Management of Physical Symptoms in Patients with Advanced Cancer During the Last Weeks and Days of Life

Patients with advanced cancer are faced with many devastating symptoms in the last weeks and days of life, such as pain, delirium, dyspnea, bronchial hypersecretions (death rattle), and intractable seizures. Symptom management in the last weeks of life can be particularly challenging because of the high prevalence of delirium complicating symptom assessment, high symptom expression secondary to psychosocial and spiritual factors, limited life-expectancy requiring special considerations for prognosis-based decision-making, and distressed caregivers. There is a paucity of research involving patients in the last weeks of life, contributing to substantial variations in clinical practice. In this narrative review, we shall review the existing literature and provide a practical approach to in-patient management of several of the most distressing physical symptoms in the last weeks to days of life.

Haloperidol for the treatment of opioid addiction in advanced cancer patients: a case series

Opioid addiction, if not well diagnosed and treated, can be a significant challenge for optimal pain management even in cancer patients. To date there is no definitive pharmacological standard of care for treating addiction, especially in this setting of patients. We present a clinical case series of three opioid-addicted advanced cancer patients, effectively treated with haloperidol, a well-known first-generation typical antipsychotic.

Factors Associated with Improvement in Uncontrolled Cancer Pain without Increasing the Opioid Daily Dose among Patients Seen by an Inpatient Palliative Care Team

Background: Increasing the total opioid dose is the standard approach for managing uncontrolled cancer pain. Other than simply increasing the opioid dose, palliative care interventions are multidimensional and may improve pain control in the absence of opioid dose increase. Objective: The purpose of this study was to determine the proportion of patients referred to our inpatient palliative care (IPC) team who achieved clinically improved pain (CIP) without opioid dose increase. Design: We reviewed consecutive patients referred to our IPC team. Setting/Subjects: Eligibility criteria included (1) taking opioid medication; (2) having ≥2 consecutive visits with the IPC team; and (3) an Edmonton Symptom Assessment Scale (ESAS) pain score ≥4 at consultation. Measurements: We assessed patient demographics and clinical variables, including cancer type, opioid prescription data (type, route, and oral morphine equivalent daily dose [MEDD]), presence of opioid rotation, psychological consultation, changes in adjuvant medications (e.g., corticosteroids; antiepileptics-gabapentin and pregabalin; benzodiazepines; and neuroleptics), and achievement of CIP. Results: Of the 300 patients enrolled, CIP was achieved in 196 (65%) patients. Of CIP patients, 85 (43%) achieved CIP without an increase in MEDD. CIP without MEDD increase was associated with more adjuvant medication changes (p = 0.003), less opioid rotation (p = 0.005), and lower symptom distress scale of ESAS (p = 0.04). Conclusions: Nearly half of the patients achieved CIP without MEDD increase, suggesting that the multidimensional palliative care intervention is effective in improving pain control in many opioid-tolerant patients without the need to increase the opioid dose.

Pain Management for Patients With Advanced Cancer in the Opioid Epidemic Era

Use of opioids for the treatment of pain is necessary for the majority of patients with advanced cancer, however its use has become challenging in the face of the opioid epidemic and the emerging evidence that patients with cancer are also at risk for nonmedical opioid use. This article proposes an assessment and treatment plan that incorporates universal screening with monitoring for all patients with cancer who are considered for opioid treatment to assess their risk for opioid misuse and harm. Timely identification with appropriate management, including referral of at-risk patients, will allow oncology professionals to optimize the risk-to-benefit and support the safe use of opioids for patients with cancer.

Association between tobacco use, pain expression, and coping strategies among patients with advanced cancer

BACKGROUND

The objective of the current study was to evaluate the association between tobacco use, symptom expression, and coping strategies in patients with advanced cancer.

METHODS

The authors prospectively enrolled patients with advanced cancer and collected data regarding patient demographics, cancer diagnosis, morphine equivalent daily dose, cigarette smoking status using the Behavioral Risk Factor Surveillance System, symptom expression as measured by the Edmonton Symptom Assessment System, the Cut down/Annoyed/Guilty/Eye opener alcoholism questionnaire, the Screener and Opioid Assessment for Patients with Pain-short form survey, and the Brief COPE Questionnaire.

