Delirium in advanced cancer leading to distress in patients and family caregivers.

BACKGROUND: Information is limited about the experiences of delirium among patients with advanced cancer and their caregivers, which makes designing interventions to relieve delirium-related distress difficult. To better understand the experience and thus permit the design of effective interventions, we collected and analyzed data from patients with advanced cancer who had recovered from delirium and their family caregivers. METHOD: Phenomenological interviews were conducted separately with 37 caregivers and 34 patients. One investigator reviewed verbatim transcripts of the audio-taped interviews to identify themes, which the research team confirmed. RESULTS: Most patients and all caregivers had vivid memories of the experience; their descriptions were consistent. Most also attributed the confusion to pain medication. Caregivers had concerns about how best to help patients, patients' imminent deaths, and their own well-being. CONCLUSIONS: The main finding that delirium leads to distress for both patients and caregivers indicates the importance of recognizing, treating, and, if possible, preventing delirium in this population. Concerns about pain medications also indicate the need to educate patients and caregivers about symptom management. Caregivers also need emotional support.

The impact of palliative care consultation on symptom assessment, communication needs, and palliative interventions in pediatric patients with cancer.

BACKGROUND: There are few data describing symptom prevalence in children with cancer. The available literature suggests that similar to adults, symptom prevalence and distress are high and that communication regarding end-of-life care needs is limited. OBJECTIVES: We evaluated symptom prevalence, treatment recommendations, and communication about end-of-life care issues for children seen in pediatric palliative care consultation (PCC) at one National Cancer Institute-designated comprehensive cancer center. The goal of our study was to obtain baseline data to target areas in need of intervention. METHODS: A retrospective chart review was conducted of consecutive patients referred to a newly initiated PCC service. Analysis was descriptive. RESULTS: Over the 9-month study period, 15 children were referred. Median age was 13 years (2-24), with 10 males. Eleven children were receiving chemotherapy and/or radiation. Median number of documented symptoms at PCC was 5 per child (2-10). PCC universally resulted in the detection of symptoms not identified by the primary team, for a median of 3 new symptoms per patient (0-9). Documented communication about most end-of-life care issues with parents was uncommon, and rarely involved children. Initial PPCC resulted in recommendations for medication changes in 14 of 15 children, allied health consultation in 8, counseling in 11, patient care conference in 3, and family conference in 6. For the 12 patients who died, median time from PPCC to death was 8 days (1-96). CONCLUSIONS: PCC, although late in the course, resulted in the detection of multiple symptom control and communication needs, and corresponding treatment recommendations.

Switching from methadone to a different opioid: what is the equianalgesic dose ratio?

INTRODUCTION: Methadone (ME) is a highly effective opioid agonist used for difficult pain syndromes. However, in the management of cancer pain with strong opioids, rotation to a different opioid (opioid rotation) may be required because of side effects or poor pain control. Rotation from methadone to another opioid has received limited study and therefore may be difficult because of the absence of a uniformly accepted dose conversion ratio. METHODS: Retrospectively reviewed consecutive medical records of patients undergoing an opioid rotation from methadone to an alternative opioid were evaluated. For inclusion, patients were required to have received methadone for at least 3 days and have reached stable dose of the alternative opioid(s) during the 7 days following. Stable dose was defined as a 30% or less change in opioid dose from one day to the next. RESULTS: Records of 39 patients met inclusion criteria. Excluded from analysis were 5 patients who were restarted on methadone within 7 days, 2 with irregular opioid use resulting in negligible regular opioid doses post-switch, and 3 due to concerns about reliability of multiple routes used for fentanyl. Data from 29 patients, 10 female, mean age 48 +/- 14.4 years, were evaluable. The mean dose ratio for oral methadone to oral morphine equivalent daily dose (MEDD) was 1:4.7 (95% confidence interval [CI], 3.0-6.5; n = 16), and for intravenous (IV) methadone to MEDD was 1:13.5 (95% CI, 6.6-20.5; n = 13), p = 0.06. Methadone dose was significantly correlated to stable MEDD after switching opioids for both methadone IV and oral (Spearman = 0.86, p = 0.0001 and Spearman = 0.72, p = 0.0024), respectively. Mean day of achieving stable dose was day 2.5 +/- 0.2 for IV methadone and day 2.6 +/- 0.3 for oral methadone. CONCLUSION: These dose ratios are new findings that may assist in switching patients more safely to alternative opioids when side effects or pain problems occur when patients are receiving methadone. An important difference in analgesic potency appears to exist between IV and oral ME. Future research with prospective studies is required.

