ellen J. M. de Nijs
- Center of Expertise in Palliative CareLeiden University Medical CenterLeidenThe Netherlands
| | - Jacques Hoornweg
- Foundation ‘Hospice Duin‐ en Bollenstreek’SassenheimThe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Yvette M. van der Linden
- Center of Expertise in Palliative CareLeiden University Medical CenterLeidenThe Netherlands,Netherlands Comprehensive Cancer Organisation (IKNL)UtrechtThe Netherlands
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Gerlach LB, Zhang L, Strominger J, Kim HM, Teno J, Bynum JPW, Maust DT. Variation in Benzodiazepine and Antipsychotic Prescribing Among Hospice Agencies. J Gen Intern Med 2022; 37:3814-3822. [PMID: 35469359 PMCID: PMC9640505 DOI: 10.1007/s11606-022-07604-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 04/06/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Benzodiazepines and antipsychotics are routinely prescribed for symptom management in hospice. There is minimal evidence to guide prescribing in this population, and little is known about how prescribing varies across hospice agencies. OBJECTIVE Examine patient- and hospice agency-level characteristics associated with incident prescribing of benzodiazepines and antipsychotics in hospice. DESIGN Retrospective cohort study of a 20% sample of Medicare beneficiaries newly enrolled in hospice. PARTICIPANTS Medicare hospice beneficiaries ≥ 65 years old between 2014 and 2016, restricted to those without benzodiazepine (N = 169,688) or antipsychotic (N = 190,441) prescription fills in the 6 months before hospice enrollment. MAIN MEASURES The primary outcome was incident (i.e., new) prescribing of a benzodiazepine or antipsychotic. A series of multilevel Cox regression models with random intercepts for hospice agency were fit to examine the association of incident benzodiazepine and antipsychotic prescribing with patient and hospice agency characteristics. KEY RESULTS A total of 91,728 (54.1%) and 58,175 (30.5%) hospice beneficiaries were newly prescribed an incident benzodiazepine or antipsychotic. The prescribing rate of the hospice agency was the strongest predictor of incident prescribing: Compared to patients in bottom-quartile benzodiazepine-prescribing agencies, those in top-quartile agencies were 10.7 times more likely to be prescribed an incident benzodiazepine (adjusted hazard ratio [AHR] 10.7, 95% CI 10.1-11.3). For incident antipsychotic prescribing, patients in top-quartile agencies were 51.7 times more likely to receive an antipsychotic (AHR 51.7, 95% CI 44.3-60.4) compared to those in the bottom quartile. Results remained consistent accounting for comfort kit prescribing. CONCLUSIONS The pattern of benzodiazepine or antipsychotic prescribing of a hospice agency strongly predicts whether a hospice enrollee is prescribed these medications, exceeding every other patient-level factor. While the appropriate level of prescribing in hospice is unclear, this variation may reflect a strong local prescribing culture across individual hospice agencies.
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Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Lan Zhang
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Hyungjin Myra Kim
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Joan Teno
- Department of General Internal Medicine and Geriatrics, Oregon Health and Sciences University, Portland, OR, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Donovan T Maust
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Vidal C, Romero I, Neto I. Malignant Peritoneal Mesothelioma: A Challenging Case for Palliative Care. Cureus 2022; 14:e27580. [PMID: 36059360 PMCID: PMC9428408 DOI: 10.7759/cureus.27580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2022] [Indexed: 11/05/2022] Open
Abstract
Malignant peritoneal mesothelioma (MPM) is a rare and very aggressive malignancy of serosal membranes, which typically presents with abdominal pain, distension, and ascites. Due to its rarity and nonspecific symptoms, it is usually diagnosed late, when the disease burden is extensive and the therapy is inevitably palliative. It represents a complex challenge for clinicians because the treatment options are very poor and the illness has a great impact on patients’ life. We present a complex case of a young patient with MPM who was admitted to our palliative care unit.
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You W, Fan XY, Lei C, Nie CC, Chen Y, Wang XL. Melatonin intervention to prevent delirium in hospitalized patients: A meta-analysis. World J Clin Cases 2022; 10:3773-3786. [PMID: 35647160 PMCID: PMC9100708 DOI: 10.12998/wjcc.v10.i12.3773] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/01/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Evaluation of the effectiveness of melatonin is necessary to prevent the development of delirium in hospitalized patients. Melatonin (N-acetyl-5-methoxytryptamine) is a hormone produced by the pineal gland of the brain from the amino acid tryptophan. Synthetic melatonin supplements have been used for various medical conditions, especially sleep-related diseases, and have proved to be successful.
