Declive funcional y presencia de síntomas en cuidados paliativos: ¿causa o consecuencia?

Introducción: Diversas publicaciones han relacionado el declive funcional con la aparición de síntomas,especialmente psicológicos o psiquiátricos, como ansiedad y depresión. Por otra parte, un trastorno depre-sivo inicial o previo al declive funcional también suele empeorarlo. Nos planteamos conocer la relaciónentre la existencia de declive funcional medido mediante descenso en índice de Barthel (IB) y la presenciade síntomas. Material y métodos: Estudio analítico prospectivo con los pacientes derivados a un Equipo de Soportepara Atención Domiciliaria (ESAD).Resultados: Seiscientos treinta y ocho casos, 53,9% (N = 344) hombres, 56% (N = 357) oncológicos y 44%(N = 281) no oncológicos. La edad media fue 79,64 ± 10,8 a˜nos. Obtuvimos diferencias significativas(p < 0,001) en declive funcional medido mediante descenso medio en el IB entre pacientes oncológicos(34,4) y no oncológicos (12,12). Encontramos diferencias significativas (p < 0,001) en todos los sínto-mas registrados (dolor, disnea, anorexia, náuseas, ansiedad, depresión e insomnio) con mayor frecuenciaen pacientes oncológicos, salvo en el caso de la agitación psicomotriz. En pacientes con mayor grado dedeclive funcional, con descensos en IB superior a 20 puntos, se detectó mayor presencia de síntomas. Salvodeterminados analgésicos, no hubo diferencias en los tratamientos previos; sí encontramos diferenciasen diversos tratamientos pautados por el ESAD. Conclusiones: La existencia de declive funcional y su grado pueden verse relacionados con la apariciónde síntomas, especialmente en el paciente oncológico. Introduction Several publications have related functional decline to the appearance of symptoms, especially psychiatric or psychological ones, such as anxiety and depression. Moreover, an initial depressive disorder or prior to functional decline usually worsens it. It was decided to investigate the relationship between the presence of functional decline, measured by a decrease in the Barthel index (BI), and the presence of symptoms. Material and methods A prospective analytical study conducted on patients referred to a Home Care Support Team (HCST). Results The study included 638 cases, of which 53.9% (N = 344) were male, 56% (N = 357) with cancer and 44% (N = 281) geriatric. The mean age was 79.64 years + - 10.8. Significant differences (P<.001) were found in functional decline measured by mean decline in the BI between cancer (34.4) and non-cancer patients (12.12). Significant differences (P<.001) were also found in all recorded symptoms (pain, dyspnoea, anorexia, nausea, anxiety, depression, and insomnia), more frequently in cancer patients, except psychomotor agitation. A higher presence of symptoms was detected in patients with greater functional decline, with decreases in BI above 20 points. There were no differences in previous treatments, except in certain analgesics. Differences were found in the different treatments prescribed by HCST. Conclusions The presence of functional decline and its level may be related to the appearance of symptoms, especially in cancer patients

Papel del ESAD en el tratamiento del dolor: Análisis pre-post intervención en un entorno rural

