Cognitive assessment of cancer patients

Four decades of chemotherapy-induced cognitive dysfunction: comprehensive review of clinical, animal and in vitro studies, and insights of key initiating events

Cognitive dysfunction has been one of the most reported and studied adverse effects of cancer treatment, but, for many years, it was overlooked by the medical community. Nevertheless, the medical and scientific communities have now recognized that the cognitive deficits caused by chemotherapy have a strong impact on the morbidity of cancer treated patients. In fact, chemotherapy-induced cognitive dysfunction or 'chemobrain'  (also named also chemofog) is at present a well-recognized effect of chemotherapy that could affect up to 78% of treated patients. Nonetheless, its underlying neurotoxic mechanism is still not fully elucidated. Therefore, this work aimed to provide a comprehensive review using PubMed as a database to assess the studies published on the field and, therefore, highlight the clinical manifestations of chemobrain and the putative neurotoxicity mechanisms.In the last two decades, a great number of papers was published on the topic, mainly with clinical observations. Chemotherapy-treated patients showed that the cognitive domains most often impaired were verbal memory, psychomotor function, visual memory, visuospatial and verbal learning, memory function and attention. Chemotherapy alters the brain's metabolism, white and grey matter and functional connectivity of brain areas. Several mechanisms have been proposed to cause chemobrain but increase of proinflammatory cytokines with oxidative stress seem more relevant, not excluding the action on neurotransmission and cellular death or impaired hippocampal neurogenesis. The interplay between these mechanisms and susceptible factors makes the clinical management of chemobrain even more difficult. New studies, mainly referring to the underlying mechanisms of chemobrain and protective measures, are important in the future, as it is expected that chemobrain will have more clinical impact in the coming years, since the number of cancer survivors is steadily increasing.

'Everything is as before, but nothing is as it was'-A phenomenological-hermeneutic study of meaningfulness in adult patients with refractory epilepsy after interdisciplinary epilepsy rehabilitation

BACKGROUND

Interdisciplinary Rehabilitation aimed at adults with refractory epilepsy (RE) establishes scientific evidence of higher health-related QoL, including improved self-worth and increased self-awareness as outcomes. Yet, there is very little research-based knowledge of how life transforms itself after the rehabilitation program from patients' perspectives.

AIM

The aim of this study was to identify and describe how - from the patient perspectives - life transforms itself after rehabilitation among adults with RE, focusing on the meaningfulness of interdisciplinary rehabilitation.

METHOD

Nine patients, who all completed an Interdisciplinary Rehabilitation Program in an Adult Epilepsy Clinic, were interviewed between six months and two years after rehabilitation. Nine interviews were recorded, transcribed verbatim, and analyzed as described by the phenomenological method 'Reflective Lifeworld Research' (RLR).

FINDINGS

The essence of the phenomenon was revealed as life as a struggle for a dignified existence with RE as a navigating life companion. Through the clusters of meaning, four constituents emerged from the phenomenon: 1) to accept the limitations of body and mind; 2) to be on a journey toward your inner self; 3) to be quietly understood; 4) to fight for renewed hope and recognition during transition.

CONCLUSION

The patients consider it significant to know their own bodies with the constraints that this involves. This knowledge helps them make decisions that not only have a positive effect on their epilepsy, but also raise their self-esteem and give them renewed hope and courage to face life. However, the struggle for a dignified life is continuously hard, and it comes to a head in patients' transition from 'patient to citizen', where asymmetries arise. These asymmetries leave considerable marks on the patients' worlds and challenge their renewed hope for a dignified existence.

Predictors of cognitive decline in people with cancer undergoing chemotherapy

PURPOSE

The purpose of this study was to investigate the impact of demographic factors, disease/treatment-related factors, and psychological factors on cognitive function.

METHOD

A cross-sectional study was conducted. Participants were recruited from the oncology inpatient units of two hospitals. A convenience sample of 175 patients with cancer who underwent chemotherapy were recruited. The Everyday Cognition Scale (ECog), the Korean version of the Mini Mental State Examination (K-MMSE), Functional Assessment of Cancer Therapy-Fatigue (FACT-F) scale, Hospital Anxiety and Depression Scale (HADS), and a questionnaire to collect information about demographic, disease, and treatment information were completed.

RESULTS

More participants showed a mild decline in cognitive function and self-reported cognitive decline (39.4%) than had objectively confirmed decline (20%). Notably, 53.7-62.9% of the participants showed memory loss and a decline in divided attention. Demographic factors (age, sex), disease/treatment-related factors (chemotherapy cycles, fatigue), and psychological factors (depression) were predictors of cognitive decline in 49.6% of participants.

CONCLUSIONS

Old age and cumulative chemotherapy cycles were the main influential factors for objectively confirmed cognitive decline, and fatigue was the most common predictor of self-reported cognitive decline. Depression was one of the predictors of perceived cognitive decline, but it was not significant for objectively measured cognitive function. Thus, treatment-related factors such as fatigue had a greater impact on cognitive decline than psychological factors.

Health-related quality of life in patients with serious non-specific symptoms undergoing evaluation for possible cancer and their experience during the process: a mixed methods study

PURPOSE

The purpose of this research was to measure changes in HRQoL during the diagnostic evaluation of patients presenting with non-specific symptoms possibly attributable to cancer, to describe their experiences of HRQoL and to merge these findings with intent to obtain a more comprehensive understanding of their HRQoL experience during this stressful life event.