Evaluation of the memorial delirium assessment scale (MDAS) for the screening of delirium by means of simulated cases by palliative care health professionals.

BACKGROUND: Delirium is among the most common neuropsychiatric complications of advanced cancer. The Memorial Delirium Assessment Scale (MDAS) is a widely used and validated screening tool for delirium in cancer patients. OBJECTIVE: The purpose of this study was to assess the use of the MDAS by different palliative care health professionals after receiving formal training and a guiding manual for administration and scoring. MATERIALS AND METHODS: Thirty-one palliative care health professionals received a training session on the MDAS, including description of the tool, validation, and scoring. Participants also received copies of a proposed standardized manual for completion of the MDAS. Two of the investigators presented three simulated cases to the participants, who independently completed a scoring sheet for each case. The data were then analyzed according to the cases and the profession of the operators. RESULTS: Thirty-one scoring sheets were analyzed (11 physicians, 12 nurses, and 8 others). A correct diagnosis was achieved by 30 (96.8%) of the 31 participants in case 1 (nondelirious, true score = 5, median = 5, range = 2-15), 28 of 31 (90.3%) in case 2 (severe mixed delirium, true score = 20, median = 18, range = 10-26), and 31 of 31 in case 3 (mild hypoactive delirium, true score = 14, median = 19, range = 13-25). Overall percentage of error was 31% for items 2, 3, and 4 (cognitive) and 45% for all other items (observational) (p < 0.001). The percentage of error did not differ between physicians and nurses and other palliative care professionals (p > 0.99). CONCLUSIONS: Our preliminary results suggest that adequate training and a guiding manual can enhance the application of MDAS by palliative care health professionals in the teaching settings. Clinical studies to assess the utility of the MDAS as a screening tool are justified to further confirm these findings.

Objective evaluation of physical function in patients with advanced lung cancer: a preliminary report.

PURPOSE: This prospective study was designed in order to compare the most common subjective measurements of physical function in patients with advanced lung cancer with an objective physical functional test (Simmonds Functional Assessment Tool [SFA]). PATIENTS AND METHODS: One hundred patients agreed to participate and complete the study before or after their outpatient medical oncology appointment. Patients underwent assessment using the Karnofsky, the Brief fatigue Inventory, The Functional Assessment of Cancer Therapy-Lung patients (FACT-L) and the Edmonton Symptom Assessment Scale (ESAS). These results were compared to the SFA tool. The SFA consists of six tasks: tying a belt, putting coins in a cup, reaching above head, standing up/sitting down, reaching forward and walking 50 feet. RESULTS: Ninety-nine patients completed the study over 8 months: median Karnofsky performance status was 85 (70 to 100), Edmonton Symptom Assessment Scale (ESAS) score (0 to 10) was generally low (0.5 to 2.8). SFA scores were significantly different in patients compared to a control group. The correlation between the subscales of the SFA and the Karnofsky, the Brief Fatigue Inventory, The FACT-L and the ESAS was generally low to moderate (r values: 0.22 to 0.38). There was generally a moderate correlation between the different subjective scales (r values: 0.3 to 0.62). CONCLUSION: Adherence to the SFA tool was excellent. The low to moderate correlation between the abnormalities found in the objective SFA and the subjective fatigue tests suggest that objective evaluation of the functional capacity provides a potentially useful and independent end-point for clinical trials and therapeutic interventions. These assessment tools should be used complementary to each other to better assess the functional status of patients with advanced lung cancer. Large trials of objective functional assessment are justified.

Bowel and bladder continence, wound healing, and functional outcomes in patients who underwent sacrectomy.