Objectives: To determine the frequency of use of analgesics in terminal patients attended in home, and factors that may be involved in pain perception, in addition to the interventions carried out. Methods: prospective, interventional and analytical study in patients attended to Homecare Support Team (HSCT) of Barbastro. Variables studied: age, sex, number of visits, time tracking, presence of pain and other concomitant symptoms, Visual Analogic Scale (VAS), diagnosis, analgesics previous and post-intervention, previous and post-intervention average dose of analgesics. Statistical study with SPSS 15.0. Results: n = 638, men 53.9 % (n = 344), mean age 10.8 ± 79.64 years, cancer patient 56 % (n = 357), mean follow-up time 56 ± 56.56 days, 2.5 ± 2.68 mean visits per process. Pain in first visit 43.3 % (n = 276), mean VAS 6.54 ± 1.87, pain 47.1 % of men (n = 162) and 38.8 % of women (n = 114) (p < 0.05), pain in oncology 56.6 % (n = 202) and 26.3 % of non-cancer patients (n = 74) (p < 0.001). No differences between groups in VAS. Before intervention by HCST we found statistically significant differences (p < 0.005) on morphine and tramadol, and greater significance (p < 0.001) in transdermal and transmucosal fentanyl, paracetamol, metamizol and NSAIDs, all more common in uncontrolled pain. Previous mean doses of all these drugs showed no significant differences between groups, although they were higher in the group of uncontrolled pain. In these, analgesics were prescribed or modified, being statistically significant difference pre-post-intervention (p < 0.001) in transdermal and transmucosal fentanyl, tramadol, paracetamol, metamizol, NSAIDs, pregabalin and with p < 0.05 in gabapentin. Was obtained difference (p < 0.05) in mean dose only in transdermal fentanyl and codeine dose post-intervention of HCST. We obtain positive correlations between pain and anorexia, anxiety, depression and insomnia; in cancer patients between pain and anxiety and insomnia, and non-cancer patients between pain, nausea and depression. No differences between groups in previous use of benzodiazepines, antidepressants and other treatments; there was differences in depression, anxiety and insomnia. After intervention, we obtain significant differences in use of these treatments and sedation. Conclusions: after intervention of HCST there was gradual increase of all analgesic; it should conduct a full assessment of the patient's symptoms and treatment of multifactorial symptoms in addition to questioning the patient adequately about the presence of associated symptoms, given the high correlation of them.Objetivos: Determinar la frecuencia de uso de analgésicos en pacientes terminales atendidos en domicilio, analizando factores que pudieran intervenir en la percepción del dolor, además de las actuaciones llevadas a cabo. Material y métodos: Estudio analítico prospectivo e intervencional con pacientes derivados al Equipo de Soporte para Atención Domiciliaria (ESAD) de Barbastro. Variables estudiadas: edad, sexo, número de visitas, tiempo de seguimiento, presencia de dolor y de otros síntomas concomitantes, Escala Visual Analógica (EVA), diagnóstico, analgésicos previos y post-intervención, dosis media previa de analgésicos y post-intervención. Estudio estadístico con SPSS 15.0. Resultados: n = 638, 53,9 % hombres (n = 344), edad media 79,64 ± 10,8 años, 56 % oncológicos (n = 357), seguimiento medio 56 ± 56,56 días, media de 2,68 ± 2,5 visitas por proceso. Dolor en primera visita 43,3 % (n = 276), EVA media 6,54 ± 1,87, dolor 47,1 % de hombres (n = 162) y 38,8 % de mujeres (n = 114) (p < 0,05), dolor en 56,6 % de oncológicos (n = 202) y en 26,3 % de crónico-dependientes (n = 74) (p < 0,001). No diferencias en EVA entre grupos. Entre analgésicos pautados en pacientes con dolor controlado y sin controlar previa intervención del ESAD encontramos diferencias estadísticamente significativas (p < 0,005) en morfina y tramadol, y con mayor significación (p < 0,001) en fentanilo transdérmico y transmucosa, paracetamol, metamizol y AINE, todos más frecuentes en dolor no controlado. Las dosis medias previas de todos estos fármacos no mostraron diferencias significativas entre los grupos, aunque eran mayores en el grupo de dolor no controlado. En estos, se pautan o modifican analgésicos, encontrándose diferencias estadísticamente significativas pre-post intervención (p < 0,001) en fentanilo transdérmico y transmucosa, tramadol, paracetamol, metamizol, AINE, pregabalina y con p < 0,05 en gabapentina. Se obtiene diferencias (p < 0,05) únicamente en las dosis posteriores a la actuación del ESAD en fentanilo transdérmico y codeína. Obtenemos correlaciones positivas entre dolor y anorexia, ansiedad, depresión e insomnio; en pacientes oncológicos entre dolor y ansiedad e insomnio, y en pacientes crónico-dependientes entre dolor, náuseas y depresión. No diferencias entre grupos en uso previo de benzodiacepinas, antidepresivos y otros tratamientos, aunque sí en clínica de depresión, ansiedad e insomnio. Tras intervención, diferencias significativas en uso de estos tratamientos y de sedación. Conclusiones: Tras la actuación del ESAD se puede apreciar el aumento progresivo de todas las medicaciones analgésicas; se debería realizar una valoración completa de la sintomatología del paciente y un tratamiento de síntomas multifactorial, además de interrogar al paciente de forma adecuada acerca de la presencia de síntomas asociados, dada la elevada correlación de los mismos

&ldquo;Compassionate City&rdquo; in Patients with Advanced Illnesses and at the End of Life: A Pilot Study

