ABSTRACT
OBJECTIVES: This study aimed to explore the prevalence of potentially inappropriate medications (PIMs) in a cohort of older adults with advanced cancer referred to palliative care. Secondary objectives were to describe the categories of identified PIMs and assess risk factors associated with their presence in this population. METHODS: This retrospective, observational study evaluated patients with advanced cancer admitted to a tertiary university hospital in Madrid, Spain and referred to palliative care between 1 January 2020 and 30 June 2020. Demographic, clinical, and pharmacotherapeutic data were obtained from the electronic medical records and regional databases. PIMs were assessed using the Screening Tool of Older Persons Prescriptions in Frail adults (STOPPFrail) criteria, V1. RESULTS: Among 123 patients (median age 80 years (IQR 73.5-87), 64.2% male), 74% presented at least one PIM according to the STOPPFrail criteria. The most common categories of inappropriate medications were lipid-lowering therapies, proton pump inhibitors, calcium supplements, and oral antidiabetics. The number of chronic comedications was significantly associated with PIM presence. CONCLUSIONS: Our study found a high prevalence of PIM among a cohort of older adults with advanced cancer and short life expectancy. This underlines the need for a comprehensive medication review to optimise pharmacotherapy in this population.
ABSTRACT
BACKGROUND: The infection by SARS-CoV-2 (COVID-19) has been especially serious in older patients. The aim of this study is to describe baseline and clinical characteristics, hospital referrals, 60-day mortality, factors associated with hospital referrals and mortality in older patients living in nursing homes (NH) with suspected COVID-19. METHODS: A retrospective observational study was performed during March and April 2020 of institutionalized patients assessed by a liaison geriatric hospital-based team. Were collected all older patients living in 31 nursing homes of a public hospital catchment area assessed by a liaison geriatric team due to the suspicion of COVID-19 during the first wave, when the hospital system was collapsed. Sociodemographic variables, comprehensive geriatric assessment, clinical characteristics, treatment received including care setting, and 60-days mortality were recorded from electronic medical records. A logistic regression analysis was performed to analyze the factors associated with mortality. RESULTS: 419 patients were included in the study (median age 89 years old, 71.6 % women, 63.7 % with moderate-severe dependence, and 43.8 % with advanced dementia). 31.1 % were referred to the emergency department in the first assessment, with a higher rate of hospital referral in those with better functional and mental status. COVID-19 atypical symptoms like functional decline, delirium, or eating disorders were frequent. 36.9% had died in the 60 days following the first call. According to multivariate logistic regression age (p 0.010), Barthel index <60 (p 0.002), presence of tachypnea (p 0.021), fever (p 0.006) and the use of ceftriaxone (p 0.004) were associated with mortality. No mortality differences were found between those referred to the hospital or cared at the nursing home. CONCLUSIONS AND IMPLICATIONS: 31% of the nursing home patients assessed by a liaison geriatric hospital-based team for COVID-19 were referred to the hospital, being more frequently referred those with a better functional and cognitive situation. The 60-days mortality rate due to COVID-19 was 36.8% and was associated with older age, functional dependence, the presence of tachypnea and fever, and the use of ceftriaxone. Geriatric comprehensive assessment and coordination between NH and the hospital geriatric department teams were crucial.
