The last three days of life: a comparison of pain management in the young old and the oldest old hospitalised patients using the Resident Assessment Instrument for Palliative Care

Palliative use of midazolam in acute geriatric units: a multicenter ambispective study

INTRODUCTION

End-of-life management in acute geriatric units (AGUs) is frequent but complex. Midazolam is the drug of choice for the management of refractory symptoms (particularly in the context of sedation) at the end of life. The objective of the present ambispective analysis was to investigate the frequency and modalities of midazolam use for palliative care in AGUs in France.

METHODS

We conducted a prospective study in four AGUs in France, in order to identify patients having received comfort care only and having been treated with midazolam. We then retrospectively documented the modalities of midazolam use, the indications, and the level of effectiveness.

RESULTS

Of the 210 patients identified as having received comfort care only in the AGU, 68 (32.4% (95%CI, 26.1 to 39.2%)) had received midazolam. The indication for midazolam corresponded to sedation in 67.6% of cases. The modalities of midazolam use at the end -of -life were rarely personalized, with low dose levels (less than 0.5 mg/h), mainly subcutaneous administration, and little anticipatory prescribing or dose level titration. The modalities did not appear to vary with the indication (anxiolysis vs. sedation).

DISCUSSION

The present study is one of the first to have described the frequency and characteristics of palliative midazolam use in the AGU. Our results showed that the end-of-life use of midazolam is rarely personalized, not explicitly documented, and often not compliant with the current guidelines on palliative sedation practices.

CLINICAL TRIALS REGISTRATION NUMBER

NCT02949635. Registration Date: 2016-09-07.

The Impact of Aging on Symptom Prevalence and Management in Terminally ill Patients With Cancer

CONTEXT

With global population aging, the number of older patients with cancer is increasing. However, few data are available on palliative care for these patients.

OBJECTIVES

To evaluate differences in symptom prevalence and the need for medical interventions among patients of different ages in a palliative care unit.

METHODS

In this retrospective analysis, a consecutive sample of 1032 terminally ill patients with cancer were categorized into the following age ranges: <70, 70-79, 80-89, and ≥90 years. We evaluated symptom prevalence, the need for palliative medicines, opioid dose on the day before death, and the need for palliative sedation. Trend tests were used to examine whether the prevalence of findings increased or decreased with age.

RESULTS

As age increased, significant decreasing trends were observed in the prevalence of pain, dyspnea, fatigue, constipation, nausea, drowsiness, difficulty sleeping, anxiety, and dysuria but not in appetite loss, edema, sputum production, or delirium. As age increased, significant decreasing trends were also observed in the need for opioids, benzodiazepines, antiemetics, and anticholinergics. The median opioid doses in the <70, 70-79, 80-89, and ≥90 years age groups were 118, 72, 48, and 48 mg oral morphine equivalents/day, respectively (P < 0.0001). The need for palliative sedation showed a significant decreasing trend as age increased (P < 0.0001).

CONCLUSION

We found age to be inversely related to symptom prevalence and medical interventions among terminally ill patients with cancer, contributing to the understanding of the experience of older patients with cancer.

Pharmacological treatment in the dying geriatric patient: describing use and dosage of opioids in the acute geriatric wards and palliative care units of three hospitals

PURPOSE

The quality of dying of the older person could be optimized. One of the cornerstones to achieve better symptom control in the dying patient can be the use of opioids. However, little benchmark data concerning the use and dosage of opioids in the terminal phase in older persons are available.

METHODS

In this multi-centric retrospective study, we included patients 75 years and older who died on the acute geriatric unit (AGU) and the palliative care unit (PCU) in three hospitals (during a 2-year period). Sudden deaths were excluded. Demographic and clinical variables, and data concerning use and dosage of opioids in the last 72 h before death were collected.

RESULTS

Data from 556 patients were collected (38.5% from PCU, 61.5% from AGU). Older patients on the PCU were younger and suffered more frequently from end-stage malignancies. Most older patients on PCU (98.2%) received opioids with a mean dosage of 88.2 mg in 72 h. On the AGU, 75.5% of patients was treated with opioids with a mean dosage of 27.7 mg in 72 h. After adjusting for the variables age, gender and underlying pathology, use of opioids (OR 11.9; 95% CI 2.7-51.7; p = 0.022) and dosage (B 28.8; 95% CI 4.1-53.4; p = 0.001) still differed between the PCU and the AGU. Dosage of opioids was also associated with suffering from cancer or not.

CONCLUSIONS

This descriptive benchmark study shows that opioids are given to 75.5% of dying older patients on the AGU at a mean dose of 27.7 mg over the last 72 h versus 98.2% and 88.2 mg, respectively, on the PCU. Further prospective studies including detailed information on symptomatology and more in-depth clinical information on trajectory of dying and cause of death are necessary.

Dying With Unrelieved Pain-Prescription of Opioids Is Not Enough

CONTEXT

Fear of pain resonates with most people, in particular, in relation to dying. Despite this, there are still people dying with unrelieved pain.