RESULTS

Among 399 patients, 195 (49%) were never-smokers, 158 (40%) were former smokers, and 46 (11%) were current smokers. The most common malignancies were gastrointestinal (21%) and breast (19%). Current smokers demonstrated significantly higher pain scores at the time of consultation compared with former or never-smokers (mean 6.4 vs 5.9 vs 5.1, respectively; P = .015), demonstrated increased morphine equivalent daily dose (median 90 mg/day vs 60 mg/day vs 50 mg/day, respectively; P = .002), were more likely to screen as positive on the Cut down/Annoyed/Guilty/Eye opener questionnaire (33% vs 24% vs 8.7%, respectively; P < .0001) and were more likely to screen as positive (≥4) on the Screener and Opioid Assessment for Patients with Pain-short form survey (74% vs 13% vs 9.3%, respectively; P < .0001). Compared with former and never-smokers, current smokers were significantly more likely to cope maladaptively with substance use (P = .02), denial (P = .007), and self-blame (P < .0001).

CONCLUSIONS

Among patients with advanced cancer, current and former smokers appear to be significantly more likely to have higher pain expression and thus require higher opioid doses, and to have more risk factors for using opioids in a nonprescribed manner. The results of the current study highlight the need to provide closer monitoring and increased psychosocial support for patients with cancer who smoke while receiving chronic opioid therapy.

Comparison of analgesic effect of oxycodone and morphine on patients with moderate and advanced cancer pain: a meta-analysis

BACKGROUND

Morphine and oxycodone are considered as wide-spreadly used opioids for moderate/severe cancer pain. However, debate exists about the evidence regarding their relative tolerability and underlying results.

METHODS

A systematic search of online electronic databases, including PubMed, Embase, Cochrane library updated on October 2017 were conducted. The meta-analysis was performed including the studies that were designed as randomized controlled trials.

RESULTS

In total, seven randomized clinical trials met our inclusion criteria. No statistical differences in analgesic effect between oxycodone and morphine were observed. Both the pooled analysis of API (MD =0.01, 95% CI -0.22 - 0.23; p = 0.96) and WPI (MD = - 0.05, 95% CI -0.21 - 0.30; p = 0.72) demonstrated clinical non-inferiority of the efficacy of morphine compared with oxycodone, respectively. Additionally, no significant difference in PRR response was observed in either oxycodone or morphine that were used in patients (MD =0.99, 95% CI -0.88 - 1.11; p = 0.87). With the pooled result of AEs indicating the comparable safety profiles between the 2 treatment groups, the meta-analysis on the nausea (OR = 1.20, 95% CI 0.90-1.59; p = 0.22), vomiting (OR = 1.33, 95% CI 0.75-2.38; p = 0.33), somnolence (OR = 1.35, 95% CI 0.95-1.93; p = 0.10), diarrhea (OR = 1.01, 95% CI 0.60-1,67; p = 0.98), and constipation (OR = 1.04, 95% CI 0.77-1.41; p = 0.79) was conducted, respectively.

CONCLUSIONS

In the current study, no remarkable difference was identified either in analgesic efficacy or in tolerability of oxycodone and morphine as the first-line therapy for patients with moderate to severe cancer pain. Thus, no sufficient clinical evidence on the superior effects of oxycodone to morphine was provided in this experimental hypothesis.

Pediatric Oncology: Managing Pain at the End of Life

Pain is a common and highly distressing symptom in pediatric patients with advanced malignancies. Prompt recognition, assessment, and treatment of pain are necessary, especially at the end of life. Opioid medications remain the mainstay of treatment of malignant pain in children at the end of life and the amount of opioids required for adequate pain control in patients is highly variable. Nonpharmacological approaches including behavioral and physical approaches in addition to non-opioid pain medications should be used when possible to augment pain control. Identification and treatment of any underlying pathology is important and use of adjuvant medications based on pathophysiology and source of pain should be considered. In cases where adequate pain control is not achieved through these multiple modalities, an interdisciplinary approach including potential interventional techniques and alternative treatments is required. This multimodal approach to pain management is best provided by interdisciplinary teams, as these teams can best address the complex causes of pain and associated distress that occurs in patients and within families.

Association Between Tobacco Use, Symptom Expression, and Alcohol and Illicit Drug Use in Advanced Cancer Patients

CONTEXT

Limited knowledge exists examining the association between smoking status, symptom expression, and alcohol or illicit drug use.

