Volume 2, Number 6 Dear Colleague, November is National Hospice Month, making this a good time to learn more about hospice service, and to help you do so, the National Hospice and Palliative Care Organization just last month released its newest report on hospice care in the United States. Statistical highlights include that approximately 38.8% of those who died in the U.S. last year received hospice care, that the average length of service was 67.4 days, that four of five hospice care patients are 65 years or older and that more than one-third are 85 years or older. Another trend of interest to hospice care providers is that patients with cancer now account for fewer than half of all hospice admissions (41.3%), far lower numbers than when hospice care was first established in the 1970s. Today, hospice admissions include high percentages of patients with chronic heart disease (11.8%), dementia (10.1%), and lung disease (7.9%), as well as those with unspecified debilities (11.2%). The full report is available for download on the organization’s Web site (www.nhpco.org). This month’s issue of VIA will further your awareness of hospice care issues with summaries of journal articles on helping patients specify preferences for end-of-life care, recommendations on use of medications for chronic pain, how depression affects cancer patients’ quality of life, and the numbers of seniors experiencing cognitive impairment, Please call us at 1-866-847-8222 if you have questions or would like to speak with a hospice medical director or other hospice specialist in your community. Regards, Kevin S. Henning, MD, FAAFP Diplomate, American Board of Hospice and Palliative Medicine  R E G I O N A L  M E D I C A L  D I R E C T O R  |  VistaCare

Kevin S. Henning, MD, FAAFP Diplomate, American Board of Hospice and Palliative Medicine Table of Contents » Proactive Planning: Intervention Improves Nursing Home Residents’ End-of-Life Care » Pain Management: Expert Panel Issues Consensus Statement on Use of Step III Opioids » Pain Beliefs: Depression and Quality of Life for Patients With Cancer » Cognitive Impairment: Longitudinal Study Addresses Non-dementia Prevalence Print-Friendly Version Email a Friend

The following is a summary of the article “Improving End-of-Life Outcomes in Nursing Homes by Targeting Residents at High Risk of Mortality for Palliative Care: Program Description and Evaluation” by Cari Levy, MD, Monica Morris, BS, and Andrew Kramer, MD, that appeared in the March 1, 2008, Journal of Palliative Medicine.

A retrospective chart review compared end-of-life care outcomes to assess use of a program titled Making Advance Planning a Priority (MAPP). This initiative first identified individuals at high mortality risk, then informed the attending physicians of those at risk, obtained either palliative care or a hospice consultation depending on patient prognosis, and evaluated patients’ documents related to advance care preferences. To assess efficacy, researchers compared charts of nursing home residents who died one year before implementation with those who died one year after the program was launched. Points of comparison consisted of: 1) location of patient at time of death, 2) existence of an advance directive, 3) presence of a cardiopulmonary resuscitation order, 4) utilization of either palliative care or hospice consultation and 5) term of palliative care or hospice services before death. Following MAPP intervention, the nursing home residents were significantly less likely to die in the hospital and more likely to be referred for palliative care. All post-MAPP program residents had advance directives in place at time of death. Results supported the researchers’ hypotheses regarding ways to better meet end-of-life needs. Read more.

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The following is a summary of the article “Opioids and the Management of Chronic Severe Pain in the Elderly: Consensus Statement of an International Expert Panel with Focus on the Six Clinically Most Often Used World Health Organization Step III Opioids (Buprenorphine, Fentanyl, Hydromorphone, Methadone, Morphine, Oxycodone)” by Joseph Pergolizzi, MD, Rainer H. Böger, MD, Keith Budd, MD, Albert Dahan, MD, Serdar Erdine, MD, Guy Hans, MD, Hans-Georg Kress, MD, Ph.D., Richard Langford, MD, Ph.D., Rudolf Likar, MD, FRCA, Robert B. Raffa, Ph.D., and Paola Sacerdote, Ph.D., featured in May 23, 2008, (online version of Vol. 8, Issue 4) of Pain Practice.

