188 Journal of Pain and Symptom Management
2 February 2024
PC-FACS December 2023
Attending to Spiritual Well-being
Minimizing Aggressive End-of-Life Care
Training in Opioid Misuse, Substance Use Disorders
Managing Stress for PICU Parents
Treating Depression with Intravenous Ketamine
Understanding Risks of Post-op Antipsychotic Use
Rave Reviews
Attending to Spiritual Well-being
Dimensions of Spiritual Well‑being in Relation to Physi-
cal and Psychological Symptoms: A Cross‑Sectional
Study of Advanced Cancer Patients Admitted to a Palli-
ative Care Unit
Background: Patients with advanced cancer often expe-
rience symptoms such as insomnia, fatigue, pain,
depression, and anxiety.1,2 Can spiritual well-being
(SWB) function as a resource for adults experiencing
cancer-related symptoms?
Design and Participants: This study explored the impact
of the three SWB dimensions (meaning, peace, and
faith) on physical and psychological symptoms among
a convenience sample of patients with advanced cancer
in the hospice ward at Shengjing Hospital of China
Medical University. Patients completed questionnaires
on SWB and cancer-related symptoms (insomnia,
fatigue, pain, depression, and anxiety) upon admission.
The Athens Insomnia Scale, Cancer Fatigue Scale, can-
cer pain numerical rating scales, and Hospital Anxiety
and Depression Scale (HADS) were used. Analyses
included t tests, ANOVA, and Pearson correlation, and
hierarchical regression evaluated associations between
SWB dimensions and symptom experience after adjust-
ing for covariates.
Results: Patients (N=108) were aged mean 65 years old
(§13 yrs); approximately 75% were married or part-
nered, and 51% had achieved an education level of at
least middle school. In univariate analysis, patients who
knew (vs did not know) their advanced cancer diagno-
sis reported higher HADS scores (depression, 12§
5.6 vs 9§4.9 [P=.018]; anxiety, 11§5 vs 8.7§4.4
Ó 2023 Published by Elsevier Inc. on behalf of American Academy of
Hospice and Palliative Medicine.
Vol. 67 No.
[P=.038]). SWB was negatively associated with cancer-
related symptoms (r= 0.37 to 0.69; P<.001). Addi-
tionally, meaning, peace, and faith correlated with
each other (r=0.71-0.76; P<.001). In multivariate analy-
sis, the three dimensions accounted for additional vari-
ance of cancer-related symptoms (18%-44%). For
insomnia, fatigue, and pain, meaning or peace repre-
sented individual protective variables. Meaning was
negatively associated with insomnia (b= 0.52, P<.001)
and fatigue (b= 0.56, P<.001), and peace showed an
association with cancer pain (b= 0.42, P<.001). Peace
and faith were negatively associated with depression
and anxiety, but meaning represented a positive effect
on anxiety (b=0.28, P=.036).
Commentary: This cross-sectional study illustrates the
associations of physical symptoms with three subcom-
ponents of SWB among inpatient hospice patients with
advanced cancer. Although this study’s small size and
cross-sectional design limit drawing causal inferences
from these results alone, in the context of the literature
this study provides further evidence of the protective
effect of spiritual well-being against distress from physi-
cal symptoms.
Bottom Line: Spiritual well-being—broadly defined as
meaning, peace, and faith—and physical well-being are
inextricably linked, and effective control of physical dis-
tress requires attention to spiritual distress as well.
Reviewer: Myrick C. Shinall Jr., MD PhD, Vanderbilt
University Medical Center, Nashville, TN
References
1. Henson LA, Maddocks M, Evans C, Davidson M,
Hicks S, Higginson IJ. Palliative care and the manage-
ment of common distressing symptoms in advanced
cancer: pain, breathlessness, nausea and vomiting, and
fatigue. J Clin Oncol. 2020;38(9):905-14. doi:10.1200/
JCO.19.00470.
2. Bail JR, Traeger L, Pirl WF, Bakitas MA. Psychologi-
cal symptoms in advanced cancer. Semin Oncol Nurs.
2018;34(3):241-51. doi:10.1016/j.soncn.2018.06.005.
