Friday, October 11, 2013

Palliative care in patients without cancer: Impact of the end-of-life care team.

Nihon Ronen Igakkai Zasshi. 2013;50(4):491-3.


Department of Palliative Medicine, National Center for Geriatrics and Gerontology.


Palliative care improves the quality of life of patients and their families facing problems associated with life-threatening illnesses by promoting the prevention and relief of suffering. 

Palliative care in Japan has been developed mainly for cancer patients. At the National Center for Geriatrics and Gerontology, an end-of-life care team (EOLCT) has been developed to promote palliative care for patients without cancer. 

In the first 6 months of its operation, 109 requests were received by the team, 40% of which were for patients without cancer or related disease, including dementia, frailty due to advanced age, chronic respiratory failure, chronic heart failure, and intractable neurologic diseases. 

The main purpose of the EOLCT is to alleviate suffering. 
The relevant activities of the team include the use of opioids, providing family care, and giving support in decision-making (advance care planning) regarding withholding; enforcement; and withdrawal of mechanical ventilators, gastric feeding tubes, and artificial alimentation. 

The EOLCT is also involved in ongoing discussions of ethical problems. The team is actively engaged in the activities of the Japanese Geriatric Society and contributes to the development of decision-making guidelines for end-of-life by the Ministry of Health, Labour and Welfare.

 The EOLCT can be helpful in promoting palliative care for patients with diseases other than cancer. The team offers support during times of difficulty and decision-making.

Palliative care in low- and medium-resource countries.

Cancer J. 2013 Sep-Oct;19(5):410-3.


A portion of this manuscript will be incorporated into a chapter in an upcoming book on global cancer care, Editors, Kenneth Miller, MD, and Miklos Simon, MD, Praeger Press. From *The Johns Hopkins University/Sinai Hospital of Baltimore Internal Medicine Residency Program, Baltimore, MD; †Friends of Hospice Ethiopia (formerly PHEALPS [Partnership of Hospice Ethiopia & ASIH L˚ngbro Park, Sweden]); ‡Sinai Hospital of Baltimore, Palliative Care Program, Baltimore, MD.


Low- and medium-resource countries are facing a significant increase in the incidence of noncommunicable diseases such as cancer. 

Unfortunately, the majority of patients with cancer present with advanced disease, and disease-directed treatment may be unlikely to be effective and/or not available. 
Globally, there will be a growing need for palliative care services.
There has been significant progress in the provision and integration of palliative care into the health care policy and systems. 
Nonetheless, palliative care services vary significantly between regions of the world and also between countries in the same region. 
Some common barriers to care include the lack of a trained workforce to provide palliative care, lack of availability of opioids or the restriction of their use, cultural attitudes of physicians and patients, and also funding. 

Despite these challenges, there are examples of low- and medium-resource countries that are providing excellent palliative care that is being integrated into the health care system and the cancer care continuum.

This article provides an overview of the progress in providing palliative care in low- and medium-resource countries. In addition, more specific information is provided on palliative care in low-resource countries in Latin America, Asia, and Africa. 

Finally, a more personal perspective is presented on the development of palliative care in Ethiopia, as an example.

Knowledge and attitudes regarding pain management among Jordanian nursing students.

Nurse Educ Today. 2013 Apr;33(4):339-45.


Faculty of Nursing, Mutah University, Al-Karak, Jordan.



The presence of pain is one of the main reasons why people seek health care, however pain is often undertreated. Inadequate treatment has been linked to health care professionals' failure to assess pain and to intervene appropriately. It may also result from the limited attention given to pain management in nursing curricula.


The objectives of this study were to explore the current knowledge and attitudes regarding pain management among baccalaureate nursing students and the factors that might influence such knowledge and attitudes, and nursing students perceived barriers to adequate pain management during clinical practice.


The descriptive design included a sample of 240 baccalaureate nursing students in three nursing schools in three governmental universities in Jordan. The Knowledge and Attitudes Survey Regarding Pain scale was used to measure knowledge and attitudes regarding pain management. Data were analyzed by descriptive statistics and independent sample t test. Data were collected over a period of three months from April 2012 to June 2012.


Of the 340 distributed questionnaires; 240 completed questionnaires were returned. The data showed that nursing students were found to have inadequate knowledge and attitudes related to pain and its management. The mean correct score for the entire scale was 34.1%. (SD=9.9). Findings revealed that there were significant differences found in the students' scores related to pain management training and frequency of using pain assessment tools (p<0.05).The most frequently identified barriers were lack of knowledge and training regarding pain management followed by not using pain assessment tools by nurses who are working in the clinical areas.