METHODS

A convergent mixed methods (MM) design was used and involved quantitative data about HRQoL measured by the EORTC-QLQ-C30 instrument and qualitative interview data about patients' HRQoL experiences. Participants completed the EORTC-QLQ-C30 questionnaire prior to and after evaluation. The baseline questionnaire informed the purposive sampling for the qualitative interview study, and open-end questions matched to the EORTC-QLQ-C30 constructs were used in the semi-structured interviews.

RESULTS

A total of 838 patients were enrolled in the quantitative study; 680 (81 %) also completed follow-up. Twenty-one patients participated in interviews. The MM findings are the meta-inferences drawn by looking across the matched quantitative and qualitative findings: physical function, social function, role function, emotional function, cognitive function, social function, symptoms and quality of life.

CONCLUSION

The survey results illustrate that HRQoL improved over time and the qualitative findings confirmed and further expanded the survey results. The MM analysis underlines that the HRQoL experience cannot be observed independently from context. Participants adapted to their situation over time, and this may change their perceptions of HRQoL. These findings can be used to enhance evidence-based care as clinicians need to be aware of how the context influences the HRQoL experience.

Genetic variation and cognitive dysfunction in opioid-treated patients with cancer

BACKGROUND AND PURPOSE

The effects of single-nucleotide polymorphisms (SNPs) on the cognitive function of opioid-treated patients with cancer until now have not been explored, but they could potentially be related to poor functioning. This study aimed at identifying associations between SNPs of candidate genes, high opioid dose, and cognitive dysfunction.

METHODS

Cross-sectional multicenter study (European Pharmacogenetic Opioid Study, 2005-2008); 1586 patients; 113 SNPs from 41 genes.

INCLUSION CRITERIA

cancer, age ≥18 year, opioid treatment, and available genetic data. Cognitive assessment by Mini-Mental State Examination (MMSE).

ANALYSES

SNPs were rejected if violation of Hardy-Weinberg equilibrium (P < 0.0005), or minor allele frequency <5%; patients were randomly divided into discovery sample (2/3 for screening) and validation sample (1/3 for confirmatory test); false discovery rate of 10% for determining associations (Benjamini-Hochberg method). Co-dominant, dominant, and recessive models were analyzed by Kruskal-Wallis and Mann-Whitney tests.

RESULTS

In the co-dominant model significant associations (P < 0.05) between MMSE scores and SNPs in the HTR3E,TACR1, and IL6 were observed in the discovery sample, but the replication in the validation sample did not confirm it. Associations between MMSE scores among patients receiving ≥400 mg morphine equivalent dose/day and SNPs in TNFRSF1B,TLR5,HTR2A, and ADRA2A were observed, but they could not be confirmed in the validation sample. After correction for multiple testing, no SNPs were significant in the discovery sample. Dominant and recessive models also did not confirm significant associations.

CONCLUSIONS

The findings did not support influence of those SNPs analyzed to explain cognitive dysfunction in opioid-treated patients with cancer.

The experiences of health-related quality of life in patients with nonspecific symptoms who undergo a diagnostic evaluation for cancer: a qualitative interview study

The diagnostic phase of cancer can affect health-related quality of life (HRQoL). The aim of this study was to investigate how patients with nonspecific symptoms experience HRQoL while undergoing diagnostic evaluations for cancer. Twenty-one participants who had completed a fast-track evaluation for possible cancer at one of three hospitals in the Capital Region, Denmark were interviewed 2-4 weeks after completing diagnostic evaluations. The interviews were semi-structured and were supported by an interview guide based on the same themes as in The European Organisation for Research and Treatment of Cancer Quality of Life questionnaire (EORCT-QLQ-C30). Data analysis was based on qualitative content analysis by Krippendorff. The analysis generated six categories: symptoms, physical-, role-, emotional-, cognitive- and social functioning, and the diagnostic fast-track experience. From these categories, a main theme was identified: Health-related quality of life is not solely affected by the diagnostic process. The results provide a comprehensive understanding of HRQoL in the diagnostic phase of possible cancer, which can be used not only to enhance evidence-based care, but also in the interpretation of the EORTC-QLQ-C30 scores. Psycho-social support with a focus on individual informational needs during the diagnostic phase may be warranted.

Identifying factors significant to continuity in basic palliative hospital care-from the perspective of patients with advanced cancer

Based on the research method grounded theory and semistructured patient interviews at home following hospitalization, the aim was to provide information on issues relating to the identification and alleviation of patients' physical and emotional problems, understood as continuity in palliative care. The interviews were based on selected problems that patients found significant. The results are distilled into the core category disheartening interactions and four categories: falling outside the professional framework, not being seen as a person, unidentified/unmet need for guidance and involvement, and patient strategy-minimizing conflict. The categories are significant in generating and maintaining continuity in basic palliative care.

Prevalence and predictors of cognitive dysfunction in opioid-treated patients with cancer: a multinational study

PURPOSE

To identify prevalence and associated factors of cognitive dysfunction in opioid-treated patients with cancer.

PATIENTS AND METHODS

EPOS (European Pharmacogenetic Opioid Study) is a prospective cross-sectional multicenter study in which adult patients with cancer who received treatment with opioids for moderate or severe pain for at least 3 days were included. Cognitive function was assessed using the Mini-Mental State Examination (MMSE). MMSE scores were categorized into definite cognitive dysfunction (scores < 24), possible cognitive dysfunction (scores 24-26), and no cognitive dysfunction (scores > 26). Factors potentially associated with cognitive dysfunction were assessed. Associations between MMSE and explanatory variables were analyzed by ordinal logistic regression models.

