Marcos Montagnini

Rehabilitation of the Hospice and Palliative Care Patient

Disability is a common problem among hospice and palliative care patients. It leads to depression, poor quality of life, increased caregiver needs, health care resource utilization, and need for institutionalization. There is a growing body of evidence that rehabilitation interventions improve functional status, quality of life, and symptoms such as pain and anxiety in this population. Having adequate knowledge about rehabilitation is essential for the provision of comprehensive end-of-life care. The goals of this article are to review the role and benefits of rehabilitation in hospice and palliative care; to discuss the elements of patient assessment for rehabilitation including the use of functional assessment tools; and to review the roles of physical, occupational, and speech therapy in hospice and palliative care patients.

The Utilization of Physical Therapy in a Palliative Care Unit

BACKGROUND In the supportive oncology and palliative care settings, rehabilitation interventions are often overlooked and underutilized, despite high levels of functional disability in these patients. As a result, little is known about the utilization or effectiveness of rehabilitation interventions in palliative care populations. OBJECTIVE To assess the utilization of physical therapy (PT) in a hospital-based palliative care unit, to characterize functional disabilities in patients who received PT, and to identify factors related to functional improvement following a course of PT. METHODS Retrospective chart review of 100 patients (mean age 70 years, 97% male) discharged from the Milwaukee Veterans Hospital Palliative Care unit over 15 months. Activities of daily living (ADL) performance scores were recorded on admission, at 2 weeks, and at completion of the PT program and correlated with demographic and disease-related variables. RESULTS Thirty-seven patients received a formal PT assessment, and 18 patients underwent PT. The most common functional disabilities in patients who received PT were deconditioning, pain, imbalance, and focal weakness. Ten patients demonstrated improvement in ADL function at 2 weeks. Six patients completed the course of PT. Albumin was significantly correlated with functional improvement. When controlling for albumin, patients with diagnosis of dementia were more likely to show improvement in functional status than patients without a dementia diagnosis. CONCLUSION PT assessment and utilization were uncommon in this group. When utilized, PT benefited 56% of patients. Factors related to functional improvement following a PT course were a higher albumin level and a diagnosis of dementia. Prospective trials of PT in palliative care patients are needed to better define response rate and predictors of response.

Position statement on interdisciplinary team training in geriatrics: An essential component of quality health care for older adults

Interdisciplinary team training (IDT) is an important component of ensuring quality geriatric care delivery, which can be complex and time intensive, requiring coordination of many medical, psychosocial, and therapeutic interventions and professionals. The Partnership for Health in Aging (PHA), a loose coalition of more than 30 organizations representing healthcare professionals who care for older adults supported by the American Geriatrics Society, identified IDT training in geriatrics as a priority area in addressing the geriatrics workforce shortage described in the 2008 Institute of Medicine report, Retooling for An Aging America: Building the Health Care Workforce. A PHA Workgroup on Interdisciplinary Team Training in Geriatrics was convened to review the literature focused on geriatrics IDT training and to develop a position statement that would inform and influence groups involved in the development and expansion of academic and continuing education programs in IDT training, including professional associations, credentialing and licensing bodies, accreditation organizations, and university administrators. There are significant challenges to expanding the development and implementation of geriatrics IDT training for health professionals, and such training will be successful only with substantial and sustained advocacy from the above professional groups.

Pain and palliative medicine.

Severe pain is highly prevalent, with rates of 40% to 70% in patients with advanced cancer, liver disease, heart failure, human immunodeficiency virus, and renal failure. Wide variations in pain assessment and reporting methods and the measurement of multiple symptoms should be addressed in future studies. Regarding psychological approaches, determining whether hypnotherapy or other individual psychotherapeutic interventions reduce pain and/or psychological distress in a palliative care population is difficult. Interest is increasing in the concept of demoralization syndromes and the role of posttraumatic stress disorder in modulating responses to pain at the end of life. We review evidence from multiple studies that the use of rehabilitative therapy improves functional status and pain control among patients with advanced cancer, and we raise the possibility that rehabilitation therapy will be helpful in patients with other advanced diseases. We summarize ongoing clinical trials of electronic order sets, clinical care pathways, and care management pathways to improve pain management in palliative care. Wagners Chronic Illness Model provides a way of analyzing how healthcare systems can be changed to provide adequate and continuing pain management in palliative care. Much work remains to ensure that pain is recognized, treated, and monitored effectively.