AIM To determine the effect of melatonin on the prevention of delirium in hospitalized patients.
METHODS A literature search of the CNKI, Wanfang Database, VIP Database, China Biomedical Literature Database, PubMed, Embase, Cochrane Library, Web of Science, and other databases was conducted. The CNKI, Wanfang Database, VIP Database (VIP), and China Biomedical Literature Database were searched for Chinese studies, and PubMed, Embase, Cochrane Library, Web of Science and other databases were searched for international studies. It will be established in June 2021 in a randomized controlled trial (RCT) whether melatonin treatment for 6 mo prevents delirium in hospitalized patients. Literature screening, quality review, and data extraction were carried out using the Cochrane Manual 5.1.0 systematic evaluation method, and Stata 15.0 software and Review Manager 5.3 were used for meta-analysis and processing.
RESULTS A total of 18 new RCT articles and 18 experimental subjects were identified. The results of the meta-analysis showed that following the occurrence of delirium, melatonin reduced the incidence of delirium in patients (RR = 0.69, 95%CI: 0.60-0.80), which is of significance, but heterogeneity was significant I2 = 62%. Subgroup analysis was performed to examine the source of heterogeneity, and it was found that different patient types were the source of heterogeneity; the research on subgroup analysis was of high quality and homogeneous. To determine the reliability and robustness of the research results, a sensitivity analysis was carried out. The results showed that after excluding individual studies one by one, the effect size was still within 95%CI, which strengthened the reliability of the original meta-analysis results. Melatonin has a significant preventive effect on delirium in hospitalized medical patients [RR = 0.60, 95%CI: 0.47-0.76), P < 0.001].
CONCLUSION Melatonin can reduce the rate of delirium in medical patients, and the role of melatonin in reducing the incidence of delirium in surgical patients and critical care unit patients requires further study.
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Affiliation(s)
- Wei You
- Emergency Department Intensive Care Unit, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Xiao-Yu Fan
- Department of General Surgery, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Cheng Lei
- School of Public Health and Management, Chongqing Medical University, Chongqing 400000, Chongqing, China
| | - Chen-Cong Nie
- Department of Nursing, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Yao Chen
- Emergency Department Intensive Care Unit, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Xue-Lian Wang
- Emergency Department Intensive Care Unit, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
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An open-label clinical trial of oral transmucosal haloperidol and oral transmucosal olanzapine in the treatment of terminal delirium at home. Trials 2022; 23:311. [PMID: 35422053 PMCID: PMC9011988 DOI: 10.1186/s13063-022-06238-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 03/27/2022] [Indexed: 11/29/2022] Open
Abstract
Background The phenomenon of restlessness, agitation, or cognitive disturbances experienced by dying patients is well-known in palliative care; more than half of these patients will experience delirium symptoms at end-of-life. When not identified early and effectively managed, delirium symptoms could lead to caregiver and patient distress and harm. Methods Eighty patients with a prognosis of 7 days or less will be recruited for an open-label randomised control trial. The two arms compare oral-transmucosal haloperidol 2.5 mg vs olanzapine 5 mg over 72 h. The severity of agitation, delirium and toxicities of treatments will be compared at the 24th, 48th and 72nd hour after drug administration. Discussion This trial is the first to compare anti-psychotics in the management of delirium at the dying stage in the home hospice setting using the oral transmucosal route. Ethical considerations, as well as recruitment procedures, are discussed. Trial registration This study was registered in ClinicalTrials.gov – identifier NCT04750395
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11
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Bramati P, Bruera E. Delirium in Palliative Care. Cancers (Basel) 2021; 13:cancers13235893. [PMID: 34885002 PMCID: PMC8656500 DOI: 10.3390/cancers13235893] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022] Open
Abstract
Simple Summary Delirium is a generalized cerebral dysfunction that occurs frequently near the end of life. In palliative care, delirium is frequently a sign of impending death; it is distressing for patients, families, and caregivers; and the goals of management, assessment, and treatment are controversial. We provide an update on these topics mainly focusing on patients with cancer. Abstract Delirium, a widespread neuropsychiatric disorder in patients with terminal diseases, is associated with increased morbidity and mortality, profoundly impacting patients, their families, and caregivers. Although frequently missed, the effective recognition of delirium demands attention and commitment. Reversibility is frequently not achievable. Non-pharmacological and pharmacological interventions are commonly used but largely unproven. Palliative sedation, although controversial, should be considered for refractory delirium. Psychological assistance should be available to patients and their families at all times.
