Culturally Adapted RN-MD Collaborative SICP-Based ACP: Feasibility RCT in Advanced Cancer Patients.

CONTEXT: Cultural adaptation is essential for optimizing programs centered around autonomy, such as the Serious Illness Care Program (SICP), especially for populations valuing family-involved decision-making. OBJECTIVES: We aimed to evaluate the feasibility and efficacy of a culturally adapted SICP-based nurse-physician collaborative Advance Care Planning (ACP) intervention tailored for patients with advanced cancer who prefer family-involved decision-making. METHODS: Oncology nurses, extensively trained and closely collaborating with physicians, conducted structured discussions with patients in the intervention group. The culturally adapted SICP-based ACP intervention was supplemented with trust-building, family involvement, and understanding of patient values. Primary inclusion criteria included patients within six weeks of initiating first-line palliative chemotherapy. Primary endpoints were achieving a 70% completion rate and assessing spiritual well-being (FACIT-Sp) at six months. Secondary endpoints included anxiety (GAD-7), depression (PHQ-9), quality of life (QOL) (CoQoLo), and ACP progress (ACP Engagement Scale) at the same interval. RESULTS: Forty-one patients (67.2%) completed the six-month follow-up, falling short of the targeted completion rate. The least-squares mean change from baseline in spiritual well-being at six months was 3.00 in the intervention group and -2.22 in the standard care group (difference, 5.22 points; 95% confidence interval, 1.38-9.06; P = 0.009). Similar superiority of the intervention was observed in QOL and ACP progress. CONCLUSION: Despite not meeting the targeted completion rate, the intervention group demonstrated enhanced spiritual well-being, QOL, and ACP progress. Our findings suggest revisions to the intervention manual to improve feasibility and to progress to an efficacy-focused randomized controlled trial.

Usefulness of Gabapentin as an Alternative/Adjunct Therapy for Delirium: A Retrospective Observational Study.

BACKGROUND: Antipsychotics are commonly used to treat delirium but can adversely affect the extrapyramidal and cardiac conduction systems. Antipsychotic use has also been reported to be associated with increased mortality in older adults. Therefore, alternative and adjunct medications for delirium are necessary. We retrospectively assessed the efficacy and safety of gabapentin (GBP) as an alternative and adjunct medication for delirium. METHODS: We retrospectively investigated the records of patients with delirium treated with GBP (71 patients; median age, 81 years; interquartile range, 76-87.5 years; 54.9% males) at a general hospital. We examined duration to delirium improvement, as assessed by the Intensive Care Delirium Screening Checklist (ICDSC) and DSM-5 criteria, as well as adverse events. RESULTS: The median (interquartile range) GBP dose was 200 mg (150-350 mg) /day. A total of 71.8% and 85.9% of the patients failed to meet the diagnostic criteria for delirium at 2 days and 5 days after initial administration, respectively (p<0.05). In subgroup analysis, patients with a history of epilepsy or cerebrovascular disease responded better to GBP than did those without such histories, suggesting that patients with abnormal/borderline neuronal activity respond to GBP even though they do not exhibit seizures. GBP did not induce extrapyramidal symptoms, cardiac conduction disturbances, hyperglycemia, or epilepsy but caused sleepiness and myoclonus. CONCLUSIONS: GBP may improve delirium with fewer adverse effects and may be a safe alternative or adjunct treatment for delirium. Dosage adjustment may be necessary to prevent sleepiness.

A revision of JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements.

OBJECTIVE: The Japanese Psycho-Oncology Society and the Japanese Association of Supportive Care in Cancer have recently revised the clinical practice guidelines for delirium in adult cancer patients. This article reports the process of developing the revised guidelines and summarizes the recommendations made. METHODS: The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multi-disciplinary members, created three new clinical questions: non-pharmacological intervention and antipsychotics for the prevention of delirium and trazodone for the management of delirium. In addition, systematic reviews of nine existing clinical questions have been updated. Two independent reviewers reviewed the proposed articles. The certainty of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development, and Evaluation system. The modified Delphi method was used to validate the recommended statements. RESULTS: This article provides a compendium of the recommendations along with their rationales, as well as a short summary. CONCLUSIONS: These revised guidelines will be useful for the prevention, assessment and management of delirium in adult cancer patients in Japan.