Source: Yang Y, Zhao X, Cui M, Wang Y. Dimensions of
spiritual well‑being in relation to physical and psychologi-
cal symptoms: a cross‑sectional study of advanced cancer
patients admitted to a palliative care unit. BMC Palliat
Care. 2023;22(1):137. doi:10.1186/s12904-023-01261-x.
Access this article on PubMed.
0885-3924/$ - see front matter
https://doi.org/10.1016/j.jpainsymman.2023.12.001
Vol. 67 No. 2 February 2024 PC-FACS December 2023
Minimizing Aggressive End-of-Life Care
Aggressive End-of-Life Care Across Gradients of Cog-
nitive Impairment in Nursing Home Patients with Meta-
static Cancer
Background: Studies examining end-of-life care in older
cancer patients have not accounted for cognitive
impairment (COG-I) gradients.1-4 How is COG-I sever-
ity associated with the odds of receiving aggressive end-
of-life care?
Design and Participants: This study examined end-of-life
care patterns across COG-I gradients among older
patients with metastatic cancer and nursing facility stays
(NFS). Patients with NFS and who died with metastatic
cancer between 2013 and 2017 were identified using
data from the linked Surveillance Epidemiology and
End Results−Medicare and Minimum Data Set 3.0
data. Markers of aggressive end-of-life care in the last
30 days of life were cancer-directed treatment; inten-
sive care unit admission, more than one emergency
department (ED) visit, or more than one hospitaliza-
tion; hospice enrollment in the last 3 days of life; and
in-hospital death. In addition to descriptive analysis,
multivariable logistic regression evaluated the indepen-
dent association between COG-I severity and aggressive
end-of-life care.
Results: Of the 40,833 patients (mean age=80 yrs [SD=7.4],
51% female, 38% married), 49% were cognitively intact;
24% had mild COG-I; 20% moderate COG-I; and 6.7%
severe COG-I. The percentage who received aggressive
end-of-life care was 63% and 74% among those who were
cognitively intact and those with severe COG-I, respec-
tively. Compared to cognitively intact patients, those with
severe COG-I had higher odds of receiving any type of
aggressive end-of-life care (adjusted odds ratio [aOR]=1.9
[95% CI=1.7-2]); highest for more than 1 ED visits
(aOR=1.4 [95%CI=1.3-1.5]) and in-hospital death
(aOR=2.3 [95% CI=2.1-2.5]), and lowest for cancer-
directed treatment (aOR=0.76 [95% CI=0.68-0.85]) and
late-entry into hospice (aOR=0.71 [95%CI=0.62-0.81]).
The odds of in-hospital death associated with severe
COG-I were higher among those with short- vs long-term
stays (aOR=2.6 [95% CI=2.4-2.8] and aOR=1.4 [95%
CI=1.2-1.7], respectively).
Commentary: This population-based retrospective
cohort study demonstrates the need to integrate geriat-
ric assessments into cancer care for older adults with
cognitive impairment. Early referral to palliative care
may reduce aggressive end-of-life care, especially as
individuals with COG-I and metastatic cancers often
have challenging symptomatology, which may drive
preventable ED visits. Palliative care clinicians should
be aware of the risks of increased aggressiveness of can-
cer care in patients with severe COG-I. Future mixed
methods research should examine outcomes like
189
palliative care access and referrals, preventable ED vis-
its, and care transitions in patients with COG-I.
Bottom Line: Older adults with metastatic cancer and
cognitive impairment with NFS, are more likely to
receive aggressive care in the last 6 months of life
despite receiving less cancer-directed therapy and ear-
lier entry into hospice.
Reviewer: Sonal Admane, MD MPH, University of Texas
MD Anderson Cancer Center, Houston, TX
References
1. GBD 2019 Dementia Forecasting Collaborators. Esti-
mation of the global prevalence of dementia in 2019
and forecasted prevalence in 2050: an analysis for the
global burden of disease study 2019. Lancet Public
Health. 2022;7(2):e105-e125. doi:10.1016/S2468-2667
(21)00249-8.
2. Givens JL, Selby K, Goldfeld KS, Mitchell SL. Hospi-
tal transfers of nursing home residents with advanced
dementia. J Am Geriatr Soc. 2012;60(5):905-909.
doi:10.1111/j.1532-5415.2012.03919.x.
3. Mitchell SL, Teno JM, Kiely DK, et al. The clinical
course of advanced dementia. N Engl J Med. 2009;361
(16):1529-1538. doi:10.1056/NEJMoa0902234.
