Sophie Pautex

Pain in Severe Dementia: Self‐Assessment or Observational Scales?

OBJECTIVES: To assess the performance of self‐assessment scales in severely demented hospitalized patients and to compare it with observational data.

Are there differences in the prevalence of palliative care-related problems in people living with advanced cancer and eight non-cancer conditions?: a systematic review

CONTEXT If access to effective palliative care is to extend beyond cancer patients, an understanding of the comparative prevalence of palliative care problems among cancer and non-cancer patients is necessary. OBJECTIVES This systematic review aimed to describe and compare the prevalence of seventeen palliative care-related problems across the four palliative care domains among adults with advanced cancer, acquired immune deficiency syndrome, chronic heart failure, end-stage renal disease (ESRD), chronic obstructive pulmonary disease, multiple sclerosis, motor neuron disease, Parkinsons disease, and dementia. METHODS Three databases were searched using three groups of keywords. The results of the extraction of the prevalence figures were summarized. RESULTS The electronic searches yielded 4697 hits after the removal of 1784 duplicates. Of these hits, 143 met the review criteria. The greatest number of studies were found for advanced cancer (n=57) and ESRD patients (n=47), and 75 of the 143 studies used validated scales. Few data were available for people living with multiple sclerosis (n=2) and motor neuron disease (n=3). The problems with a prevalence of 50% or more found across most of the nine studied diagnostic groups were: pain, fatigue, anorexia, dyspnea, and worry. CONCLUSION There are commonalities in the prevalence of problems across cancer and non-cancer patients, highlighting the need for palliative care to be provided irrespective of diagnosis. The methodological heterogeneity across the studies and the lack of non-cancer studies need to be addressed in future research.

Symptom assessment in elderly cancer patients receiving palliative care

BACKGROUND The purpose of this study is to examine the concordance of symptom assessment among the multiple raters in French-speaking elderly patients with an advanced cancer benefiting from palliative care. PATIENTS AND METHODS This study was conducted in a geriatric hospital with palliative care specificity. During 6 months, patient, nurse and physician completed the Edmonton symptom assessment system on two consecutive days. RESULTS 42 patients with an advanced oncological disease were included. Mean age was 72+/-9.04 (range 52-88) and 23 were females. Mean mini mental status examination (MMSE) was 27.5+/-1.6. First assessment was completed at a median of day 8 after admission. Nurses, physicians and patients assessments were reproducible between days 1 and 2 (P>0.05). Pearson correlation coefficient significantly associated nurse assessment with patient assessment for pain, depression, anxiety, drowsiness, appetite and wellbeing (P<0.05). Physician assessment was associated with patient assessment for pain, depression, drowsiness, appetite, wellbeing and shortness of breath (P<0.05). However, regression analysis looking for patient score from both physicians and nurses scores weakly correlated all these factors (R2<0.6), except for appetite (R2 for day 1/day 2: 0.79/0.64). CONCLUSIONS French-speaking elderly cancer patients without cognitive failure and in stable general condition are consistent in their symptom assessment, and they have to be considered as the gold standard. Nevertheless, interdisciplinary assessment is probably a valid surrogate to self-assessment by the patient but only when the latter is truly impossible.

Sleep disordered breathing in the elderly.

Sleep disordered breathing (SDB), i.e., obstructive, central or mixed sleep apneas, has been recognized as a common occurrence in the elderly. Aging is per se associated with a decrease in the quality of sleep; SDB may further disrupt the sleep architecture in older subjects. The prevalence of obstructive sleep apnea (OSA) increases with aging; available studies report prevalence rates of 11–62%. Furthermore, OSA has been associated with increased mortality in older adults. Central apneas and periodic breathing occur with increased frequency either in subjects with neurological disorders such as infarction, tumor, sequelae of infection, diffuse encephalopathies, or in chronic heart failure. Patients with cerebrovascular disease (stroke, or transient ischemic attacks) have a markedly high prevalence of SDB, mainly OSA. In these patients, SDB is associated with a poorer functional prognosis at 3 and 12 months after the acute event, and a higher mortality. The clinical impact of SDB on cognitive function appears to be modest in patients without dementia, although there is a moderate increase in daytime sleepiness. In Alzheimer’s disease (AD) however, SDB occurs more frequently than in non-demented older subjects, and its severity is correlated with the degree of cognitive impairment. The hypothesis of a causal relationship between AD and SDB remains a subject of controversy. The possibility of SDB should be considered in the elderly in the differential diagnosis of “reversible dementias”, increased daytime sleepiness, or unexplained right-sided heart failure.

