Anja Velghe

Prevalence of Symptoms in Older Cancer Patients Receiving Palliative Care: A Systematic Review and Meta-Analysis

CONTEXT Symptom control is an essential part of palliative care and important to achieve optimal quality of life. Studies showed that patients with all types of advanced cancer suffer from diverse and often severe symptoms. Research focusing on older persons is scarce because this group is often excluded from studies. Consequently, it is unclear which symptoms older palliative care patients with cancer experience and what is the prevalence of these symptoms. To date, no systematic review has been performed on the prevalence of symptoms in older cancer patients receiving palliative care. OBJECTIVES The objective of this systematic review was to search and synthesize the prevalence figures of symptoms in older palliative care patients with cancer. METHODS A systematic search through multiple databases and other sources was conducted from 2002 until April 2012. The methodological quality was evaluated. All steps were performed by two independent reviewers. A meta-analysis was performed to pool the prevalence of symptoms. RESULTS Seventeen studies were included in this systematic review. Thirty-two symptoms were identified. The prevalence of these symptoms ranged from 3.5% to 77.8%. The most prevalent symptoms were fatigue, excretory symptoms, urinary incontinence, asthenia, pain, constipation, and anxiety and occurred in at least 50% of patients. CONCLUSION There is a high degree of uncertainty about the reported symptom prevalence because of small sample sizes, high heterogeneity among studies, and the extent of instrument validation. Research based on rigorous methods is needed to allow more conclusive results.

Validation of the G8 screening tool in older patients with aggressive haematological malignancies

BACKGROUND Incidence rates of haematological malignancies increase with age. In these older cancer patients, important information may be missed without a Comprehensive Geriatric Assessment (CGA). A validated screening instrument is needed to identify those patients for whom a CGA would be beneficial. The G8 has recently been validated as a screening tool for older cancer patients in need of a CGA. OBJECTIVES To test the performance of the G8 screening tool in older patients with aggressive haematological malignancies to identify those who would benefit from a CGA. METHODS Cross-sectional study of patients ≥70 years with a recently diagnosed haematological malignancy. G8, CGA (including six questionnaires) and Cumulative Illness Rating Scale for Geriatrics (CIRS-G) were completed in each patient. The CGA was considered abnormal when at least one questionnaire showed an impaired score. RESULTS Fifty patients with median age of 76 years were included; 88% (N = 44) had an abnormal CGA. ROC curve analyses revealed a G8 score ≤14 obtained a sensitivity of 89% (95% CI 75-96) and a specificity of 100% (95% CI 54-100), suggesting an optimal cut-off point. AUC ± SE was 0.949 ± 0.030. Inclusion of comorbidity in the CGA did not change the performance of the G8 (0.943 ± 0.034; P = 0.895). CONCLUSION The G8 can be used as a valid screening tool in older patients with aggressive haematological malignancies to identify those patients who would benefit from a CGA. Comorbidity should be assessed routinely and independently of the G8.

Hand grip strength as a screening tool for frailty in older patients with haematological malignancies

Objectives: Frailty is a geriatric syndrome characterized by decreased physiological reserves and an age-related vulnerability to stressors with higher risk of adverse health outcomes. Comprehensive geriatric assessment (CGA) might detect frailty but is time-consuming, implying the need for initial frailty screening. Most frailty screening tools do not include functional measures. Hand grip strength (HGS) is a reliable surrogate for overall muscle strength and predicts functional decline, morbidity and mortality. No studies are available in cancer patients on HGS as screening tool for frailty. We aimed to assess whether HGS can be used as a screening tool to predict an abnormal CGA and therefore frailty. Methods: Single centre cohort study in 59 patients aged 70 years or more with a haematological malignancy. HGS was measured using a vigorimeter. A patient was considered frail if any of the CGA elements were impaired. Results: Mean HGS before start of therapy in women was 37.0 ± 14.3 kPa and in men 66.1 ± 13.1 kPa. An abnormal CGA was present in 52 subjects (88%). HGS was associated with concurrent abnormal CGA (p = 0.058 in women, p = 0.009 in men). AUC was 0.800 (SE = 0.130) in women and 0.847 (SE = 0.118) in men. Optimal HGS cut-off points for likelihood of abnormal CGA were ≤52 kPa in women and ≤80 kPa in men. Discussion: In older patients with haematological malignancies, impairment in muscle function is present at diagnosis. HGS seems a promising screening tool to identify patients with abnormal CGA.