Preliminary study of assessing cognitive impairment in older patients with chronic obstructive pulmonary disease by using a cognitive functional assessment tool via a touchscreen personal computer.

Background: Unique cognitive impairments related to chronic obstructive pulmonary diseases (COPD) have been increasingly reported. Considering the dementia risk and medication management, older patients with COPD should be evaluated for cognitive impairment. This study aimed to examine whether specific cognitive impairments related to COPD could be detected by an assessment tool using a touchscreen personal computer (PC) in older patients with COPD. Methods: This study included 28 older male patients with COPD and 30 healthy older male individuals. A touchscreen PC-based cognitive assessment application called CogEvo was used to assess and compare the cognitive function according to five domains: spatial cognition, orientation, working memory, executive function, and attention. Results: Analysis of variance showed an interaction effect on the indices of cognitive function based on five domains between the two groups, indicating differences in the characteristics of cognitive function in such groups. Betweengroup comparisons as a subtest showed that attention, executive function, and working memory were significantly lower in the COPD group than in the healthy group. Conclusions: CogEvo can detect specific cognitive impairments associated with COPD, suggesting that it can be potentially used as a screening tool for cognitive impairment in older patients with COPD.

Comparison of Psychological Quality of Life Between Long-Term Survivors of Childhood Cancer and Their Families.

Purpose: Although treatment outcomes for childhood cancer have improved in recent years, some patients continue to experience physical symptoms and psychological stress several years after the end of treatment. This study aimed to examine the correlation between the quality-of-life (QOL) scores of childhood cancer survivors (CCSs) aged 18-39 and (1) their families and (2) the time since the end of treatment. Methods: Measuring the QOL of CCSs attending the long-term follow-up (LTFU) and those of their families. The Short-Form Health Survey (SF-36) was used for CCSs and the Caregiver Quality of Life Index-Cancer (CQOLC) for their families. Spearman's rank correlation analyses were used to examine the relationship between the CCSs' and their families' QOL and the time since the end of treatment. Results: Twenty-nine CCSs (mean age, 24.2 years; mean the time since the end of treatment, 13.9 years), each paired with one family member, were included. Time since the end of treatment was positively correlated with the CCSs' QOL on the physical component score (ρ = 0.42, p = 0.03) and negatively correlated with mental health (MH) (ρ = -0.50, p = 0.01), a subscale of the mental component score (MCS). Furthermore, the CCSs' QOL on the MCS was positively correlated with their families' QOL scores (ρ = 0.58, p < 0.01). Conclusion: Psychological stress may persist in CCSs long after treatment, even when physical symptoms improve. Therefore, it is necessary to establish a comprehensive support system for the LTFU of CCSs, including MH care and QOL monitoring for patients and their families.

[Management of Delirium in Patients with Cancer].

Delirium is a condition in which the main symptom is a mild disturbance of consciousness caused by a physical abnormality or medication, and various symptoms such as cognitive dysfunction, hallucinations, delusions, and mood swings appear with any disease. Delirium is frequently observed in patients with cancer, especially in the terminal stage, and is observed in about 90% of patients just before death. Hypercalcemia due to bone metastases, brain metastases, and the use of opioids and steroids for symptom relief are direct factors in the development of delirium. Furthermore, there are many opportunities to encounter delirium at the end of life caused by conditions that are difficult to recover from, such as brain metastasis, liver failure, and hypoxic encephalopathy. In the management of delirium, "search for the cause(s)and its treatment"and"environmental adjustment"are the most important. Then, pharmacotherapy is considered to reduce the severity of delirium. Antipsychotics are the basic medication of choice. The route of administration, half-life, dosage form, adverse events of medication, as well as patient factors such as the presence or absence of diabetes and the subtype of delirium should be comprehensively considered when selecting a medication. The timing of medication discontinuation should also be kept in mind once medication therapy is initiated. On the other hand, when delirium is caused by factors that are difficult to recover from, the goal of treatment is to alleviate the painful symptoms caused by delirium, and it is important to take a holistic approach for patients and family members.

