Association of Antipsychotic Dose With Survival of Advanced Cancer Patients With Delirium

CONTEXT

Delirium is common in patients with advanced cancer, and antipsychotics are widely used for its management.

OBJECTIVES

We aimed to explore the association of the antipsychotic dose with survival of terminally ill cancer patients with delirium.

METHODS

A secondary analysis of a multicenter prospective observational study was conducted. We enrolled adult advanced cancer patients who developed delirium and received antipsychotics at 14 palliative care units in Japan between September 2015 and May 2016. Hazard ratios of survival after starting antipsychotics between groups with different oral chlorpromazine equivalent doses: low: <100 mg, moderate: 100-200 mg, high: ≥200 mg, were calculated with adjustment for potential confounders using Cox regression. The antipsychotic dose-specific mortality risk was estimated with smooth splines.

RESULTS

Of 453 patients enrolled, 422 patients were analyzed. The median antipsychotic dose was 92.6 mg: low-dose (N = 231), moderate-dose (122), and high-dose (69). The median survival of all patients was 11 days. Compared with the low-dose group, the high-dose group showed a significantly shorter survival (HR: 1.46, 95%CI: 1.08-1.98). Smooth splines demonstrated that HR continuously increased as the antipsychotic dose increased. In patients treated with atypical antipsychotics, the high-dose group showed a significantly shorter survival than the low-dose group (HR: 2.86), while in patients treated with typical antipsychotics, survival was not significantly different (0.99).

CONCLUSIONS

Higher doses of antipsychotics were associated with increased mortality in terminally ill cancer patients with delirium. To minimize the potential mortality risk, antipsychotics should be started at low doses and titrated carefully.

Title: Effects of Antibiotics on Respiratory Symptoms in Terminally Ill Cancer Patients With Pneumonia: A Multicenter Cohort Study

CONTEXT

Patients in the terminal stages of cancer are frequently affected by infection, especially pneumonia; but the effects of antibiotics on respiratory symptoms and factors associated with improvement are still unclear.

OBJECTIVES

This study aimed to clarify the effects of antibiotics on respiratory symptoms of terminally ill cancer patients with pneumonia, and to explore factors associated with the improvement.

METHODS

This was a prospective cohort study in which we consecutively recruited terminally ill cancer patients diagnosed with pneumonia and treated with antibiotics at one of 23 palliative care units across Japan. At the baseline and Day 3, primarily responsible palliative care specialists recorded patient backgrounds, the results of physical and laboratory examination, and patient symptoms using the Support Team Assessment Schedule. Improvement was defined as improvement of dyspnea, cough, and sputum production on Day 3.

RESULTS

Among all 1896 patients admitted during the study periods, 137 patients (7.2%) were enrolled into this study. Improvement was achieved in 65 patients (47.4%; 95% confidence intervals, 39-56). Univariate analyses revealed that the Palliative Prognostic Index (PPI), respiratory rate (RR), and oxygen requirement were significantly associated with the improvement. A multiple logistic regression analysis identified that PPI score of ≤ 6 and RR of <20 were independently associated with the improvement (odds ratios, 4.4 [1.6-12] and 2.5 [1.1-5.5], respectively).

CONCLUSION

Antibiotics may relieve respiratory symptoms from pneumonia in approximately half of the terminally ill cancer patients. PPI and respiratory rate are useful to identify the patients who received benefits of antibiotics.

Epidemiology of Respiration with Mandibular Movement in Advanced Cancer Patients: A Multicenter Prospective Cohort Study

Background: Respiration with mandibular movement (RMM) is one of the important clinical signs of impending death. However, there is very limited data on its natural course. Objective and Methods: This study was conducted in 23 inpatient palliative care units in Japan. It aimed to explore the natural course of RMM. Results: Among a total of 1526 cancer patients included, 1065 patients (69.8%) had RMM. A total of 14.8% patients experienced respiratory arrest within 30 minutes from RMM onset, 14.3% within 30-60 minutes, 34.4% within 1-4 hours, 17.5% within 4-12 hours, 8.9% within 12-24 hours, and 10.4%> 24 hours. Mean oxygen saturation and percentage of patients with SpO₂ ≥90% at RMM onset were found to be significantly higher in patients with longer durations from RMM onset to death (p < 0.001). Conclusion: RMM occurred in a majority (80%) of dying patients within 12 hours. A minority of the patients survived >24 hours.