L’hôpital de jour gériatrique : quels objectifs, quelle organisation, quelle efficience ?Une revue de la littérature

A systematic review of the international literature concerning the organisation of the Geriatric Day Hospital (GDH) was performed. From 1987 till now, few papers were found describing the activity and the effectiveness of the GDH. All the studies comparing specific geriatric approaches to regular medicine demonstrate the efficiency of geriatric care, particularly the geriatric assessment. So, with a degree of evidence 1a, a better outcome is found for patients undergoing a geriatric assessment and intervention, compared to patients having no geriatric assessment at all. However, there is no evidence of benefit for the geriatric day hospital compared to patients treated in a geriatric ward or other location of geriatric care. Moreover, there is no clear consensus on the settings and activities of a geriatric day hospital. Terms as day unit, day hospital, day care, are used interchangeably and are not always covering the same activity. The same remark can be made on the exact composition of the geriatric multidisciplinary team and its role. However nurses and paramedical workers are always mentioned as all performing geriatric assessment. The diagnostic activities on the GDH are seldom described and studied. More information is available on rehabilitation activity, often developed in specific patient populations such as stroke patients, dementia patients, cardiac patients or patients with other chronic diseases. In this selected patient populations positive effects on outcome are shown in the GDH (level of evidence 1a). Another problem is the heterogeneity of the population. For scientific reason the GDH should focus on organising care for specific medical problems. Diseases as dementia, stroke, cardiac insufficiency, could be good models to investigate the efficiency of geriatric assessment and interventions within the setting of a GDH.