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Gerlach LB, Powell V, Zhang L, Bynum JPW, Maust DT. The Most Common Medications Billed to the Medicare Hospice Benefit Among Hospice Beneficiaries in the U.S. J Pain Symptom Manage 2021; 62:e3-e6. [PMID: 34051294 PMCID: PMC8419064 DOI: 10.1016/j.jpainsymman.2021.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/17/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Victoria Powell
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lan Zhang
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Donovan T Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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13
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Featherstone I, Hosie A, Siddiqi N, Grassau P, Bush SH, Taylor J, Sheldon T, Johnson MJ. The experience of delirium in palliative care settings for patients, family, clinicians and volunteers: A qualitative systematic review and thematic synthesis. Palliat Med 2021; 35:988-1004. [PMID: 33784915 PMCID: PMC8189008 DOI: 10.1177/02692163211006313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Delirium is common in palliative care settings and is distressing for patients, their families and clinicians. To develop effective interventions, we need first to understand current delirium care in this setting. AIM To understand patient, family, clinicians' and volunteers' experience of delirium and its care in palliative care contexts. DESIGN Qualitative systematic review and thematic synthesis (PROSPERO 2018 CRD42018102417). DATA SOURCES The following databases were searched: CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase, MEDLINE and PsycINFO (2000-2020) for qualitative studies exploring experiences of delirium or its care in specialist palliative care services. Study selection and quality appraisal were independently conducted by two reviewers. RESULTS A total of 21 papers describing 16 studies were included. In quality appraisal, trustworthiness (rigour of methods used) was assessed as high (n = 5), medium (n = 8) or low (n = 3). Three major themes were identified: interpretations of delirium and their influence on care; clinicians' responses to the suffering of patients with delirium and the roles of the family in delirium care. Nursing staff and other clinicians had limited understanding of delirium as a medical condition with potentially modifiable causes. Practice focused on alleviating patient suffering through person-centred approaches, which could be challenging with delirious patients, and medication use. Treatment decisions were also influenced by the distress of family and clinicians and resource limitations. Family played vital roles in delirium care. CONCLUSIONS Increased understanding of non-pharmacological approaches to delirium prevention and management, as well as support for clinicians and families, are important to enable patients' multi-dimensional needs to be met.
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Affiliation(s)
| | - Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent’s Health Network, Sydney, NSW, Australia
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - Pamela Grassau
- School of Social Work, Carleton University, Ottawa, ON, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Palliative Care, Bruyere Continuing Care, Ottawa, ON, Canada
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - Trevor Sheldon
- Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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14
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Gerlach LB, Fashaw S, Strominger J, Ogarek J, Zullo AR, Daiello LA, Teno J, Shireman TI, Bynum JPW. Trends in antipsychotic prescribing among long-term care residents receiving hospice care. J Am Geriatr Soc 2021; 69:2152-2162. [PMID: 33837537 DOI: 10.1111/jgs.17172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/09/2021] [Accepted: 03/22/2021] [Indexed: 11/30/2022]
Abstract
IMPORTANCE The Centers for Medicare & Medicaid Services' (CMS) National Partnership to Improve Dementia Care in Nursing Homes ("CMS National Partnership") focuses on reducing antipsychotic prescribing to long-term care residents. Hospice enrollment is not an exclusionary condition for the antipsychotic quality measure reported by CMS. It is unclear how prescribing in hospice may have been impacted by the initiative. OBJECTIVE Estimate the association of the CMS National Partnership with trends in antipsychotic prescribing among long-term care residents in hospice. DESIGN Interrupted time-series analysis of a 100% Minimum Data Set sample with linked hospice claims from 2011 to 2017. SETTING Long-term care nursing facilities. PARTICIPANTS Older adults ≥65 residing in long-term care (n = 3,741,379) and limited to those enrolled in hospice (n = 821,610). MAIN OUTCOME Quarterly prevalence of antipsychotic and other psychotropic (antianxiety, hypnotic, antidepressant) use among long-term care residents; overall and among residents with dementia, stratified by hospice enrollment. RESULTS From 2011 to 2017, parallel declines in antipsychotic prescribing were observed among long-term care residents enrolled and not enrolled in hospice (hospice: decline from 26.8% to 18.7%; non-hospice: decline from 23.0% to 14.4%). Following the 2012 CMS National Partnership, quarterly rates of antipsychotic prescribing declined significantly for both residents enrolled and not enrolled in hospice care. Declines in antipsychotic prescribing were greater for residents with dementia, with similar rates among residents enrolled and not enrolled in hospice. Among residents with dementia enrolled in hospice, use of other psychotropic medication classes including antianxiety, antidepressant, and hypnotic use remained relatively stable over time. CONCLUSIONS AND RELEVANCE Declines in antipsychotic prescribing during the CMS National Partnership occurred among long-term care residents in hospice, where use may be deemed clinically appropriate. Nursing homes are an important location for the provision of dementia end-of-life care and the drivers of potentially unintended reductions in antipsychotic use merits further investigation.