4. Koroukian SM, Schiltz NK, Warner DF, Stange KC,
Smyth KA. Increasing burden of complex multimorbid-
ity across gradients of cognitive impairment. Am J Alz-
heimers Dis Other Demen. 2017;32(7):408-417. doi:10.1177/
1533317517726388.
Source: Koroukian SM, Douglas SL, Vu L, et al. Aggres-
sive end-of-life care across gradients of cognitive
impairment in nursing home patients with metastatic
cancer. J Am Geriatr Soc. 2023;71(11):3546-3553. doi:
10.1111/jgs.18526.
Access this article on PubMed.
Training in Opioid Misuse, Substance Use Disorders
Caring for Patients with Opioid Misuse or Substance
Use Disorders in Hospice: A National Survey
Background: Patients with substance use disorders
(SUDs) including opioid use disorder (OUD) have ele-
vated rates of comorbid serious illness.1-3 What are hos-
pice clinicians’ experiences with these conditions?
Design and Participants: This study explored hospice
clinicians’ knowledge, practices, and comfort caring
for patients with opioid misuse and SUD. Clinicians
were recruited (convenience sample) via US hospice
and palliative care organizations to complete an online
survey. Analyses used descriptive statistics; self-assessed
knowledge, skill, and attitude question response ratings
(Likert scale: 1=strongly disagree/least comfortable;
5=strongly agree/most comfortable; <4=nonagree-
ment/lacking comfort); and content analysis.
190
Results: Participants (N=175) were 40% nurses, 40%
physicians, 16% nurse practitioners, and 1.2% social
workers. Respondents reported caring for at least two
patients per month with concern for opioid misuse
(60%), OUD (40%), or SUD (61%). Most felt confi-
dent identifying opioid misuse (94%) and taking SUD
histories (79%). A minority reported lack of confi-
dence initiating conversations with patients regarding
opioid misuse (25%) or substance use (27%) concerns.
Sixty-two percent felt it is their role to treat hospice
patients for SUD, though 56% lacked comfort in using
buprenorphine for OUD treatment. Although 94% felt
it is their role to treat pain in hospice patients with
SUD and that hospice can help patients with SUD
(94%), many were uncomfortable managing pain in
patients taking buprenorphine (45%) or naltrexone
(49%) for SUD. Seventy-three percent felt comfortable
managing pain in patients taking methadone for SUD.
Upon enrollment for those being treated for OUD,
30% reported they only sometimes or never coordinate
care with buprenorphine clinics or prescribers, and
16% reported they have never coordinated transition
of care with a patient’s methadone clinic.
Commentary: This first survey of hospice clinicians
regarding knowledge and experience with opioid mis-
use and addiction begins to quantify knowledge gaps in
the field of hospice and palliative medicine (HPM).
While the sample size was small, it was distributed
broadly via HPM professional societies, and most
respondents had more than 5 years’ experience in hos-
pice. Respondents reported frequent encounters car-
ing for patients with possible opioid misuse, OUD, or
SUD, yet nearly half of respondents were uncomfort-
able managing pain in patients taking buprenorphine
or naltrexone. This need for additional training was
repeated in the qualitative results, which identified the
importance of skills in managing pain and SUD with
buprenorphine. Methods to educate practicing clini-
cians on these topics should be investigated, as efforts
solely targeting fellowship education will be insufficient
to meet current needs.4
Bottom Line: The current clinical workforce in hospice
needs additional training in the management of opioid
misuse, OUD, and SUD.
Reviewer: Jared Lowe, MD HMDC, University of North
Carolina School of Medicine, Chapel Hill, NC
References
1. Schulte MT, Hser Y-I. Substance use and associated
health conditions throughout the lifespan. Public Health
Rev. 2014;35(2). doi:10.1007/bf03391702.
2. Manhapra A, Becker WC. Pain and addiction: an
integrative therapeutic approach. Med Clin North Am.
2018;102(4):745-763; doi:10.1016/j.mcna.2018.02.013.
3. McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug
dependence, a chronic medical illness: implications for
Vol. 67 No. 2 February 2024
treatment, insurance, and outcomes evaluation. JAMA.
2000;284(13):1689-1695; doi:10.1001/jama.284.13.1689.