OBJECTIVES

The goal of this study was to clarify these associations in patients with advanced cancer.

METHODS

We retrospectively reviewed 560 charts and identified 300 consecutive advanced cancer patients who completed a comprehensive smoking questionnaire. Data including the Edmonton Symptom Assessment System, Cut down/Annoyed/Guilty/Eye opener (CAGE) alcoholism screening questionnaire, illicit drug use history, and daily opioid requirements-morphine equivalent daily dose-were collected.

RESULTS

Among 300 patients, 119 (40%) were never smokers, 148 (49%) former smokers, and 33 (11%) current smokers. The most common malignancies were gastrointestinal (28%) and lung (20%). Current smokers were more likely to be single (P < 0.01) and significantly younger than former smokers (P < 0.001) but did not differ in age from never smokers. Never smokers were more likely to be female (P < 0.001). Current smokers reported significantly higher pain expression than former and never smokers (median 7 vs. 5.5 vs. 5, respectively, P = 0.02), higher CAGE positivity (42% vs. 21% vs. 3%, P < 0.001) and were more likely to have a history of illicit drug use (33% vs. 16% vs. 3%, P < 0.001). The morphine equivalent daily dose was not significantly different according to smoking status.

CONCLUSION

In advanced cancer, patients who were former or current smokers were significantly more likely to have a history of CAGE positivity and illicit drug use compared with never smokers. Current smokers expressed significantly higher pain. A smoking history may be a marker of an increased risk of opioid misuse.

Patient-controlled analgesia at the end of life at a pediatric oncology institution

BACKGROUND

Patient controlled anesthesia (PCA) is increasingly used to manage pain in pediatric cancer patients and is important in the treatment of escalating pain at the end of life. The description of the use of opioid PCA in this population has been limited.

PROCEDURE

This retrospective chart review of the last 2 weeks of life addressed the following objectives: (1) to describe the patient population treated with opioid PCA; (2) to describe the morphine-equivalent doses (MED) (mg/kg/day); and (3) to describe the pain scores (PS).

RESULTS

Twenty-eight percent of inpatients used opioid PCA for pain control during the last 2 weeks of life. The mean MED (mg/kg/day) (SD) at 2 weeks prior and the day of death were 10.7 (17.9) and 19 (25.8). The mean MED increased over the last 2 weeks of life for all patients and across age groups and cancer diagnoses (all P < 0.05). The mean MED was significantly higher in the younger age group (age <13 vs. age ≥ 13) on the day of death (P < 0.04). There was a significant change in mean PS over the last 2 weeks of life (P < 0.001), with the highest PS on the day before death. The most frequently used concurrent medications were benzodiazepines (91%).

CONCLUSIONS

Children and young adults with cancer experience high opioid requirements and significant dose increases during the last 2 weeks of life. Additionally, PS increase toward the end of life. Opioid rotation and addition of adjuvant medications merit consideration in the context of escalating opioid requirements.

Conceptual analysis of suffering in cancer: a systematic review

OBJECTIVE

Patient suffering is a neglected area of care, partly because of poor definitions. The aim of this study was to distill what is currently known about suffering in the health literature in order to generate a conceptual basis for further research.

METHODS

A systematic review focusing on suffering across all cancers was undertaken. The search included peer-reviewed English articles published between 1992 and 2012 in MEDLINE, Embase, PsycINFO and the Cochrane Library databases focusing on conceptualisation of suffering in adult cancer patients. Seminal theoretical articles conceptualising suffering more generally were also eligible. To ensure identification of a sufficiently broad range of conceptualisations of suffering in cancer, the search strategy was drafted iteratively. Study findings were subjected to conceptual analysis using the evolutionary method.

RESULTS

One hundred twenty-eight studies were identified, which discussed definitions or conceptualisations of suffering. In terms of its attributes, suffering is defined as 'an all-encompassing, dynamic, individual phenomenon characterized by the experience of alienation, helplessness, hopelessness and meaninglessness in the sufferer which is difficult for them to articulate. It is multi-dimensional and usually incorporates an undesirable, negative quality.' Surrogate terms, antecedents and consequences of suffering are described.

CONCLUSIONS

The systematic review revealed that suffering includes holistic suffering, which is multidimensional, oscillating, individual and difficult for individuals to express. Opportunities should be provided for patients to express their suffering. The potential for suffering to be transcended needs to be recognized and facilitated by healthcare staff.