Efficacy of Proportional Sedation and Deep Sedation Defined by Sedation Protocols: A Multicenter, Prospective, Observational Comparative Study

PURPOSE

To investigate the efficacy of two types of palliative sedation: proportional and deep sedation, defined by sedation protocols.

METHODS

From a multicenter prospective observational study, we analyzed the data of those patients who received the continuous infusion of midazolam according to the sedation protocol. The primary endpoint was goal achievement at 4 hours: in proportional sedation, symptom relief (Integrated Palliative care Outcome Scale: IPOS ≤ 1) and absence of agitation (modified Richmond Agitation-Sedation Scale: RASS ≤ 0); in deep sedation, the achievement of deep sedation (RASS ≤ -4). Secondary endpoints included deep sedation as a result of proportional sedation, communication capacity (Communication Capacity Scale item 4 ≤ 2), IPOS and RASS scores, and adverse events.

RESULTS

A total of 81 patients from 14 palliative care units were analyzed: proportional sedation (n = 64) and deep sedation (n = 17). At 4 hours, the goal was achieved in 77% (n = 49; 95% confidence interval: 66-87) with proportional sedation; and 88% (n = 15; 71-100) with deep sedation. Deep sedation was necessary in 45% of those who received proportional sedation. Communication capacity was maintained in 34% with proportional sedation and 10% with deep sedation. IPOS decreased from 3.5 to 0.9 with proportional sedation, and 3.5 to 0.4 with deep sedation; RASS decreased from +0.3 to -2.6, and +0.4 to -4.2, respectively. Fatal events related to the treatment occurred in 2% (n = 1) with proportional and none with deep sedation.

CONCLUSION

Proportional sedation achieved satisfactory symptom relief while maintaining some patients' consciousness, and deep sedation achieved good symptom relief while the majority of patients lost consciousness.

Prevalence and associated factors of orphan symptoms in advanced cancer patients: a multicenter observational study

PURPOSE

The aims of this study were to examine the prevalence of myoclonus, sweating, pruritus, hiccup, and vesical and rectal tenesmus, and to explore associated factors in patients with advanced cancer.

METHODS

This multicenter prospective cohort study was conducted in 23 inpatient hospices/palliative care units in Japan from January to December 2017. The prevalence and characteristics of each symptom were assessed on admission and in the 3 days before death. We selected factors that might influence the occurrence of each symptom and investigated the association.

RESULTS

A total of 1896 patients were enrolled. The prevalence of orphan symptoms rose from admission to the 3 days before death: myoclonus 1.3 to 5.3% (95% CI 0.9-1.9%/4.3-6.5%), sweating 1.8 to 4.1% (95% CI 1.3-2.6%/3.1-5.1%), hiccup 1.1 to 1.8% (95% CI 0.7-1.7%/1.2-2.6%), and tenesmus 0.7 to 0.9% (0.4-1.2%/0.5-1.5%). Prevalence of pruritus fell from 3.5 to 2.5% (95% CI 2.7-4.4%/1.8-3.4%). Sweating, pruritus, and hiccups persisted throughout the day in nearly half of the patients. Myoclonus was significantly associated with brain tumors, sweating with opioids and antipsychotics, pruritus with liver and biliary tract cancer, cholestasis and severe diabetes, hiccup with male gender, digestive tract obstruction, severe diabetes, and renal failure. Vesical tenesmus was associated with urinary cancer, antipsychotics, and anticholinergics and rectal tenesmus with pelvic cavity cancer.

CONCLUSION

We found that orphan symptoms occurred in 0.5-5.0% of patients, increased over time except for pruritus, and persisted in half of the patients.

Reversibility of delirium in Ill-hospitalized cancer patients: Does underlying etiology matter?

Background

The objective of this study was to explore the underlying etiologies associated with the resolution and improvement of delirium in ill‐hospitalized cancer patients.

Methods

We conducted a secondary analysis of a multicenter, prospective, observational study to estimate the effectiveness of pharmacotherapy for delirium. Participants were cancer patients with delirium. We assessed the Delirium Rating Scale, Revised‐98 (DRS‐R98) severity scale score at baseline and three days after pharmacotherapy initiation. Delirium resolution was defined as a DRS‐R98 severity scale score ≤9, and improvement was defined as ≥50% reduction at Day 3.