Seven categories of opoid use for managing chronic pain in the elderly are addressed in this consensus report drawn from evidence-based literature analyzed by an international panel. Criteria for selection include efficacy, side effects, onset of treatment, drug interactions, potential for misuse, and practical factors, including cost and availability of the medication, as well as severity and kind of pain. Contents include use of opoids (generally transdermal buprenorphine) as advised for 1) cancer pain, 2) noncancer-related pain with individual dose titration based on tolerability, 3) neuropathic pain and 4) in patients with impaired renal and hepatic function. In addition, the report covers use of opoids in the event of 5) respiratory depression, 6) immunosuppression, and 7) the patient adverse event profile with regard to effects on the central nervous and gastrointestinal systems.

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The following is a summary of the article “Depression and Quality of Life in Cancer Patients With and Without Pain: the Role of Pain Beliefs” by Azadeh Tavoli, Ali Montazeri, Rasool Roshan, Zahra Tavoli and Mahdiyeh Melyani, featured in BMC Cancer 2008, 8:177.

This study conducted by researchers at the Cancer Institute, the Iranian Institute for Health Sciences Research and the Department of Psychology at Shahed University, all in Tehran, Iran, investigates the multidimensionality of pain in order to 1) compare depression and quality of life in gastrointestinal cancer patients who do and do not report pain, and 2) determine correlations among reported pain beliefs, incidence of depression and quality of life. Statistical analyses drew from these measurement methodologies: 1) the Hospital Anxiety and Depression Scale (HADS); 2) the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30); and the Pain Beliefs and Perceptions Inventory (PBPI). Results showed significant correlations involving pain consistency, depression and quality of life, as well as pain permanence and depression. No significant relationships were evident among depression, quality of life and pain beliefs regarding self-blame and knowledge of the disease. Presenting findings in the context of a global literature analysis, the researchers posit that pain belief factors are not culture specific and call on clinicians to simultaneously relieve physical, psychological, and emotional distress in support of a biopsychosocial model of chronic pain. Read more.

To view this article in its entirety, click here. To schedule a free hospice education seminar in your office, contact your local VistaCare office at 1-866-847-8222.

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The following is a summary of the article “Prevalence of Cognitive Impairment without Dementia in the United States” by Brenda L. Plassman, Ph.D.; Kenneth M. Langa, MD, Ph.D.; Gwenith G. Fisher, Ph.D.; Steven G. Heeringa, Ph.D.; David R. Weir, Ph.D.; Mary Beth Ofstedal, Ph.D.; James R. Burke, MD, Ph.D.; Michael D. Hurd, Ph.D.; Guy G. Potter, Ph.D.; Willard L. Rodgers, Ph.D.; David C. Steffens, MD, MHS; John J. McArdle, Ph.D.; Robert J. Willis, Ph.D.; and Robert B. Wallace, MD, that appeared in Annals of Internal Medicine, March 18, 2008.

According to this study funded by the National Institute on Aging, large numbers of the senior population in America demonstrate measurable cognitive impairment that does not reach the threshold for dementia and that may or may not qualify as pre-dementia. A prevalence rate of 22 percent was found, which amounts to a number of individuals 70 percent higher than the population with dementia in this age group. The longitudinal study took place from July 2001 to March 2005 and involved participants in the Aging, Demographics and Memory Study (ADAMS) drawn from the nationally representative Health and Retirement Study (HRS) who were 71 years of age or older. Prominent subtypes include prodromal Alzheimer’s and cerebrovascular diseases. Follow up tracked annual rates for progression to dementia as well as mortality. In 2002, researchers estimate, 5.4 million people in the U.S. had cognitive impairment without dementia (22.2 percent of the population age 71 and older). Read more.

To view this article in its entirety, click here. To receive a free hospice eligibility kit, visit www.VistaCare.com/eligibility or contact your local VistaCare office at 1-866-847-8222.

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