State of art of managing pain in patients with cancer

Pain in cancer patients involves complex interactions between physiological, psychological, sociocultural, sensory, cognitive, and behavioral dimensions. Pain management interventions will be most effective when pharmacological and nonpharmacological treatments are individualized after exploring the various contributors to pain and suffering, and the patient and family are educated and involved in decision making. This entails a systematic multidimensional approach with frequent reassessments of pain and related outcomes.

Pain Management for Persons Living With HIV Disease

Context:

Pain management (PM) has not been routinely incorporated into HIV/AIDS care and treatment in resource-constrained settings.

Objectives:

We describe training for multidisciplinary teams tasked with integrating care management into HIV clinics to address pain for persons living with HIV in Nigeria.

Methods:

Education on PM was provided to mixed-disciplinary teams including didactic and iterative sessions following home and hospital visits. Participants identified challenges and performed group problem solving.

Results:

HIV trainers identified barriers to introducing PM reflecting views of the patient, providers, culture, and the health environment. Implementation strategies included (1) building upon existing relationships; (2) preliminary advocacy; (3) attention to staff needs; and (4) structured data review.

Conclusion:

Implementing PM in Nigerian HIV clinics requires recognition of cultural beliefs.

Midwifing distress at end of life: Missed opportunities?

Birth and death are rites of passage, and preparation is important (Richards, 2007). Palliative care clinicians describe end of life as a meaningful stage of life filled with opportunity and mystery. However, in palliative care, we have a tendency to overlook dying as a means of spiritual awakening, and there is little understanding, and little or no demand, among palliative care patients, or in the broader culture, to learn the skills of dying.

The use of very-low-dose methadone for palliative pain control and the prevention of opioid hyperalgesia

BACKGROUND

Opioid dose escalation may cause hyperalgesia, mediated by the N-methyl-D-aspartate (NMDA) pathway. Methadone is an atypical opioid that inhibits hyperalgesia through NMDA-blockade, especially at low doses.

OBJECTIVE

To evaluate the efficacy of using very-low-dose methadone as the sole long-acting opioid agent in a hospice practice.

DESIGN

A retrospective, observational study of the use of methadone, ≤15 mg daily, with as-needed short-acting opiates. Adjuvant nonopioid medications included haloperidol, which may have NMDA-blocking effects.

SETTING/SUBJECTS

We reviewed the records of 240 patients admitted to a community-based hospice from July 1, 2011 to April 1, 2012, with data collected until hospice discharge or until April 30, 2012.

MEASUREMENTS

Descriptive statistics were used to summarize patient demographics, medication regimens, and reported pain scores measured on a numeric rating scale from 0 to 10.

RESULTS

All patients received short-acting opiates, in a morphine-equivalent dose of 5 mg every 4 hours as needed, while 40% also received methadone at a median daily dose of 5 mg. Of those on methadone, almost half received scheduled haloperidol. The population had a median reported pain score of 0 and a peak score of 3, with similar results seen for cancer and noncancer groups. Two-thirds of patients never reported a pain score greater than 3.

CONCLUSION

The use of very-low-dose methadone in conjunction with adjuvant haloperidol resulted in excellent pain control without dose escalation or opioid-induced hyperalgesia, for both cancer and noncancer diseases. We conclude that low-dose methadone should be part of first-line treatment in palliative pain management.

Drug therapy optimization at the end of life

Older people reaching end-of-life status are particularly at risk of adverse effects of drug therapy. Polypharmacy, declining organ function, co-morbidity, malnutrition, cachexia and changes in body composition all sum up to increase the risk of many drug-related problems in individuals who receive end-of-life care. End of life is defined by a limited lifespan or advanced disability. Optimal prescribing for end-of-life patients with multimorbidity, especially in those dying from non-cancer conditions, remains mostly unexplored, despite the increasing recognition that the management goals for patients with chronic diseases should be redefined in the setting of reduced life expectancy. Most drugs used for symptom palliation in end-of-life care of older patients are used without solid evidence of their benefits and risks in this particularly frail population. Appropriate dosing or optimal administration routes are in most cases unknown. Avoiding or discontinuing drugs that aim to prolong life or prevent disability is usually common sense in end-of-life care, particularly when the time needed to obtain the expected benefits from the drug is longer than the life expectancy of a particular individual. However, discontinuation of drugs is not standard practice, and prescriptions are usually not adapted to changes in the course of advanced diseases. Careful consideration of remaining life expectancy, time until benefit, goals of care and treatment targets for each drug seems to be a sensible framework for decision making. In this article, some key issues on drug therapy at the end of life are discussed, including principles of decision making about drug treatments, specific aspects of drug therapy in some common geriatric conditions (heart failure and dementia), treatment of acute concurrent problems such as infections, evidence to guide the choice and use of drugs to treat symptoms in palliative care, and avoidance of some long-term therapies in end-of-life care. Solid evidence is lacking to guide optimal pharmacotherapy in most end-of-life settings, especially in non-cancer diseases and very old patients. Some open questions for research are suggested.

