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Mercadante S, Masedu F, Maltoni M, De Giovanni D, Montanari L, Pittureri C, Bertè R, Russo D, Ursini L, Marinangeli F, Aielli F. Symptom expression in advanced cancer patients admitted to hospice or home care with and without delirium. Intern Emerg Med 2019; 14:515-520. [PMID: 30334235 DOI: 10.1007/s11739-018-1969-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/10/2018] [Indexed: 11/26/2022]
Abstract
The aim of this study is to investigate the relationship between delirium and symptom expression in advanced cancer patients admitted to palliative care services. This is a secondary analysis of a consecutive sample of advanced cancer patients who were admitted to home care and hospices, and prospectively assessed for a period of 10 months. The Edmonton Symptom Assessment Scale (ESAS) and the MDAS (Memorial Delirium Assessment Scale) were measured at admission (T0) and after seven days of home care or hospice care (T7). Of the eight hundred and forty-eight patients screened in the period, 585 were not considered in the analysis for various reasons. The mean age was 72.1 years (SD 13.7), and 146 patients were males (55.5%). The mean Karnofsky status recorded at T0 is 34.1 (SD = 6.69). The mean duration palliative care assistance is 38.4 days (SD = 48, range 2-220). Of 263 patients who had a MDAS available at T0, 110 patients (41.8%) had a diagnosis of delirium. Of them, 167 patients had complete data regarding MDAS measurement, either at T0 and T7. A larger number of patients (n 167, 63.5%) had delirium after a week of palliative care. Patients with delirium are likely to be older, to have a lower Karnofsky level at T0, and to be home care patients. At T0, weakness, nausea, drowsiness, lack of appetite, and well-being are associated with delirium. At T7, weakness, poor appetite, and poor well-being are significantly associated with delirium. 27% of patients who had a normal cognitive status at T0 developed delirium at T7. In patients with delirium, an improvement in the cognitive status corresponds to a significant improvement in weakness, depression, and appetite. Conversely, the occurrence of delirium in patients who had a normal cognitive status at admission significantly increases the level depression, while the level of weakness and appetite decrease. Symptom expression is amplified in patients with delirium admitted to home care or hospices, while patients without delirium can be more responsive to palliative treatments with a significant decrease in intensity of ESAS items.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care and Pain relief and supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90145, Palermo, Italy.
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | | | | | | | - Raffaella Bertè
- Palliative Care, Oncology Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | | | - Laura Ursini
- "Casa Margherita" Hospice, ASL 01, Avezzano-Sulmona-L'Aquila, L'Aquila, Italy
| | - Franco Marinangeli
- Anesthesiology and Pain Medicine, Department of Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Mercadante S, Marinangeli F, Masedu F, Valenti M, Russo D, Ursini L, Massici A, Aielli F. Hyoscine Butylbromide for the Management of Death Rattle: Sooner Rather Than Later. J Pain Symptom Manage 2018; 56:902-907. [PMID: 30172864 DOI: 10.1016/j.jpainsymman.2018.08.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/22/2018] [Accepted: 08/22/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Death rattle (DR) is a dramatic sign in the dying patient. Existing studies with anticholinergic agents are controversial, as this class of drugs has been commonly administered without considering the rationale of the mechanism of action. A meaningful use of these drugs may provide a better outcome. OBJECTIVES The aim of this study was to assess the efficacy of hyoscine butylbromide (HB), given prophylactically in comparison with HB administered once DR occurs. METHODS Dying patients having a score of ≥3 in the Richmond Agitation-Sedation Scale-palliative version were included in the study. HB (60 mg/day) was given when DR occurred (Group 1) or as pre-emptive treatment (Group 2). The onset of DR (death rattle free time) and intensity of DR were recorded at intervals until death. RESULTS Eighty-one and 51 patients were randomized to Group 1 and 2, respectively. Patients in Group 2 survived longer than those in Group 1 (P < 0.05). DR occurred in 49 (60.5%) and three patients (5.9%) in Group 1 and 2, respectively (P = 0.001). A significant difference in the number of patients reporting DR was found at intervals examined (30 minutes, one hour, and then every six hours until death [P = 0.001]). In Group 1 and 2, DR free time was 20.4 (20.5) and 27.3 hours (25.2), respectively (P = 0.001). In Group 1, the treatment was considered effective in 10 patients (20.4%) only, after a mean of 14.4 hours (SD 8.57). CONCLUSION The prophylactic use of HB is an efficient method to prevent DR, whereas the late administration produces a limited response, confirming data from traditional studies performed with anticholinergics. This could be considered a new paradigm to manage a difficult and dramatic sign, such as DR.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Sicily, Italy.
