Disappearance of a stutter shortly before death.

A patient with a stutter caused by the trauma of the death of a loved one was able to recover normal speech 1 week before her death, which resulted from intestinal obstruction caused by ovarian cancer. The stutter appeared to have been overcome using a combination therapy of sophrology, self-regulation, and drug therapy. During a genuine resilience process, the patient was able to overcome an earlier existential fracture. In this final phase of life, health professionals and the family fully respected the patient's independence to remain in control of events. She repeatedly refused to have a nasogastric tube inserted to extract fecal matter from the stomach. This patient consequently repossessed her own language of expression in a body that was shattered by cancerous illness and the consequences of treatments. She thus managed to find a successful balance between the body, the spirit, and the brain.

Are older French patients as willing as older American patients to undertake chemotherapy?

PURPOSE: A view often held in Europe is that older Europeans are less willing than older Americans to undertake chemotherapy. This study assesses whether this view is valid. PATIENTS AND METHODS: Three-hundred twenty outpatients aged 70 years and older were interviewed via anonymous questionnaires: French patients with and without cancer and American patients with and without cancer. The response rate was 61% (195 of 320 questionnaires). Ages ranged from 70 to 95 years (29% aged 80 years and older). Two scenarios were presented: a strong chemotherapy (platinum/taxane combination-like) and a milder chemotherapy (weekly vinorelbine-like). The options were to refuse chemotherapy or to accept for a threshold chance of cure, of life prolongation, or of symptom relief. Functional status, education, self-rated health, and depression were controlled for. RESULTS: French noncancer patients (34%) were less willing to accept the strong chemotherapy than French cancer patients (77.8%), American noncancer patients (73.8%), and American cancer patients (70.5%) (P <.001 for each pair). This was also true for the moderate chemotherapy (67.9% v 100%, 95.2%, and 88.5%, respectively; P <.001). Age and sex did not correlate with response, but self-rated health, cancer status, and nationality did. Thresholds varied from patient to patient. CONCLUSION: Whereas older French people without cancer are more reluctant than older Americans to envision chemotherapy, older cancer patients in both countries have the same amenability to treatment. Chemotherapy options should be fully discussed with older cancer patients, given that most are willing to consider them.

Management of patients with amyotrophic lateral sclerosis.

UNLABELLED: Standard recommendations for the clinical management of patient with ALS have been edited in recent years. These documents emphasise the importance of patient's autonomy. AIM OF STUDY: To measure how these different recommendations can be applied in the context of a general hospital without a specific ALS clinic. METHODS: Review of medical records of 21 patients with an ALS diagnosis treated by the University Hospitals Geneva who died from 1996-2002. RESULTS: Patients suffered from distressing symptoms during their last hospitalisation. Artificial nutrition was given to 5 patients. Six patients had non invasive ventilation (NIV). Written advance directives were only available in 2 cases. Discussions about theses issues were also conducted late in the evolution of the disease. CONCLUSION: Some discrepancies between our daily practice and the existing recommendations exist, particularly regarding the key issues of artificial nutrition and ventilatory support.

Geriatric medical oncology in the care of elderly cancer patients.

Most cancers are diagnosed after 70 years of age but standard management and treatment for elderly cancer patients remain to be established. To determine whether the availability and recognition of medical oncology may influence cancer care in this population, five successive periods were studied. The number of formal written consultations given at the geriatric hospital and at the center for continuous care was measured. Over a period of 36 months, the number of consultations rose from an initial 1.5% (n=26) and 3.8% (n=25) to 3% (n=71) and 12.5% (n=103) of the respective total number of admissions. As expected, the increase exactly matched both main geographical location and functional position of the single appointed medical oncologist. However, following the definitive establishment of the medical oncologist at the center for continuous care, the number of formal written consultations markedly decreased. At the geriatric hospital, medical oncology returned to the 'status quo ante' whereas it was quite simply incorporated in the daily care of all cancer patients at the center for continuous care. Thus, improvement of cancer care in the elderly may first depend on human resources such as trained specialists to make a true difference with the prior situation.

Multiple malignant tumours in the elderly.

Aging of the population and technical improvements may contribute to increase the possibility of multiple malignant tumours to be diagnosed. Over a period of 18 years, 2,749 consecutive autopsies of elderly patients were performed. In addition to macroscopic examination of every single organ, bone marrow and prostate were routinely stained and microscopically examined. One hundred and sixty-seven patients with multiple malignant tumours were found. Mean age was 81.1 years for females and 80.1 years for males. Mean interval between tumours was 2.4 years for females and 1.0 year for males. First tumours were most of the time diagnosed clinically (n = 121 vs. 46) whereas second tumours were diagnosed at autopsy (n = 121 vs. 46). Origin and metastastic sites of tumours were not different between the first and second tumour. Prostate and breast were the most frequent organs involved in males and females. Multiple malignant tumours in the elderly are not rare and the second tumour is frequently diagnosed after death despite occurring relatively soon after the diagnosis of the first tumour. Multiple malignant tumours may represent a significant clinical challenge leading to further diagnostic procedures and differentiated therapeutic approaches.