Psychometric properties of the Doloplus-2 observational pain assessment scale and comparison to self-assessment in hospitalized elderly.

ObjectivesSelf-report is the “gold standard” for pain assessment, however, observational pain scales, such as Doloplus-2 must be used for patients who cannot communicate. In this follow-up study, we report the psychometric properties of the observational Doloplus-2 scale using the visual analog scale (VAS) pain score as a gold standard and evaluate its performance. MethodProspective clinical study of 180 hospitalized older patients who demonstrated good comprehension and reliable use of the VAS: 131 participants with dementia and 49 without. All participants assessed their chronic pain using the VAS. Doloplus-2 was independently completed by the nursing team. ResultsMean age of patients (133 women, 47 men) was 83.7±6.5. Median mini-mental state examination of patients with diagnosis of dementia was 18.0±7.7. Nearly half of the patients (49%) reported that they experienced pain in response to a direct question. The administration of Doloplus-2 was possible in all 180 patients. Doloplus-2 correlated moderately with self-assessment (Spearman coefficient: 0.46). In a multiple regression model, Doloplus-2 predicted 41% of the variability in pain intensity measured by VAS. The somatic dimension alone explained 36% of the variance, the psychosocial bloc 5% with no better contribution of the psychomotor bloc. To shorten Doloplus-2, we constructed a version with only the 5 items that were significantly associated with the VAS score in the multiple regression models. DiscussionThe observational Doloplus-2 scale correlates moderately with self-assessment pain score and has adequate internal consistency. Our data also suggest that Doloplus-2 could be substantially shortened as the brief version performed similarly to the complete Doloplus-2.

Role of advance directives in palliative care units: a prospective study:

Advance directives (ADs) might be useful in achieving improved communication and satisfaction with decision making at the end-of-life. Our aims were to better characterise patients with advanced oncological disease who decided to complete ADs and to measure the effect of ADs completion on the satisfaction level with end-of-life care from both patients and their relatives. A prospective study was conducted in three palliative care units. Patients with advanced cancer were included if they met the following criteria: an estimated life expectancy of <6 months, fluency in French, Mini Mental State Examination >20 and not yet completed ADs. All the patients received information about ADs and decided whether to complete ADs or not. The level of satisfaction with involvement in the decision process concerning end-of-life care was assessed by means of a written questionnaire. In all, 53 of 228 patients were included, and 12 decided to complete ADs. Patients who completed ADs had statistically less depression one week after inclusion (P = 0.030), had a lower anxiety score on the second week and had a lower depression score on the third week. There was a trend towards a higher satisfaction level with the involvement of the patients in end-of-life care for those completing ADs (P = 0.878). In conclusion, each patient with an advanced progressive disease should be informed about ADs and be encouraged to complete the ADs with the aim to ease many fears as well as to improve communication.

Effect of Topical Morphine (Mouthwash) on Oral Pain Due to Chemotherapy- and/or Radiotherapy-Induced Mucositis: A Randomized Double-Blinded Study

PURPOSE The objective of the study was to determine if mouthwashes with a morphine-containing solution decrease oral pain associated with radiotherapy- and/or chemotherapy-induced oral mucositis (OM). METHODS Randomized double-blinded crossover study to evaluate the effect of topical oral application of 2 per thousand morphine solution in patients suffering from radiotherapy- and/or chemotherapy-induced OM. Participants assigned to either the morphine solution or a placebo mouthwash received one of the solutions days 1-3 and were then switched over to the other treatment for days 4-6. RESULTS Nine patients were randomized in both groups. All patients (mean age, 55.1 +/- 3.0) except one had head and neck cancers. Mean intensity of pain associated with mucosal injury (World Health Organization [WHO] mucositis > or =2) was on a 10-point visual analogue scale: 6.0 +/- 2.7). The analysis of variance (ANOVA) model that included morphine or placebo, day and time of mouthwash, and mouthwash effect shows that pain alleviation 1 hour after mouthwash was significantly influenced by the gesture of the mouthwash (p < 0.001 with either morphine or placebo) and almost by the efficiency of morphine (p = 0.020). Duration of pain relief was 123.7 (standard deviation [SD] +/- 98.2) minutes for morphine. Most other reported symptoms were present at the baseline and were probably associated with the main disease and not secondary to the morphine mouthwash. CONCLUSIONS Our results suggest a possible analgesic effect of topical morphine in line with previous studies. However, more efforts must be made for the adjustment of systemic analgesics and the development of new alternatives to treat locally OM-associated pain.

A common definition of geriatric palliative medicine.