The study findings demonstrated that nursing students have insufficient knowledge and attitudes regarding pain and its management and could benefit from additional education and training on that issue.
Copyright © 2013 Elsevier Ltd. All rights reserved.

Knowledge of palliative care: An online survey.

Nurse Educ Today. 2013 Sep 9. 


Doctor of Oncology and Palliative care Nursing, Faculty of Nursing, Al al-Bayt University, Mafraq 25113, Jordan. Electronic address:



The main purpose of palliative care is to manage symptoms among patients, reduce their burden of pain, and improve their quality of life. Nurses are an essential part of the palliative care team in providing high standards of care since they spend the longest time with patients. However, lack of adequate knowledge of palliative care is considered as one of the main barriers to palliative care development and practise.


To evaluate Jordanian nursing students' knowledge about palliative care.


Design A quantitative research method and descriptive online-survey design were used. Settings and Participants The sample consisted of 220 students enrolled in five nursing schools (four governmental and one private) in Jordan. The Palliative Care Quiz for Nursing was used to measure students' knowledge.


The sample consisted of 220 nursing students; the mean age was 20.5, SD 2.5, and most of the students were female (67), 74 (34%) were fourth-year students and 58 (26%) were in their third year. The total mean score was low, at 8.0 (SD 3.1), ranging from 0 to 18 and the number of correctly answered statements ranged from 60 (27%, statement no. 3) to 145 (66%, statement no. 2). It was found that there were no significant impacts (H (3)=5.69, p=0.137) for place of study. However, students' knowledge was strongly affected by their academic level (H (3)=12.60, p=0.005).


Integrating palliative care education is required as the mainstay to improve students' knowledge and therefore practise. 
This education needs to be comprehensive in covering the basic principles of palliative care and symptom management and it should be distributed throughout the different courses to discuss palliative care within different contexts, such as elderly, paediatric and adult settings.
© 2013.


Jordan, Knowledge, Nursing, Palliative care, Students, Symptoms management

The Distinct Role of Palliative Care in the Surgical Intensive Care Unit.

Semin Cardiothorac Vasc Anesth. 2013 Sep 26.


Palliative care is expanding its role into the surgical intensive care units (SICU). Embedding palliative philosophies of care into SICUs has considerable potential to improve the quality of care, especially in complex patient care scenarios. This article will explore palliative care, identifying patients/families who benefit from palliative care services, how palliative care complements SICU care, and opportunities to integrate palliative care into the SICU. 

Palliative care enhances the SICU team's ability to recognize pain and distress; establish the patient's wishes, beliefs, and values and their impact on decision making; develop flexible communication strategies; conduct family meetings and establish goals of care; provide family support during the dying process; help resolve team conflicts; and establish reasonable goals for life support and resuscitation.

 Educational opportunities to improve end-of-life management skills are outlined. 

It is necessary to appreciate how traditional palliative and surgical cultures may influence the integration of palliative care into the SICU.

 Palliative care can provide a significant, "value added" contribution to the care of seriously ill SICU patients.

Managing urinary incontinence at the end of life: an examination of the evidence that informs practice.

Int J Palliat Nurs. 2013 Sep;19(9):449-56.


Clinical Academic Fellow and Staff Nurse, University of Southampton and University Hospital Southampton NHS Foundation Trust.


To achieve a 'good' death, management of urinary incontinence at the end of life arguably should be as much a priority for nursing attention as managing symptoms such as pain and nausea. 
To understand how contemporary best practice is described and the nature of interventions prescribed for managing this issue, this article reviews the content of 16 seminal palliative care textbooks and 10 journal articles (retrieved through systematic search techniques) that discuss the management of urinary incontinence for patients at the end of life. 

The findings depict an area of nursing that has been governed by 'common sense' and precedent rather than evidence-based research, particularly regarding the use of indwelling urinary catheters. 

There is very little robust research evidence on this topic. 

Further research is required to ascertain the current state of practice in settings where patients who are approaching the end of life are cared for and the needs and preferences of patients and families.

The Palliative Care Knowledge Questionnaire for PEACE: Reliability and Validity of an Instrument To Measure Palliative Care Knowledge among Physicians.

J Palliat Med. 2013 Sep 28. 


1 Palliative Care Team, Saku Central Hospital , Nagano, Japan .


Abstract Background: 
In Japan, a nationwide palliative care education program for primary palliative care (the Palliative care Emphasis program on symptom management and Assessment for Continuous medical Education: PEACE) was established in 2008. Effective delivery of such programs relies on adequate evaluations of program efficacy; however, such an instrument does not exist. 

