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DIAGNOSIS DOES MATTER: MEDICATION DOSING IN END-OF-LIFE CARE FOR PERSONS WITH DEMENTIA
AAGP Annual Meeting 2019 Poster Number: EI - 14
DIAGNOSIS DOES MATTER: MEDICATION DOSING IN END-OF-LIFE CARE FOR PERSONS WITH DEMENTIA Sheni Meghani1; Salma Velazquez2 1
VA Eastern Kansas Healthcare System Kansas University Medical Center
2
Introduction: Background: We provide end-of-life care to veterans with various diagnoses both in acute and long-term care settings. During our practice we noticed differences in dose requirements of various medications used to control symptoms based on primary terminal diagnoses. Literature review did not show any evidence suggesting correlation of doses of medications and primary terminal diagnoses in end-of-life care. Objective: To review medication use, doses, symptoms and diagnoses to establish whether terminal diagnosis would impact the amount of medications required for symptom management in end-of-life care. Methods: We conducted a retrospective chart review of patients who died in the Topeka VA Medical Center inpatient setting from January 1, 2018 to May 31, 2018. Various clinical events were reviewed during the last 48 hours of life of these deceased patients. Results: There were 20 patients who died during the review period; 19 (95%) of them were men. Average age was 74.45 years (range 66 to 95). Out of the total, 5 (25%), 5 (25%) and 4 (20%) of patients had terminal diagnosis of dementia, malignancy and thought disorder respectively. Thirteen (65%) died in acute medical setting and the rest of them died in long-term care setting. None of these patients had a change in care setting during last 48 hours of life. All of these patients experienced pain, anxiety and terminal delirium during last 48 hours of their life, based on clinical assessment. Opiates, lorazepam and haloperidol were used to manage these symptoms during end-of-life care. All of these patients required parenteral (intravenous or subcutaneous) use of medications for symptom control during the last 48 hours of life. Data showed differences in dose requirements of medications based on the primary terminal diagnosis. During the last 48 hours of life, patients with primary terminal diagnosis of dementia required 146.8 mg of parenteral morphine equivalent (PME), 40.9 mg of lorazepam and 68.5 mg of haloperidol in comparison to 42 mg, 11.7 mg and 14.9 mg of respective medications for patients without primary terminal diagnosis of dementia. During the same period, patients with primary terminal diagnosis of thought disorders required 53.6 mg of haloperidol compared to 19 mg for other patients. The PME requirement for patients with and without malignancy as primary terminal diagnosis was 67.8 mg and 68.4 mg respectively. Conclusions: During the last 48 hours of their life, patients with primary terminal diagnosis of dementia required 3 times more morphine, 4 times more lorazepam and 4 times more haloperidol than patients without primary terminal diagnosis of dementia for management of end-of-life symptoms. During the last 48 hours of their life, patients with primary terminal diagnosis of thought disorder required 2.5 times more haloperidol than patients without primary terminal diagnosis of thought disorder. During the last 48 hours of their life, patients with primary terminal diagnosis of malignancy required almost the same doses of morphine equivalent as patients without primary terminal diagnosis of malignancy. Limitations: - Very small sample size - Retrospective review of charts - Single site - Short period of study Implications for Future Research: Our data suggest that patients with dementia required much higher doses of opiate, lorazepam and haloperidol for symptom management during their end-of-life care. This is contradictory to the commonly prevalent clinical understanding that these medications should be used in lower doses in patients with diagnosis of dementia. Further research is needed to study the relation of terminal diagnosis and medication requirements in end-of-life care. Further research is also needed to study physiological and biochemical changes during the terminal state that might influence amount of medications required to treat symptoms. Sponsored by the VA Caucus This research was funded by: None