Perception Gap in Health-Related Quality of Life Between Young Adult Survivors of Childhood Cancer and Their Family.

Young adult survivors of childhood cancer may have a perception gap with their families. Patients aged 18-39 years after treatment of cancer and their families (28 pairs) completed a survey that contained questions on health-related quality of life using the 36-item short form survey. There was a significant difference in the role-social component score (mean difference -2.23; p = 0.04) with family reporting higher scores than patients. Families may overestimate the social function of cancer survivors, emphasizing the importance of the long-term follow-up by taking into account the risk of a gap (IRB approval No.: R2257-1).

Low-Dose Trazodone for Delirium in Patients with Cancer Who Received Specialist Palliative Care: A Multicenter Prospective Study.

Background: Clinical usefulness of trazodone for delirium in patients receiving palliative care is unclear. Objectives: To examine the safety and effectiveness of trazodone for delirium. Design: A secondary analysis of a multicenter prospective observational study. Setting/Subjects: The setting involves nine psycho-oncology consultation services and 14 inpatient palliative care units in Japan. Measurements: The measurement involves the Delirium Rating Scale (DRS) Revised-98 for effectiveness and the CTCAE (Common Terminology Criteria for Adverse Events) version 4 for safety assessments. Results: Thirty-eight patients enrolled the study. Mean age was 75 years. After three-day observation, the DRS total score (11.6 ± 5.3 to 8.7 ± 6.5 [difference -2.9, 95% confidence interval -5.3 to -0.5, p = 0.02]); sleep-wake cycle disturbance (p = 0.047), lability of affect (p < 0.001), and motor agitation subscales (p < 0.001) were significantly decreased. The most frequent adverse event was somnolence (n = 9). Conclusions: Low-dose trazodone treatment was generally safe and may be effective in reducing delirium severity.

Rasch Analysis of the Assessment of Quality of Activities (A-QOA), an Observational Tool for Clients With Dementia.

IMPORTANCE: The Assessment of Quality of Activities (A-QOA) is an observation-based tool for assessing the strength of engagement in an activity by the person performing it in a natural context. By quantifying the quality of engagement, the A-QOA can help occupational therapy practitioners be better able to select meaningful activities and more clearly understand the effectiveness of various choices. OBJECTIVE: To examine use of the A-QOA as a valid unidimensional scale and to clarify preliminary results on its internal scale validity and item reliability using the Rasch model. PARTICIPANTS: One hundred thirty-one participants with dementia performing 262 activities. OUTCOMES AND MEASURES: We used the Rasch model to clarify the psychometric properties of A-QOA's measurement quality. RESULTS: Rasch analysis revealed that 21 of the 25 items reached an acceptable level of fit, and 4 did not. After eliminating the 4 misfitting items, the resulting A-QOA was determined to have both acceptable internal scale validity and item separation reliability, which are fundamental psychometric properties of a clinical observational instrument. CONCLUSIONS AND RELEVANCE: The A-QOA can be used to quantitatively assess the strength of engagement in an activity by the person performing it by using the observational method. WHAT THIS ARTICLE ADDS: In clinical settings, the A-QOA can be used both to select activities for clients with dementia and to quantitatively show the effects of occupational therapy interventions.

Psychologic stress and disease activity in patients with inflammatory bowel disease: A multicenter cross-sectional study.