RESULTS

We included 1,915 patients with cancer from 17 centers. MMSE scores less than 27 were observed in 32.9% of patients. Patients with lung cancer had higher odds (adjusted odds ratio, 1.46; 95% CI, 1.09 to 1.95) for having lower MMSE scores compared with patients with other cancer diagnoses. Patients receiving daily opioid doses of 400 mg or more (oral morphine equivalents) had 1.75 (95% CI, 1.25 to 2.46) times higher odds of having lower MMSE scores compared with those receiving daily doses less than 80 mg. Other risk factors for cognitive dysfunction were older age, low Karnofsky performance status (KPS), time since diagnosis (< 15 months), and absence of breakthrough pain (BTP).

CONCLUSION

One third of opioid-treated patients with cancer had possible or definite cognitive dysfunction. Lung cancer, daily opioid doses of 400 mg or more (oral morphine equivalents), older age, low KPS, shorter time since cancer diagnosis, and absence of BTP were predictors for cognitive dysfunction.

Delirium resolution in hospitalized older patients with cancer

Delirium is a troubling complication in hospitalized older patients with cancer. Although preventable and potentially reversible, delirium may be prolonged. Persistent delirium at the time of hospital discharge is common and associated with multiple adverse outcomes. We conducted a secondary data analysis to examine delirium resolution in 43 hospitalized older patients with cancer who had prevalent or incident delirium. We describe trajectories of delirium resolution and evaluate differences in patients with and without delirium resolution. Delirium was assessed using the NEECHAM confusion scale. Forty-one of the 43 patients had delirium during hospitalization before discharge; 2 had delirium only at the time of discharge. Although delirium resolved in 13 patients, a significant majority (70%) had delirium at discharge. Patients with delirium resolution were less functionally impaired before hospitalization and exhibited fewer etiologic risk patterns at admission. Mild delirium was more likely to resolve than severe delirium. All patients with chronic cognitive impairment had persistent delirium. Care for hospitalized older patients with cancer should incorporate delirium prevention and intervention strategies. Caregiver education, communication between providers, and follow-up are critical when delirium persists. Additional research focusing on the management and impact of persistent delirium in hospitalized older patients with cancer is needed.

The Brief Pain Inventory: pain's interference with functions is different in cancer pain compared with noncancer chronic pain

OBJECTIVES

The Brief Pain Inventory (BPI) is a highly recommended and frequently used multidimensional pain assessment tool. The BPI includes 2 dimensions: pain intensity and pain's interference with functions. Our aims were to explore how patients respond to pain interference items by comparing responses from patients who had cancer with patients who had noncancer chronic pain (NCCP), and to explore how different levels of health-related quality of life affect upon pain's interference with functions.

METHODS

Three hundred patients with cancer and 286 patients with NCCP were asked to complete the BPI and the European Organization for Research and Treatment of Cancer's Quality of Life Questionnaire (EORTC QLQ-C30). The pain interference items were indexed into total interference, interference with physical functions, and interference with psychologic functions. Regression analyses were used to explore differences in pain's interference by group, pain intensity, and a possible interaction effect between them. The analyses were adjusted for age, sex, and all EORTC QLQ-C30 scales.

RESULTS

The cancer patients reported higher values of physical interference than NCCP patients with the same level of pain intensity (P<0.001). NCCP patients reported higher values of psychologic interference than cancer patients (P=0.023). For total interference, these effects eliminated each other. When adjusting for age, sex, and the EORTC QLQ-C30 subscales, the results still remained significant except that adjusting for the subscale for physical function made the group effect insignificant for physical interference (P=0.30).

DISCUSSION

The results indicate that patients are unable to report isolated pain's interference using the BPI. When reporting pain's interference with physical functioning, the level of physical functioning is more important than the level of pain. Patients' diagnoses have to be taken into account when interpreting reported pain's interference with functions.

Doloplus-2, a valid tool for behavioural pain assessment?

BACKGROUND

The Doloplus-2 is used for behavioural pain assessment in cognitively impaired patients. Little data exists on the psychometric properties of the Doloplus-2. Our objectives were to test the criterion validity and inter-rater reliability of the Doloplus-2, and to explore a design for validations of behavioural pain assessment tools.

METHODS

Fifty-one nursing home patients and 22 patients admitted to a geriatric hospital ward were included. All were cognitively impaired and unable to self-report pain. Each patient was examined by an expert in pain evaluation and treatment, who rated the pain on a numerical rating scale. The ratings were based on information from the medical record, reports from nurses and patients (if possible) about pain during the past 24 hours, and a clinical examination. These ratings were used as pain criterion. The Doloplus-2 was administered by the attending nurse. Regression analyses were used to estimate the ability of the Doloplus-2 to explain the expert's ratings. The inter-rater reliability of the Doloplus-2 was evaluated in 16 patients by comparing the ratings of two nurses administrating the Doloplus-2.