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Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Shekinah Fashaw
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Jessica Ogarek
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - Lori A Daiello
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - Joan Teno
- Department of Internal Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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15
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Guo D, Lin T, Deng C, Zheng Y, Gao L, Yue J. Risk Factors for Delirium in the Palliative Care Population: A Systematic Review and Meta-Analysis. Front Psychiatry 2021; 12:772387. [PMID: 34744847 PMCID: PMC8566675 DOI: 10.3389/fpsyt.2021.772387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/23/2021] [Indexed: 02/05/2023] Open
Abstract
Objective: Delirium is common and highly distressing for the palliative care population. Until now, no study has systematically reviewed the risk factors of delirium in the palliative care population. Therefore, we performed a systematic review and meta-analysis to evaluate delirium risk factors among individuals receiving palliative care. Methods: We systematically searched PubMed, Medline, Embase, and Cochrane database to identify relevant observational studies from database inception to June 2021. The methodological quality of the eligible studies was assessed by the Newcastle Ottawa Scale. We estimated the pooled adjusted odds ratio (aOR) for individual risk factors using the inverse variance method. Results: Nine studies were included in the review (five prospective cohort studies, three retrospective case-control studies and one retrospective cross-section study). In pooled analyses, older age (aOR: 1.02, 95% CI: 1.01-1.04, I 2 = 37%), male sex (aOR:1.80, 95% CI: 1.37-2.36, I 2 = 7%), hypoxia (aOR: 0.87, 95% CI: 0.77-0.99, I 2 = 0%), dehydration (aOR: 3.22, 95%CI: 1.75-5.94, I 2 = 18%), cachexia (aOR:3.40, 95% CI: 1.69-6.85, I 2 = 0%), opioid use (aOR: 2.49, 95%CI: 1.39-4.44, I 2 = 0%), anticholinergic burden (aOR: 1.18, 95% CI: 1.07-1.30, I 2 = 9%) and Eastern Cooperative Oncology Group Performance Status (aOR: 2.54, 95% CI: 1.56-4.14, I 2 = 21%) were statistically significantly associated with delirium. Conclusion: The risk factors identified in our review can help to highlight the palliative care population at high risk of delirium. Appropriate strategies should be implemented to prevent delirium and improve the quality of palliative care services.
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Affiliation(s)
- Duan Guo
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Taiping Lin
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Chuanyao Deng
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Yuxia Zheng
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Langli Gao
- West China School of Nursing, Sichuan University, Chengdu, China.,Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Jirong Yue
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
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16
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Lawlor PG, McNamara-Kilian MT, MacDonald AR, Momoli F, Tierney S, Lacaze-Masmonteil N, Dasgupta M, Agar M, Pereira JL, Currow DC, Bush SH. Melatonin to prevent delirium in patients with advanced cancer: a double blind, parallel, randomized, controlled, feasibility trial. Palliat Care 2020; 19:163. [PMID: 33087111 PMCID: PMC7579814 DOI: 10.1186/s12904-020-00669-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/07/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Delirium is highly problematic in palliative care (PC). Preliminary data indicate a potential role for melatonin to prevent delirium, but no randomized controlled trials (RCTs) are reported in PC. METHODS Patients aged ≥18 years, with advanced cancer, admitted to an inpatient Palliative Care Unit (PCU), having a Palliative Performance Scale rating ≥ 30%, and for whom consent was obtained, were included in the study. Patients with delirium on admission were excluded. The main study objectives were to assess the feasibility issues of conducting a double-blind RCT of exogenous melatonin to prevent delirium in PC: recruitment, retention, procedural acceptability, appropriateness of outcome measures, and preliminary efficacy and safety data. Study participants were randomized in a double-blind, parallel designed study to receive daily melatonin 3 mg or placebo orally at 21:00 over 28 days or less if incident delirium, death, discharge or withdrawal occurred earlier. Delirium was diagnosed using the Confusion Assessment Method. Efficacy endpoints in the melatonin and placebo groups were compared