Parental Morphine Equivalent Lorazepam Haloperidol
S126
Patients with primary terminal diagnosis of dementia
Patients without primary terminal diagnosis of dementia
146.8 mg 40.9 mg 68.5 mg
42 mg 11.7 mg 14.9 mg
Am J Geriatr Psychiatry 27:3S, March 2019
AAGP Annual Meeting 2019 Poster Number: EI - 15
EFFICACY OF A MULTIDISCIPLINARY SPECIALIZED CARE UNIT IN REDUCING SEVERE BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA (BPSD) IN PATIENTS WITH MAJOR NEUROCOGNITIVE DISORDERS: A RETROSPECTIVE STUDY Fran¸c ois Rousseau1,2; Evelyn Keller1,2; Nassima Azouaou2; Manel Jarboui2; Lorraine Telleria-Bernal2; Alexandra Simard3; Phylicia Verreault1,4; Chantal Merette2,4; Johanne Duguay1; Annie Labbe4; Rossana Peredo Nunez de Arco4 1
IUSMQ Laval University 3 CHU de Quebec 4 CERVO brain research center 2
Introduction: Behavioural and psychological symptoms (BPSD) associated with major neurocognitive disorder (MNCD) represent the psychological and behavioural problems that appear as the disease progresses. BPSD may vary according to the etiology and stage of MNCD, and are associated with a higher risk of premature institutionalization. Non-pharmacological interventions and pharmacological interventions have been widely used to address BPSD. The literature supports the use of an integrated approach including person-centered non-pharmacological and pharmacological interventions. Methods: The aim of this study was twofold: to characterize the patient population of a multidisciplinary specialized care unit involving at the IUSMQ in Quebec City using non-pharmacological and pharmacological interventions for patients with severe BPSD symptoms. Second, to evaluate the efficacy of the specialized care unit in reducing BPSD symptoms as measured by the neuropsychiatric inventory (NPI). Data were retrospectively collected from the medical chart and entered into a database. Only the participants for whom a measure of the NPI was recorded at admission and at discharge were included in this study (N = 54 participants). Results: Analysis of this clinical sample revealed that the NPI score was significantly reduced at discharge as compared to admission. The subscales showing a statistically significant reduction were agitation/aggression, anxiety, disinhibition, irritability/lability and aberrant motor activity. Conclusions: These results suggest that a combined approach implemented by a multidisciplinary team can reap significant benefits for BPSD patients with advanced stage MNCD hospitalized on a special care unit. This research was funded by: Cashman-Gauthier foundation Quebec Alzheimer’s disease association PDF: http://submissions.mirasmart.com/Verify/AAGP2019/Original/AAGP2019-000339/AAGP2019-000339_Fig1.pdf Results of the paired samples ttest evaluating change in neuropsychiatric symptoms between admission and discharge for N = 54 participants Mean difference
SD
t
p
95% CI
Cohen’ s d
- 9.15 - 0.26 - 0.09 - 2.37 0.06 - 1.11 - 0.54 0.13 -1.33 - 1.54 - 0.85 - 0.54 -0.69
15.22 3.18 2.44 3.92 1.69 3.76 2.03 3.85 4.39 4.28 2.94 3.20 4.10
-4.42 -0.60 -0.28 -4.44 0.24 - 2.17 - 1.94 0.25 -2.23 - 2.64 - 2.13 - 1.23 -1.23
< .001 .552 .781 < .001 .810 .034 .058 .806 .030 .011 .038 .223 .225
-13.30 − -4.99 -1.13 − 0.61 -0.76 − 0.57 -3.44 − -1.30 -0.41 − 0.52 -2.14 − -0.08 -1.09 − 0.02 -0.92 − 1.18 -2.53 − -0.14 -2.70 − -0.37 -1.65 − -0.05 -1.41 − 0.34 -1.80 − 0.43
0.60 0.10 0.04 0.69 0.03 0.30 0.30 0.41 0.82 0.43 0.22 0.17 0.21
Total score Delusions Hallucinations Agitation/Aggression Depression/Dysphoria Anxiety Elation/Euphoria Apathy/Indifference Disinhibition Irritability/Lability Aberrant motor activity Night-time behavioral disturbances Appetite/Eating abnormalities
Note. Paired samples ttest evaluating if the mean difference is statistically different than zero. SD = standard deviation, CI = confidence interval. Cohen’s dis a measure of effect size (0.20 = small effect size, 0.50 = medium effect size, 0.80 = large effect size). Negative scores indicate a reduction in symptoms.