RESULTS

There was no association between the Doloplus-2 and the expert's pain ratings (R2 = 0.02). There was an association (R2 = 0.54) between the expert's ratings and the Doloplus-2 scores in a subgroup of 16 patients assessed by a geriatric expert nurse (the most experienced Doloplus-2 administrator). The inter-rater reliability between the Doloplus-2 administrators assessed by the intra-class coefficient was 0.77. The pain expert's ratings were compared with ratings of two independent geriatricians in a sub sample of 15, and were found satisfactory (intra-class correlation 0.74).

CONCLUSION

It was challenging to conduct such a study in patients with cognitive impairment and the study has several limitations. The results do not support the validity of the Doloplus-2 in its present version and they indicate that it demands specific administration skills.

Delirium in Hospitalized Older Patients With Cancer

PURPOSE/OBJECTIVES

To examine key aspects of delirium in a sample of hospitalized older patients with cancer.

DESIGN

Secondary analysis of data from studies on acute confusion in hospitalized older adults.

SETTING

Tertiary teaching hospital in the southeastern United States.

SAMPLE

76 hospitalized older patients with cancer (mean age = 74.4 years) evenly divided by gender and ethnicity and with multiple cancer diagnoses.

METHODS

Data were collected during three studies of acute confusion in hospitalized older patients. Delirium was measured with the NEECHAM Confusion Scale on admission, daily during hospitalization, and at discharge. Patient characteristics and clinical risk markers were determined at admission.

MAIN RESEARCH VARIABLES

Prevalent and incident delirium, etiologic risk patterns, and patient characteristics.

FINDINGS

Delirium was noted in 43 (57%) patients; 29 (38%) were delirious on admission. Fourteen of 47 (30%) who were not delirious at admission became delirious during hospitalization. Delirium was present in 30 patients (39%) at discharge. Most delirious patients had evidence of multiple (mean = 2.3) etiologic patterns for delirium.

CONCLUSIONS

Delirium was common in this sample of hospitalized older patients with cancer. Patients with delirium were more severely ill, were more functionally impaired, and exhibited more etiologic patterns than nondelirious patients.

IMPLICATIONS FOR NURSING

Nurses caring for older patients with cancer should perform systematic and ongoing assessments of cognitive behavioral performance to detect delirium early. The prevention and management of delirium hinge on the identification and treatment of the multiple risk factors and etiologic mechanisms that underlie delirium. The large number of patients discharged while still delirious has significant implications for posthospital care and recovery.

Hospitalized patients experienced suffering in life with incurable cancer

The concept 'suffering' has been central within nursing since Florence Nightingale. But few researchers have made empirical studies about the lived phenomenon. Several researchers within nursing agree that more research concerning individual groups of patients has to be initiated. Within research about patients with incurable cancer focus has been on death, the terminal period and patients experience of being dying. This qualitative study was initiated to describe the characteristics of a group of Danish hospitalized patients' experienced suffering in life with incurable cancer. Twenty-five semi-structured interviews were arranged with 12 patients ones a week within a period of 4 weeks. In week 2 and 4, the interviews were supplemented by questions developed on the basis of the potential signs of suffering which appeared during the participant observations that took place the day before each interview. C. S. Peirce's semiotic and phenomenological grounded theory of signs was used in order to identify the potential signs. A phenomenological methodology developed by A. Giorgi was used to develop and describe the general structure of the phenomenon. The phenomenon is described as: 'The experience of living in an increasingly unpredictable existents at the mercy of the body, the consciousness, the illness, the death, the treatment, the professionals, one's articulateness, the past, the present and the future, influenced by increasing powerlessness, loneliness and isolation, and the experience of existing in an persistent, and with time, unconquerable struggle to maintain and regain control'.

Methods for assessment of cognitive failure and delirium in palliative care patients: implications for practice and research

The most commonly encountered clinical conditions presenting with cognitive failure (CF) are delirium, dementia and amnestic disorders. Of these, delirium is probably the most prevalent in palliative care, and it is potentially reversible. Thus, improvement in diagnostics seems warranted. The objectives of this review were to examine the methods for assessment of CF and delirium in palliative care. Twenty-two studies were reviewed: 64% were published in 2000 or later. Twelve reports focused on delirium, six on CF, while the remaining four assessed confusion (2), hallucinations and general psychological morbidity. Median sample size was 100 (20393). Ten different instruments were used: The Mini Mental State Exam was used in 13 studies. Five studies were validation reports of new or existing instruments. The term CF is an imprecise description of a loss in one or more of the cognitive functions. The interchangeable use of CF as a description of specific diagnoses should be avoided, as this contributes to prevalence rates that are not representative. Assessment tools that discriminate between the different diagnostic entities presenting with CF should be used in future studies.

Cognitive dysfunction and subjective complaints of cancer patients

Although the neurotoxicity of many anticancer therapies is well documented, the impact of cancer treatment on cognitive functioning has been studied less frequently. The present study examines deficits in cognitive functioning and their correlation with medical data as well as with psychosocial variables. A standardised neuropsychological test battery and several questionnaires were administered to a random sample of 119 patients. 24% of our patients fulfilled our criterion for cognitive impairment. There were no significant associations between the results of the neuropsychological testing and the current affective status or self-reports of attentional deficits in daily life. Cognitive impairment occurs in a clinically relevant percentage of cancer patients and cannot be explained exclusively due to depression or anxiety. Since subjective and objective cognitive impairment data showed little correlation, neuropsychological evaluation should not only be based on subjectively-reported complaints, but also on objective measurements.