OBJECT: Total or partial sacrectomy is a rare procedure in patients with locally invasive tumors involving the sacrum; it may be associated with functional loss, such as bowel and bladder dysfunction and gait abnormality. In this study the authors examined functional outcome following sacrectomy. METHODS: The authors reviewed the charts of 50 consecutive patients who had undergone sacrectomy between July 1993 and August 2002. There were 23 male and 27 female patients whose mean age was 46 years (range 13-86 years). Twelve patients with rectal cancer underwent a separate analysis. The patients without rectal cancer were divided into two groups: those who had undergone colostomy for bowel diversion (Group 1, six cases), and those who had not (Group 2, 32 cases). In Group 1 patients the median hospital length of stay (LOS) was 48.5 days (the 25th% and 75th percentiles are 26 and 58, respectively), and in Group 2 patients the median LOS was 18.5 days (the 25th and 75th percentiles are 8 and 41, respectively; p = 0.14). In Group 2 (non-rectal cancer without colostomy), LOS was greater in patients in whom a myocutaneous flap was used compared with those in whom no flap was used (36 days compared with 8.5 days, respectively; p = 0.0012); in patients with bowel incontinence the median LOS was significantly longer than that in patients with bowel continence (39 days compared with 8 days, respectively; p = 0.0026). The incidence of bowel incontinence in Group 2 was closely related to the integrity of the S-3 nerve root (p = 0.05). CONCLUSIONS: Awareness of the association between S-3 nerve root resection and bowel and bladder incontinence may help surgeons' decision-making process.

Pain intensity assessment by bedside nurses and palliative care consultants: a retrospective study.

OBJECTIVE: To evaluate the specificity, sensitivity, and accuracy of pain intensity assessments (0-10) conducted by registered nurses (RN) and clinical nurse assistants (CAN) as compared to those conducted by the palliative care consultant (PCC). PATIENTS AND METHODS: We performed a retrospective review of charts of patients who had received palliative care consult between April 2002 and August 2002. Data on patient demographic, date of palliative care consult, and date and intensity of pain assessment were collected. A numerical rating scale from 0 (no pain) to 10 (worst pain) was used to assess pain intensity. The data were included for analysis if the pain intensity assessment was performed during the same shift by all three care providers (RN, CNA, and PCC). RESULTS: Forty-one charts were found to include a complete pain assessment performed by the RN, CNA, and PCC. The agreement of pain intensity between the PCC and both the RN and CNA was poor. For a diagnosis of moderate-to-severe pain, the RN's intensity assessment had a specificity of 90% but a sensitivity of 45%, and the CNA's intensity assessment had a specificity of 100% but a sensitivity of only 30%. The Spearman correlation coefficient between the intensity assessments performed by the PCC and the RN was 0.56 (p=0.00) and between those by the PCC and the CNA 0.22 (p=0.15). CONCLUSION: Lack of agreement between pain intensity assessments performed by the PCC and bedside nurse suggests possible inconsistencies in the way the assessments were performed. Better education on how to perform standard pain intensity assessment is needed.

Nutritional status of cancer patients and its relationship to function in an inpatient rehabilitation setting.

BACKGROUND: Malnutrition is associated with prolonged hospitalization, lower survival rate, and various medical complications. However, little is known about malnutrition and its relationship with the functional status. We undertook this retrospective study to examine whether or not malnutrition affects rehabilitation outcome in patients who had undergone cancer rehabilitation. METHODS: We conducted a review of the charts of 30 consecutive cancer patients who had been admitted to the inpatient rehabilitation unit in a tertiary cancer center, from the beginning of March 2001 to the end of April 2001. RESULTS: The patients' mean rehabilitation stay was 9 days and their mean age was 58 years (range 22-86 years). On rehabilitation admission, 15 of the patients (50%) had a below normal prealbumin (<18 mg/dl) level (95% confidence interval 31-69%), and on discharge 10 of the patients (33%) had a below normal prealbumin level (95% CI 17-54%). The serum prealbumin concentration level correlated with motor functional independence measure scores on admission. After inpatient rehabilitation, statistically significant gains in functional independence measure scores (P<0.0001) were obtained in patients with below normal admission prealbumin, as well as in those whose prealbumin levels were within the normal range; no statistically significant difference was found in functional gain between these two groups. CONCLUSION: Our study showed that a large number of cancer rehabilitation patients had malnutrition. Nevertheless, functional gain was achieved in all patients after rehabilitation, whether or not malnutrition was present. We conclude that malnourished patients should still be considered candidates for rehabilitation.