Am J Geriatr Psychiatry 27:3S, March 2019
S127
DIAGNOSIS DOES MATTER: MEDICATION DOSING IN END-OF-LIFE CARE FOR PERSONS WITH DEMENTIA Sheni Meghani1; Salma Velazquez2 1
VA Eastern Kansas Healthcare System Kansas University Medical Center
2
Introduction: Background: We provide end-of-life care to veterans with various diagnoses both in acute and long-term care settings. During our practice we noticed differences in dose requirements of various medications used to control symptoms based on primary terminal diagnoses. Literature review did not show any evidence suggesting correlation of doses of medications and primary terminal diagnoses in end-of-life care. Objective: To review medication use, doses, symptoms and diagnoses to establish whether terminal diagnosis would impact the amount of medications required for symptom management in end-of-life care. Methods: We conducted a retrospective chart review of patients who died in the Topeka VA Medical Center inpatient setting from January 1, 2018 to May 31, 2018. Various clinical events were reviewed during the last 48 hours of life of these deceased patients. Results: There were 20 patients who died during the review period; 19 (95%) of them were men. Average age was 74.45 years (range 66 to 95). Out of the total, 5 (25%), 5 (25%) and 4 (20%) of patients had terminal diagnosis of dementia, malignancy and thought disorder respectively. Thirteen (65%) died in acute medical setting and the rest of them died in long-term care setting. None of these patients had a change in care setting during last 48 hours of life. All of these patients experienced pain, anxiety and terminal delirium during last 48 hours of their life, based on clinical assessment. Opiates, lorazepam and haloperidol were used to manage these symptoms during end-of-life care. All of these patients required parenteral (intravenous or subcutaneous) use of medications for symptom control during the last 48 hours of life. Data showed differences in dose requirements of medications based on the primary terminal diagnosis. During the last 48 hours of life, patients with primary terminal diagnosis of dementia required 146.8 mg of parenteral morphine equivalent (PME), 40.9 mg of lorazepam and 68.5 mg of haloperidol in comparison to 42 mg, 11.7 mg and 14.9 mg of respective medications for patients without primary terminal diagnosis of dementia. During the same period, patients with primary terminal diagnosis of thought disorders required 53.6 mg of haloperidol compared to 19 mg for other patients. The PME requirement for patients with and without malignancy as primary terminal diagnosis was 67.8 mg and 68.4 mg respectively. Conclusions: During the last 48 hours of their life, patients with primary terminal diagnosis of dementia required 3 times more morphine, 4 times more lorazepam and 4 times more haloperidol than patients without primary terminal diagnosis of dementia for management of end-of-life symptoms. During the last 48 hours of their life, patients with primary terminal diagnosis of thought disorder required 2.5 times more haloperidol than patients without primary terminal diagnosis of thought disorder. During the last 48 hours of their life, patients with primary terminal diagnosis of malignancy required almost the same doses of morphine equivalent as patients without primary terminal diagnosis of malignancy. Limitations: - Very small sample size - Retrospective review of charts - Single site - Short period of study Implications for Future Research: Our data suggest that patients with dementia required much higher doses of opiate, lorazepam and haloperidol for symptom management during their end-of-life care. This is contradictory to the commonly prevalent clinical understanding that these medications should be used in lower doses in patients with diagnosis of dementia. Further research is needed to study the relation of terminal diagnosis and medication requirements in end-of-life care. Further research is also needed to study physiological and biochemical changes during the terminal state that might influence amount of medications required to treat symptoms. Sponsored by the VA Caucus This research was funded by: None