Results

We enrolled 566 patients (491 patients had performance status of 3 or 4). The resolution and improvement rates in all patients were 22.6% and 19.3%, respectively. Univariate analysis determined that nonrespiratory infection (OR 2.18, 95% CI 1.38‐3.45) was significantly associated with greater resolution, while dehydration (0.40, 0.19‐0.87), organic damage to the central nervous system (CNS) (0.32, 0.43‐0.72), hypoxia (0.25, 0.12‐0.52), and hyponatremia (0.34, 0.12‐0.97) were significantly associated with no resolution. Potential causes associated with delirium improvement were nonrespiratory infection (1.93, 1.19‐3.13), organic damage to the CNS (0.40, 0.18‐1.90), and hypoxia (0.32, 0.16‐0.65). After multivariate analysis, dehydration (0.34, 0.15‐0.76), organic damage to the CNS (0.25, 0.10‐0.60), and hypoxia (0.29, 0.14‐0.61) were significantly associated with no resolution.

Conclusions

Delirium caused by nonrespiratory infection may be reversible, while delirium associated with dehydration, organic damage to the CNS, hypoxia, or hyponatremia seems to be irreversible in ill‐hospitalized cancer patients.

Adding items that assess changes in activities of daily living does not improve the predictive accuracy of the Palliative Prognostic Index

BACKGROUND

Changes in activities of daily living in cancer patients may predict their survival. The Palliative Prognostic Index is a useful tool to evaluate cancer patients, and adding an item about activities of daily living changes might improve its predictive value.

AIM

To clarify whether adding an item about activities of daily living changes improves the accuracy of Palliative Prognostic Index.

DESIGN

Multicenter prospective cohort study.

SETTING

A total of 58 palliative care services in Japan.

PARTICIPANTS

Patients aged >20 years diagnosed with locally extensive or metastatic cancer (including hematological neoplasms) who had been admitted to palliative care units, were receiving care by hospital-based palliative care teams, or were receiving home-based palliative care. Palliative care physicians recorded clinical variables at the first assessment and followed up patients 6 months later.

RESULTS

A total of 2425 subjects were recruited and 2343 of these had analyzable data. The C-statistic of the original Palliative Prognostic Index was 0.801, and those of modified Palliative Prognostic Indices ranged from 0.793 to 0.805 at 3 weeks. For 6-week survival predictions, the C-statistic of the original Palliative Prognostic Index was 0.802, and those of modified Palliative Prognostic Indices ranged from 0.791 to 0.799. The weighted kappa of the original Palliative Prognostic Index was 0.510, and those of modified Palliative Prognostic Indices ranged from 0.484 to 0.508.

CONCLUSION

Adding items about activities of daily living changes to the Palliative Prognostic Index did not improve prognostic value in advanced cancer patients.

Predictors of Delirium in Corticosteroid-Treated Patients with Advanced Cancer: An Exploratory, Multicenter, Prospective, Observational Study

BACKGROUND

Corticosteroids are often used to treat fatigue and anorexia, but occasionally produce delirium. Information on the predictors of delirium in corticosteroid-treated cancer patients remains limited.

OBJECTIVE

To identify potential factors predicting the development of delirium in corticosteroid-treated cancer patients.

DESIGN

An exploratory, multicenter, prospective, observational study.

SETTING/SUBJECTS

Inclusion criteria for this study were patients who had metastatic or locally advanced cancer and a fatigue or anorexia intensity score of 4 or more on a 0-10 Numerical Rating Scale.

MEASUREMENT

Univariate and multivariable analyses were performed to identify the predictors of delirium diagnosed by the Confusion Assessment Method (CAM) within three days of initiation of corticosteroids.

RESULTS

Among 207 patients administered corticosteroids, 35 (17%; 95% confidence interval [CI] 12%-23%) developed at least one episode of delirium diagnosed by the CAM. Factors predictive of the development of delirium were as follows: Palliative Performance Scale ≤20, Eastern Cooperative Oncology Group Performance Status (ECOG PS) = 4, the Support Team Assessment Schedule (STAS) score of drowsiness >1, concurrent opioid use, parenteral hydration volume ≤500 mL, and the absence of lung metastasis. A multivariable analysis identified the independent factors predicting responses as ECOG PS = 4 (odds ratio [OR] 4.0; 95% CI 1.7-9.3), STAS score of drowsiness >1 (OR 3.4; 95% CI 1.4-8.2), and concurrent opioid use (OR 3.7; 95% CI 1.0-13).