To the Editor: Twenty percent of the European population is aged 60 and older (144 million), and 15% is aged 80 and older (108 million). By 2050, the proportion of the population aged 80 and older will reach 26% (187 million). In this scenario, the prevalence of disability, frailty, and comorbidity will grow quickly and will increasingly affect provision of health care by increasing costs for inpatient care and medications, the need for formal caregiving, and the prevalence of acute complications and adverse outcomes. Because physicians will be expected to provide optimal care for older persons, including those who are terminally ill, they will need to have some specific skills. Treating these patients’ complex social, psychological, and medical needs requires state-of-the-art geriatrics and palliative care knowledge and is best accomplished using a multidisciplinary, team-based approach. Palliative care for these patients involves not only treating the primary disease process and managing the patients’ multiple chronic medical conditions and geriatric syndromes, but also assessing and treating the physical and psychological symptom distress and establishing appropriate goals of care and treatment plans in the setting of unpredictable prognoses. Good palliative and geriatric medicine are closely related, although the aim of geriatric medicine is more often centered on the improvement, the rehabilitation, or the stabilization of a patient’s situation. Palliative medicine principles do not completely fit older patients because of the need for a comprehensive geriatric assessment, the recognition of the unique features of symptom (e.g., pain in people with dementia), and the focus on ageand diseasespecific drug prescribing, different from good practice in mainstream palliative care. Previous studies suggest that pain and other symptoms are underassessed and undertreated and are associated with a number of negative outcomes. In March 2007, a group of European geriatricians involved in geriatric palliative medicine (GPM) met for the first time to discuss GPM in Europe. This group became an officially recognized group of the European Union Geriatric Medical Society (EUGMS) and met for the fifth time in May 2009. The main goal of the group is to establish a European network of physicians to improve GPM. During two of their meetings, the group met to discuss a definition of GPM. The aim of developing this definition was to encourage geriatricians to integrate the main principles of palliative care (symptom management, talk about dying, advance directives, recognition of the terminal phase of the care process so that patients and family can come to rituals and good-byes) into daily geriatric practice. To construct the definition, the group relied on the World Health Organization (WHO) definition of palliative care, the WHO booklet ‘‘Better Palliative Care for Older People,’’ and the definitions of geriatric medicine from different geriatric organizations. The complete interest group and the EUGMS committee have reviewed the definition. GPM is the medical care and management of older patients with health-related problems and progressive, advanced disease for which the prognosis is limited and the focus of care is quality of life. Therefore GPM

Palliative care education in Swiss undergraduate medical curricula: a case of too little, too early

Palliative medicine education is an important strategy in ensuring that the needs of terminally ill patients are met. A review was conducted in 2007 of the undergraduate curricula of all five of Switzerland’s medical schools to identify their palliative care-related content and characteristics. The average number of mandatory hours of palliative care education is 10.2 h (median 8 h; range 0–27 h), significantly short of the 40 h recommended by the European Palliative Care Association’s Education Expert Group. The median time allocated to designated palliative care blocks is 3 h (range 0–8 h). Most of the education occurs before the clinical years, and there are no mandatory clinical rotations. Three schools offer optional clinical rotations but these are poorly attended (<10% of students). Although a number of domains are covered, ethics-related content predominates; 21 of a total of 51 obligatory hours (41%). Communication related to palliative care is largely limited to ‘breaking bad news’. In two of the schools, the teaching is done primarily by palliative care physicians and nurses (70% or more of the teaching). In the others, it is done mostly by educators in other clinical specialties and ethics (approximately 90% of the teaching). These findings show significant deficiencies.

Difficulties of residents in training in end-of-life care. A qualitative study

Residents in training are first-line physicians in hospital settings and they are in the process of developing knowledge and mastering clinical skills. They have to confront complex tasks calling upon their personal background, professional identity and relationships with the patients. We conducted a qualitative study investigating the difficulties they perceive in end-of-life care. In all, 24 consecutive residents were presented with a written query asking them to indicate the difficulties they identify in the management of patients hospitalised for end-of-life care. Their responses were submitted to content analysis. Physicians’ mean age was 28 ± 2.2 years, 37% were women, average postgraduate training duration was 2.5 ± 1.3 years. Content analysis elicited eight categories of difficulties: abitily to provide adequate explanations, understand the patients’ needs, have sufficient theoretical knowledge, avoid flight, avoid false reassurance, manage provision of time, face one’s limits as a physician and be able to help despite everything. Residents’ responses showed that they identify the complexity of care in terminally-ill patients early in their training. Their responses pointed to the ‘right distance’ in-between getting involved and preserving oneself as a dimension of major importance.