4. Chua IS, Fratt E, Ho JJ, Roldan CS, Gundersen DA,
Childers J. Primary addiction medicine skills for hos-
pice and palliative medicine physicians: a modified Del-
phi study. J Pain Symptom Manage. 2021;62(4):720-729.
doi:10.1016/j.jpainsymman.2021.02.035.
Source: Langmann GA, Childers J, Merlin JS, et al. Car-
ing for patients with opioid misuse or substance use dis-
orders in hospice: a national survey [published online
ahead of print October 12, 2023]. J Palliat Med.
doi:10.1089/jpm.2023.0082.
Access this article on PubMed.
Managing Stress for PICU Parents
Navigating Stress in the Pediatric Intensive Care Unit
Among Parents of Children with Severe Neurological
Impairment
Background: Children with severe neurological
impairment (SNI) comprise approximately 50% of US
pediatric intensive care unit (PICU) admissions.1,2
What are family caregivers’ experiences?
Design and Participants: This qualitative single-center
study examined how parents and family caregivers of
children with SNI navigate stress during PICU admis-
sions. Content and thematic network analysis evaluated
1:1 semistructured interviews conducted near PICU dis-
charge with parents and family caregivers.
Results: Participants (15 caregivers of 15 children) were
20% fathers and 13% Asian, 13% Black, 13% American
Indian/Alaska Native, and 6% Pacific Islander. Chil-
dren (median age=8 yrs [range=1-21]) had a median
length of stay of 10 days, and 80% had congenital/
chromosomal conditions. The first theme was self-acti-
vation (87%) and had five subthemes: advocating and
showing up (53%), finding moments for self-care
(33%), seeking understanding and education (13%),
accessing support from family and friends (13%), and
harnessing positivity (7%). The second theme was let-
ting go (93%) and also had five subthemes: being sup-
ported by compassionate clinicians (67%), letting
clinicians lead (33%), giving in to distraction (27%),
disconnecting from emotions (20%), and leaving it to
faith and spirituality (7%).
Commentary: This single-center qualitative study high-
lights how parents and caregivers of children with SNI
manage stress during PICU admissions. Similar themes
emerged in this study that are in line with studies of
parents with children with critical illnesses, highlighting
that parent and caregiver stress responses are not illness
specific. Hope and faith are values that clinicians must
balance carefully with discussions of prognosis in order
to maintain trust and support parental coping.3,4 Aware-
ness of parents’ coping strategies allows clinicians to
Vol. 67 No. 2 February 2024 PC-FACS December 2023
better understand parental perspectives, recognize and
praise use of adaptive coping skills, and suggest strategies
for maladaptive coping. Future, multi-institutional stud-
ies should include longitudinal assessment of parental
coping strategies and assess correlates of parental coping
with patient and parent or caregiver outcomes.
Bottom Line: Thematic strategies of “self-activation” and
“letting go” are constructs that parents and caregivers
of children with SNI use to navigate stress during PICU
admissions.
Reviewer: C. Christian Paine, MD, University of Missis-
sippi Medical Center, Jackson, MS
References
1. Berry JG, Poduri A, Bonkowsky JL, et al. Trends in
resource utilization by children with neurological
impairment in the United States inpatient health care
system: a repeat cross-sectional study. PLoS Med. 2012;9
(1):e1001158-10. doi:10.1371/journal.pmed.1001158.
2. Moreau JF, Fink EL, Hartman ME, et al. Hospitaliza-
tions of children with neurologic disorders in the
United States. Pediatr Crit Care Med. 2013;14(8):801-810.
doi:10.1097/PCC.0b013e31828aa71f.
3. Feudtner C, Walter JK, Faerber JA, et al. Good-parent
beliefs of parents of seriously ill children. JAMA Pediatr.
2015;169(1):39-47. doi:10.1001/jamapediat
rics.2014.2341.
4. Mack JW, Wolfe J, Cook EF, Grier HE, Cleary PD,
Weeks JC. Hope and prognostic disclosure. J Clin Oncol.
2007;25(35):5636-5642. doi:10.1200/JCO.2007.12.6110.
Source: Bogetz JF, Yu J, Oslin E, et al. Navigating stress in
the pediatric intensive care unit among parents of chil-
dren with severe neurological impairment. J Pain Symp-
tom Manage. 2023:66(6):647-655. doi:10.1016/j.
jpainsymman.2023.08.025.
