Monitoring the depth of palliative sedation by video-pupillometry: A case report.

BACKGROUND: Palliative sedation is sometimes interrupted by undesired arousals. Pupillometry has been used in anesthesiology to monitor pain and sedation but has never been used during palliative sedation. ACTUAL CASE: A 48 years-old patient, with multi-metastatic cancer, underwent palliative sedation to manage global suffering. On the second day, the patient experienced arousal which required medication adjustments to ensure pain relief and increased sedation. POSSIBLE COURSE OF ACTION: Depth of sedation is monitored with clinical scales, such as the Richmond Agitation-Sedation Scale. But these scales do not measure brain stem activity and are poor at predicting arousal. FORMULATION OF A PLAN: During palliative sedation, an infrared pupillometer was used to monitor pupil size and pupillary reactivity (Neurolight®, IDMed®, Marseille, France). OUTCOME: The pupillary light reflex was depressed during deep sedation. In our case, we observed a low-normal reflex along with dilated pupil before arousal. LESSONS FROM THE CASE: Our case suggests that reflex intensity and pupil size might predict arousals during palliative sedation. VIEW ON RESEARCH PROBLEMS, OBJECTIVES, OR QUESTIONS GENERATED BY THE CASE: Prospective studies are needed to confirm our findings. Pupillometry's acceptability should also be questioned from patient's, families', and caregivers' perspectives.

End of life care practice and symptom management outcomes of nursing home residents with dementia: secondary analyses of IQUARE trial.

PURPOSE: End-of-life care is a central issue in nursing homes. Poor care outcomes have been reported, especially among residents with dementia. Our aim was two-fold: to assess whether the diagnosis of dementia was associated with specific patterns of care and symptom management for residents with dementia during the last 6 months of life, and to compare these patterns of care between residents with dementia who died within 6 months and those who survived longer. METHODS: Secondary prospective analyses of the IQUARE trial (trial registration number NCT01703689). 175 nursing homes in South West France. Residents with and without dementia at baseline (May-June 2011), stratified according to their vital status at 6-month follow-up. RESULTS: Of 6275 residents enrolled in IQUARE study (including 2688 with dementia), 494 (7.9%) died within 6 months. Compared to residents without dementia (n = 254), those with dementia (n = 240) were less likely to be self-sufficient (OR = 0.08, 95% CI 0.01-0.64). They were more likely to have physical restraints (OR = 1.65, 95% CI 1.08-2.51) and less likely to be prescribed benzodiazepines (OR = 0.58, 95% CI 0.38-0.88). Among residents with dementia, those who died during the first 6 months of follow-up were more likely to be identified with a formal "end-of-life" status (OR = 5.71, 95% CI 3.48-9.37) although such identification remains low with only 15% of them. They were more likely to experience pain (OR = 1.43, 95% CI 1.04-1.97) and to be physically restrained (OR = 1.46, 95% CI 1.08-1.98). However, pain relief and psychological distress management were not improved. CONCLUSIONS: Poor quality indicators such as physical restraints are associated with end-of-life care for residents with dementia. Among symptom management outcomes, pain medication remains low even if pain complaint increased at life end.

[Prognostic indices for older adults during the year following hospitalization in an acute medical ward: An update]. / Repérage du haut risque de mortalité durant la première année qui suit une hospitalisation en médecine aiguë chez les patients de plus de 65 ans : revue de la littérature.

CONTEXT: As population grow older, chronic diseases are more prevalent. It leads to an increase of hospitalization for acute decompensation, sometimes iterative. Management of these patients is not always clear, and care provided is not always proportional to life expectancy. Making decisions in acute situations is not easy. OBJECTIVE: This review aims to list and describe mortality scores within a year following hospitalization of patients of 65 years or older. SOURCES: Following keywords were searched in title and abstract of articles via an advanced search in PudMed, and by searching Mesh terms: "aged", "aged, 80 and over", "mortality", "prognosis", "hospitalized", "models, statistical", "acute geriatric ward", "frailty", "outcome". STUDIES SELECTION: Studies published in English between 1985 and 2015 were selected. Last article was published in June 2015. Articles that described prognostic factors of mortality without a scoring system were excluded. Articles that focus either on patients in the Emergency Department and in Intensive Care Unit, or living in institution were excluded. RESULTS: Twenty-two scores are described in 17 articles. These scores use items that refer to functional status, comorbidities, cognitive status and frailty. Scores of mortality 3 or 6 months after hospitalization are not discriminative. Few of the 1-year mortality prognostic score are discriminative with AUC≥0.7. LIMITS: This review is not systematic. CONCLUSION: Practical use of these scores might help management of these patients, in order to initiate appropriate reflexion and palliative care if necessary.