Objectives: To evaluate, in a Compassionate City pilot experience (Sevilla), the impact results on health in a population of people with advanced illness and at the end of life. Methods: The project was undertaken in Sevilla, Spain, between January 2019 and June 2020. A longitudinal, descriptive study was conducted using a longitudinal cohort design with two cross-sectional measurements, pre and post intervention. All patients who entered the program on the start date were included. The networks of care around people with advanced illness and at the end of life, palliative care needs, quality of life, loneliness, anxiety, depression, caregivers&rsquo; burden and family satisfaction were evaluated. The interventions were conducted by community promoters assigned to the &ldquo;Sevilla Contigo, Compassionate City&rdquo; program. Results: A total of 83 people were included in the program. The average number of people involved in care at the beginning of the evaluations was 3.6, increasing to 6.1 at the end of the interventions. The average number of needs detected at the beginning was 15.58, and at the end of interventions, it was 16.56 out of 25. The unmet needs were those related to last wishes (40.7%), emotional relief (18.5%), entertainment (16%), help to walk up and down stairs (8.6%) and help to walk (6.2%). A total of 54.2% showed improved loneliness in the final evaluation. Out of 26 people evaluated for pre and post quality of life, 7 (26.9%) improved their quality of life in the general evaluation and 5 (19.2%) displayed improved anxiety/depression. A total of 6 people (28.6%) improved their quality-of-life thermometer scores. A total of 57.7% of caregivers improved their burden with a mean score of 17.8

Health care services utilization and cost in the last year of life in Colombia: a retrospective study

Introduction: Health care costs at the end of life cause a high expenditure on health care resources. Theimplementation of integrated palliative care programs has proven to be cost-efficient. The study aimedto analyze the consumption and cost of health care resources during the last year of life of patients whoare not part of a palliative care program.Methods: A descriptive, longitudinal and retrospective study was conducted in patients of a Colombian healthinsurance company who died in 2013 due to pathologies that were susceptible and non-susceptibleto palliative care. Causes of death were obtained from official death certificates. McNamara et al. strategyof classification was applied and adapted to assess services received during the last year of life. Analysisof costs was conducted by pathologies at different levels of care.Results: 3,392 deaths in 2013 (70% susceptible to palliative care and 30% non-susceptible to palliativecare). Total health care cost: USD 47,550,155. Patients susceptible to palliative care were responsible for84% of the year’s expenditure (the annual expenditure) (USD 40 million). There were significant differencesbetween the average costs for susceptible and non-susceptible palliative care patients (USD 16,878 versusUSD 7,433 per year, p &lt; 0.001). The average cost per patient for the last three months of life represented52% of the expenditure during the last year of life (USD 8,754). The last month of life was 25.6% of theexpenditure during the last year of life (USD 4,324).Conclusions: Cost of care for the last three months of life of susceptible palliative care patients generatesa huge health care expenditure, mainly attributable to hospital care cost. The implementation of a palliativecare program could decrease these assistance costs

Development and Management of Networks of Care at the End of Life (the REDCUIDA Intervention): Protocol for a Nonrandomized Controlled Trial

Background: End-of-life needs can be only partly met by formalized health and palliative care resources. This creates the opportunity for the social support network of family and community to play a crucial role in this stage of life. Compassionate communities can be the missing piece to a complete care model at the end of life. Objective: The main objective of this study is to evaluate the REDCUIDA (Redes de Cuidados or Network of Care) intervention for the development and management of networks of care around people with advanced disease or at the end of life. Methods: The study is a 2-year nonrandomized controlled trial using 2 parallel groups. For the intervention group, we will combine palliative care treatment with a community promoter intervention, compared with a control group without intervention. Participants will be patients under a community palliative care team’s supervision with and without intervention. The community promotor will deliver the intervention in 7 sessions at 2 levels: the patient and family level will identify unmet needs, and the community level will activate resources to develop social networks to satisfy patient and family needs. A sample size of 320 patients per group per 100,000 inhabitants will offer adequate information and will give the study 80% power to detect a 20% increase in unmet needs, decrease families’ burden, improve families’ satisfaction, and decrease the use of health system resources, the primary end point. Results will be based on patients’ baseline and final analysis (after 7 weeks of the intervention). We will carry out descriptive analyses of variables related to patients’ needs and of people involved in the social network. We will analyze pre- and postintervention data for each group, including measures of central tendency, confidence intervals for the 95% average, contingency tables, and a linear regression. For continuous variables, we will use Student t test to compare independent samples with normal distribution and Mann-Whitney U test for nonnormal distributions. For discrete variables, we will use Mann-Whitney U test. For dichotomous variables we will use Pearson chi-square test. All tests will be carried out with a significance level alpha=.05. Results: Ethical approval for this study was given by the Clinical Research Committee of Andalusian Health Service, Spain (CI 1020-N-17), in June 2018. The community promoter has been identified, received an expert community-based palliative care course, and will start making contacts in the community and the palliative care teams involved in the research project. Conclusions: The results of this study will provide evidence of the benefit of the REDCUIDA protocol on the development and assessment of networks of compassionate communities at the end of life. It will provide information about clinical and emotional improvements, satisfaction, proxy burden, and health care resource consumption regarding patients in palliative care