Access this article on PubMed.
Treating Depression with Intravenous Ketamine
Change in Patient Centered Outcomes of Psychologi-
cal Well-being, Sleep, and Suicidality Following Treat-
ment with Intravenous Ketamine for Late Life
Treatment Resistant Depression
Background: Depression in late life increases physical
disability, dementia, and overall mortality risks.1-3 Does
intravenous ketamine (IK) for older adults with treat-
ment-resistant depression (TRD) affect patient-cen-
tered outcomes?
Design and Participants: This study is a secondary analy-
sis evaluating patient-centered outcomes of a pilot
study that assessed IK for late life TRD. In the acute
phase (AP), participants 60 years old or older received
twice-weekly IK for 4 weeks. Then, participants with
Montgomery Asberg Depression Rating Scale
191
(MADRS) total score less than 10 or 30% or greater
reduction from baseline proceeded to the continua-
tion phase (CP), which was an additional 4 weeks of
once a week IK. The National Institute of Health
Toolbox Psychological Well Being Positive Affect
and General Life Satisfaction subscales (self reports
generated a t score), Pittsburgh Sleep Quality Index
(“very bad” to “very good”), and Scale for Suicidal Ide-
ation (0-2, “none” to “moderate/strong”) were the
secondary outcomes studied.
Results: Of 25 participants (mean age=72 yrs [SD=4.9],
52% female, and 100% European descended), 22 com-
pleted the AP; 15 were eligible for the CP, and 15 com-
pleted it. Baseline, AP-end, and CP-end psychological
well being t scores were a mean of 30 (SD=4.4), 38
(7.8), and 42 (7.6), respectively; life satisfaction scores
were a mean of 30 (6.1), 38 (9.1), and 42 (7.9), respec-
tively; and positive affect scores were 29 (4.1), 39 (7.8),
and 42 (9), respectively. Among AP responders, base-
line to AP-end psychological well being scores
improved from a mean of 30 (4) to 41 (6.3) and main-
tained at CP-end (42 [7.6]). Meanwhile, AP nonres-
ponders’ psychological well being was unchanged
from baseline to AP-end (30 [3.6] to 31 [5.7]). Of the
total participants, 36%, 77%, and 73% reported “very/
fairly good” sleep at baseline, AP-end, and CP-end,
respectively. Responders’ baseline-to-AP-end “very/
fairly good” sleep reports rose from 33% to 87%, while
nonresponders’ rose from 40% to 57%. Six scored 2 or
more at baseline on suicidality; of these, four improved
by AP-end, one increased, and one withdrew. There
were no cases of treatment emergent suicidality.
Commentary: Depression that does not improve after
two or more adequate treatment courses with antide-
pressants is characterized as TRD. This paper reports a
secondary analysis of a previously published pilot study,
which found that older patients with TRD showed
improvement in MADRS scores after IK treatment.4
This secondary analysis showed that patients treated
with IK also had improved sleep and psychological
well-being, in addition to decreased suicidality. This is
an important addition to the literature, as psychologi-
cal well-being correlates with increased functional sta-
tus, overall physical health, and decreased mortality.5
These results must be taken in the context of a small
sample size and lack of control group. Future phase III
studies should include more patients in addition to
control groups of patients receiving both pharmaco-
therapy and psychotherapy and should be followed for
a longer time period.
Bottom Line: Intravenous ketamine for TRD in older
adults may improve patient well-being, sleep, and suici-
dality, although more data is necessary.
Reviewer: Corey X. Tapper, MD MS, Johns Hopkins Uni-
versity School of Medicine, Baltimore, MD
192
References
1. Diniz BS, Butters MA, Albert SM, Dew MA, Reynolds
CF. Late life depression and risk of vascular dementia
and Alzheimer’s disease: systematic review and meta-
analysis of community based cohort studies. Br J Psy-
chiatry. 2013;202(5):329 335. doi:10.1192/bjp.
bp.112.118307.
2. Schulz R, Drayer RA, Rollman BL. Depression as a
risk factor for non-suicide mortality in the elderly. Biol
Psychiatry. 2002;52(3):205 225. doi:10.1016/S0006-
3223(02)01423-3.
