2012 APA - IPS: What Is the Role of Psychiatry in End-of-Life Care?

New York, NY — Researchers in Quebec City, Canada, presented the results of their study examining the prevalence of psychiatric disorders and the use of psychotropic medications in terminal cancer patients in a poster at the American Psychiatric Association 64^th Institute on Psychiatric Services.

It is known that psychiatric disorders are severe and frequent complications in patients with terminal cancer, but few studies have analyzed the prevalence of psychiatric disorders or the use of psychotropic medications in this population.

Researchers conducted a chart review of a consecutive cohort of patients covering a five-month period from May to September 2008 from the date of admission to hospice until death. In 100 patients admitted to a 15-bed hospice that accepts only patients clinically assessed as having a prognosis of two months or less, the study cohort survived for an average of only two weeks, which is standard for this setting. The cohort included slightly more women (53%) than men and had a mean age of 68.7 years. The primary cancer sites were respiratory tract (26%), digestive system and pleural (21%), colorectal (13%), breast (5%), prostate (5%), and other (30%).

The most frequent psychiatric diagnoses upon admission or diagnosis in hospice were delirium (22 on admission, 50 during stay), significant delirium symptoms (0 on admission, 76 during stay), and anxiety disorders (17 on admission, 5 during stay). Sleep disorders were lower than anticipated (6 on admission, 5 during stay). Of note was the finding that only two patients had depressive disorders on admission, and none received this diagnosis during the stay.

“Delirium was the most common problem due to issues such as brain metastases, multi-organ failure, and other to metabolic causes,” said Pierre Gagnon, MD, one of the study authors.

Ninety-nine percent of patients received psychotropic medications. About half of the medications were started prior to admission with the remainder added in hospice. Ninety-four percent of patients were treated with first-generation antipsychotics (mainly haloperidol) for delirium (45.6%), anxiety disorders (9.4%), nausea and vomiting (20.8%), sleep disorders (13.1%), and other problems (11.1%). Eighty-four percent of patients were treated with benzodiazepines for sleep disorders (47.2%) and anxiety disorders (33.6%). Thirteen percent were treated with second-generation antipsychotics for depressive disorders (43.4%), delirium (12.1%), and anxiety (12.1).

“As death approaches, treatment with benzodiazepines increases, often with methotrimeprazine” said Gagnon. “At 24-48 hours before death, the object is not to reverse delirium, but to sedate the patient for relief of symptoms such as agitation and pain to prevent suffering.”

Given that psychiatric disorders have a major impact on the quality of death as demonstrated in this study, the expertise of psychiatrists holds a valuable place in palliative care.