OBJECTIVES

We quantified the risk, and investigated risk factors, for dying with unrelieved pain in a nationwide observational cohort study.

METHODS

Using data from Swedish Register of Palliative Care, we analyzed 161,762 expected deaths during 2011-2015. The investigated risk factors included cause of death, place of death, absence of an end-of-life (EoL) conversation, and lack of contact with pain management expertise. Modified Poisson regression models were fitted to estimate risk ratios (RRs) and 95% confidence intervals (CIs) for dying with unrelieved pain.

RESULTS

Unrelieved pain during the final week of life was reported for 25% of the patients with pain, despite prescription of opioids PRN in 97% of cases. Unrelieved pain was common both among patients dying of cancer and of nonmalignant chronic diseases. Statistically significant risk factors for unrelieved pain included hospital death (RR = 1.84, 95% CI 1.79-1.88) compared with dying in specialist palliative care, absence of an EoL conversation (RR = 1.42, 95% CI 1.38-1.45), and dying of cancer in the bones (RR = 1.13, 95% CI 1.08-1.18) or lung (RR = 1.10, 95% CI 1.06-1.13) compared with nonmalignant causes.

CONCLUSION

Despite almost complete prescription of opioids PRN for patients with pain, patients die with unrelieved pain. Health care providers, hospitals in particular, need to focus more on pain in dying patients. An EoL conversation is one achievable intervention.

Instruments for the functional assessment of elderly persons in palliative care: an integrative review

Abstract Objective: to identify validated instruments that can be used for the functional assessment of elderly persons in Palliative Care. Method: an integrative review focused on identifying instruments for the functional assessment of elderly persons in palliative care was carried out by searching publications in periodicals indexed in seven electronic databases. Descriptors, keywords and Boolean operators were used for a cross-database search in November 2017. A total of 357 abstracts were identified, from which 53 articles were selected for reading, of which 21 met the inclusion criteria. Results: this strategy allowed the identification of eight scales and one test for the functional assessment of elderly persons in palliative care. Conclusion: eight scales and a functional test which also provide guidelines for improving the quality of life of elderly people in palliative care were identified, demonstrating that it is practically impossible to disassociate physical functional performance from social and psychological aspects.

Behavioral Pain Intervention for Hospice and Palliative Care Patients: An Integrative Review

Despite the advances in pain management, achieving optimal pain control in hospice and palliative care is challenging. Patient/caregiver's lack of pain management knowledge, poor pain reporting, and poor adherence to pain management regimens are all associated with inadequate pain control. The purpose of this integrated review is to examine behavioral interventions designed for patients and caregivers to improve pain control in hospice and palliative care settings. Ten studies were identified through a database search. Seven of the 10 studies found significant improvement in at least 1 pain marker. Of the 7 studies that looked at changes in pain knowledge, 5 had significant improvements in at least 1 knowledge subscale. The 2 studies that looked at adherence to pain management found significant improvements. One limitation of the reviewed studies was that the delivery of them would not be efficient across all health-care settings, and, as a consequence, more technologically sophisticated delivery methods are needed. Therefore, while it is clear from the review that effective pain management interventions have been developed for hospice and palliative care patients, it is also clear that future research needs to focus on providing these same interventions through a more technologically sophisticated delivery method.

Age differences in the last week of life in advanced cancer patients followed at home

A retrospective analysis of a consecutive sample of patients admitted to a home care program was performed. Data were recorded in the last week through a backward analysis from the day before death as follows: 1 week before dying (-1W), 3 days before death (-3D), and the day before dying (-1D). Data to be collected included the Edmonton Symptom Assessment System (ESAS), background pain intensity, the prevalence of breakthrough pain, the use of opioids in the last week, and the need for palliative sedation, with indications, duration, and drugs used. Patients were distributed according to the following age ranges: adults (<65 years, A) and aged (≥65 years, O). Of the latter group, three subgroups were assessed: old (65-74 years, O1), very old (75-84 years, O2), and the oldest (≥85 years, O3). Four hundred eleven patients were assessed. At -W1, no statistical differences in intensity of ESAS items ≥4 among the age subgroups were found. For ESAS values at -1W, -3D, and -1D, no statistical differences were found unless for anorexia at -1W (p = 0.000) (more likely), depression at -3D (p = 0.000) (less likely), depression (p = 0.000), and dyspnea (p = 0.01) (less likely) at -1D in the oldest group (O3). No differences in pain intensity among the groups were found (p = 0.54). Opioid doses increased in time and were significantly lower in older patients (p = 0.000). The subcutaneous route was more frequently used at -3D and -1D in older patients. No differences in opioid switching were found among the groups (p = 0.56). Adult patients required more often palliative sedation (p = 0.003). Older patients have problems relatively similar to adult patients in the last week of life, unless for some symptoms. Older patients had also a lower opioid consumption, a more frequent use of the subcutaneous route, and a lower need for palliative sedation.