3. Cuijpers P, Smit F. Excess mortality in depression:
a meta analysis of community studies. J Affect Disord.
2002;72(3):227 236. doi:10.1016/S0165-0327(01)
00413-X.
4. Oughli HA, Gebara MA, Ciarleglio A, et al. Intrave-
nous ketamine for late life treatment resistant
depression: a pilot study of tolerability, safety, clinical
benefits, and effect on cognition. Am J Geriatr Psychiatry.
2023;31(3):210 221. doi:10.1016/j.jagp.2022.11.013.
5. Chida Y, Steptoe A. Positive psychological well
being and mortality: a quantitative review of prospec-
tive observational studies. Psychosom Med. 2008;70
(7):741 756. doi:10.1097/PSY.0b013e31818105ba.
Source: Vanderschelden B, Gebara MA, Oughli HA, et
al. Change in patient centered outcomes of psycho-
logical well-being, sleep, and suicidality following treat-
ment with intravenous ketamine for late life
treatment resistant depression. Int J Geriatr Psychiatry.
2023;38(7):e5964. doi:10.1002/gps.5964.
Access this article on PubMed.
Understanding Risks of Post-op Antipsychotic Use
Comparative Safety Analysis of Oral Antipsychotics for
In-Hospital Adverse Clinical Events in Older Adults
After Major Surgery: A Nationwide Cohort Study
Background: Postoperative delirium is the most common
complication after major surgery in older adults.1-3 What
is the risk for adverse clinical events associated with anti-
psychotic use in the postoperative setting?
Design and Participants: This retrospective study ana-
lyzed the Premier Healthcare Database (2009-2018) to
compare the risk for in-hospital adverse events associ-
ated with oral haloperidol (≤ 4 mg on the day of initia-
tion), olanzapine (≤ 10 mg), quetiapine (≤ 150 mg),
and risperidone (≤ 4 mg) in patients 65 years old or
older (without psychiatric disorders) after major sur-
gery. The risk ratios (RRs) for in-hospital death, cardiac
arrhythmia events, pneumonia, and stroke or transient
ischemic attack (TIA) were estimated after propensity
score overlap weighting.
Results: In total, 17,115 patients were included. The
weighted population (in-hospital death risk of 3.1%)
Vol. 67 No. 2 February 2024
had a mean age of 79.5 to 80 years old (SD=7.5-7.9);
was 60% to 63% female; and was 86% to 88% White,
4.6% to 4.9% Black, and 7.8% to 11% other. The most
common surgeries were orthopedic (60% to 61%), gas-
trointestinal (14% to 15%), and vascular (7.6% to
8.2%). Among the four antipsychotics, quetiapine was
the most prescribed (53% of total exposure). There
was no in-hospital death risk difference among patients
treated with haloperidol (3.7%, reference), olanzapine
(2.8%; RR=0.74 [95% CI=0.42-1.3]), quetiapine (2.6%;
RR=0.70 [95% CI=0.47-1]), and risperidone (3.3%;
RR=0.90 [95% CI=0.53-1.4]). The risk for nonfatal clin-
ical events ranged from 2% to 2.6% for a cardiac
arrhythmia event, 4.2% to 4.6% for pneumonia, and
0.6% to 1.2% for stroke or TIA, with no differences by
treatment group. Risk ratios comparing atypical anti-
psychotics and haloperidol (reference) ranged from 1
(95% CI=0.52-1.9; risperidone) to 1.3 (95% CI=0.77-
2.1; quetiapine) for cardiac arrhythmia events; 0.97
(95% CI=0.62-1.6; olanzapine) to 1.1 (95% CI=0.80-1.5;
quetiapine) for pneumonia; and 1.3 (95% CI=0.35-3.5;
olanzapine) to 2 (95% CI=0.94-4.6; quetiapine) for
stroke or TIA.