| | - Franco Marinangeli
- Department of Life Health and Environmental Sciences, Anesthesiology and Pain Medicine, University of L'Aquila, L'Aquila, Italy
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Marco Valenti
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | | | - Laura Ursini
- "Casa Margherita" Hospice, ASL 01 Avezzano-Sulmona-L'Aquila, L'Aquila, Italy
| | | | - Federica Aielli
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
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Mercadante S, Masedu F, Maltoni M, Giovanni DD, Montanari L, Pittureri C, Bertè R, Ursini L, Marinangeli F, Aielli F. The prevalence of constipation at admission and after 1 week of palliative care: a multi-center study. Curr Med Res Opin 2018; 34:1187-1192. [PMID: 28728515 DOI: 10.1080/03007995.2017.1358702] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM To assess the prevalence and intensity of constipation in advanced-cancer patients referred to palliative care, and to assess changes after 1 week of specialist palliative care. METHODS This was a prospective multi-center study in advanced patients for a period of 1 year. At admission (T0), age, gender, primary tumor, concomitant diseases, Karnofsky status, Palliative prognostic score (PaP), Edmonton Symptom Assessment scale (ESAS), Memorial Delirium Assessment Scale (MDAS), and bowel function index (BFI) were collected. In BFI, high values represent severe constipation. The use of medication was also recorded, as well as possible causes of constipation. The same parameters were recorded 1 week after admission for palliative care (T7). RESULTS A total of 246 patients were screened for constipation. The mean BFI at T0 was 42.4 (SD = 26.92). One hundred and sixty-three patients (66.3%) had a BFI >28. The mean BFI at T7 was 35.7 (SD = 28.8), with a significant decrease from T0 to T7 (p = .000). A significant decrease of BFI in patients with a BFI >28 was reported (p = .000). In patients with a BFI ≤28 there was a significant worsening of constipation (p = .000). In patients with a BFI >28 at T0 there was a significant increase in the use of laxatives at T7 in comparison with patients having a BFI ≤28 (p = .002). In patients with a BFI ≤28 at T0, who had a significant worsening of BFI (Δ > 12), the use of laxatives was significantly lower in comparison to patients who had a BFI >28 (p = .000). In the multivariate analysis, dehydration and the use of benzodiazepines were independently associated with higher BFI scores. CONCLUSION Constipation is present in approximately two-thirds of patients, and is principally associated with dehydration and the use of benzodiazepines. Patients with normal bowel function at initial assessment may see a worsening in their condition a week later due to lack of prevention or subsequent under-treatment.
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Affiliation(s)
| | - Francesco Masedu
- b Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine , University of L'Aquila , Italy
| | - Marco Maltoni
- c Palliative Care Unit , Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS , Meldola , FC , Italy
| | | | - Luigi Montanari
- e Palliative Care Unit , AUSL Della Romagna , Ravenna , Italy
| | | | - Raffaella Bertè
- g Palliative Care, Oncology Department , Guglielmo da Saliceto Hospital , Piacenza , Italy
| | - Laura Ursini
- h "Casa Margherita" Hospice, ASL 01 Avezzano-Sulmona-L'Aquila , L'Aquila , Italy
| | - Franco Marinangeli
- i Anesthesiology and Pain Medicine, Department of Life Health and Environmental Sciences , University of L'Aquila , L'Aquila , Italy
| | - Federica Aielli
- b Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine , University of L'Aquila , Italy
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Mercadante S, Masedu F, Balzani I, De Giovanni D, Montanari L, Pittureri C, Bertè R, Russo D, Ursini L, Marinangeli F, Aielli F. Prevalence of delirium in advanced cancer patients in home care and hospice and outcomes after 1 week of palliative care. Support Care Cancer 2017; 26:913-919. [PMID: 28980071 DOI: 10.1007/s00520-017-3910-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/25/2017] [Indexed: 01/24/2023]
Abstract
AIM The aim of this study was to assess the prevalence of delirium in advanced cancer patients admitted to different palliative care services in Italy and possible related factors. The secondary outcome was to assess the changes of delirium after 1 week of palliative care. METHODS A consecutive sample of patients was screened for delirium in period of 1 year in seven palliative care services. General data, including primary tumor, age, gender, concomitant disease, palliative prognostic score (PaP), and Karnofsky status, were collected. Possible causes or factors associated with delirium were looked for. The Edmonton Symptom Assessment Scale was used to assess physical and psychological symptoms and the Memorial Delirium Assessment Scale (MDAS) to assess the cognitive status of patients, at admission (T0) and 1 week after palliative care (T7). RESULTS Of 848 patients screened, 263 patients were evaluated. Sixty-six patients had only the initial evaluation. The mean Karnofsky status was 34.1 (SD = 6.69); the mean PaP score at admission was 6.9 (SD = 3.97). The mean duration of palliative care assistance, equivalent to survival, was 38.4 days (SD = 48, range 2-220). The mean MDAS values at admission and after 1 week of palliative care were 6.9 (SD = 6.71) and 8.8 (SD = 8.26), respectively. One hundred ten patients (41.8%) and 167 patients (67.3%) had MDAS values ≥ 7 at admission and after 1 week of palliative care, respectively. Age, dehydration, cachexia, chemotherapy in the last three months, and intensity of drowsiness and dyspnea were independently associated with a MDAS > 7. A worsening of drowsiness, the use of opioids, and the use of corticosteroids were independently associated with changes of MDAS from T0 to T7. CONCLUSION Although the prevalence of delirium seems to be similar to that reported in other acute settings, delirium tended to worsen or poorly responded to a palliative care treatment. Some clinical factors were independently associated with delirium. This information is relevant for decision-making when delirium does not change despite a traditional intervention. Continuous assessment of delirium should be performed in these settings to detect deterioration of cognitive function. Further studies should elucidate whether an earlier approach to palliative care would decrease the prevalence of delirium at a late stage of disease.
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Affiliation(s)
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Isabella Balzani
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Forlì-Cesena, Italy
| | | | | | | | - Raffaella Bertè
- Palliative Care, Oncology Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | | | - Laura Ursini
- "Casa Margherita" Hospice, ASL 01 Avezzano-Sulmona-L'Aquila, L'Aquila, Italy
| | - Franco Marinangeli
- Anesthesiology and Pain Medicine, Department of Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Abstract
A method to induce only one permanent and localized dynamic Brillouin grating in polarization maintaining optical fibers is introduced. The generation of the grating exploits the thumbtack correlation of the chaotic laser signals. A numerical calculation, corroborated by a theoretical analysis, is performed and the grating properties, length, and reflectance determined.
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Affiliation(s)
- M Santagiustina
- CNIT- Dipartimento di Ingegneria dell'Informazione, Universitá di Padova, Via G. Gradenigo, 6/B, I-35131 Padova, Italy.
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