Assessing cancer pain

Regular assessment for the presence of pain and response to pain management strategies should be high priority in cancer patients. Pain is a multidimensional experience in cancer patients. Pain management will be most effective when treatments are individualized after exploring the various physical and non-physical components of pain, and the patient and family are educated and involved in decision making. This article discusses the various issues that are pertinent to the assessment of pain in cancer patients.

Dying is a Transition

Purpose:

End-of-life care is designed as response to patients' verbally communicated needs. The concept of dying as a process would allow us to improve care. This concept may combine the needs of the dying, their outburst of emotions, gradual maturation, family processes, acute problems such as decreasing independence, with their inner experience and transformation of perception. In this study we explored dying patients' mode of perception, and deeper reasons for anxiety and existential suffering.

Methods:

Dying inpatients of a major cancer centre treated by an interdisciplinary team were eligible. Psychotherapy records of cancer patients (course, reactions, discussions with nurses and physicians) provided the data. Participant observation and Interpretative Phenomenological Analysis (IPA) was applied.

Results:

Our data (pilot study N=80/follow-up-study N=600) suggest that patients undergo transition into another state of consciousness beyond anxiety, ego, and pain. Transition appears to have three stages. Anxiety, struggle, denial/acceptance, family processes, and maturation (ie, finding meaning and dignity, coping with trauma) may depend on the transitional process and also hinder or facilitate this transitional process.

Conclusions:

Understanding dying as transition may induce a radical reinterpretation of what patients need.

Undocumented alcoholism and its correlation with tobacco and illegal drug use in advanced cancer patients

BACKGROUND

The objectives of this retrospective study were to determine the frequency of undiagnosed alcoholism among patients with advanced cancer who were referred to palliative care and to explore its correlation with alcoholism, tobacco abuse, and use of illegal drugs.

METHODS

The authors reviewed 665 consecutive charts and identified 598 patients (90%) who completed a screening survey that was designed to identify alcoholism, the Cut Down, Annoyed, Guilty, Eye Opener (CAGE) questionnaire, including 100 consecutive patients who had CAGE-positive and CAGE-negative results. Data on tobacco and illegal drug use, the Edmonton Symptom Assessment Scale, and the morphine equivalent daily dose were collected.

RESULTS

The frequency of CAGE-positive results in this palliative care population was 100 of 598 patients (17%). Only 13 of 100 patients (13%) in that CAGE-positive group had been identified as alcoholics before their palliative care consultation. Compared with CAGE-negative patients, CAGE-positive patients were younger (aged 58.6 years vs 61.3 years; P = .07), predominantly men (68 of 100 patients vs 51 of 100 patients; P = .021), more likely to have a history of tobacco use (86 of 100 patients vs 48 of 100 patients; P < .001), more likely to be actively using nicotine (33 of 100 patients vs 9 of 100 patients; P = .02), and more likely to have a history of illegal recreational drug use (17 of 100 patients vs 1 of 100 patients; P < .001). Pain and dyspnea were worse in patients who had a history of nicotine use. Both CAGE-positive patients and patients who had a history of tobacco use more frequently were receiving strong opioids at the time of their palliative care consultation.

CONCLUSIONS

The current findings suggested that alcoholism is highly prevalent and frequently under diagnosed in patients with advanced cancer. CAGE-positive patients were more likely to have a history of, or to actively engage in, smoking and illegal recreational drug use, placing them at risk for inappropriate opioid escalation and abuse.