First steps towards validation of a symptom scale for palliative elderly

Most of palliative patients want to be taken care of at home by their general practitioner (GP) until the moment they die. GP’s need to continuously educate themselves in order to be able to perform this task. We want to know the learning needs of GP’s and the preferences and barriers they have towards continuing medical education (CME) in palliative care. We also want to know if organizers of CME share these insights and take them into account.Aim: After two large scale studies on medical end-of-life practices in Belgium in 1998 and 2001, we conducted a follow-up study in 2007 to investigate trends in frequency and characteristics of these practices and differences before and after the enactment of the laws on palliative care and on euthanasia in 2002. Methods: We drew a stratified at random sample of 6927 cases from all deaths that occurred between June and November 2007 in Flanders, Belgium and mailed questionnaires about medical end-of-life practices to the certifying physicians. Results: Response rate was 58.4%. In 2007, the rate of intensified pain alleviation in Flanders increased from 18.4% of all deaths in 1998 and 22.0% in 2001 to 26.7% in 2007, and that of non-treatment decisions from 14.6 % in 2001 to 17.4% in 2007. In 1.9% of all deaths physicians reported euthanasia, a rate that was higher than that in 1998 (1.1%) and 2001 (0.3%). The rate of lethal drug use without the patient’s explicit request was lower in 2007 (1.8% of all deaths) than that in 1998 (3.2%), but similar to that in 2001 (1.5%). No shift in characteristics of patients whose death was the result of using these drugs was found. In 14.5% of all deaths in 2007, physicians reported continuous and deep sedation until death, which was substantially more often than in 2001 (8.2%). In 2007, physicians discussed medical end-of-life practices more often with competent patients, relatives and colleagues than in 1998. Conclusion: The enactment of the Belgian laws on palliative care and on euthanasia was followed by an increase in all types of medical end-of-life practices, with the exception of the use of lethal drugs without patient’s explicit request. No shift toward the use of life-ending drugs in vulnerable patient groups was observed. The substantial increase in the frequency of deep sedation demands more in-depth research. Funding: Institute for the Promotion of Innovation by Science and Technology - Flanders.Aim: This study investigates attitudes towards physician-assisted death in minor patients of all physicians involved in the treatment of dying minor patients in Flanders, Belgium, and how these attitudes are related to physicians’ and patients’ characteristics and actual medical end-of-life practices. Method : Physicians signing death certificates of all 250 patients aged 1-17 years who died between June 2007 and November 2008 in Flanders, Belgium, were sent an anonymous questionnaire on their attitudes and end-of-life practices in the death concerned. Results : Response was obtained from 124 physicians for 71% of eligible cases (N=149). Sixty-nine percent of physicians favors an extension of the Belgian law on euthanasia to include minors, 27% thinks this should be done by setting clear age limits. Sixty-one percent thought parental consent is required before taking life-shortening decisions and 52% found the administration of a lethal drug to a non competent minor on parental request was acceptable. Cluster-analysis yielded a cluster acceptant of (68% of physicians) and a cluster (32% of physicians) reluctant towards physician-assisted death in minors. Controlling for physician specialty and patient characteristics, acceptant physicians were more likely to engage in various practices with a (co-)intention of shortening the patient’s life than reluctant physicians. Conclusion : A majority of Flemish physicians involved in the care of dying children seems to accept physician-assisted dying in children under certain circumstances and favors an amendment to the euthanasia law to include minor patients. The approach favored is assessing competency rather than setting an arbitrary age-limit. These stances may encourage policy-makers to develop guidelines for medical end-of-life practices in minors that address specific challenges arising in this patient group, including how children and parents should be involved in the decision-making process.Background: Up to 80% of people with cancer experience involuntary weight loss and difficulty eating. These symptoms of cancer cachexia syndrome can be experienced as distressing by both patients and their carers. The most effective way of managing weight- and eating-related distress is yet to be established. Aims: To report the first systematic review of the effect on symptom experience of psychosocial interventions offered to cancer patient-carer dyads. Methods: Searches were conducted of MEDLINE, EMBASE, PsycINFO and CINAHL databases, for studies of experimental design testing non-pharmacological interventions for patient-carer dyads experiencing cancer related problems. Limits were English language; 1998 to 9/2008; adults. 1534 abstracts were assessed against inclusion/exclusion criteria using a process involving two reviewers. Sixty publications were selected for full-text examination and 30 included in the review. Information relevant to the review question was extracted, quality assessed using the Cochrane Collaboration’s tool for assessing risk of bias, and presented as a narrative synthesis. Results: The 30 reviewed studies investigated patient and carer outcomes from interventions focused on i/ patients, ii/ carers, iii/ models of service delivery, iv/ couples. Generally, when a clearly defined non-pharmacological intervention was tested a beneficial effect was found. Few couple-focused interventions have been tested empirically. In two of the three studies that compared a couple with individual focused intervention, the couple focus was found superior (no effect was found in the third, lower quality, study). Conclusion: Couple based psychosocial interventions may have benefit for cancer patient-carer dyads. Further investigation is warranted of couple focused intervention for patient-carer dyads living with weight-and eating-related distress.number: 2 Abstract type: Plenary The European Pharmacogenetic Opioid Study (EPOS): Influence from Genetic Variability on Opioid Use in 2209 Cancer Pain Patients Klepstad P., Fladvad T., Skorpen F., Bjordal K., Caraceni A., Dale O., Davies A., Kloke M., Lundstrom S., Maltoni M., Radbruch L., Sabatowski R., Sigurdadottir V., Strasser F., Fayers P., Kaasa S., The European Palliative Care Research Collaborative (EPCRC) and The European Association for Palliative Care Research Council (EAPC-RN) Norwegian University of Science and Technology, Medical Faculty, Trondheim, Norway, Norwegian University of Science and Technology, Trondheim, Norway, Oslo University Hospital, Oslo, Norway, National Cancer Institute, Milan, Italy, The Royal Marsden NHS Foundation Trust, London, United Kingdom, Kliniken Essen-Mitte, Essen, Germany, Stockholms Sjukhem Foundation, Department of Palliative Medicine, Stockholm, Sweden, Valerio Grassi Hospice, Forli, Italy, RWTH Aachen University, Aachen, Germany, University Hospital ‘Carl Gustav Carus’ Dresden, Dresden, Germany, Landspitali University Hospital, Reykjavik, Iceland, Oncology and Palliative Care Center, St Gallen, Switzerland, Department of Public Health University of Aberdeen, Aberdeen, United Kingdom Background: Cancer pain patients vary in opioid doses. Preclinical and clinical studies suggest that opioid efficacy is related to genetic variability. However, the studies have small samples, findings are not validated or replicated, and some candidate genes are not studied. This is the first large population study to assess the associations of genetic variability with opioid doses using a confirmatory validation population. Methods: 2209 adult Caucasian cancer patients