Parental Morphine Equivalent Lorazepam Haloperidol
S126
Patients with primary terminal diagnosis of dementia
Patients without primary terminal diagnosis of dementia
146.8 mg 40.9 mg 68.5 mg
42 mg 11.7 mg 14.9 mg
Am J Geriatr Psychiatry 27:3S, March 2019
AAGP Annual Meeting 2019 Poster Number: EI - 15
EFFICACY OF A MULTIDISCIPLINARY SPECIALIZED CARE UNIT IN REDUCING SEVERE BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA (BPSD) IN PATIENTS WITH MAJOR NEUROCOGNITIVE DISORDERS: A RETROSPECTIVE STUDY Fran¸c ois Rousseau1,2; Evelyn Keller1,2; Nassima Azouaou2; Manel Jarboui2; Lorraine Telleria-Bernal2; Alexandra Simard3; Phylicia Verreault1,4; Chantal Merette2,4; Johanne Duguay1; Annie Labbe4; Rossana Peredo Nunez de Arco4 1
IUSMQ Laval University 3 CHU de Quebec 4 CERVO brain research center 2
Introduction: Behavioural and psychological symptoms (BPSD) associated with major neurocognitive disorder (MNCD) represent the psychological and behavioural problems that appear as the disease progresses. BPSD may vary according to the etiology and stage of MNCD, and are associated with a higher risk of premature institutionalization. Non-pharmacological interventions and pharmacological interventions have been widely used to address BPSD. The literature supports the use of an integrated approach including person-centered non-pharmacological and pharmacological interventions. Methods: The aim of this study was twofold: to characterize the patient population of a multidisciplinary specialized care unit involving at the IUSMQ in Quebec City using non-pharmacological and pharmacological interventions for patients with severe BPSD symptoms. Second, to evaluate the efficacy of the specialized care unit in reducing BPSD symptoms as measured by the neuropsychiatric inventory (NPI). Data were retrospectively collected from the medical chart and entered into a database. Only the participants for whom a measure of the NPI was recorded at admission and at discharge were included in this study (N = 54 participants). Results: Analysis of this clinical sample revealed that the NPI score was significantly reduced at discharge as compared to admission. The subscales showing a statistically significant reduction were agitation/aggression, anxiety, disinhibition, irritability/lability and aberrant motor activity. Conclusions: These results suggest that a combined approach implemented by a multidisciplinary team can reap significant benefits for BPSD patients with advanced stage MNCD hospitalized on a special care unit. This research was funded by: Cashman-Gauthier foundation Quebec Alzheimer’s disease association PDF: http://submissions.mirasmart.com/Verify/AAGP2019/Original/AAGP2019-000339/AAGP2019-000339_Fig1.pdf Results of the paired samples ttest evaluating change in neuropsychiatric symptoms between admission and discharge for N = 54 participants Mean difference
SD
t
p
95% CI
Cohen’ s d
- 9.15 - 0.26 - 0.09 - 2.37 0.06 - 1.11 - 0.54 0.13 -1.33 - 1.54 - 0.85 - 0.54 -0.69
15.22 3.18 2.44 3.92 1.69 3.76 2.03 3.85 4.39 4.28 2.94 3.20 4.10
-4.42 -0.60 -0.28 -4.44 0.24 - 2.17 - 1.94 0.25 -2.23 - 2.64 - 2.13 - 1.23 -1.23
< .001 .552 .781 < .001 .810 .034 .058 .806 .030 .011 .038 .223 .225
-13.30 − -4.99 -1.13 − 0.61 -0.76 − 0.57 -3.44 − -1.30 -0.41 − 0.52 -2.14 − -0.08 -1.09 − 0.02 -0.92 − 1.18 -2.53 − -0.14 -2.70 − -0.37 -1.65 − -0.05 -1.41 − 0.34 -1.80 − 0.43
0.60 0.10 0.04 0.69 0.03 0.30 0.30 0.41 0.82 0.43 0.22 0.17 0.21
Total score Delusions Hallucinations Agitation/Aggression Depression/Dysphoria Anxiety Elation/Euphoria Apathy/Indifference Disinhibition Irritability/Lability Aberrant motor activity Night-time behavioral disturbances Appetite/Eating abnormalities
Note. Paired samples ttest evaluating if the mean difference is statistically different than zero. SD = standard deviation, CI = confidence interval. Cohen’s dis a measure of effect size (0.20 = small effect size, 0.50 = medium effect size, 0.80 = large effect size). Negative scores indicate a reduction in symptoms.
Am J Geriatr Psychiatry 27:3S, March 2019
S127