Symptom assessment in elderly cancer patients receiving palliative care.

BACKGROUND: The purpose of this study is to examine the concordance of symptom assessment among the multiple raters in French-speaking elderly patients with an advanced cancer benefiting from palliative care. PATIENTS AND METHODS: This study was conducted in a geriatric hospital with palliative care specificity. During 6 months, patient, nurse and physician completed the Edmonton symptom assessment system on two consecutive days. RESULTS: 42 patients with an advanced oncological disease were included. Mean age was 72+/-9.04 (range 52-88) and 23 were females. Mean mini mental status examination (MMSE) was 27.5+/-1.6. First assessment was completed at a median of day 8 after admission. Nurses, physicians and patients assessments were reproducible between days 1 and 2 (P>0.05). Pearson correlation coefficient significantly associated nurse assessment with patient assessment for pain, depression, anxiety, drowsiness, appetite and wellbeing (P<0.05). Physician assessment was associated with patient assessment for pain, depression, drowsiness, appetite, wellbeing and shortness of breath (P<0.05). However, regression analysis looking for patient score from both physicians and nurses scores weakly correlated all these factors (R2<0.6), except for appetite (R2 for day 1/day 2: 0.79/0.64). CONCLUSIONS: French-speaking elderly cancer patients without cognitive failure and in stable general condition are consistent in their symptom assessment, and they have to be considered as the gold standard. Nevertheless, interdisciplinary assessment is probably a valid surrogate to self-assessment by the patient but only when the latter is truly impossible.

Evaluation of a nystatin-containing mouth rinse for terminally ill patients in palliative care.

PURPOSE: To evaluate the antifungal effect of a nystatin mouth rinse to control oral candidiasis of elderly patients in palliative care. MATERIALS AND METHODS: 52 cancer patients (mean age: 83 years) hospitalized in a long term care facility for chronically ill geriatric patients. Mouth rinsing with 15 ml nystatin solution (4,000 Ul/ml) was carried out for one minute, six times daily, over two weeks. Yeasts were collected and seeded on CHROMagar. Growth was read qualitatively and quantitatively after two days' incubation at 37 degrees C. RESULTS: Clinical signs of oral candidiasis were observed in 31% of cases. High yeast scores were observed in 58% of the residents. There was an association between signs of oral candidiasis and high yeast scores (p < 0.001). Treatment for two weeks caused no clinical changes nor reduced yeast scores. CONCLUSIONS: No clinical or antifungal effect from the nystatin suspension suggests that the concentration of nystatin in the mouth rinse was too low. A more effective procedure should be employed for antifungal treatment of terminally ill patients. Appropriate antimicrobial solutions with lubricating activity should be developed and applied to prevent oral diseases.

Breakthrough pain in elderly patients with cancer: treatment options.

The prevalence of pain is high in the elderly and increases with the occurrence of cancer. Pain treatment is challenging because of age-related factors such as co-morbidities, and over half of the patients with cancer pain experience transient exacerbation of pain that is known as breakthrough pain (BTP). As with background pain, BTP should be properly assessed before being treated. The first step to be taken is optimizing around-the-clock analgesia with expert titration of the painkiller. Rescue medication should then be provided as per the requested need, while at the same time preventing identified potential precipitating factors. In the elderly, starting treatment with a lower dose of analgesics may be justified because of age-related physiological changes such as decreased hepatic and renal function. Whenever possible, oral medication should be provided prior to a painful maneuver. In the case of unpredictable BTP, immediate rescue medication is mandatory and the subcutaneous route is preferred unless patient-controlled analgesia via continuous drug infusion is available. Recently, transmucosal preparations have appeared in the medical armamentarium but it is not yet known whether they represent a truly efficient alternative, although their rapid onset of activity is already well recognized. Adjuvant analgesics, topical analgesics, anesthetic techniques and interventional techniques are all valid methods to help in the difficult management of pain and BTP in elderly patients with cancer. However, none has reached a satisfying scientific level of evidence as to nowadays make the development of undisputed best practice guidelines possible. Further research is therefore on the agenda.

Palliative sedation for status epilepticus in a patient with progressive multifocal leukoencephalopathy.

Palliative sedation is defined as the use of sedative drugs in order to reduce the patient's consciousness in case of refractory symptoms. The most used drug is midazolam, a benzodiazepine with a short half-life administered either intravenously or subcutaneously. We discuss on a clinical case requiring an exceptionally high dosage of midazolam-up to 160 mg iv daily-to achieve palliative sedation. The patient was an HIV positive 29-year-old male who was suffering from progressive multifocal leukoencephalopathy complicated by a refractory status epilepticus and who was suspected of previous benzodiazepines and opioid abuse. In such situations of a suffering brain doses of midazolam to achieve symptom control may be much higher than expected.