BACKGROUND AND AIMS: Psychologic stress can affect the pathogenesis of inflammatory bowel disease (IBD), but the precise contribution of psychologic stress to IBD remains unclear. We investigated the association of psychologic stress with disease activity in patients with IBD, especially in terms of mental state and sleep condition. METHODS: This was a multi-center observational study comprising 20 institutions. Data were collected using survey forms for doctors and questionnaires for patients, and the association of psychologic stress with clinical parameters was investigated. Mental state was evaluated using the Center for Epidemiologic Studies Depression (CES-D) scale, and sleep condition was evaluated by querying patients about the severity of insomnia symptoms. RESULTS: A total of 1078 IBD patients were enrolled, including 303 patients with Crohn's disease and 775 patients with ulcerative colitis. Seventy-five percent of IBD patients believed that psychologic stress triggered an exacerbation of their disease (PSTE group) and 25% did not (non-PSTE group). The CES-D scores were significantly higher for patients with clinically active disease than for those in remission in the PSTE group (median (interquartile range) = 7 (4-9.5) vs. 5 (3-7), p < .0001), but not in the non-PSTE group (5 (2-8) vs. 4 (3-7), p = 0.78). Female sex and disease exacerbation by factors other than psychologic stress were independent factors of psychologic stress-triggered disease exacerbation. Also, patients with insomnia had higher disease activity than those without insomnia, especially in the PSTE group. CONCLUSIONS: A worsened mental state correlates with disease activity in IBD patients, especially those who believe that their disease is exacerbated by psychologic stress.

Factors that influence psychiatric help-seeking behavior in Japanese university students.

We investigated the periods from symptom onset to the first visit to the psychiatric consultation and the factors that influence psychiatric help-seeking behavior in university students. Students who first visited the psychiatric department of university health care center were the study participants. We surveyed the elicited information such as age, sex, period from symptom onset to the first visit, main symptoms, General Health Questionnaire GHQ-12, and perception of stigma associated with receiving a psychiatric consultation. We analyzed the factors affecting the duration until a psychiatric consultation was made using logistic regression analysis, examining age, sex, contents of the problem, GHQ-12, and stigma as independent variables. Of the participants, 48.2 % did not consult with a psychiatrist for more than 6 months and 51 participants (36.7 %) took more than a year before a consultation. We divided the study participants into two groups: early examinees and delayed examinees. In order to investigate the factors affecting the two groups, logistic regression analysis was performed. Of the independent variables, one consultation content (physical symptoms; odds ratio (OR) = 9.21, 95 % CI (confidence interval) = 2.00-42.62, p = 0.004) and the GHQ-12 (OR = 1.17, 95 % CI = 1.05-1.31, p = 0.005) were significant factors. It became clear that physical symptoms significantly accelerated consultation with psychiatry. When various problems occurred, the decision to seek a psychiatry consultation required a long time. Health education focusing on the values of seeking an early consultation is required so that when students have mental health problems they will seek psychiatric services in a timely manner.

JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements.

BACKGROUND: The Japanese Psycho-Oncology Society and Japanese Association of Supportive Care in Cancer recently launched the clinical practice guidelines for delirium in adult cancer patients. The aim of the guidelines was to provide evidence-based recommendations for the clinical assessment and management of delirium in cancer patients. This article reports the process of developing the guideline and summarizes the recommendations made. METHODS: The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multidisciplinary members, formulated nine clinical questions. A systematic literature search was conducted to identify relevant articles published prior to through 31 May 2016. Each article was reviewed by two independent reviewers. The level of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development and Evaluation system. The modified Delphi method was used to validate the recommendation statements. RESULTS: This article provides a summary of the recommendations with rationales for each, as well as a short summary. CONCLUSIONS: These guidelines will support the clinical assessment and management of delirium in cancer patients. However, additional clinical studies are warranted to further improve the management of delirium.

Psychological Effects of Hands-On Training Using Public Transportation among Inpatients with Physical Disabilities: Analysis of the Self-Efficacy and Perception of Occupational Enablement Using a Multimethod Design.

INTRODUCTION: This study is aimed at understanding how practicing the use of public transportation can affect the self-efficacy and perceptions of occupational enablement among patients with physical disabilities in a recovery rehabilitation hospital. METHOD: We recruited 21 inpatients with physical disabilities caused by stroke or orthopedic diseases from a recovery rehabilitation hospital in Japan and used a multimethod design including an intervention study and a follow-up survey. The intervention study utilized a before-after trial and provided hands-on training in the use of public transportation as the intervention. How self-efficacy and perceptions of occupational enablement changed before and after the intervention was measured using the visual analog scale (VAS). The follow-up survey was conducted to investigate whether patients used public transportation postdischarge. RESULTS: Only differences in the VAS scores regarding self-efficacy were significant between before and after the hands-on training in the use of public transportation, whereas differences regarding the perceptions of occupation enablement were not. Self-efficacy after the intervention was higher than that before the intervention. In the follow-up survey, both VAS scores of the psychological factors were significantly higher in the group that used public transportation postdischarge than in the group that did not. CONCLUSION: Providing hands-on training in the use of public transportation for inpatients with physical disabilities increased their self-efficacy, indicating that psychological factors should be evaluated to predict their occupational skill improvement and to verify the outcomes of an occupational therapeutic intervention.