Subject(s)
COVID-19 , Aged , Aged, 80 and over , Female , Geriatric Assessment , Humans , Male , Nursing Homes , Referral and Consultation , SARS-CoV-2ABSTRACT
El cáncer de pene es una afección poco común que en el 4-5 % de los casos presenta recidiva local tras penectomía. Las úlceras tumorales son lesiones que aparecen en el contexto de tumores de alto grado de malignidad y/o fase avanzada de la enfermedad oncológica. Se caracterizan por tener un difícil manejo, ya que en la mayoría de los pacientes presentan dolor, mal olor, exudado abundante, sangrado y alto riesgo de infección. El objetivo de este artículo es describir el caso clínico de un varón con cáncer de pene avanzado que presentaba una lesión ulcerada tumoral con curas complejas, en el que se desestimaron medidas activas de tratamiento, optando por un enfoque paliativo. El abordaje del paciente oncológico con una úlcera tumoral supone un gran desafío para el equipo asistencial. El cuidado de las úlceras neoplásicas exige profesionales altamente cualificados en la materia debido a la complejidad y variabilidad de las curas así como la presencia de síntomas derivados. Gracias a la colaboración de todos los miembros del equipo, familia y paciente se controlaron los síntomas derivados de la úlcera tumoral, contribuyendo a la mejora en la calidad de vida en la etapa final de la enfermedad. (AU)
Cancer of the penis is a rare condition that in 4-5 % of cases presents with local recurrence after penectomy. Tumor ulcers are lesions that appear in the context of tumors with a high degree of malignancy and/or advanced phase of oncological disease. They are characterized by difficult management since in most patients they are associated with pain, bad odor, abundant exudate, bleeding, and high risk of infection. The objective of this article is to describe the clinical case of a man with advanced penile cancer who presented with an ulcerated tumor with complex management; active treatment measures were rejected, and a palliative approach was then selected. Approaching a cancer patient with a tumor ulcer is a great challenge for the healthcare team. Caring for neoplastic ulcers requires highly qualified professionals in the field due to the complexity and variability of the cures as well as the presence of derived symptoms. Thanks to the collaboration of all team members, the family, and the patient the symptoms derived from the tumor ulcer were controlled, contributing to improving quality of life in the final stage of the disease. (AU)
Subject(s)
Humans , Male , Aged, 80 and over , Penile Neoplasms , Ulcer/prevention & control , Palliative Care , Ulcer/drug therapy , Quality of Life , Nursing CareSubject(s)
Palliative Care , Penile Neoplasms , Aged, 80 and over , Humans , Male , Penile Neoplasms/therapyABSTRACT
La polimedicación y la utilización inapropiada de medicamentos en los pacientes mayores con enfermedad en fase terminal constituyen un grave problema sanitario, tanto por el incremento de efectos adversos prevenibles como por los costes sanitarios asociados a los mismos. Existen diferentes publicaciones que recomiendan la suspensión de determinados medicamentos cuando la esperanza de vida es limitada y el objetivo terapéutico no es la prevención ni la curación, sino el control de los síntomas. Recientemente se han publicado una lista de criterios explícitos (STOPP-Frail) que pueden ayudar al médico prescriptor a la toma de decisiones en la deprescripción de determinados fármacos en pacientes de edad avanzada y con enfermedad en fase terminal. En este artículo se presenta la versión traducida al castellano de los STOPP-Frail que pasará a llamarse STOPP-Pal para evitar confusiones con el concepto de fragilidad más utilizado
Multiple medication and inappropriate drug prescription are prevalent and challenging problems in older patients in end-of-life situations, and increases both preventable adverse events and health care costs. Recent literature recommends de-prescribing some drugs in patients with short life expectancy, when the aim of drug treatments is not prevention or cure, but symptom control. Recently, a list of explicit criteria (STOPP-Frail) intended to guide prescribing physicians in decision making on the use of drugs in older patients with terminal conditions. This article presents a Spanish version of such criteria, which have been named STOPP-Pal to avoid confusion with the current concept of frailty
Subject(s)
Humans , Aged , Inappropriate Prescribing , Palliative Care/standards , Potentially Inappropriate Medication List , Frailty , TranslationsABSTRACT
Multiple medication and inappropriate drug prescription are prevalent and challenging problems in older patients in end-of-life situations, and increases both preventable adverse events and health care costs. Recent literature recommends de-prescribing some drugs in patients with short life expectancy, when the aim of drug treatments is not prevention or cure, but symptom control. Recently, a list of explicit criteria (STOPP-Frail) intended to guide prescribing physicians in decision making on the use of drugs in older patients with terminal conditions. This article presents a Spanish version of such criteria, which have been named STOPP-Pal to avoid confusion with the current concept of frailty.