The panorama of opioid-related cognitive dysfunction in patients with cancer: a critical literature appraisal

BACKGROUND

Opioids have an essential role in the management of pain in cancer patients, particularly those with advanced disease. Cognitive dysfunction is a recognized complication of opioid use. However, misconceptions and controversy surround the nature and prevalence of its occurrence. A projected increase in the aging cancer population highlights the need for a better understanding of this phenomenon.

METHODS

A critical appraisal of the literature evidence in relation to the pattern, pathophysiology, assessment, impact, and management of cognitive dysfunction due to opioid use in cancer pain management is given.

RESULTS

Studies in cancer patients with less advanced disease reveal subtle evidence of cognitive impairment, largely related to initial dosing or dose increases. In advanced cancer, opioid-induced cognitive dysfunction usually occurs in the form of delirium, a multifactorial syndrome. The presence of both cognitive impairment and delirium frequently is misdiagnosed or missed. Potential risk factors include neuropathic and incidental pain, opioid tolerance, somatization of psychologic distress, and a history of drug or alcohol abuse. Elevation of opioid metabolites with renal impairment may contribute to cognitive dysfunction. Recognition of opioid-related cognitive dysfunction is improved by objective screening. Successful management requires either dose reduction or a change of opioid, in addition to addressing other reversible precipitants such as dehydration or volume depletion.

CONCLUSIONS

Opioid-related cognitive dysfunction tends to be subtle in the earlier stages of cancer, whereas delirium, a more florid form with behavioral disturbance is likely to be present in the advanced cancer population. In patients with advanced disease, an optimal management approach requires careful clinical assessment, identification of risk factors, objective monitoring of cognition, maintenance of adequate hydration, and either dose reduction or switching to a different opioid.

Visual hallucinations: a prevalence study among hospice inpatients

The aim of the study was to determine the prevalence of visual hallucinations among hospice inpatients, and the prevalence of a number of possible associated risk factors. One hundred consecutive admissions to St. John's Hospice in Wirral were screened for visual hallucinations in a semi-structured interview. The prevalence of opioid administration, other drugs known to cause hallucinations, brain tumours, liver metastases, bone metastases, lung metastases, known renal failure, eye disease, Alzheimer's disease, Parkinson's disease, other neurodegenerative disorder, psychiatric disorder and epilepsy were also recorded. Subjects were screened for cognitive function using the Folstein mini-mental state examination (MMSE). Survival times from assessment to death were calculated. The results were analysed using arithmetical means with 95% confidence intervals (CI) and odds ratios with 95% confidence intervals. Almost half (47%) the patients had experienced visual hallucinations within the previous month. Hypnagogic or hypnopompic hallucinations of a person standing by the bedside were the commonest type. Median survival time for hallucinators was 15 days (range 0-50 days) and for non-hallucinators was 11 days (range 0-89 days). There was no significant difference in cognitive scores between hallucinators and non-hallucinators. Hallucinations were associated with multiple possible risk factors in every case. Hallucinators were more likely to be taking opioids, although the association was not strong (odds ratio 4.48, 95% CI = 1.6-12.19), and were taking larger numbers of potentially hallucinogenic drugs. It is not clear why some patients on opioids hallucinate and others do not. Data on the prevalence of various possible risk factors yielded ample material for the planning of future studies.

The Bedside Confusion Scale: Development of a Portable Bedside Test for Confusion and Its Application to the Palliative Medicine Population

BACKGROUND

Clinical tests for confusion in medically ill patients are frequently burdensome and difficult to use. Available tests lack portability and tend to be shunned in clinical practice by physicians.

OBJECTIVE

To develop a simple, sensitive bedside test for confusion.

DESIGN

Prospective comparison study.

SETTING

An in-patient palliative medicine unit in a large urban hospital.

PATIENTS

Thirty-one consecutive patients admitted to the unit.

INTERVENTION

None.

MEASUREMENTS

A 2-minute screening test, the Bedside Confusion Scale (BCS), which utilizes an observation of level of consciousness at the time of clinical interaction, followed by a timed task of attention, was administered to 31 consecutively admitted patients. The results were compared to a previously validated test, the Confusion Assessment Method (CAM). The BCS and the CAM were scored in standardized fashion and results of the two populations compared. Demographic and clinical characteristics of the patient population, along with the Karnofsky performance scores (KPS) and neurological findings were registered.

RESULTS

Using the CAM as the reference standard, the sensitivity of the BCS was 100%. Worsening KPS and more abnormalities on neurological examination were seen across normal (BCS = 0), borderline (BCS = 1), and abnormal (BCS >/= 2) groups (p > 0.01, trend test).

CONCLUSIONS

In an in-patient palliative medicine population, the BCS correlates with the previously validated CAM and exhibits high sensitivity, an essential quality of a useful screening test.

