Clinical factors influencing death rattle breathing in palliative care cancer patients : Non-interventional study.

BACKGROUND AND AIM: In the last days of life the clinical symptom of death rattle breathing is manifested in many awake or semiconscious patients in palliative care. Scientific studies on relevant influencing factors on the characteristics of the clinical symptom of death rattle breathing in patients in palliative care are rare. MATERIAL AND METHODS: The design of the study is based on a non-interventional prospective study with questionnaire evaluation and was implemented at the palliative care unit at the Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care at the Clinical Center Klagenfurt, Austria. The questionnaire was developed by the authors of this study. RESULTS: The study had a predefined duration of 10 months (from February to November 2012) and during this period a total of 273 patients were admitted to the palliative care unit of the Clinical Center in Klagenfurt. Of these 105 (38.5 %) died and could therefore be included in the evaluation but 3 patients in palliative care (2.9 %) did not fulfil the inclusion criteria of a malignant disease. In total 102 patients, 43 females (42.2 %) and 59 males (57.9 %) were evaluated. The average age was 69 years with a range of 41-92 years. The largest proportion of the random sample (62.8 %) was in the patient age group from 61 to 80 years old and death rattle breathing could be observed in 26 patients (25.3 %) of the total sample. In a specific subgroup analysis regarding the intensity of the symptom, many of the affected patients suffered noisy breathing or severe death rattle breathing. In these cases it was primarily women in the group of patients with death rattle breathing. Gender was found to be a statistically relevant influencing factor (p = 0.034) on the intensity of the symptom. CONCLUSION: The great majority of the variables studied showed no influence on the development of the symptom of death rattle breathing; however, more intensive forms were manifested in female patients. The small study population could be a limitation of the present study although the prospective design allows valid conclusions to be drawn. In the future studies should be implemented in order to improve treatment of patients suffering from death rattle breathing.

[Efficacy of glycopyrronium bromide and scopolamine hydrobromide in patients with death rattle: a randomized controlled study]. / Die Wirkung von Glycopyrroniumbromid im Vergleich mit Scopolamin-Hydrobromicum beim terminalen Rasseln: Eine randomisierte, doppelblinde Pilotstudie.

BACKGROUND: Death rattle is an extremely distressing symptom for the dying patient and for his environment. The aim of this study was to assess the efficacy of glycopyrronium bromide as compared with scopolamine hydrobromide in alleviating death rattle in terminal cancer patients with cognitive impairment. METHODS: In a randomized, controlled study design patients were allocated in two groups. Group A received scopolamine hydrobromide in a dose of 0.5 mg intravenously every 6 hours for a period of 12 hours, group B received glycopyrronium bromide 0.4 mg every 6 hours for a period of 12 hours. In addition, standardized sedatives were administered as required and the analgesic therapy continued either orally or, if necessary, subcutaneously or intravenously in equipotent doses. Every 2 hours death rattle was assessed and rated on a scale of 1 to 5 (1 = audible breathing noises, 5 = very severe rattling noises). In addition, restlessness and expressions of pain were assessed and rated on a scale of 1 to 3 (1 = mild, 2 = moderate, 3 = severe). RESULTS: 13 patients were included in the study, 7 patients were allocated to group A and 6 patients to group B. There were no significant differences in demographic data, age, weight and diagnosis distribution between the two groups. Group B demonstrated a significant reduction of death rattle in the first 12 hours (p = 0.029) in comparison to group A. There were no significant differences concerning the side effects (restlessness, expressions of pain) in both groups. CONCLUSION: Glycopyrronium bromide given in a dose of 0,4 mg every six hours demonstrated a significant reduction of death rattle compared to scopolamine hydrobromide. Concerning side effects (restlessness, expressions of pain) there was no difference between both substances.

[Primary central nervous system lymphoma in elderly patients--a therapeutical challenge]. / Primäre ZNS-Lymphome und ältere Patienten--eine therapeutische Herausforderung.

The importance of whole brain radiotherapy in elderly patients with primary central nervous system lymphoma (PCNSL) and other therapeutic options are discussed on the basis of a case study.

Pharmacokinetic and pharmacodynamic properties of tramadol IR and SR in elderly patients: a prospective, age-group-controlled study.

BACKGROUND: Tramadol is widely prescribed, even to the eldest patients. Although age-related differences in pharmacologic responsiveness are to be expected, the pharmacodynamic and pharmacokinetic (PK) properties of tramadol have not been systematically compared between patients of various ages. OBJECTIVE: The aim of this study was to explore the effectiveness, PK properties, and safety profile of 2 galenic tramadol formulations in 3 similarly sized age groups with malignant and nonmalignant pain of moderate to severe intensity. METHODS: This prospective, age-group-controlled study was conducted at the ambulatory pain clinic of the Landeskrankenhaus Kärnten, Klagenfurt, Austria. Male and female adults with malignant and nonmalignant pain of moderate to severe intensity were eligible. Patients were stratified into similarly sized age groups, as follows: >or=75, 65-<75, and <65 years. Patients first received the immediate-release galenic formulation of tramadol (tramadol IR) until steady state was achieved, followed by the sustained-release formulation (tramadol SR) until steady state. Serum concentrations of tramadol and its active metabolite (O-desmethyl-tramadol [M1]) were measured using gas chromatography to estimate the age-related PK handling of the analgesic drug. Three validated scales were used to measure pain intensity during the study: a 100-mm visual analog scale (VAS), an 11-point numeric analog scale (NAS), and a 4-point verbal rating scale (VRS). Tolerability was assessed by evaluating daily answers about the potential occurrence of adverse events (and respective details such as type and severity) from baseline until the end of the observation period. RESULTS: A total of 100 patients were enrolled (58 women, 42 men; mean [SD] age, 65.2 [15.0] years; >or=75, 30 patients; 65-<75, 31 patients; and <65 years, 39 patients). Predominant causes of pain were neoplasms (27.4% of causes) and injury and other external causes (20.8%), and diseases of the musculoskeletal and connective-tissues systems (19.8%). Fifty-five patients completed the study and provided all data as planned. Mean (SEM) steady-state tramadol IR doses were 250 (20.2), 277 (39.8), and 325 (33.1) mg/d in patients aged >or=75, 65-<75, and 65 years, respectively (P = NS); tramadol SR, 278 (27.5), 306 (39.7), and 340 (35.1) mg/d (P = NS). Serum concentrations of tramadol and M1 were statistically similar across all 3 age groups. Overall, mean pain intensity scores, as measured using the VAS and NAS, were decreased from baseline (62.4 [2.0] mm and 6.22 [0.22] points, respectively) to steady state with tramadol IR (23.6 [2.9] mm and 2.65 [0.30] points) and tramadol SR (16.9 [2.5] mm and 1.91 [0.26] points) (all, P < 0.001). Pain intensity before and improvements during both treatment phases were similar across all 3 age groups. RESULTS: for pain intensity on the VRS also did not find age-related differences. The predominant adverse effects were nausea (27.0% of patients), dizziness and giddiness (18.0%), and malaise and fatigue (15.0%); no significant differences in adverse events were found between age groups. CONCLUSIONS: The fate of tramadol and its active metabolite, and their clinical effects, have been examined here for the first time in a prospective cohort study, which compared patients aged <65 years, 65-<75 years, and >or=75 years. In contrast to expectations, it was concluded that tramadol IR and tramadol SR were both generally well tolerated and effective in the treatment of moderate to severe pain in any of the 3 age groups in these patients. Although the eldest group of patients consumed, on average, 20% less tramadol (P = NS) than the youngest group, the PK properties of both drugs were not changed when given to elderly patients.