Psychological variables potentially implicated in opioid-related mortality as observed in clinical practice

Opioid-related deaths in the United States have become a public health problem, with accidental and unintended overdoses being especially troubling. Screening for psychological risk factors is an important first step in safeguarding against nonadherence practices and identifying patients who may be vulnerable to the risks associated with opioid therapy. Validated screening instruments can aid in this attempt as a complementary tool to clinicians' assessments. A structured screening is imperative as part of an assessment, as clinician judgment is not the most reliable method of identifying nonadherence. As a complement to formal screening, we present for discussion and possible future study certain psychological variables observed during years of clinical practice that may be linked to medication nonadherence and accidental overdose. These variables include catastrophizing, fear, impulsivity, attention deficit disorders, existential distress, and certain personality disorders. In our experience, chronic pain patients with dual diagnoses may become "chemical copers" as a way of coping with their negative emotion. For these patients, times of stress could lead to accidental overdose. Behavioral, cognitive-behavioral (acceptance and commitment, dialectical behavior), existential (meaning-centered, dignity), and psychotropic therapies have been effective in treating these high-risk comorbidities, while managing expectations of pain relief appears key to preventing accidental overdose.

Unrelieved pain and suffering in patients with advanced cancer

Even with specialist-level palliative care, cancer pain can be difficult to treat especially when the pain is complicated by profound suffering. It is paramount to consider not only the patients' biochemical factors but also their psychosocial and spiritual/existential influences. A multidimensional approach with knowledge of the risk factors for poor pain control is important to prevent, detect, and manage risk factors for intractable pain, including psychosocial distress, addictive behavior, and delirium in patients with terminal cancer. We present 3 cases of patients with advanced cancer with intractable bone pain whose hospital courses were complicated by severe psychosocial distress and delirium. We also propose an algorithm of multidimensional approach to unrelieved pain and suffering in patients with advanced cancer.

Existential suffering in the palliative care setting: an integrated literature review

CONTEXT

Existential and spiritual concerns in relation to palliative end-of-life care have received increasing attention over the past decade.

OBJECTIVES

To review the literature specifically related to existential suffering in palliative care in terms of the significance of existential suffering in end-of-life care, definitions, conceptual frameworks, and interventions.

METHODS

A systematic approach was undertaken with the aim of identifying emerging themes in the literature. Databases using CINAHL (1980-2009), MEDLINE (1970-2009), and PsychINFO (1980-2009) and the search engine of Google Scholar were searched under the key words existential suffering, existential distress, existential pain, palliative and end of life care.

RESULTS

The search yielded a total of 156 articles; 32% were peer-reviewed empirical research articles, 28% were peer-reviewed theoretical articles, and 14% were reviews or opinion-based articles. After manually searching bibliographies and related reference lists, 64 articles were considered relevant and are discussed in this review. Overall analysis identifies knowledge of the following: 1) emerging themes related to existential suffering, 2) critical review of those identified themes, 3) current gaps in the research literature, and 4) recommendations for future research. Findings from this comprehensive review reveal that existential suffering and deep personal anguish at the end of life are some of the most debilitating conditions that occur in patients who are dying, and yet the way such suffering is treated in the last days is not well understood.

CONCLUSION

Given the broad range of definitions attributed to existential suffering, palliative care clinicians may need to be mindful of their own choices and consider treatment options from a critical perspective.

Spousal suffering and partner's depression and cardiovascular disease: the Cardiovascular Health Study

OBJECTIVES

To assess the effects of suffering in a spouse on prevalent and incident psychiatric (depression) and physical morbidity (cardiovascular disease [CVD]) in their partner, controlling for known risk factors for depression and CVD.

DESIGN

Descriptive longitudinal study.

PARTICIPANTS

A total of 1,330 older married couples enrolled in the Cardiovascular Health Study, a large epidemiologic study of the elderly.

MEASUREMENTS

Predictor variables were physical, psychological, and existential/spiritual indicators of suffering. Primary outcomes were prevalent and incident depression and CVD.

RESULTS

Controlling for known risk factors for depression, the authors found a dose-response relationship between suffering in a spouse and concurrent depression in their partner as well as a relationship between suffering and the partner's future risk for depression. With respect to CVD, and controlling for subclinical CVD at baseline, husbands whose wives reported high levels of suffering also had higher rates of prevalent CVD, but there were no significant associations between wives suffering and husbands incident CVD. There were no associations between husbands' suffering and wives' prevalent or incident CVD.