using a WHO step III opioid were included at 20 centers in 11 European countries. SNPs in genes reported to influence opioid efficacy or with a putative influence on opioid mechanisms were analyzed (SNPlex Genotyping System). Non-genetic factors that predicted opioid dose (pain, time on opioids, age, gender, Karnofsky performance status (KPS) and bone or CNS metastases) were included as covariates. The patients were randomly divided into one development sample, and one validation sample used for confirmatory tests on the SNPs initially detected. Results: Mean age was 62 years, mean KPS was 59 and mean average pain intensity was 3.5. The patients used morphine (n=830, mean 202 mg/24h), oxycodone (n=446, mean 141 mg/24h), fentanyl (n=699, mean 78 mg/h) or other opioids (n=234). In the primary analyzes none of 123 SNPs in the genes OPRM1, OPRD1, OPRK1, ARRB2, GNAZ, HINT, Stat6, ACBB1, COMT, HRH1, ADRA2A, MC1R, TACR1, GCH1, DRD2, DRD3, HTR3A, HTR3B, HTR 2A, HTR3C, HTR3D, HTR3E, HTR1 or CNR1 showed significant associations with opioid dose in both the development and the validation analyzes. Conclusion: Genetic variability in 123 SNPs in 25 candidate genes did not predict the need for opioids in 2209 cancer pain patients. The study demonstrates the importance to validate findings obtained in genetic association studies in order to avoid the report of spurious associations. More comprehensive results, interpretations and future directions for gene symptom interactions EPOS analyses will be presented. Abstract number: 3 Abstract type: Plenarynumber: 3 Abstract type: Plenary Does Increasing Advance Care Planning Reduce Terminal Hospitalizations among Nursing Home Residents? Teno J.M., Gozalo P., Mitchell S., Bynum J., Dosa D., Mor V. Brown University, Community Health, Providence, United States, Harvard Medical School, Boston, United States, Dartmouth College, Hanover, United States Objective: Terminal hospitalizations are costly and often avoidable with appropriate advance care planning (ACP). This study examined changes in ACP as measured by written DNR orders in US Nursing Homes (NH) and whether changes in facility rate of DNR orders is associated with reduction in terminal transfers of NH residents to die in a hospital. Design, setting, and participants: Nursing home panel study of whether increasing rates of DNR orders is associated with reductions in terminal hospitalizations controlling for changes in facility characteristics (staffing, use of NP/PA, case mix of nursing residents, admission volume, racial composition, payer mix). Main outcomes measures: Facility rate of terminal hospitalizations in the last 7 days of life between 1999 and 2007. Results: The average facility rate of terminal hospitalizations was 15.7% with some fluctuation between 1999 (15.4) and 2007 (14.9%). Nursing homes with initially low rates of DNR orders that increased to higher rates had lower terminal hospital admission rates in 2007 (9.9%) than facilities with continuously low DNR rates (20.7%). Even after applying a multivariate fixed effect model with an instrumental variable, the effect of DNR order rate on terminal hospitalization was .049 (95% CI -.044, -.055) indicating that for every 10% increase in DNR orders there was 0.49% decrease in terminal hospitalizations. This rate an be compared to the increase of .55% in the terminal hospitalization rate when a NH became disproportionately dependent on Medicaid funding or the .37% decrease in terminal hospitalization rate associated with adding a nurse practitioner to the clinical staff complement. Conclusion: Nursing homes that improved advance care planning practices as measured by facility rate of DNR orders revealed significantly lower rates of terminal hospitalizations. This research was funded by the US National Institute of Aging, that is part of the US National Institute of Health. Research into the cognitively impaired Abstract number: 5 Abstract type: Invited lecturenumber: 5 Abstract type: Invited lecture Acute Cognitive Failure and Delirium in Palliative Care: The Role of Opioid Analgesics and Other Potentially Reversible Causes Palliative Medicine 2010; 24: S5 S229 ! The Author(s), 2010. Reprints and permissions: sagepub.co.uk/journalsPermissions.nav 10.1177/0269216310366390 Gagnon P., Gaudreau J.-D. Centre Hospitalier Univerisitaire de Québec HDQ, Psycho-oncologie, Québec, QC, Canada, Université Laval, Faculty of Pharmacy, Québec, QC, Canada, Université Laval, Faculty of Pharmacy and Department of Psychiatry, Québec, QC, Canada Aim: Review the associations between opioids, psychoactive medications, and other potentially reversible causes of delirium in palliative care. Methods: Data were obtained from three prospective studies conducted at our center and from a critical review of the literature. Two prospective observational studies were conducted to measure delirium incidence and associated factors. Another multicenter study of delirium prevention in terminal cancer was conducted among seven palliative care units in Canada. The Nursing Delirium Screening Scale, the Confusion Rating Scale and the Confusion Assessment Method were used. Results: The literature review remains equivocal as to which medication is clearly involved in inducing delirium. In two of our studies, opioids were associated with the development of delirium, especially at a dosage over 90 mg. of morphine equivalent per day. Corticosteroids, at a threshold of 15 mg. dexamethasone equivalent per day, and Benzodiazepines, above 2 mg. of lorazepam equivalent per day, were also associated with delirium in one of our study. However, the role of benzodiazepines remains controversial as it was associated with a lower incidence of symptoms of hyperactive delirium in our multicenter study. Other drugs, such as co-analgesics and anticonvulsants, are also often suspected as being delirogenic. Other reversible causes, such as alcohol or benzodiazepine withdrawal, hypercalcemia, infections, and pulmonary embolism must also be considered. These factors are especially critical in patients with past history of delirium who are at a higher risk. Conclusion: Opioids remain the most frequent reversible cause of delirium in palliative care, especially at higher dosage. Benzodiazepines and corticosteroids are also often identified as potential reversible causes of delirium in studies, as are many other drugs and pathologies. All these factors should be carefully considered in delirium prevention, especially in patients at a higher risk. Epidemiology and Policy Abstract number: 8 Abstract type: Oralnumber: 8 Abstract type: Oral Why Are Men at Increased Risk of Depression Compared to Women in Palliative Care? Hayes R.D., Lee W., Rayner L., Price A., Hotopf M. Institute of Psychiatry / King’s College London, General Hospital Psychiatry, London, United Kingdom Aim: To identify potential explanatory factors for the excess depression found among men in palliative care to identify clinically relevant risk markers for depression in men and women. Methods: 300 participants recruited as new patients of a large hospice in South East London were interviewed. Depression was measured using a validated instrument: the Primary Care Evaluation of Mental Disorder (PRIME-MD). Further data were collected during the interview and from case records. Results: The higher prevalence of depression in men was not explained by a higher prevalence of particular types of cancer in men nor due to confounding by age, ethnicity, cancer stage, social support, religious beliefs, loss of dignity and time until death. Interactions between gender and other variables were examined. Needing any help with daily tasks was significantly associated with depression in men only. This association was not affected by marital status, level of social support, ethnicity or age. We also observed a dose response relationship between the degree to which men needed help with basic tasks and the proportion of men who were depressed (P for trend=0.01), but the reverse trend for women (P=0.04) (see table).