MUSCLE ENDURANCE, CANCER-RELATED FATIGUE, AND RADIOTHERAPY IN PROSTATE CANCER SURVIVORS

Introduction: In this study we investigated muscle and cancer‐related fatigue (CRF) in prostate cancer survivors (CS) undergoing radiotherapy (RT). Methods: In 13 CS and 12 controls, CRF was assessed by the Piper Fatigue Scale (PFS), Epworth Sleepiness Scale—Depression subscale (CES‐D), physical activity (accelerometer), and hemoglobin levels (Hb). Muscle measures included strength, activation, contractile properties, and endurance during intermittent dorsiflexion. Testing occurred before and after 6 weeks of RT in CS. Results: After RT, the PFS score increased from initial levels in CS only without changes in sleepiness, depression, or physical activity. Hb decreased in CS only [mean (SD): pre, 15 (1.1); post, 14.5 (1.1) g/dl; P = 0.04]. Endurance decreased in CS [mean (SD): pre, 519 (340) s; post, 388 (203) s; P = 0.04] and increased in controls [mean (SD: pre, 616 (387) s; post, 753 (553) s; P = 0.03]. Only endurance was associated with PFS in CS (r = −0.55, P = 0.05). Discussion: Muscle endurance is impaired after RT and may contribute to CRF in CS. Muscle Nerve, 2011

Assessing health status differences between Veterans Affairs home-based primary care and state Medicaid Waiver Program clients.

OBJECTIVES Comprehensive health care for older adults is complex, involving multiple comorbidities and functional impairments of varying degrees and numbers. In response to this complexity and associated barriers to care, home-based care models have become prevalent. The home-based primary care (HBPC) model, based at a Michigan Department of Veterans Affairs Medical Center, and the Michigan Waiver Program (MWP) that includes home-based care are 2 of these. Although both models are formatted to address barriers to effective and efficient health care, there are differences in disease prevalence and functional performance between groups. The objective of this study was to explore the differences between the 2 groups, to shed some light on potential trends that could suggest areas for resource allocation by service providers. DESIGN Using a retrospective analysis of data collected using the interRAI-home care, we examined a cross-sectional representation of clients enrolled in HBPC and MWP in 2008. PARTICIPANTS The HBPC sample had 89 participants. The MWP database contained 9324 participants from across the State of Michigan and were weighted to be comparable to the HBPC population in sex and age, and to simulate the HBPC sample size. RESULTS Veterans were more independent in basic activities of daily living performance, but there was no difference in the rate of reported falls between the 2 groups. Veterans had more pain and a higher prevalence of coronary artery disease (z = 7.0; P < .001), Chronic obstructive pulmonary disease (z = 3.9; P < .001), and cancer (z = 8.5; P < .001). There was no statistically significant difference between the 2 groups in terms of the prevalence of geriatric syndromes. Scores on subscales of the interRAI-home care indicated a lower risk of serious health decline and adverse outcomes for MWP compared with HBPC clients (1.4 ± 1.1 vs 0.9 ± 0.1; z = 2.5; P = .012). Veterans receiving home-based care through the Veterans Affairs Medical Center were more burdened by chronic disease and had higher degrees of loneliness than their MWP counterparts- factors, which may increase their likelihood of hospitalizations. MWP participants had more cases of cerebrovascular accident (z = 2.1; P = .039), as well as a higher rate of diagnosed dementias (z = 2.7; P = .006). Though not different, stress among caregivers in both groups, and depression in clients of both groups were substantial. Overall, sleep, pain, coronary artery disease, chronic obstructive pulmonary disease, and cancer are significant issues for Veteran clients, and clients treated through MWP home-care in Michigan have higher than national average rates of dementias, diabetes, hypertension, and coronary artery disease. CONCLUSION With expanded home care models of service on the horizon, comparisons such as the one presented here could identify more efficient and effective service, with potential for improved client health outcomes.

