[Parkinson's disease, Alzheimer's disease and oncological diseases in residential geriatric care : Pain frequency and selected healthcare features in comparison]. / Morbus Parkinson, Morbus Alzheimer und onkologische Erkrankungen in der stationären Altenhilfe : Schmerzhäufigkeit und ausgewählte Versorgungsmerkmale im Vergleich.

BACKGROUND: Adequate pain management and palliative care structures are of significant importance in residential nursing homes. Whilst professional pain treatment and palliative care measures are frequently implemented for residents with oncological diseases, this is often not the case for residents with neurological disorders. Such a potential undertreatment is even more challenging when the means of interaction and communication with affected persons are aggravated by impairments in cognitive function. OBJECTIVE: To examine differences in selected health care service characteristics between nursing home residents with Parkinson's disease, Alzheimer's disease and residents diagnosed with cancer. MATERIAL AND METHODS: Secondary data analysis of residents' survey and medical record data from 13 nursing homes as part of the study "Action Alliance Pain-free City Münster". RESULTS: Compared with residents with Parkinson's disease and cancer, nursing home residents with Alzheimer's disease exhibited significantly more severe impairment in cognitive function, less additional pain-associated diagnoses, shorter length of stay in nursing homes and more indications of pain. CONCLUSION: The generally high level of pain in all observed residents elucidates the principle necessity of adequate pain assessment and an interprofessional pain treatment. Furthermore, there seems to be a still unmet need for specifically adapted pain management strategies especially for the steadily increasing number of people with Parkinson's disease and Alzheimer's disease living in nursing homes. This should be a future high priority task for (nursing) practice and research against the background of the vulnerability of nursing home populations.

[Provision of palliative care for people with advanced dementia]. / Palliativversorgung von Menschen mit fortgeschrittener Demenz.

As a result of a literature-based expert process, this review provides an overview about the principles of palliative care for people with advanced dementia that are relevant for clinical practice. In particular, the indications, impact and aims of palliative care for advanced dementia are described. Life-prolonging measures and management of symptoms at the end of life are discussed. Furthermore, the overview focuses on the legal basis of decision making.

Cathepsin S increases tau oligomer formation through limited cleavage, but only IL-6, not cathespin S serum levels correlate with disease severity in the neurodegenerative tauopathy progressive supranuclear palsy.

Limited cleavage promotes the aggregation propensity of protein tau in neurodegenerative tauopathies. Cathepsin S (CatS) is overexpressed in brains of patients suffering from tauopathies such as Alzheimer's disease (AD). Furthermore, CatS serum levels correlate with survival in the elderly. The current study investigates whether limited cleavage by CatS promotes tau aggregation, and whether CatS serum levels may correlate with disease severity in tauopathies. Oligomer formation of fluorescently labeled protein tau was monitored by single particle fluorescence spectroscopy after coincubation with CatS. Tau cleavage patterns were investigated by SDS-PAGE. For serum analyses, samples were collected from 42 patients with probable progressive supranuclear palsy (PSP) according to NINDS-PSP criteria. Disease severity was assessed by PSP rating scale (PSP-RS), PSP staging system (PSP-S) and Schwab and England Activities of Daily Living (SEADL). CatS, cystatin C (CysC) and interleukin 6 (IL-6) serum levels were determined by ELISA, ECLIA and turbidimetry, respectively. SDS-PAGE demonstrated a distinct cleavage pattern of protein tau after coincubation with CatS. Furthermore, tau oligomer formation was increased 2.4-fold (p < 0.05) after limited cleavage. Serum CatS and CysC levels did not correlate with disease severity in PSP. Of note, IL-6 correlated with PSP-S (r = 0.41; 95% CI 0.11-0.65; p = 0.008), SEADL (r = -0.37; 95% CI -0.61 to -0.06; p = 0.017) and the history and gait/midline subdomains of the PSP-RS. While CatS facilitates tau aggregation in vitro, serum levels of CatS appear not to correlate with disease severity. The observed correlation of IL-6 with disease severity warrants further investigation of inflammatory markers in PSP.

[Integration of Palliative and Hospice Care Structures in the Care of Neurological Patients: Opinion of Chief Consultant Neurologists in Germany]. / Integration von Palliativ- und Hospizstrukturen in die Versorgung neurologischer Patienten ­ Meinungsbild neurologischer Chefärzte in Deutschland.