Cognitive impairment and its influence on pain and symptom assessment in a palliative care unit: development of a Minimal Documentation System

Symptom assessment in the palliative care unit must consider the reduced physical and mental status of the patients. Standardized instruments are often not completed by patients with cognitive impairment. We tried to combine minimal burden for patients and staff with sufficient information content in a Minimal Documentation System (MIDOS) for pain and symptom assessment in palliative care patients. From January to July 1998, 108 patients (123 consecutive admissions) with a mean age of 63 years (range 32-87 years) were admitted to the palliative care unit. Pain was reported as the reason for admission in 70% of the patients, and 71% were treated with opioids. Using a cut-off point of 20/21, 35% of the patients were impaired in the Mini Mental State Examination (MMSE). The number of missing values in the Brief Pain Inventory (BPI) and the quality-of-life questionnaire SF-12 correlated highly with each other and with the MMSE sum score, but not with the summary scores of BPI or SF-12. Only 31 patients completed the SF-12 quality-of-life questionnaire. Age was not correlated to MMSE scores, and neither were opioid doses for 26 patients with slow-release oral morphine or for 20 patients with transdermal fentanyl. Only a minority of patients was able to use the numerical scale for symptoms other than pain, though most patients were able to score symptom intensity on the verbal categorical scale. Pain and symptom assessments were performed by the physician for 17% of the patients at admission, and for 16% of the follow-up controls because self-assessment was not possible. In this study, cognitive impairment prevented symptom assessment with longer and more complicated instruments such as the SF-12 in a large number of the patients admitted to the palliative care unit. Assessment instruments for patients with advanced disease must provide simple categorical scales and the possibility of being administered by interview.

Neuropsychological performance in cancer patients: the role of oral opioids, pain and performance status

The aim of the present study was to evaluate the possible influence of oral opioids, pain and performance status on some aspects of psychomotor function and cognition in cancer patients. One hundred and thirty cancer patients between 40 and 76 years of age were consecutively included in the study. In order to separate the impact of performance status, pain and oral opioids on neuropsychological functioning the patients were allocated in a cross-sectional design to five different groups. Group 1 (N=40), which was considered the control group, was characterized by being in Karnofsky Performance Status (KPS) A ('Able to carry on normal activity and work. No special care is needed'), had no pain and received no oral opioid medication. Group 2 (N=19) was characterized by being in KPS B ('Unable to work. Able to live at home and care for most personal needs. A varying degree of assistance is needed'), had no pain and received no oral opioid medication. Group 3 (N=19) was characterized by being in KPS B, had pain, but received no oral opioid medication. Group 4a (N=31) was characterized by being in KPS B, had pain and received stable doses of oral opioids. Group 4b (N=21) was characterized by being in KPS B, had no pain and received stable doses of opioids. Assessments comprised pain intensity, sedation, opioid doses, time from ingestion of last opioid dose to testing and opioid side effects. The neuropsychological tests used were continuous reaction time (CRT), finger tapping test (FTT) and paced auditory serial addition task (PASAT). Regarding the neuropsychological tests group 1 was compared with each of the other groups and respecting the hierarchy of increasing numbers of stigmatizing factors group 1 was compared with group 2, group 2 with group 3 and so forth. Concerning CRT, group 1 performed statistically significantly faster than groups 2, 4a and 4b. Concerning FTT, group 1 performed statistically significantly faster than groups 3 and 4a. Concerning PASAT, groups 1 and 4b performed statistically significantly better than group 4a. Furthermore, the pain-relieved groups 2 and 4b performed statistically significantly better in PASAT than the pain-suffering groups 3 and 4a. We conclude that in cancer patients the impact of stigmatizing factors (oral opioids, pain and reduced performance status) seems to impair some important aspects of neuropsychological performance, but more specifically our results indicate that (1) the use of long-term oral opioid treatment in cancer patients per se did not affect any of the neuropsychological tests used in the present study, (2) cancer patients being in KPS B had statistically significantly slower CRT than patients being in KPS A and (3) pain itself may deteriorate the performance of PASAT more than oral opioid treatment.

Substituting proxy ratings for patient ratings in cancer clinical trials: an analysis based on a Southwest Oncology Group trial in patients with brain metastases

In studies of the effect of cancer treatment in the advanced disease setting, researchers have attempted to avoid missing data for quality of life (QOL) assessments by either substituting proxy for patient assessments from the outset or by interspersing proxy measures when patients are unable to respond. Although poor agreement between patient and proxy assessments has been amply demonstrated in the literature, interest in using proxy measures persists. Completion of the Spitzer QL-Index by a small sample of patients with brain metastases and family member proxies provided data for evaluating the ability to substitute proxy for patient QOL assessments. These data cannot address treatment efficacy due to the modest sample size. Rather, the analyses serve to alert researchers to the important distinction (in a clinical trial setting) between agreement and the use of the proxy as a surrogate. We present several methods for evaluating the accuracy of proxy measures and for identifying other sources of error and bias that may vary with time or with treatment arm. Lin's concordance correlation coefficient suggests that proxies are generally a poor substitute for capturing a patient's perspective of his/her QOL. A longitudinal analysis suggests that the use of proxy rather than patient responses could lead to different conclusions concerning radiation therapy's effect on QOL.

The effects of morphine on dyspnea and ventilatory function in elderly patients with advanced cancer: a randomized double-blind controlled trial

BACKGROUND

Dyspnea represents a very frequent and distressing symptom in patients with advanced cancer. This study was undertaken to assess the efficacy of morphine on dyspnea and its safety for ventilatory function in elderly advanced cancer patients.

PATIENTS AND METHODS

Nine elderly patients with dyspnea due to lung involvement were randomized to receive either morphine subcutaneously (5 mg in seven opioid-naïve patients and 3.75 mg in two patients on top of their regular oral dose of 7.5 mg q4 h) or placebo on day 1. On day 2, they were crossed over to receive the alternate treatment. Dyspnea was assessed every fifteen minutes using a visual analogue scale (VAS: 0-100 mm) and the ordinal scale developed by Borg (0-10 points). Pain, somnolence and anxiety were assessed using VAS. Respiratory effort, respiratory rate and oxygen saturation were also measured repeatedly.