Objective: This study aimed to develop and validate a measurement tool to quantify knowledge level of physicians about broader areas of palliative care, by which the effect of an education program could be measured. Methods: We conducted a cross-sectional, anonymous, self-administered questionnaire survey with a group of 801 conveniently sampled physicians in October 2010. To examine the test-retest reliability of items and domains, the questionnaire was reissued two weeks after the first survey was completed. This study used psychometric methods, including item response theory, intraclass correlation coefficients, and known-group validity. 

Results: The response rate was 54% (n=434). We included 33 items across the following 9 domains: (1) philosophy of palliative care, (2) cancer pain, (3) side effects of opioids, (4) dyspnea, (5) nausea and vomiting, (6) psychological distress, (7) delirium, (8) communication regarding palliative care, and (9) community-based palliative care. For these items, the intraclass correlation was 0.84 and the Kuder-Richardson Formula 20 (KR-20) test of internal consistency was 0.87. There was a significant difference in the scores between palliative care specialists and other physicians. 


We successfully validated a newly developed palliative care knowledge questionnaire to evaluate PEACE effectiveness (PEACE-Q). 
The PEACE-Q could be useful for evaluating both palliative care knowledge among physicians and education programs in primary palliative care.

Noncomfort Medication Use in Acute Care Inpatients Comanaged by Palliative Care Specialists Near the End of Life: A Cohort Study.

Am J Hosp Palliat Care. 2013 Oct 1. 



1Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada.


Background/ OBJECTIVE: To examine comfort medication (CM) and noncomfort (NC) medication use in inpatients comanaged by palliative care (PC) near the end of life.


Chart review of inpatients comanaged by the PC service at 2 academic hospitals. Medications were categorized as CM and NC medication according to the published guidelines.


Seventy patients met inclusion criteria. In the final week of life, inpatients were receiving a mean of 6 CM (40 doses) and 7 NC medications (41 doses). 
Four new NC medications were started per patient, but only 3 were discontinued. 
The NC medications were most frequently discontinued on the day of PC consult, but 14% were stopped on the day of death/PC unit transfer.

Inpatients comanaged by PC continue to receive NC medications as they near the end of life.


drug therapy, end of life, inappropriate prescribing, pain management, palliative care

Examining the Effect of the Case Management Model on Patient Results in the Palliative Care of Patients With Cancer.

Am J Hosp Palliat Care. 2013 Oct 4. 


1Zubeyde Hanim School of Health, Nigde University, Nigde, Turkey.


We aimed to investigate the improvement in symptoms, quality of life, patient and family satisfaction with care, and direct costs resulting from a palliative care program based case management model.

The research was implemented at the Medical Oncology Clinic hospital of a University between September 2009 and September 2011. The research sample consisted of a total of 44 patients (22 control and 22 intervention group). 

The research tools were the Edmonton Symptom Diagnosis System, the Karnofsky Performance Scale, the EORTCQLQ-C30 Quality of Life Scale, a patient and family satisfaction form, and a patient cost record form.


The difference between total symptom mean scores and the sub-dimension symptoms of pain, fatigue, nausea, depression, anxiety, lack of appetite, lethargy, well-being, dyspnea, and constipation post-hospitalization and post-discharge of patients in the control and experimental groups were found to be statistically significant (p < 0.05). 

The level of decrease in symptom severity in the experimental group patients was more than in the control group (p < 0.000). 
The satisfaction level of patients and family in the palliative care based case management service was higher than that for conventional service in the control group (p < 0.05). 
No statistical difference was detected between the experimental and control groups regarding health costs and duration of hospitalization (p > 0.05).

We provided a better symptom control, improved the patient s quality of life (excluding physical and congnitive functions), and patient and family satisfaction levels were higher in the palliative care based case management intervention group, but direct health costs were not affected.


care management, case management, multidisciplinary team, nursing, palliative care, symptom control

[Polyneuropathic Pain Therapy with a Patient Suffering from Generalized Castrate Resistant Prostate Cancer -  Clinical Case Report.]

[Article in Czech]

Klin Onkol. 2013 Fall;26(5):354-357.