The use of psychosocial support services among Japanese breast cancer survivors.

BACKGROUND: This study aimed to investigate the use of psychosocial support services, the intention to use these services, and to elucidate the characteristics of survivors most likely to use support services among Japanese breast cancer survivors. METHODS: We invited breast cancer survivors to complete an online questionnaire via an email sent to subscribers of a non-profit organization mailing list. We asked participants questions related to demographics, opinions on the state of psychosocial support services, and their interest in using these services. Participants were also asked to complete the Hospital Anxiety and Depression Scale and the Brief Cancer Worry Inventory (BCWI). RESULTS: We analyzed the data of 171 participants. Those who used some form of psychosocial support service constituted 50.9% of the participant population. Participants used cancer consulting and support center services (13.5%), hospital and non-hospital support groups (12.9%, respectively), psychiatry (11.1%), hospital and non-hospital cancer salons (8.8%, respectively), psychosomatic medicine (8.2%), therapist counseling (6.4%) and psycho-oncology department services (4.1%). Non-users who suffered from adjustment disorders or major depression (52.1%) reported higher total BCWI and the subscale scores had no concrete plans to use psychosocial support services. CONCLUSIONS: The usage levels of psychiatry, psychosomatic medicine and psycho-oncology services in our study were higher than those reported in any previous Japanese study within the psycho-oncology field. Participants joining a breast cancer survivors' mailing list, or their being female, may have led to a higher use of such services. A high degree of distress does not necessarily lead cancer survivors to seek psychosocial support services.

Novel Therapeutic Strategies for Delirium in Patients With Cancer: A Preliminary Study.

To compare the efficacy of antipsychotics (APs) for delirium treatment in patients with cancer, 27 patients treated with 1 of the 4 APs, haloperidol (HPD), risperidone (RIS), olanzapine (OLZ), and quetiapine (QTP), were divided into 2 groups: long half-life (T1/2; HPD, RIS, and OLZ) versus short T1/2 (QTP) or the multiacting receptor-targeted APs (MARTAs; OLZ and QTP) versus the non-MARTA (HPD and RIS). The symptom severity was evaluated by the memorial delirium rating scale (MDAS) on days 0, 3, and 7 following intervention. Significant improvements in total MDAS scores were found in all groups on day 3. However, on day 7, only the short T1/2 group and MARTA group showed significant improvement. Consideration of an AP's pharmacological properties may be helpful for improving the outcomes of pharmacological delirium intervention in patients with cancer.

[Cancer-related Cognitive Impairment: Current Knowledge and Future Challenges].

Cancer patients often suffer from various distresses, including cognitive impairment. Cognitive impairment during and after cancer diagnosis and treatment are collectively called "Cancer-related cognitive impairment (CRCI)". The number of publications about cognitive impairment due to cancer therapy, especially chemotherapy, hormonal therapy, and radiotherapy, has been growing. Patients often worry not only about their disease condition and therapies, but also experience concerns regarding their memory, attention, and ability to concentrate. Even subtle CRCI can have a significant impact on social relationships, the ability to work, undergo treatment, accomplish meaningful goals, and the quality of life. Longitudinal studies of cancer patients indicated that up to 75% experience CRCI during treatment. Furthermore, CRCI may persist for many years following treatment. However, it is not well understood by most physicians and medical staff. CRCI can be mediated through increased inflammatory cytokines and hormonal changes. In addition, the biology of the cancer, stress, and attentional fatigue can also contribute to CRCI. Genetic factors and co-occurring symptoms may explain some of the inter-individual variability in CRCI. Researchers and patients are actively trying to identify effective interventional methods and useful coping strategies. Many patients are willing to discuss their disease condition and future treatment with medical staff and/or their families. Some patients also hope to discuss their end-of-life care. However, it is difficult to express their will after developing cognitive impairment. Advance care planning (ACP) can help in such situations. This process involves discussion between a patient, their family, and clinicians to clarify and reflect on values, treatment preferences, and goals to develop a shared understanding of how end-of-life care should proceed. The number of cancer patients with cognitive impairment has been increasing owing to the super-aging of society. Psychiatrists need to develop appropriate care for them and understand the value of ACP. In this review, an outline of CRCI is given, especially related to cancer therapy such as chemotherapy, hormonal therapy, and radiation therapy. In addition, the importance of ACP to facilitate a living will for patients likely to develop impaired cognitive functions in the future is described.