using time-to-event analysis: days from study entry to onset of incident delirium. RESULTS Over 16 months, 60/616 (9.7%; 95% CI: 7.5-12.4%) screened subjects were enrolled. The respective melatonin (n = 30) vs placebo (n = 30) outcomes were: incident delirium in 11/30 (36.7%; 95%CI: 19.9-56.1%) vs 10/30 (33%; 95% CI: 17.3-52.8%); early discharge (6 vs 5); withdrawal (6 vs 3); death (0 vs 1); and 7 (23%) vs 11 (37%) reached the 28-day end point. The 25th percentile time-to-event were 9 and 18 days (log rank, χ2 = 0.62, p = 0.43) in melatonin and placebo groups, respectively. No serious trial medication-related adverse effects occurred and the core study procedures were acceptable. Compared to those who remained delirium-free during their study participation, those who developed delirium (n = 21) had poorer functional (p = 0.036) and cognitive performance (p = 0.013), and in particular, poorer attentional capacity (p = 0.003) at study entry. CONCLUSIONS A larger double-blind RCT is feasible, but both subject accrual and withdrawal rates signal a need for multisite collaboration. The apparent trend for shorter time to incident delirium in the melatonin group bodes for careful monitoring in a larger trial. TRIAL REGISTRATION Registered on July 21st 2014 with ClinicalTrials.gov : NCT02200172 .
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Affiliation(s)
- Peter G. Lawlor
- grid.28046.380000 0001 2182 2255Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Bruyère Street, Ottawa, ON K1N 5C8 Canada ,grid.418792.10000 0000 9064 3333Bruyère Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Ottawa Hospital Research Institute, Ottawa, Canada ,grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
| | | | | | - Franco Momoli
- grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, London, Canada
| | - Sallyanne Tierney
- grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
| | | | - Monidipa Dasgupta
- grid.39381.300000 0004 1936 8884Department of Geriatric Medicine, Department of Medicine, University of Western Ontario, London, Canada
| | - Meera Agar
- Centre of Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Hamilton, Canada
| | - Jose L. Pereira
- grid.25073.330000 0004 1936 8227Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Canada
| | - David C. Currow
- Centre of Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Hamilton, Canada
| | - Shirley H. Bush
- grid.28046.380000 0001 2182 2255Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Bruyère Street, Ottawa, ON K1N 5C8 Canada ,grid.418792.10000 0000 9064 3333Bruyère Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Ottawa Hospital Research Institute, Ottawa, Canada ,grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
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17
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Ramírez-Jarquín UN, Shahani N, Pryor W, Usiello A, Subramaniam S. The mammalian target of rapamycin (mTOR) kinase mediates haloperidol-induced cataleptic behavior. Transl Psychiatry 2020; 10:336. [PMID: 33009372 PMCID: PMC7532208 DOI: 10.1038/s41398-020-01014-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/20/2020] [Accepted: 07/03/2020] [Indexed: 12/17/2022] Open
Abstract
The mammalian target of rapamycin (mTOR) is a ubiquitously expressed serine/threonine kinase protein complex (mTORC1 or mTORC2) that orchestrates diverse functions ranging from embryonic development to aging. However, its brain tissue-specific roles remain less explored. Here, we have identified that the depletion of the mTOR gene in the mice striatum completely prevented the extrapyramidal motor side effects (catalepsy) induced by the dopamine 2 receptor (D2R) antagonist haloperidol, which is the most widely used typical antipsychotic drug. Conversely, a lack of striatal mTOR in mice did not affect catalepsy triggered by the dopamine 1 receptor (D1R) antagonist SCH23390. Along with the lack of cataleptic effects, the administration of haloperidol in mTOR mutants failed to increase striatal phosphorylation levels of ribosomal protein pS6 (S235/236) as seen in control animals. To confirm the observations of the genetic approach, we used a pharmacological method and determined that the mTORC1 inhibitor rapamycin has a profound influence upon post-synaptic D2R-dependent functions. We consistently found that pretreatment with rapamycin entirely prevented (in a time-dependent manner) the haloperidol-induced catalepsy, and pS6K (T389) and pS6 (S235/236) signaling upregulation, in wild-type mice. Collectively, our data indicate that striatal mTORC1 blockade may offer therapeutic benefits with regard to the prevention of D2R-dependent extrapyramidal motor side effects of haloperidol in psychiatric illness.