CONCLUSION

Delirium in corticosteroid-treated advanced cancer patients may be predicted by PS, drowsiness, and concurrent opioid use. Larger prospective studies are needed to confirm these results.

Predictors of responses to corticosteroids for anorexia in advanced cancer patients: a multicenter prospective observational study

PURPOSE

Although corticosteroids are widely used to relieve anorexia, information regarding the factors predicting responses to corticosteroids remains limited. The purpose of the study is to identify potential factors predicting responses to corticosteroids for anorexia in advanced cancer patients.

METHODS

Inclusion criteria for this multicenter prospective observational study were patients who had metastatic or locally advanced cancer and had an anorexia intensity score of 4 or more on a 0-10 Numerical Rating Scale (NRS). Univariate and multivariate analyses were conducted to identify the factors predicting ≥2-point reduction in NRS on day 3.

RESULTS

Among 180 patients who received corticosteroids, 99 (55 %; 95 % confidence interval [CI], 47-62 %) had a response with ≥2-point reduction. Factors that significantly predicted responses were Palliative Performance Scale (PPS) > 40 and absence of drowsiness. In addition, factors that tended to be associated with ≥2-point reduction in NRS included PS 0-3, absence of diabetes mellitus, absence of peripheral edema, presence of lung metastasis, absence of peritoneal metastasis, baseline anorexia NRS of >6, presence of pain, and presence of constipation. A multivariate analysis showed that the independent factors predicting responses were PPS of >40 (odds ratio = 2.7 [95 % CI = 1.4-5.2]), absence of drowsiness (2.6 [1.3-5.0]), and baseline NRS of >6 (2.4 [1.1-4.8]).

CONCLUSIONS

Treatment responses to corticosteroids for anorexia may be predicted by PPS, drowsiness, and baseline symptom intensity. Larger prospective studies are needed to confirm these results.

Predictors of Responses to Corticosteroids for Cancer-Related Fatigue in Advanced Cancer Patients: A Multicenter, Prospective, Observational Study

CONTEXT

Although corticosteroids are widely used to relieve cancer-related fatigue (CRF), information regarding the factors predicting responses to corticosteroids remains limited.

OBJECTIVES

The aim of this study was to identify potential factors predicting responses to corticosteroids for CRF in advanced cancer patients.

METHODS

Inclusion criteria for this multicenter, prospective, observational study were patients who had metastatic or locally advanced cancer and had a fatigue intensity score of 4 or more on a 0-10 Numerical Rating Scale (NRS). Univariate and multivariate analyses were conducted to identify the factors predicting two-point reduction or more in NRS on day 3.

RESULTS

Among 179 patients who received corticosteroids, 86 (48%; 95% CI 41%-56%) had a response with two-point reduction or more. Factors that significantly predicted responses were performance status score of 3 or more, Palliative Performance Scale score more than 40, absence of ascites, absence of drowsiness, absence of depression, serum albumin level greater than 3 mg/dL, serum sodium level greater than 135 mEq/L, and baseline NRS score greater than 5. A multivariate analysis showed that the independent factors predicting responses were baseline NRS score greater than 5 (odds ratio [OR] 6.6, 95% CI 2.8-15.4), Palliative Performance Scale score more than 40 (OR 4.4, 95% CI 2.1-9.3), absence of drowsiness (OR 3.4, 95% CI 1.7-6.9), absence of ascites (OR 2.3, 95% CI 1.1-4.7), and absence of pleural effusion (OR 2.2, 95% CI 1.0-5.0).

CONCLUSION

Treatment responses to corticosteroids for CRF may be predicted by baseline symptom intensity, performance status, drowsiness, and severity of fluid retention symptoms. Larger prospective studies are needed to confirm these results.

Independent validation of the modified prognosis palliative care study predictor models in three palliative care settings

CONTEXT

Accurate prognostic information in palliative care settings is needed for patients to make decisions and set goals and priorities. The Prognosis Palliative Care Study (PiPS) predictor models were presented in 2011, but have not yet been fully validated by other research teams.