Association between depressive symptoms and changes in sleep condition in the grieving process.

PURPOSE: Bereaved families often suffer from insomnia and depression. However, the associations between depressive state and changes in sleep condition during the grieving process have not been investigated. This study aimed to clarify the prevalence of insomnia symptoms and to explore associations between present depressive state and changes in sleep condition in the grieving process in bereaved families of Japanese patients with cancer. METHODS: A cross-sectional, multicenter survey was conducted in 103 certified palliative care units. A questionnaire asking insomnia symptoms and depressive symptoms by the Center for Epidemiological Studies Depression Scale (CES-D) was mailed to bereaved families (N = 987). The association between present depressive state (CES-D ≥7) and sleep conditions in the grieving process were analyzed. RESULTS: A total of 561 families were enrolled for analysis. Fifty-three percent of family members were considered to be in a depressive state at the time of the investigation. Prevalence of past insomnia was 86.5% at "within a few weeks before the patient's death" (T1) and 84.5% at "within 6 months after the patient's death" (T2) in all bereaved family members. However, in contrast to decreased severity of insomnia between T1 and T2 in the non-depressive group (p < 0.05), severity of insomnia was unchanged in the depressive group during this period (p = 0.139). CONCLUSIONS: Insomnia symptoms are highly prevalent and may be associated with posthumous depressive state in bereaved Japanese families. These results suggest the need for careful observation of changes in sleep condition during the grieving process.

Fluvoxamine alleviates paclitaxel-induced neurotoxicity.

Paclitaxel (Px) is an effective chemotherapeutic agent for the treatment of various cancers. However, it is often associated with neurological side effects, including chemotherapy-associated cognitive impairment (CACI), such as "chemobrain". Previously, we reported that endoplasmic reticulum (ER) stress is involved in Px-induced neurotoxicity, and immunoglobulin heavy chain binding protein (BiP) inducer X (BIX) alleviates Px-induced neurotoxicity. However, BIX has not been used in clinical practice yet. We recently reported that fluvoxamine (Flv) alleviates ER stress via induction of sigma-1 receptor (Sig-1R). The purpose of this study was to investigate whether Flv could alleviate Px-induced neurotoxicity in vitro. SK-N-SH cells were pre-treated for 12 h with or without 10 µg/ml Flv followed by treatment with 1 µM Px with or without co-existence of 10 µg/ml Flv for 24 h. To investigate the involvement of Sig-1R in alleviation effect on Px-induced neurotoxicity,1 µM NE100, an antagonist of Sig-1R, was added for 24 h. Neurotoxicity was assessed using the MTS viability assay and ER stress-mediated neurotoxicity was assessed by evaluating the expression of C/EBP homologous protein (CHOP), cleaved caspase 4, and cleaved caspase 3. Pre-treatment with Flv significantly alleviated the induction of CHOP, cleaved caspase 4, and cleaved caspase 3 in SK-N-SH cells. At the same time, pre-treatment with Flv significantly induced Sig-1R in SK-N-SH cells. In addition, viability was significantly higher in Flv-treated cells than in untreated cells, which was reversed by treatment with NE100. Our results suggest that Flv alleviates Px-induced neurotoxicity in part through the induction of Sig-1R. Our findings should contribute to one of the novel approaches for the alleviation of Px-induced neurotoxicity, including chemobrain.