Subject(s)
Inappropriate Prescribing , Palliative Care/standards , Potentially Inappropriate Medication List , Aged , Frailty , Humans , TranslationsABSTRACT
La identificación de pacientes en situación de enfermedad crónica avanzada y complejidad, y la fragmentación de cuidados hacia el final de la vida aconsejan trazar un plan terapéutico a largo plazo, congruente con los valores y preferencias de los pacientes, a la vez que con un pronóstico vital y funcional razonables. Disponer de una herramienta de ajuste en la adecuación de la intensidad diagnóstica y terapéutica sería de ayuda en la continuidad de cuidados y podría ser facilitadora de la toma de decisiones en las transiciones y en los cambios dinámicos que presentan los pacientes a medida que se acercan al final del proceso vital
The identification of patients with advanced and complex chronic diseases, and the fragmentation of care towards the end of life, requires the drawing up a long-term therapeutic plan. This should take into account the values and preferences of the patients, as well as the vital and functional prognosis. Having an adjustment tool for determining the diagnostic and therapeutic effort is helpful in the continuity of care, as well as in decision-making in the transitions and dynamic changes of patients as they approach the end of life process
Subject(s)
Humans , Male , Female , Aged , Hospice Care/methods , Multiple Chronic Conditions/epidemiology , Advance Care Planning/organization & administration , Land Management and Planning , Diagnosis of Health Situation , Decision Support Techniques , Hospitalization/statistics & numerical data , Organ Transplantation/statistics & numerical data , Geriatric Assessment/methodsABSTRACT
The identification of patients with advanced and complex chronic diseases, and the fragmentation of care towards the end of life, requires the drawing up a long-term therapeutic plan. This should take into account the values and preferences of the patients, as well as the vital and functional prognosis. Having an adjustment tool for determining the diagnostic and therapeutic effort is helpful in the continuity of care, as well as in decision-making in the transitions and dynamic changes of patients as they approach the end of life process.
Subject(s)
Advance Care Planning/standards , Terminal Care/standards , Consensus Development Conferences as Topic , Humans , Life Support Care/standards , Spain , Urban HealthABSTRACT
Objetivo. Evaluar los cambios producidos en la práctica de la sedación paliativa en la agonía en pacientes mayores hospitalizados antes y después de la implantación de un protocolo hospitalario de sedación paliativa. Material y métodos. Estudio retrospectivo descriptivo tipo antes-después de pacientes mayores de 65 años que fueron tratados con midazolam y fallecieron durante la hospitalización en un hospital terciario en 2 trimestres, uno previo y otro posterior a la implantación del protocolo. Se excluyó a aquellos en quienes la indicación de midazolam no fue la sedación paliativa y los ingresados en cuidados intensivos. Se registraron las características de los pacientes y su servicio de ingreso, el consentimiento, la limitación del esfuerzo terapéutico y el proceso de sedación (síntoma refractario, dosis, evaluación y otros medicamentos). Se analizaron las asociaciones empleando la prueba de la chi al cuadrado y la t de Student. Resultados. Se incluyó a 143 pacientes sin diferencias relevantes entre ambos grupos en cuanto a características demográficas ni sintomatología. Se registró la indicación de no reanimación cardiopulmonar en aproximadamente el 70% de cada grupo y el consentimiento para la sedación en el 91% antes y el 84% después del protocolo. Las dosis de inducción y de mantenimiento de midazolam se adecuaban a las recomendaciones en el 1,31% de los pacientes antes y el 10,4% después del protocolo (p = 0,02) y las dosis de rescate en el 1,31 y el 11,9%, respectivamente (p = 0,01). La dosis de midazolam utilizada en pacientes en quienes se usó el protocolo fue significativamente menor que cuando no se empleó (9,86 mg vs. 18,67 mg, p < 0,001). La escala de Ramsay fue utilizada en el 8 y el 12% y el Equipo de Soporte Hospitalario de Cuidados Paliativos intervino en el 36 y el 16% de los casos, respectivamente (p = 0,008). Conclusiones. El uso de midazolam en la sedación paliativa en la agonía mejoró ligeramente tras la instauración de un protocolo hospitalario de sedación paliativa. El porcentaje de sedaciones adecuadas y el proceso general apenas mejoró con el protocolo. Es necesario continuar el proceso de formación y reevaluar la efectividad de estas medidas en el futuro (AU)