OBJECTIVES

The primary aim of this study is to examine the accuracy and to validate the modified PiPS (using physician-proxy ratings of mental status instead of patient interviews) in three palliative care settings, namely palliative care units, hospital-based palliative care teams, and home-based palliative care services.

METHODS

This multicenter prospective cohort study was conducted in 58 palliative care services including 16 palliative care units, 19 hospital-based palliative care teams, and 23 home-based palliative care services in Japan from September 2012 through April 2014.

RESULTS

A total of 2426 subjects were recruited. For reasons including lack of followup and missing variables (primarily blood examination data), we obtained analyzable data from 2212 and 1257 patients for the modified PiPS-A and PiPS-B, respectively. In all palliative care settings, both the modified PiPS-A and PiPS-B identified three risk groups with different survival rates (P<0.001). The absolute agreement ranged from 56% to 60% in the PiPS-A model and 60% to 62% in the PiPS-B model.

CONCLUSION

The modified PiPS was successfully validated and can be useful in palliative care units, hospital-based palliative care teams, and home-based palliative care services.

Glasgow prognostic score predicts prognosis for cancer patients in palliative settings: a subanalysis of the Japan-prognostic assessment tools validation (J-ProVal) study

PURPOSE

The Glasgow prognostic score (GPS), which uses C-reactive protein and albumin levels, is a good predictor of prognosis in cancer patients undergoing anti-tumor therapy. The objective of this study was to investigate the correlation between GPS and survival among cancer patients in palliative settings, as findings in such populations have not been well described.

METHODS

This was a subanalysis of a multicenter, prospective, cohort study in patients who were adults, diagnosed with advanced cancer, and first referred to palliative care service in Japan. Patients who were not receiving anti-tumor therapy and who had undergone laboratory examinations were eligible. Clinical features were analyzed to investigate prognostic factors.

RESULTS

A total of 1160 patients were enrolled (41.6 % female; median age, 72 years). The independent predictors were Eastern Cooperative Oncology Group performance status (ECOG PS) score of 4 (hazard ratio (HR), 1.54), liver metastasis (HR, 1.21), dyspnea (HR, 1.35), edema (HR, 1.25), prognostic performance index (HR, 1.56), neutrophil-lymphocyte ratio (HR, 1.43), and GPS of 2 (HR, 1.36). The sensitivity and specificity for 3-week prognosis of a GPS of 2 were 0.879 and 0.410. Median survival time with GPS of 0, 1, and 2 was 58 days (95 % confidence interval, 48-81), 43 days (37-50), and 21 days (19-24), respectively (log-rank test, p < 0.001).

CONCLUSION

The GPS was a good prognostic indicator for cancer patients in palliative settings.

Continuous subcutaneous infusion of lidocaine for persistent hiccup in advanced cancer

Persistent hiccup can cause anorexia, weight loss, disabling sleep deprivation, anxiety, and depression. Therefore, relief of persistent hiccup is important for advanced cancer patients and their family. Most reports on this condition are case series reports advocating the use of baclofen, haloperidol, gabapentin, and midazolam. However, these medications are occasionally ineffective or accompanied by intolerable side effects. The sodium channel blocker lidocaine has been shown to be effective in treating a variety of disorders thought to involve neuropathic mechanisms. Intravenous administration of lidocaine is common but efficacy has also been reported for subcutaneous infusion. In advanced cancer patients, subcutaneous infusion is easy, advantageous, and accompanied by less discomfort. We report a case of severe and sustained hiccup caused by gastric cancer that was successfully treated with a continuous subcutaneous infusion of lidocaine (480 mg (24 ml)/day) without severe side effects.