RESULTS

Mean changes in dyspnea 45 minutes after injection were -25 +/- 10 mm and -1.2 +/- 1.2 points for morphine, versus 0.6 +/- 7.7 mm (P < 0.01) and -0.1 +/- 0.3 points (P = 0.03) for placebo on VAS and Borg scale, respectively. No relevant changes were observed in somnolence, pain, anxiety, respiratory effort and rate, and oxygen saturation.

CONCLUSIONS

Morphine appears effective for cancer dyspnea, and it does not compromise respiratory function at the dose level used.

Communicating with individuals with dementia. The impaired person's perspective

1 To better meet needs of individuals with dementia, caregivers should focus on receiving and interpreting verbal and nonverbal messages conveyed by the afflicted individuals. 2 Prior research has focused on enhancing communication from caregivers to individuals with dementia; however, the content and meaning of communication received from individuals with dementia remains largely unexplored. 3 This study demonstrates that individuals with dementia are able to transmit meaningful communication and this communication can be interpreted by others, making client-centered interventions possible with this population. 4 If care models based on communication interpretation techniques can be built, perhaps the needs of individuals with dementia can be better met, tensions reduced, problematic behaviors decreased, and quality of life enhanced.

Neuropsychological and pharmacokinetic assessment of hospice inpatients receiving morphine

Eighteen inpatients receiving morphine for cancer pain in a palliative care unit were recruited to a study employing a range of neuropsychological tests to assess cognitive function. The tests employed were National Adult Reading Test, Williams Delayed Recall Test, Immediate Memory for Digits, Trailing Making Test, and the Digit Symbol Substitution Test. These data were correlated with biochemical tests of renal and hepatic function, morphine dose, route of administration, plasma morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) concentrations. Despite having no clinical evidence of impairment of cognitive function, the level of current intellectual functioning (Symbol Digit Substitution Test) was on average two standard deviations below normal. Immediate memory appeared to be well preserved, but Delayed Recall and Trailing Making Test scores were significantly above normal. There was no significant correlation between morphine dose, or plasma morphine and M3G and M6G concentrations, and the neuropsychological test results, although a weak correlation was found between plasma morphine concentration and digits forward (r = -0.47, p < 0.05) and Digit Symbol Substitution scores (r = -0.46, p < 0.05). Seven patients had some degree of nausea or vomiting, ascribed as an opioid adverse effect, and had higher serum creatinine concentrations, worse neuropsychological performance, and significantly higher plasma M3G concentrations (p < 0.05). These data provide some evidence to suggest that cognitive functioning in patients with advanced cancer receiving morphine may be significantly impaired despite apparent clinical normality. From these data it is not possible to determine what relative causal contribution the disease and the drug made to these observations, although renal function, plasma morphine, and M3G concentrations may be important. Future research should address a broad range of neuropsychological testing to assist in the modification of practices aimed at enhancement of quality of life, such as opioid substitution or rotation.

Validity of the McGill Quality of Life Questionnaire in the palliative care setting: a multi-centre Canadian study demonstrating the importance of the existential domain

This study was carried out in eight palliative care services in four Canadian cities. A revised version of The McGill Quality of Life Questionnaire (MQOL) is compared to a single-item scale measuring overall quality of life (SIS), and the self-administered version of the Spitzer Quality of Life Index (SA-QLI), to obtain evidence of validity. MQOL total score predicts SIS better than does SA-QLI, although much of the variance remains to be explained. The results of principal components analysis of data using this revised version of MQOL are similar to those from previous MQOL studies with different patient populations. The MQOL subscales, constructed on the basis of principal components analysis, demonstrate acceptable internal consistency reliability. The MQOL measures reflecting physical well-being and existential well-being are important for predicting SIS.

Rapid discontinuation of hypnotics in terminal cancer patients: a prospective study

PURPOSE

To determine the proportion of patients receiving hypnotics upon admission to a palliative care unit, the frequency and intensity of withdrawal symptoms after rapid hypnotic discontinuation, and the effect of discontinuation on insomnia and cognitive failure.

PATIENTS AND METHODS

120 consecutive admitted patients. Rapid hypnotic discontinuation (1-4 days) was attempted. Insomnia (visual analogue 0 = best, 100 = worst for insomnia, restedness during the morning and difficulty falling asleep), cognition (Mini-Mental State Questionnaire), and withdrawal signs were monitored.

RESULTS

Upon admission, 92/120 patients (77%) had been receiving hypnotics for a mean of 11 (standard deviation = 8) weeks. 4/92 patients (4%) refused hypnotic discontinuation. Acute mild withdrawal was observed in 2/88 patients (2%). The intensity of insomnia was not significantly different, while cognition significantly improved after hypnotic discontinuation.

CONCLUSION

A large proportion of terminal cancer patients receives hypnotic drugs chronically. These drugs are probably not useful for the treatment of their insomnia, and rapid discontinuation can be safely achieved in most patients.

Symptom management: loss of concentration

OBJECTIVE

To review the loss of the ability to concentrate in individuals with cancer, the risk factors, and nursing approaches to support and improve attentional functioning.

DATA SOURCES

Published articles and books pertaining to concentration, central nervous system toxicity, attentional fatigue, and cognitive dysfunction.