An online survey of chief neurological consultants was conducted to find out how they judged the demand for and access to palliative and hospice care (PHC) structures for their neurological patients (NP) as well as their collaboration with PHC structures. 110 of 881 chief consultants who were contacted participated in the survey. About 10 % of their NP were considered suitable for PHC. They estimated that 9 % of the deceased had died from their underlying neurological disease. The integration of PHC structures into the management of various neurological diseases was considered worthwhile but 51.9 - 78.5 % indicated that there was no or little collaboration with PHC structures. 12 % of the participants were trained in palliative care (PC). To guarantee an adequate PHC also for NP, PHC knowledge should be integrated into the curriculum and training of neurologists and the PC community should further extend its services to NP, adapting their knowledge and structures to these patients' special needs.

A consensus review on the development of palliative care for patients with chronic and progressive neurological disease.

BACKGROUND AND PURPOSE: The European Association of Palliative Care Taskforce, in collaboration with the Scientific Panel on Palliative Care in Neurology of the European Federation of Neurological Societies (now the European Academy of Neurology), aimed to undertake a review of the literature to establish an evidence-based consensus for palliative and end of life care for patients with progressive neurological disease, and their families. METHODS: A search of the literature yielded 942 articles on this area. These were reviewed by two investigators to determine the main areas and the subsections. A draft list of papers supporting the evidence for each area was circulated to the other authors in an iterative process leading to the agreed recommendations. RESULTS: Overall there is limited evidence to support the recommendations but there is increasing evidence that palliative care and a multidisciplinary approach to care do lead to improved symptoms (Level B) and quality of life of patients and their families (Level C). The main areas in which consensus was found and recommendations could be made are in the early integration of palliative care (Level C), involvement of the wider multidisciplinary team (Level B), communication with patients and families including advance care planning (Level C), symptom management (Level B), end of life care (Level C), carer support and training (Level C), and education for all professionals involved in the care of these patients and families (Good Practice Point). CONCLUSIONS: The care of patients with progressive neurological disease and their families continues to improve and develop. There is a pressing need for increased collaboration between neurology and palliative care.

Decision making at the end of life--cancer patients' and their caregivers' views on artificial nutrition and hydration.

PURPOSE: Deciding on artificial nutrition and hydration (ANH) at the end of life (EoL) may cause concerns in patients and their family caregivers but there is scarce evidence regarding their preferences. Therefore, the aim of this study was to assess the impact of factors associated with ANH decision making. METHODS: Prospective, Cross-sectional survey. Adult patients admitted to hospital for symptoms of advanced cancer as well as their family caregivers completed a self-administered questionnaire. Items included personal views and concerns about ANH. Family caregivers additionally recorded their preference for their loved one and, if applicable, previous experience with ANH decisions. RESULTS: Thirty-nine out of sixty-five patients and 30/72 relatives responded. Higher age of the patient was significantly correlated with both the patient's and the relative's decision to forgo ANH (Kruskal-Wallis test, p < 0.01). Thirty-nine percent of patients, 37 % of relatives if deciding for themselves, and 24 % of relatives if deciding on behalf of their loved one opted against ANH; 36, 40 and 52 % preferred artificial hydration (AH) only (χ (2) test, p <0.001), while 23, 23 and 24 %, respectively, wished to receive ANH. Patients felt more confident about decisions on artificial nutrition (AN) than caregivers (T test, p < 0.05) and less concerned about adverse effects of forgoing ANH on pain, agitation and sensation of hunger and thirst (χ (2) test, p < 0.05). Satisfaction of patients with communication regarding forgoing ANH (5.0 ± 2.8 on a Likert scale from 0 to 10) correlated with their confidence (Spearman's rho, p < 0.01). A thorough consultation with the attending physician on ANH issues was the favoured source of support for 77 % of patients and 97 % of relatives. A majority of patients considered their relatives' opinion (67 %) and their own advance directives (62 %) as crucial for making ANH decisions, and 46 % of them had such a document completed. CONCLUSION: Cancer patients and their relatives have similar preferences regarding ANH at the EoL, but relatives are reluctant to withhold AH if deciding for their loved one. While patients seem to be confident with ANH decision making, their caregivers may particularly benefit from discussing ANH options to dissipate fears.

[Multimorbidity of neurological patients in palliative care units]. / Multimorbidität neurologischer Patienten auf Palliativstationen.