Objective. To measure changes in the practice of palliative sedation during agony in hospitalised elderly patients before and after the implementation of a palliative sedation protocol. Material and methods. A retrospective before-after study was performed in hospitalised patients over 65 years old who received midazolam during hospital admission and died in the hospital in two 3-month periods, before and after the implementation of the protocol. Non-sedative uses of midazolam and patients in intensive care were excluded. Patient and admission characteristics, the consent process, withdrawal of life-sustaining treatments, and the sedation process (refractory symptom treated, drug doses, assessment and use of other drugs) were recorded. Association was analysed using the Chi2 and Student t tests. Results. A total of 143 patients were included, with no significant differences between groups in demographic characteristics or symptoms. Do not resuscitate (DNR) orders were recorded in approximately 70% of the subjects of each group, and informed consent for sedation was recorded in 91% before vs. 84% after the protocol. Induction and maintenance doses of midazolam followed protocol recommendations in 1.3% before vs 10.4% after the protocol was implemented (P=.02) and adequate rescue doses were used in 1.3% vs 11.9% respectively (P=.01). Midazolam doses were significantly lower (9.86 mg vs 18.67 mg, P<.001) when the protocol was used than when it was not used. Ramsay sedation score was used in 8% vs. 12% and the Palliative Care Team was involved in 35.5% and 16.4% of the cases (P=.008) before and after the protocol, respectively. Conclusions. Use of midazolam slightly improved after the implementation of a hospital protocol on palliative sedation. The percentage of adequate sedations and the general process of sedation were mostly unchanged by the protocol. More education and further assessment is needed to gauge the effect of these measures in the future (AU)
Subject(s)
Humans , Male , Female , Aged , Aged, 80 and over , Deep Sedation/methods , Deep Sedation/trends , Clinical Protocols , Palliative Care/methods , Midazolam/therapeutic use , Health Services for the Aged/organization & administration , Health Services for the Aged/standards , Retrospective Studies , Hospice Care/methods , Hospice CareABSTRACT
OBJECTIVE: To measure changes in the practice of palliative sedation during agony in hospitalised elderly patients before and after the implementation of a palliative sedation protocol. MATERIAL AND METHODS: A retrospective before-after study was performed in hospitalised patients over 65 years old who received midazolam during hospital admission and died in the hospital in two 3-month periods, before and after the implementation of the protocol. Non-sedative uses of midazolam and patients in intensive care were excluded. Patient and admission characteristics, the consent process, withdrawal of life-sustaining treatments, and the sedation process (refractory symptom treated, drug doses, assessment and use of other drugs) were recorded. Association was analysed using the Chi(2) and Student t tests. RESULTS: A total of 143 patients were included, with no significant differences between groups in demographic characteristics or symptoms. Do not resuscitate (DNR) orders were recorded in approximately 70% of the subjects of each group, and informed consent for sedation was recorded in 91% before vs. 84% after the protocol. Induction and maintenance doses of midazolam followed protocol recommendations in 1.3% before vs 10.4% after the protocol was implemented (P=.02) and adequate rescue doses were used in 1.3% vs 11.9% respectively (P=.01). Midazolam doses were significantly lower (9.86mg vs 18.67mg, P<.001) when the protocol was used than when it was not used. Ramsay sedation score was used in 8% vs. 12% and the Palliative Care Team was involved in 35.5% and 16.4% of the cases (P=.008) before and after the protocol, respectively. CONCLUSIONS: Use of midazolam slightly improved after the implementation of a hospital protocol on palliative sedation. The percentage of adequate sedations and the general process of sedation were mostly unchanged by the protocol. More education and further assessment is needed to gauge the effect of these measures in the future.