CONCLUSIONS

Multiple factors related to cancer, its treatment, and the demands of a life-threatening illness increase the risk for loss of concentration and attentional fatigue.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can assess potential loss of concentration by observation and objective and subjective measures. Attention can be conserved by reducing environmental demands and applying attention-restoring strategies.

Changing pattern of agitated impaired mental status in patients with advanced cancer: association with cognitive monitoring, hydration, and opioid rotation

In late 1990, it became standard practice at the palliative care unit of the Edmonton General Hospital to regularly administer the Mini-Mental State Questionnaire (MMSQ) and to undertake opioid rotation and hydration upon detection of cognitive failure. We retrospectively reviewed the charts of 117 and 162 patients admitted in 1988-1989 and 1991-1992, respectively, to assess the impact of these maneuvers on the prevalence of agitated impaired mental status (IMS). All patients underwent regular cognitive assessment in 1991-1992 versus none in 1988-1989. Seventy-three percent of patients received hydration in the second period versus 32% in the first (P < 0.01). The frequency of opioid rotation was also greater in the second period (41% versus 21%, P < 0.001). The incidence of agitated IMS decreased from 26% in 1988-1989 to 10% in 1991-1992 (P < 0.001). This was reflected by a lower mean dose of the major drug used to treat this condition, haloperidol (3.6 +/- 2.4 versus 5.6 +/- 3.8 mg/day, P < 0.01), and less frequent use of other neuroleptics and benzodiazepines (0.12 versus 0.38 prescriptions per patient, P < 0.01) in the second period. Our data suggest that routine cognitive monitoring, opioid rotation, and hydration may reduce the incidence of agitated IMS in terminal cancer patients.

Delirium in the older person with cancer

Delirium occurs in 25-40% of patients with cancer and in as many as 85% of patients with advanced cancer. Delirium, or acute confusion, can be short term and reversible and differs from dementia, which is chronic and irreversible. Accurate assessment is critical for effective treatment and to reduce the increased mortality associated with delirium. Assessment for differentiating depression as well as dementia is needed, because mistaken diagnoses often prolong and exacerbate the symptoms of delirium. Different treatment strategies are appropriate depending on the cause(s) of confusion. In this article, risk factors and assessment tools are reviewed, and interventions for delirium in older persons with cancer are presented. Future areas for research are identified, because there is a paucity of research on delirium in older patients with cancer.

Quality-of-life assessment in a home care program for advanced cancer patients: a study using the Symptom Distress Scale

Quality-of-life assessment in advanced cancer patients should include the study of physical function, psychological status, social interactions, and symptoms. "Symptom distress" relates to the degree of discomfort caused by specific symptoms. A Symptom Distress Scale, which has been developed by McCorkle and Young, is a self-rating instrument that evaluates 13 symptoms. In the present study, the Italian version of the Symptom Distress Scale (SDS) was used to assess the quality of life in advanced cancer patients. The internal consistency of this version was found to be good (Cronbach's coefficient alpha = 0.78). A sample group of 43 patients treated in a home care program was asked to fill out the SDS on a weekly basis. The scores showed a reduction in symptom distress, which was primarily due to improvement in pain, nausea, and bowel pattern. Home care was less effective in improving concentration and, more generally, psychological aspects. This study confirms the validity of a quality-of-life monitoring system that uses a patient self-rating symptom assessment instrument.

Suitable screening tests for cognitive impairment and depression in the terminally ill--a prospective prevalence study

Although confusional states and depression are common accompaniments of advanced cancer, few objective data are available concerning the prevalence of these clinical states or what methods are most suitable for their accurate detection. We decided that a 10-question Abbreviated Mental Test Score (AMTS) and a semistructured application of modified DSMIII-R (Diagnostic and Statistical Manual of Mental Disorder, third edition-revised) criteria for a major depressive illness were the most suitable screening tests for a terminally ill population. Thirty of 87 patients (34%) displayed significant cognitive impairment. The AMTS rating declined with approaching death and also correlated negatively with age. Of 81 patients, 21 (26%) were depressed when screened using DSMIII-R criteria for depression. One-third of patients with impaired AMTS scores also satisfied DSMIII-R criteria for depression. Of cognitively impaired patients, 90% had at least two possible causes for their confused state. We have found that both the AMTS and semistructured interview using DSMIII-R criteria for depression are useful routine screening tests in the terminally ill.

Subclinical cognitive deficits in cancer patients: a preliminary P300 study

A preliminary study of event related potentials (P300) in a group of 16 cancer patients, without cerebral metastases or focal neurological deficits, is being reported. As compared to a group of 28 normal adults, 9 out of 16 cancer patients were found to have prolonged P300 latencies, and 6 made more than two errors in their cognitive performance. These subclinical cognitive impairments in cancer patients may be related to some remote effects of cancer. These patients had not undergone any chemotherapy or radiation therapy prior to P300 studies. Further studies in a larger group of patients with gynecological cancer are being conducted.

Organic hallucinosis in patients receiving high doses of opiates for cancer pain

We report 4 patients who developed organic hallucinosis while receiving opiate analgesics for cancer pain. In all patients, the symptoms rapidly responded to haloperidol and change in the type of opiate. The hallucinations were exclusively visual. Cognitive status, determined by the Mini-mental State Questionnaire (MMSQ), was normal in all patients. Organic hallucinosis occasionally occurs in patients receiving opiates and can be a major source of distress for patients and their families.