Symptomatic hypogonadism in male survivors of cancer with chronic exposure to opioids.

BACKGROUND: Profound hypogonadism has been noted in patients receiving intrathecal opioids. The purpose of the current study was to determine whether chronic consumption of oral opioids by male survivors of cancer also would lead to central hypogonadism and whether this hypogonadism was associated with symptoms of sexual dysfunction, fatigue, anxiety, and depression. METHODS: A case-control study was conducted at The University of Texas M. D. Anderson Cancer Center (Houston, TX), in which 20 patients who were chronically consuming opioids were compared with 20 matched controls. Patients completed the Sexual Desire Inventory (SDI), the Hospital Anxiety and Depression Scale (HADS), the Functional Assessment of Chronic Illness Therapy with general and fatigue subscales (FACT-G/FACIT-F), and the Edmonton Symptom Assessment System (ESAS) questionnaires. Serum samples were collected for testosterone, follicle-stimulating hormone (FSH), and luteinizing hormone (LH). RESULTS: Comparing the opioid group with the control group, 18 of the 20 patients (90%; 95% confidence interval [CI], 65-98%) exhibited hypogonadism, compared with 8 of the 20 control patients (40%; 95% CI, 19-64%). The median testosterone level was 145 ng/dL versus 399.5 ng/dL (5.0 nmol/L vs. 13.9 nmol/L; P < 0.0001), the median FSH level was 2.85 milli-International Units (mIU)/mL versus 5.3 mIU/mL (P = 0.08), the median LH level was 1.8 mIU/mL versus 4.2 mIU/mL (P = 0.0014), the median SDI-dyadic score was 18.5 versus 40 (P = 0.01), the median SDI-solitary score was 0 versus 5 (P = 0.007), the HADS (anxiety) score was 8.5 versus 5.5 (P = 0.053), the HADS (depression) score was 7.5 versus 1.5 (P = 0.0002), the FACT-G score was 64 versus 96.3 (P = 0.0001), and the FACIT-F score was 24 versus 46 (P = 0.0003). CONCLUSIONS: Survivors of cancer who chronically consumed opioids experienced symptomatic hypogonadism with significantly higher levels of depression, fatigue, and sexual dysfunction. With the increasing use of opioids among patients with cancer, further research in improving quality-of-life outcomes is warranted.

Hypogonadism and sexual dysfunction in male cancer survivors receiving chronic opioid therapy.

The purpose of this study was to determine the prevalence of central hypogonadism and sexual dysfunction in male cancer survivors exposed to chronic high-dose oral opioid therapy. We studied 20 male patients with cancer-related chronic pain who were disease-free for at least one year. All patients consumed at least 200 mg-equivalent of morphine on a daily basis for at least one year. Participants completed the Sexual Desire Inventory questionnaire and serum levels of testosterone, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) were assessed. Serum testosterone levels were reduced in these patients. The median value was 140 ng/dL (normal 241-827). There was no compensatory increase in FSH and LH. The median FSH level was 3.5 mIU/mL (normal 1.4-18.1). The median LH level was 2.1 mIU/mL (normal 1.5-9.3). The mean dyadic sexual desire score was 23.9+/-15.7 (normal value, 42.8+/-8.9). The mean solitary sexual desire score was 1.3+/-1.9 (normal value, 10.6+/-1.9). Our data suggest that chronic exposure to high-dose oral opioid therapy may result in marked central hypogonadism and sexual dysfunction. Given the increasing use of long-term opioid therapy for chronic pain syndromes, further investigation into these findings is warranted.