CONCLUSION

Exposure to spousal suffering is an independent and unique source of distress in married couples that contributes to psychiatric and physical morbidity. More attention should be paid to the interpersonal effects of suffering in married couples and to its role in contributing to morbidity.

Alcoholism screening in patients with advanced cancer: impact on symptom burden and opioid use

PURPOSE

Alcoholism is a devastating disease that can cause patient and family suffering and is frequently underdiagnosed. Preliminary studies suggest that it is associated with increased symptom expression and opioid dose escalation. The CAGE questionnaire is a widely used tool for alcoholism screening. The purpose of this study was to determine the frequency and characteristics of patients who screen positive for alcoholism in a palliative care outpatient clinic (PCOC).

METHODS

We reviewed 665 consecutive charts of patients referred to the PCOC and collected data regarding age, gender, and type of cancer. For the first 100 consecutive CAGE positive (CAGE+) and 100 consecutive CAGE negative (CAGE-) patients, time from advanced cancer diagnosis (AC) to PCOC was calculated, and symptoms (Edmonton Symptom Assessment Scale, ESAS) and Morphine Equivalent Daily Dose (MEDD) were collected.

RESULTS

CAGE was available for 598 of 665 (90%) patients. Of 598 patients, 100 (17%) were CAGE+. CAGE+ patients were younger (58 versus 60 years, p < 0.05), predominantly male (68% versus 47%, p < 0.0001), and with head/neck malignancies (24% versus 9%, p < 0.05). CAGE+ patients were referred earlier (5 +/- 27 months after AC, p < 0.0001). At baseline, pain, sleep, dyspnea, well-being, and total symptom distress were significantly worse among CAGE+ patients. Both groups showed similar improvement in symptoms. CAGE+ patients were more frequently on opioids upon referral (47/100 versus 29/100, p < 0.05) and follow-up (27/65 versus 16/68, p < 0.05). At follow-up, opioid doses did not show significant changes.

CONCLUSION

Seventeen percent of the patients were CAGE+. These patients were referred earlier to palliative care, had more symptom expression, and were more frequently on opioids. The palliative care team successfully improved symptom control in both groups without opioid dose escalation.

Dementia patient suffering and caregiver depression

Cross-sectional and longitudinal analyses were carried out to assess the relationship between dementia patient suffering, caregiver depression, and antidepressant medication use in 1222 dementia patients and their caregivers. We assessed the prevalence of 2 types of patient suffering, emotional and existential distress, and examined their independent associations with caregiver depression and antidepressant medication use when controlling for sociodemographic characteristics of caregivers and patients, cognitive and physical disability of the patient, the frequency of patient memory problems and disruptive behaviors, and the amount of time spent caring for the patient. Multiple linear regression models showed that both aspects of perceived patient suffering independently contribute to caregiver depression (emotional distress: beta=1.24; P<0.001; existential distress: beta=0.66; P<0.01) whereas only existential suffering contributes to antidepressant medication use: odds ratio=1.25 95% confidence interval, 1.10-1.42; P<0.01. In longitudinal analyses, increases in both types of suffering were associated with increases in caregiver depression (emotional distress: beta=1.02; P<0.01; existential distress: beta=0.64; P<0.01). This is the first study to show in a large sample that perceived patient suffering independently contributes to family caregiver depression and medication use. Medical treatment of patients that maintain or improve memory but do not address suffering may have little impact on the caregiver. Alzheimer disease patient suffering should be systematically assessed and treated by clinicians.

Holistic assessment of chronic pain among elders

This pilot study assessed pain using 7 dimensions of pain (physiologic, behavioral, sensory, affective, cognitive, sociocultural, and spiritual) to better understand and identify patterns of elder response to chronic pain within a holistic framework. Previously validated instruments were used to assess 150 cognitively intact subjects, aged 65 years and older, with chronic pain. Thirteen patterns were identified reflecting distinct patterns of pain response. Two patterns comprised 85% of the responses: (1) high spiritual well-being, low physiologic pain, and high perceived independent functioning; and (2) high spiritual well-being, low physiologic pain, and lower perceived independent functioning. The 11 other patterns of pain response also varied in their responses to the pain experience. These responses reflect the unique and holistic experience of chronic pain among older adults. Holistic assessment enhances the understanding of the pain specific to the individual. Self-perceived functional dependence and the spiritual component significantly influence chronic pain experiences.