Subject(s)
Hypnotics and Sedatives/therapeutic use , Midazolam/therapeutic use , Palliative Care , Aged , Critical Care , Female , Humans , Male , Retrospective StudiesABSTRACT
INTRODUCCIÓN: La capacidad para pronosticar la supervivencia de pacientes con enfermedad terminal de la «Palliative Performance Scale» (PPS) es ampliamente reconocida. Esta escala se ha utilizado también en la planificación de cuidados y en la gestión de recursos asistenciales paliativos. OBJETIVO: Estimar la supervivencia en el centro de destino de los pacientes oncológicos que se trasladan a unidades de cuidados paliativos de media estancia (UCPME) desde un hospital de agudos según la puntuación en la escala PPS en el momento del traslado. Evaluar la asociación entre dicha puntuación y la supervivencia. MÉTODO: Estudio retrospectivo sobre pacientes oncológicos atendidos por el equipo de soporte hospitalario de cuidados paliativos del Hospital Ramón y Cajal de Madrid que fueron trasladados a una UCPME, en el período 01/07/08-31/12/09. Se estimaron las funciones de supervivencia mediante el método de Kaplan-Meier para el grupo de pacientes con puntuación en la escala PPS ≤ 20% y PPS > 20% y se compararon mediante la prueba de log-rank. Para estimar las probabilidades de supervivencia a distintos tiempos en función del valor de PPS al alta se ajustó un modelo de Cox. RESULTADOS: Fueron incluidos 77 pacientes (edad media 77 [9,6] años; 42,9% mujeres). El tumor más frecuente fue el de pulmón (14,3%). Los valores medios y desviación estándar de PPS en el momento del traslado fueron 40,9 (12,6%). En el grupo PPS ≤ 20%, la mediana de supervivencia fue de 4 IC 95% (0-9) días, y en el de PPS > 20% de 33 IC 95% (19-47) días (p = 0,006). Se obtuvo un 4% más de riesgo de mortalidad por unidad de descenso de PPS (HR = 1,04, IC 95% 1,02-1,06). CONCLUSIONES: La supervivencia de los pacientes en los centros de destino fue significativamente diferente según la puntuación de la escala PPS en el momento del traslado. A partir de los resultados se elaboró una tabla de probabilidades de fallecimiento en función de la puntuación PPS en el momento del traslado y los días transcurridos tras este
INTRODUCTION: The value of "Palliative Performance Scale" (PPS) to estimate survival of patients with terminal illness is widely recognized. This scale has also been used in care planning and resource management in palliative care. AIMS: To estimate survival in the host institution for cancer patients who move to intermediatestay palliative care units (UCPME) from an acute care hospital according to the PPS value at time of transfer. To evaluate the association between this score and survival. Method: Retrospective study of cancer patients treated by a palliative care support team and transferred to an UCPME in the period 01/07/2008 to 31/12/2009. We estimated survival by Kaplan-Meier function for the group of patients with PPS score < 20% and PPS> 20% and compared by log-rank test. A Cox model was adjusted to estimate the probability of survival at different times depending on the value of PPS at the time of discharge. RESULTS: Seventy seven patients were included (mean age 77 (9.6) years; 42.9% women). Lung cancer was the most frequent neoplasm (14.3%). The mean PPS at the time of transfer was 40.9% (12.6). Median survival was 4 days (95% CI; 0-9) in the PPS ≤ 20% group, and 33 days (95% CI; 19-47) in the PPS > 20% group (P = .006). There was a 4% increased risk of mortality per unit decrease in PPS (HR = 1.04, 95% CI 1.02-1.06). CONCLUSIONS: Patients survival in the UCPME was significantly different depending on the PPS at the time of discharge. A death probabilities table according to the PPS at the time of transfer and the days afterwards was created from the results
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Humans , Palliative Care/statistics & numerical data , Severity of Illness Index , Survival Analysis , Decision Support Systems, Clinical , Prognosis , Risk FactorsABSTRACT
No disponible
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Humans , Palliative Care/trends , Organizational Innovation , Innovation and Development Policy , Biomedical EnhancementABSTRACT
No disponible
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Humans , Palliative Care/trends , Chronic Disease/epidemiology , /trends , PrognosisABSTRACT
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