Olanzapine for the relief of nausea in patients with advanced cancer and incomplete bowel obstruction

Bowel obstruction is one of the most common complications in patients with advanced cancer. Incomplete bowel obstruction is one of the leading causes of nausea and vomiting, which may result in a substantial impairment to quality of life. We explored the antiemetic activity of olanzapine against nausea and vomiting in cancer patients with incomplete bowel obstruction. This retrospective study was carried out on a palliative care unit, using an electronic medical record from 2007 to 2009. The intensity of the symptom was evaluated and classified from the medical records on four scales. The frequency of vomiting also was noted from the medical records. During this study period, 20 patients met the inclusion criteria. The average dose of olanzapine was 4.9±1.2mg and treatment duration was 23.4±16.2 days. Olanzapine treatment led to a significant decrease in the average intensity score of nausea from 2.4±0.7 to 0.2±0.4 (P<0.001). Of the 20 patients, 18 (90%) experienced a reduction in the intensity of nausea. The average frequency of vomiting significantly decreased after olanzapine treatment from 1.1±1.3 times/day (median 0.5; range 0-4) before the treatment to 0.3±0.5 times/day (median 0; range 0-1) after the treatment (P<0.01). Before the treatment, 10 patients experienced vomiting; eight of these patients experienced a decrease in the frequency of vomiting with olanzapine treatment. Our study suggests the potential efficacy of olanzapine for relief of nausea in incomplete bowel obstruction. A prospective trial is promising.

Continuous Subcutaneous Infusion of Compound Oxycodone for the Relief of Dyspnea in Patients With Terminally Ill Cancer

Pain and dyspnea are the most prevalent and distressing symptoms in patients with terminally ill cancer. Evidences have accumulated for the effects of morphine on dyspnea, whereas little is known about the effects of oxycodone on dyspnea. We investigated the effectiveness of oxycodone for dyspnea in patients with terminally ill cancer. The injectable form of compound oxycodone (iOC) containing hydrocotarnine was administered continuously via subcutaneous route. We administered iOC to 136 patients. The effect on dyspnea was less conspicuous than pain, yet iOC was effective for dyspnea with varying degrees. None of the adverse effects observed were serious. These results suggest that continuous subcutaneous administration of oxycodone could be one of the reasonable alternatives in the management of dyspnea in patients with terminally ill cancer.

[Problems in the home palliative care revealed from questionnaires at lecture workshops organized by the Tokyo Metropolitan Home Palliative Care Support Center]

Tokyo Kosei-Nenkin Hospital operates the Tokyo Metropolitan Home Palliative Care Support Center (TMHPCSC) commissioned from the Tokyo metropolitan government. TMHPCSC held one lecture workshop for healthcare professionals and one symposium for general citizens in fiscal year ended March 2008. Questionnaires were distributed to the attendants at the beginning of meetings and collected at the end. Several problems in the present home palliative care system were revealed from the questionnaires. Those include problems associated with palliation skills, cooperation among multiple professionals, especially between medical staff and caring staff, transition from hospital to home and aging of society. These problems should be tackled as issues of the whole society.

3',5'-cyclic adenosine monophosphate augments intracellular Ca2+ concentration and gonadotropin-releasing hormone (GnRH) release in immortalized GnRH neurons in an Na+ -dependent manner

In GT1-7 cells, cAMP increases the intracellular Ca2+ concentration ([Ca2+](i)) through activation of the voltage-gated Ca2+ channels, thereby facilitating GnRH release. To activate these channels, the membrane potential must be depolarized. In the present study we hypothesize that cAMP depolarizes the cells by increasing the membrane Na+ permeability, as in the case of somatotrophs and pancreatic beta-cells. To examine this, we analyzed [Ca2+](i) and [Na+](i) in GT1-7 cells by an intracellular ion-imaging technique along with cAMP assay by RIA. Forskolin, a direct activator of adenylyl cyclase, increased [Ca2+](i) and [Na+](i) via cAMP formation. The forskolin-induced increase in [Ca2+](i) depended on the presence of Ca2+ and Na+ in the extracellular solution. This response was blocked by the voltage-gated Ca2+ channel blocker, nifedipine; the nonselective cation channel blocker, gadolinium (Gd3+); and the cyclic nucleotide-gated channel blocker, l-cis-diltiazem. In contrast, the forskolin-induced increase in [Na+](i) depended only on extracellular Na+, not on Ca2+. Gd3+ and l-cis-diltiazem also blocked the increase in [Na+](i). Furthermore, the forskolin-induced increase in GnRH release was blunted in both low Ca2+ and low Na+ media. The results indicate that cAMP increases the membrane Na+ permeability, probably through nonselective cation channels on GT1-7 cells, thereby promoting GnRH release.