Screening for falls on the geriatric ward : are instruments performing better than nurses?

IntroductionThis paper uses data from My Health @ Age (2008-2010), an EU, Northern Periphery funded project. Its aim is to offer the rapidly ageing population in the northern periphery regions of E ...Age and ageing related humour expressed in birthday cards has been suggested to support negative attitudes towards aged people. Little attention has been paid to how retired people themselves exper ...It is well known that reduced ability to perform activities of daily living (ADL) and declining mobility are both related to advanced age. This relation is also valid for low quality-of-life. It is ...The HPA-1 polymorphism of alphaIIbbeta3 arises from a Leu to Pro exchange at residue 33 of the beta3 subunit resulting in HPA-1a (Leu33) or HPA-1b (Pro33). We have documented that patients with coronary artery disease who are carriers of HPA-1b experience their myocardial infarction 5.2 years earlier than HPA-1a/1a patients (JTH 2005; 3: 1522). Based on these observations, it has been postulated that HPA-1b is a prothrombotic variant of alphaIIbbeta3. To explore the molecular nature of this phenotype, we have now generated a model overexpressing fluorescent proteins fused with alphaIIbbeta3 in transfected HEK293 cells. The yellow (YFP) and the cyan fluorescent protein (CFP) were cloned to the C-termini of the beta3 and alphaIIb subunits prior to transfection of HEK293 cells, subsequently expressing the fusion proteins of both HPA-1 isoforms. Using flow cytometry, Western blotting and specific antibodies directed against alphaIIb or beta3, we identified 12 HPA-1a and 11 HPA-1b positive clones expressing equal amounts of fluorescent fusion proteins, i.e. a 140 kD alphaIIb-CFP and a 113 kD beta3-YFP. Functional integrity of both integrin variants and proper membrane insertion were documented by intact activation through G protein-coupled receptors with organic acid, PMA-induced activation of protein kinase C and by specific binding of Alexa647 fibrinogen to alphaIIbbeta3. In the presencence of pertussis toxin or abciximab, activation or ligand binding of alphaIIbbeta3 were completely (> 98%) inhibited in both isoforms. Analysis of Src, a tyrosine kinase associated with alphaIIbbeta3, revealed that activation of the phosphotyrosine motif at residue 418 was higher in adherent HPA-1b than HPA-1a cells (P < 0.01). Upon activation of alphaIIbbeta3, analysis by FRET showed equal kinetics with signal disappearance of 40 5% in both HPA-1 variants. We therefore conclude that the postulated prothrombotic phenotype of HPA-1b (Pro33) is related to increased outside-in signaling rather than to allosteric changes of the C-terminal cytoplasmic tails of alphaIIbbeta3. Disclosure of interest: none declared.