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Affiliation(s)
- Uri Nimrod Ramírez-Jarquín
- grid.214007.00000000122199231Department of Neuroscience, The Scripps Research Institute, Florida, Jupiter, Florida 33458 USA
| | - Neelam Shahani
- grid.214007.00000000122199231Department of Neuroscience, The Scripps Research Institute, Florida, Jupiter, Florida 33458 USA
| | - William Pryor
- grid.214007.00000000122199231Department of Neuroscience, The Scripps Research Institute, Florida, Jupiter, Florida 33458 USA
| | - Alessandro Usiello
- grid.9841.40000 0001 2200 8888Department of Environmental, Biological, and Pharmaceutical Sciences and Technologies, University of Campania Luigi Vanvitelli, 81100 Caserta, Italy ,grid.4691.a0000 0001 0790 385XLaboratory of Behavioral Neuroscience, CEINGE Biotecnologie Avanzate, 80145 Naples, Italy
| | - Srinivasa Subramaniam
- Department of Neuroscience, The Scripps Research Institute, Florida, Jupiter, Florida, 33458, USA.
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18
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Hui D, De La Rosa A, Wilson A, Nguyen T, Wu J, Delgado-Guay M, Azhar A, Arthur J, Epner D, Haider A, De La Cruz M, Heung Y, Tanco K, Dalal S, Reddy A, Williams J, Amin S, Armstrong TS, Breitbart W, Bruera E. Neuroleptic strategies for terminal agitation in patients with cancer and delirium at an acute palliative care unit: a single-centre, double-blind, parallel-group, randomised trial. Lancet Oncol 2020; 21:989-998. [PMID: 32479786 DOI: 10.1016/s1470-2045(20)30307-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND The role of neuroleptics for terminal agitated delirium is controversial. We assessed the effect of three neuroleptic strategies on refractory agitation in patients with cancer with terminal delirium. METHODS In this single-centre, double-blind, parallel-group, randomised trial, patients with advanced cancer, aged at least 18 years, admitted to the palliative and supportive care unit at the University of Texas MD Anderson Cancer Center (Houston, TX, USA), with refractory agitation, despite low-dose haloperidol, were randomly assigned to receive intravenous haloperidol dose escalation at 2 mg every 4 h, neuroleptic rotation with chlorpromazine at 25 mg every 4 h, or combined haloperidol at 1 mg and chlorpromazine at 12·5 mg every 4 h, until death or discharge. Rescue doses identical to the scheduled doses were administered at inception, and then hourly as needed. Permuted block randomisation (block size six; 1:1:1) was done, stratified by baseline Richmond Agitation Sedation Scale (RASS) scores. Research staff, clinicians, patients, and caregivers were masked to group assignment. The primary outcome was change in RASS score from time 0 to 24 h. Comparisons among group were done by modified intention-to-treat analysis. This completed study is registered with ClinicalTrials.gov, NCT03021486. FINDINGS Between July 5, 2017, and July 1, 2019, 998 patients were screened for eligibility, with 68 being enrolled and randomly assigned to treatment; 45 received the masked study interventions (escalation n=15, rotation n=16, combination n=14). RASS score decreased significantly within 30 min and remained low at 24 h in the escalation group (n=10, mean RASS score change between 0 h and 24 h -3·6 [95% CI -5·0 to -2·2]), rotation group (n=11, -3·3 [-4·4 to -2·2]), and combination group (n=10, -3·0 [-4·6 to -1·4]), with no difference among groups (p=0·71). The most common serious toxicity was hypotension (escalation n=6 [40%], rotation n=5 [31%], combination n=3 [21%]); there were no treatment-related deaths. INTERPRETATION Our data provide preliminary evidence that the three strategies of neuroleptics might reduce agitation in patients with terminal agitation. These findings are in the context of the single-centre design, small sample size, and lack of a placebo-only group. FUNDING National Institute of Nursing Research.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Allison De La Rosa
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Annie Wilson
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thuc Nguyen
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jimin Wu
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marvin Delgado-Guay
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ahsan Azhar
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Arthur
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Daniel Epner
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ali Haider
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maxine De La Cruz
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yvonne Heung
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kimberson Tanco
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shalini Dalal
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Akhila Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Janet Williams
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sapna Amin
- Department of Investigational Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Terri S Armstrong
- Neuro-Oncology Branch, Centre for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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