BACKGROUND: Multimorbidity in patients with neurological diseases needs enhanced attention. Especially the treatment with medication for comorbidities should be regularly evaluated and adapted to the current condition of the patient. PROBLEM: The problem of how to deal with multimorbidity of neurological patients on palliative care units is discussed. MATERIAL AND METHODS: This article gives a retrospective review of data and presentation of own results together with a discussion on basic knowledge and expert recommendations. RESULTS: Multimorbidity of patients with neurological diseases depends on the underlying disease and age. Multimorbidity is often associated with polypharmacy which should be critically evaluated during palliative care treatment. Long-term pharmacological treatment often needs to be terminated as the side effects outweigh the benefits. Our own data show that patients leaving the palliative care unit often have a reduced amount of drugs compared to those who have died. Multimorbidity at the end of life includes dementia, delirium and epileptic seizures as well as symptoms associated with tube feeding. Artificial nutrition should be regarded as a form of pharmacological treatment and its usefulness at the end of life carefully evaluated.

[Drug therapy of anxiety and fear in palliative care patients with cancer or other illnesses : a systematic review]. / Medikamentöse therapie der angst bei patienten mit fortgeschrittenen tumorerkrankungen bzw. Patienten in der palliativen situation : systematische literaturübersicht.

BACKGROUND: Pharmacological treatment of anxiety is an important part of drug treatment in palliative care. In this review we searched for the current evidence of pharmacological treatment of anxiety in palliative care. MATERIALS AND METHODS: A systematic search of PubMed, Embase, PsycLIT, PsycINFO, CINAHL for studies of anxiety in palliative care was carried out in January 2012. Furthermore we searched the Cochrane Library, references of literature and leading textbooks. Studies were identified and information was filled in a standardized extraction sheet. Studies have been categorized and anxiety as an endpoint determined. RESULTS: A total of four controlled studies, three uncontrolled studies, two retrospective studies, one case report, two surveys, one systematic Cochrane review and one unsystematic review were analyzed and included in this review. This indicates an overall low number of studies for the pharmacological treatment of anxiety in palliative care. According to our results, benzodiazepines are the most commonly used drugs in palliative care. However, based on our review, there is no evidence-based recommendation for the therapeutic use in palliative care. CONCLUSIONS: With the existing evidence no general recommendations for pharmacological treatment of anxiety in palliative care can be given. Even for the commonly used benzodiazepines, neuroleptics, antidepressants, antihistamines and beta blockers for the treatment of anxiety no evidence based recommendations can be made. However, these medications are commonly used to treat anxiety in other patient populations and can also be used in palliative care patients. According to our review we cannot recommend a single drug or give recommendations regarding the dosage of drugs. There is a strong need for randomized controlled trials to evaluate the effect of drug treatment of anxiety in palliative care patients. The English full text version of this article will be available in SpringerLink as of November 2012 (under "Supplemental").

Bilateral and unilateral internal carotid artery dissection causing isolated hypoglossal nerve palsy: a case report and review of the literature.

Two cases of isolated hypoglossal nerve palsy due to internal carotid artery dissection are reported. In one case, a bilateral dissection was encountered. The clinical presentation and multidisciplinary management are discussed and the literature reviewed.

Mannitol, but not allopurinol, modulates changes in cerebral blood flow, intracranial pressure, and brain water content during pneumococcal meningitis in the rat.