Management of Severe Neuropathic Cancer Pain: An Illustrative Case and Review

Neuropathic cancer pain is common, very disabling and difficult to treat. It can be related to tumor invasion of neural structures and neuronal damage by surgery, chemotherapy and radiation therapy. Adjuvant analgesics are often used with opioids to control neuropathic pain in cancer patients. Methadone, a synthetic opioid with multiple mechanisms of action, is gaining increasing importance as an effective agent in the treatment of cancer related neuropathic pain. This case illustrates the challenges of managing severe pain in a patient with head and neck cancer while undergoing anti-tumor treatment. A review of the adjuvant analgesics and opioids, particularly methadone, in the management of neuropathic pain is also included.

Logic Modeling: A Tool for Improving Educational Programs

PURPOSE Palliative care education programs must be systematically designed and accurately evaluated in order to account for their impact on learners and learning communities. Logic modeling is a framework for designing educational programs and monitoring their influence. METHODS We applied a logic modeling process to a Palliative Care Educational Program (PCEP), embedded within a required month-long geriatrics rotation for third-year general internal medicine residents at the VA Medical Center in Milwaukee, Wisconsin. Each of four main categories of a logic model and the process for applying the steps to the PCEP are described. The four logic model categories that form the basis of the analysis are: (1) inputs, the raw resources consumed by the program (human resources, money, and space); (2) outputs, program activities and the number and types of actual participants; (3) outcomes, what the program will achieve in the short term (knowledge, attitudes and behavior change); and (4) impact, the results that are of ultimate interest to program stakeholders, such as placement in medically underserved areas, improved health or more efficient care. RESULTS The application of logic modeling to the PCEP exposed achievements (e.g., resident knowledge gains) and gaps (no evidence of long-term impact) in each of the model categories and has resulted in the design teams reassessment of each program component. DISCUSSION Palliative care educators can improve their programs by using the logic model categories and process steps to explicitly define and assess the links between key program components.

Management of Intractable Hiccups An Illustrative Case and Review

Often thought of as a benign and self-limited condition, hiccups can become persistent or intractable, and thus be associated with substantial morbidity and distress. In such cases, an underlying etiology is often present, and may be overlooked. Debilitating hiccups can present a major challenge to optimal symptom management. Various causes of protracted hiccups have been identified including metabolic abnormalities, central nervous system pathology, malignancy, medications, and disorders attributed to cardiac, pulmonary and gastrointestinal etiologies. We present a case of intractable hiccups in a patient with an advanced hematological malignancy and review specific therapies for the management of persistent hiccups.

Integrating Massage Therapy Within the Palliative Care of Veterans With Advanced Illnesses An Outcome Study

Aims: To describe the integration of massage therapy into a palliative care service and to examine the relationship between massage and symptoms in patients with advanced illnesses. Methods: Between April 1, 2009, and July 31, 2010, 153 patients received massage at the VA Ann Arbor Health Care System. Data on pain, anxiety, dyspnea, relaxation, and inner peace were collected pre and post massage. Diagnoses, chronic pain, and social support were also abstracted. Analysis of covariance was used to examine changes over time. Results: All short-term changes in symptoms showed improvement and all were statistically significant. Pain intensity decreased by 1.65 (0-10 scale, P < .001), anxiety decreased by 1.52 (0-10 scale, P < .001), patients’ sense of relaxation increased by 2.92 (0-10 scale, P < .001), and inner peace improved by 1.80 (0-10 scale, P < .001). Conclusion: Massage is a useful tool for improving symptom management and reducing suffering in palliative care patients.