Palliative sedation: from the family perspective.

UNLABELLED: Palliative sedation (PS) is a treatment option in case of refractory symptoms at the end of life. The emotional impact on nurses and doctors has been widely studied. We explore the experience of family members during a PS procedure. METHOD: An anonymous questionnaire was sent to the closest family members (n = 17) of patients who died while receiving palliative sedation. RESULTS: The response rate was 59% (10 of 17). Nine relatives were sufficiently informed about PS. In all, 70% evaluated the chosen moment for initiation of PS as adequate. All the relatives noticed a significant improvement in the refractory symptom with a mean reduction in the estimated suffering of 6.25 points on a visual analog scale. CONCLUSIONS: Palliative sedation should be performed in the best possible way for the patient and his family in order to efficiently reduce a refractory symptom.

Primary pulmonary malignant meningioma with lymph node and liver metastasis in a centenary woman, an autopsy case.

Primary meningiomas arising outside the central nervous system are very rare. They have been reported in the head and neck region, in the thorax, the retroperitoneum, and the pelvis. Usually, they behave as slow-growing tumors with a good prognosis. Herein, we report an autopsy case of a 108-year-old woman, known for a right-sided slowly growing lung nodule for 39 years. Death was attributed to cachexia. At post-mortem, a 15-cm mass was present in the right inferior lobe of the lung, associated with an ipsilateral hilar lymphadenopathy, and another 10-cm mass in the liver. Histology revealed a WHO grade III meningioma. No tumor was observed in the cranial cavity. This case illustrates a rare location of meningioma and highlights its biological behavior, with a very slow progression from a most probably benign tumor to a malignant lesion with metastasis over four decades.

Do brain T2/FLAIR white matter hyperintensities correspond to myelin loss in normal aging? A radiologic-neuropathologic correlation study.

BACKGROUND: White matter hyperintensities (WMH) lesions on T2/FLAIR brain MRI are frequently seen in healthy elderly people. Whether these radiological lesions correspond to irreversible histological changes is still a matter of debate. We report the radiologic-histopathologic concordance between T2/FLAIR WMHs and neuropathologically confirmed demyelination in the periventricular, perivascular and deep white matter (WM) areas. RESULTS: Inter-rater reliability was substantial-almost perfect between neuropathologists (kappa 0.71 - 0.79) and fair-moderate between radiologists (kappa 0.34 - 0.42). Discriminating low versus high lesion scores, radiologic compared to neuropathologic evaluation had sensitivity / specificity of 0.83 / 0.47 for periventricular and 0.44 / 0.88 for deep white matter lesions. T2/FLAIR WMHs overestimate neuropathologically confirmed demyelination in the periventricular (p < 0.001) areas but underestimates it in the deep WM (0 < 0.05). In a subset of 14 cases with prominent perivascular WMH, no corresponding demyelination was found in 12 cases. CONCLUSIONS: MRI T2/FLAIR overestimates periventricular and perivascular lesions compared to histopathologically confirmed demyelination. The relatively high concentration of interstitial water in the periventricular / perivascular regions due to increasing blood-brain-barrier permeability and plasma leakage in brain aging may evoke T2/FLAIR WMH despite relatively mild demyelination.

Preferences of elderly cancer patients in their advance directives.

Efforts to improve the quality of end-of-life decision-making have emphasized the principle of individual autonomy to better ensure that patients receive care consistent with their preferences. Advance directives (ADs) can be vehicles for in-depth and ongoing discussions among health care professionals, patients, and families. The aim of our study was to identify preferences and values expressed in ADs of 50 elderly patients with cancer. Main concerns of the patients were resuscitation and introduction of artificial nutrition. Very few patients had unrealistic expectation. Preferences about patient's symptom management were quite different from one to another. Content of ADs not only involved life-sustaining technology, but also psychosocial items and religious beliefs and values. All patients designated at least one surrogate. In conclusion, ADs should not be considered simply as another questionnaire, but more as a process to improve communication.

Malignant irreversible intestinal obstruction: the powerful association of octreotide to corticosteroids, antiemetics, and analgesics.

In the case of malignant intestinal obstruction, surgery often carries important mortality and morbidity risks, and feasibility is neither realistic nor reasonable. A total of 4 clinical cases of intestinal obstruction caused by advanced gastrointestinal cancers in their terminal phase are described. The association of analgesics, corticosteroids, antiemetics, and octreotide was effective to relieve symptoms of intestinal obstruction for the remaining lifetime. The insertion of a nasogastric tube was avoided in 3 of 4 cases. Death occurred 51, 56, and 64 days after clinical and radiological diagnosis of irreversible intestinal obstruction. This combination of drugs appears very powerful and well tolerated. The relatively long survival that was observed should encourage future studies of longer half-life somatostatin analogues with no need of continuous infusion or multiple daily injections.