OBJECTIVE: To investigate the benefit of the hyperosmolar agent, mannitol, and the xanthine oxidase inhibitor, allopurinol, in experimental pneumococcal meningitis in the rat. DESIGN: A prospective, randomized, controlled experimental study. SETTING: Experimental animal laboratory in a university hospital. SUBJECTS: Sixty-five anesthetized and artificially ventilated adult male Wistar rats, weighing 250 to 300 g. INTERVENTIONS: Meningitis was induced by intracisternal injection of live pneumococci. Infected rats were randomized to receive mannitol or allopurinol. MEASUREMENTS AND MAIN RESULTS: There were marked increases in regional cerebral blood flow (measured by laser-Doppler flowmetry), intracranial pressure, brain water content, and cerebrospinal fluid white blood cell count in infected rats within 6 hrs after infection (p < .05, compared with uninfected controls). Continuous infusion of mannitol (0.6 g/kg/hr iv), started just before infection, attenuated the increases of regional cerebral blood flow, intracranial pressure, and brain water content (p < .05, compared with untreated infected rats 6 hrs after infection). When continuous mannitol treatment was started 4 hrs after infection, intracranial pressure at 6 hrs was significantly lower than in untreated infected rats. When mannitol was given by a bolus injection (1.5 g/ kg iv) at 4 hrs after infection, intracranial pressure measured 0.5 hr thereafter was consistently reduced in all animals (intracranial pressure reduction by 21.3 +/- 5.1 [SEM]%). Pretreatment with allopurinol (150 mg/kg iv) did not significantly influence regional cerebral blood flow, intracranial pressure, and brain water content in pneumococci-injected rats. Both agents, mannitol and allopurinol, did not inhibit cerebrospinal fluid pleocytosis in infected rats. In uninfected rats, mannitol significantly increased regional cerebral blood flow by a nitric oxide-independent mechanism, whereas allopurinol slightly decreased blood flow. CONCLUSIONS: Mannitol attenuated pathophysiologic changes in experimental pneumococcal meningitis. One possible mechanism of the mannitol effect might be scavenging of hydroxyl radicals which have been shown to be involved in the pathophysiology of pneumococcal meningitis. The failure of allopurinol to modulate pathophysiologic parameters may suggest that during early experimental pneumococcal meningitis in the rat, the xanthine oxidase pathway seems not to be a major source of reactive oxygen species.

Effect of the bradykinin B2 receptor antagonist Hoe140 in experimental pneumococcal meningitis in the rat.

To elucidate the role of bradykinin in the complex pathophysiology of bacterial meningitis we investigated the effect of the bradykinin B2 receptor antagonist Hoe140, icatibant (D-Arg[Hyp3-Thi5-D-Tic7-Oic8]-bradykinin), on pathophysiological alterations in experimental pneumococcal meningitis. Untreated rats injected intracisternally (i.c.) with heat-killed pneumococci developed an increase of regional cerebral blood flow (185.4 +/- 27.4%, baseline 100%, mean +/- S.D.), brain water content (79.16 +/- 0.23%), intracranial pressure (21.4 +/- 6.0 mm Hg), and white blood cell count in the cerebrospinal fluid (CSF) (4621 +/- 1894 cells/microliter) within 6 h after i.c. challenge. Treatment with Hoe140 (0.1 mg/kg i.v. at baseline and 0.05 mg/kg s.c. at 2 h after i.c. challenge) attenuated the increase of brain water content (78.53 +/- 0.28%; P < 0.05), intracranial pressure (7.5 +/- 2.2 mm Hg; P < 0.05), and regional cerebral blood flow (128.6 +/- 23.1%; P < 0.05), and reduced CSF pleocytosis (2690 +/- 1898 cells/microliter. N.S.). When treatment was started 4 h after i.c. challenge Hoe140 reduced intracranial pressure (P < 0.05), but was no more capable to significantly influence the other pathophysiological parameters. Treatment with lower (0.01 mg/kg i.v. at baseline, followed by 0.005 mg/kg s.c. at 2 h) and higher (2 mg/kg i.v., followed by 1 mg/kg s.c. at 2 h) concentrations of Hoe140 was ineffective. Likewise, i.c. injection of Hoe140, at different dosages (4 nmol, 40 nmol, 400 nmol) did not significantly alter the pathophysiological parameters in pneumococci-induced meningitis, but caused changes in mean arterial blood pressure at dosages greater than 4 nmol. We conclude that bradykinin is involved as an inflammatory mediator of microvascular changes, brain edema, and increased intracranial pressure during the early phase of experimental pneumococcal meningitis.

Protective effect of a 21-aminosteroid during experimental pneumococcal meningitis.

This study investigated whether the 21-aminosteroid U74389F, an inhibitor of lipid peroxidation, attenuates pathophysiologic changes in experimental pneumococcal meningitis. Infected rats injected intravenously with vehicle of [corrected] U74389F developed increases in regional cerebral blood flow (rCBF), intracranial pressure (ICP), brain water content, and white blood cells (WBC) in cerebrospinal fluid (CSF) within 8 h after intracisternal challenge. Pretreatment with or administration of U74389F 4 h after infection significantly reduced the increase in ICP but had no effect on rCBF increase. Moreover, U74389F pretreatment significantly reduced brain water content and CSF WBC count. In vitro, U74389F inhibited iron-dependent lipid peroxidation of astrocyte cultures and the production of tumor necrosis factor-alpha, interleukin-6, and nitric oxide by stimulated macrophages. These data suggest that U74389F modulates early pathophysiologic alterations in experimental pneumococcal meningitis.