Commentary: Postoperative delirium is associated with pro-
longed hospitalization, functional decline, increased mor-
tality, and high healthcare costs.2-4 While antipsychotics
are not FDA-approved for the management of delirium,
they are often prescribed in an off-label fashion. Prior stud-
ies in palliative care populations have suggested that some
atypical antipsychotics may have a more favorable risk pro-
file compared to haloperidol.5,6 However, this retrospec-
tive study found no difference in risk of in-hospital death,
cardiac arrhythmia, pneumonia, or TIA or stroke between
oral haloperidol and oral risperidone, olanzapine, and
quetiapine. Patients with delirium in the intensive care
unity, or who are terminally ill, may be treated with short-
term use of haloperidol to manage hyperactive delirium,
agitation, and dangerous behavior despite risk of adverse
reactions, highlighting the need to personalize therapy,
treat underlying precipitating conditions, and incorporate
nonpharmacological interventions.
Bottom Line: In older adults, risperidone, olanzapine,
and quetiapine have similar risks of in-hospital adverse
events compared to oral haloperidol for delirium after
a major surgery.
Reviewer: Emily Jean Martin, MD MS FAAHPM, David
Geffen School of Medicine, University of California,
Los Angeles, CA
References
1. Marcantonio ER. Postoperative delirium: a 76-year-
old woman with delirium following surgery. JAMA.
2012;308(1):73-81. doi:10.1001/jama.2012.6857.
2. Marcantonio ER. Delirium in hospitalized older
adults. N Engl J Med. 2017;377(15):1456-1466.
doi:10.1056/NEJMcp1605501.
Vol. 67 No. 2 February 2024 PC-FACS December 2023
3. Inouye SK, Westendorp RGJ, Saczynski JS. Delirium
in elderly people. Lancet. 2014;383(9920):911-922.
doi:10.1016/S0140-6736(13)60688-1.
4. Gleason LJ, Schmitt EM, Kosar CM, et al. Effect of delir-
ium and other major complications on outcomes after
elective surgery in older adults. JAMA Surg. 2015;150
(12):1134-1140. doi:10.1001/jamasurg.2015.2606.
5. Agar MR, Lawlor PG, Quinn S, et al. Efficacy of oral
risperidone, haloperidol, or placebo for symptoms of
delirium among patients in palliative care: a random-
ized clinical trial. JAMA Intern Med. 2017;177(1):34-42.
doi:10.1001/jamainternmed.2016.7491.
6. Huybrechts KF, Gerhard T, Crystal S, et al. Differen-
tial risk of death in older residents in nursing homes
prescribed specific antipsychotic drugs: population
based cohort study. BMJ. 2012;344:e977.
Source: Kim DH, Lee SB, Park CM. Comparative safety
analysis of oral antipsychotics for in-hospital adverse
clinical events in older adults after major surgery: a
nationwide cohort study. Ann Intern Med. 2023;176
(9):1153-1162. doi:10.7326/M22-3021.
Access this article on PubMed.
Rave Reviews
Rosa WE, Brown CE, Curtis JR. Race-conscious serious
illness communication: an interpersonal tool to disman-
tle racism in practice and research. Palliat Support Care.
2023;21(3):492-497. doi:10.1017/S147895152300038X.
The authors develop a theory-based practical guide to
address racism during serious illness communication
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(SIC). Incorporating these practices can transform SIC
encounters to create physically and psychologically safe
environments for SIC to occur.
Cross SH, Kavalieratos D. Public health and palliative
care. Clin Geriatr Med. 2023;39(3):395-406. doi:10.1016/
j.cger.2023.04.003.
This article explores how policies that set the design of
hospice services create barriers to health equity for
patients suffering from serious illness. The authors
make a succinct and impactful call to develop new
models of palliative care and hospice services.
Heitner R, Rogers M, Chambers B, et al. The experience
of Black patients with serious illness in the United States:
a scoping review. J Pain Symptom Manage. 2023;66(4):
e501-e511. doi:10.1016/j.jpainsymman.2023.07.002.
This review identifies critical gaps in the literature on
racial disparities in serious illness care using the social
ecological model (SEM) to identify understudied
causal mechanisms of disparities. They demonstrate
why it is important for future research to combine
topics at more than one level of the SEM, since all lev-
els interact with each other to influence the illness
experience.
Tapper CX. Geriatric palliative care: providing excel-
lent care to lesbian, gay, bisexual, transgender, queer
older adults. Clin Geriatr Med. 2023:39(3):359-368.
doi:10.1016/j.cger.2023.04.001.
This is a narrative review with practice recommendations
for all clinicians who provide care to LGBTQ+ older
adults. The review gives specific strategies and guidelines
to ensure high-quality care for this population.