Background: Tapentadol is a µ opioid receptors agonist as well as an inhibitor of noradrenaline reuptake. This pharmacologic profile of tapentadol makes it a suitable drug of choice in nociceptive and neuropathic pain control. 
Case Report: This clinical report pressents a 65year old man with poorly differentiated prostate cancer -  Gleason score 8 (4 + 4) with metastatic bone disease. Besides the initial application of bisphosphonates, the patient had been treated with androgen deprivation therapy (cyproterone acetate + leuprolide acetate) for the period of 18 months. This therapy was terminated due to an increase of PSA levels. Subsequently, the patient underwent palliative docetaxelbased chemotherapy. There were eight cycles applied with positive clinical and laboratory effect. However, the further application was limited by the averse effects, namely the peripheral neuropathy manifested by pain in arms and legs. The peripheral neuropathy had progressive tendency even after the end of chemotherapy, and supportive treatment with gabapentin and amitryptiline failed to succeed. Four months after zoledronic acid monotherapy, the patient was started on tapentadol in 50-mg dose b.i.d., consequently escalated to 100 mg b.i.d. (to this point, 25 µg of transdermal fentanyl were used for pain management). Significant relief from neuropathic discomfort was observed three weeks from the onset of tapentadol therapy. Patients state of health normalized within three months after the initiation of therapy. Consequently, the patient was able to receive docetaxel chemotherapy again, without any neuropathic pain exacerbation on the maintenance dose of tapentadol 50 mg b.i.d. 

Conclusion: Tapentadol administration resulted in stable and longtime relief from neuropathic pain which is a frequent side effect in the course of castrateresistant prostate cancer therapy with taxanes. 

 Key words: case study -  tapentadol -  neuropathic pain -  prostate cancer Supported by the project ED2.1.00/03.0076 from European Regional Development Fund. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE "uniform requirements" for biomedical papers.Submitted: 28. 8. 2013Accepted: 14. 9. 2013.

[Colorectal cancer - personalized, stage-adjusted tumour therapy].

Dtsch Med Wochenschr. 2013 Sep;138(36):1790-5. 


Medizinische Universitätsklinik, Knappschaftskrankenhaus Bochum.


Colorectal cancer (CRC) is the second leading cause of cancer death in the western world. Every second patient dies of the disease. The introduction of new and effective chemotherapeutic substances and biologics during the past decade has significantly improved the systemic treatment of patients with CRC. In stage III colon cancer combination chemotherapy with oxaliplatin is the standard of care. Primary resection of metastases or resection after combination therapy and downsizing of lesions offers a chance for cure for some patients. In the treatment of rectal carcinoma, multimodality and neoadjuvant treatment concepts have replaced adjuvant chemoradio-therapy for locally advanced rectal cancer. In the palliative setting intensive combination treatment is indicated in colorectal cancer if tumor related symptoms or a rapid progress of the disease occur. 
The aim of palliative therapy is the prolongation of survival and the improvement of quality of life. 

The introduction of the mutational status of the KRAS oncogene as the first predictive marker into clinical care is an important step towards the personalization of treatment in CRC.

Surgery in asymptomatic patients with colorectal cancer and unresectable liver metastases: the authors' experience.

Onco Targets Ther. 2013;6:267-72. 



Department of General and Oncologic Surgery, University of Perugia, Perugia.



In asymptomatic patients with Stage IV colorectal cancer, the debate continues over the efficacy of primary resection compared to chemotherapy alone. The aim of this study was to define the optimal management for asymptomatic patients with colorectal cancer and unresectable liver metastases.


Patients receiving elective surgery (n = 17) were compared to patients receiving chemotherapy only (n = 31). Data concerning patients' demographics, location of primary tumor, comorbidities, performance status, Child-Pugh score, extension of liver metastases, size of primary, and other secondary locations were collected.


Thirty-day mortality after chemotherapy was lower than that after surgical resection (19.3% versus 29.4%; not significant). In patients with >75% hepatic involvement, mortality at 1 month was higher after receiving surgical treatment than after chemotherapy alone (50% versus 25%). In patients with <75% hepatic involvement, 30-day mortality was similar in both groups (not significant). Thirty-day mortality in patients with Stage T3 was lower in those receiving chemotherapy (16.7% versus 30%; not significant). Overall survival was similar in both groups. The risk of all-cause death after elective surgery (2.1) was significantly higher than in patients receiving chemotherapy only (P = 0.035).


This study demonstrated that in palliative treatment of asymptomatic unresectable Stage IV colorectal cancer, the overall risk of death was significantly higher after elective surgery compared to patients receiving chemotherapy alone. However, in the literature, there is no substantial difference between these treatments. 
New studies are required to better evaluate outcomes.


30-day mortality, inoperable liver replacement, large bowel, palliative surgery, tumor

Sunday, October 6, 2013

Estimating the potential life-shortening effect of continuous sedation until death: a comparison between two approaches.

J Med Ethics. 2013 Jul 11. 


Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.



In some cases, physicians estimate that continuous sedation until death may have a life-shortening effect. The accuracy of these estimations can be questioned.


The aim of this study is to compare two approaches to estimate the potential life-shortening effect of continuous sedation until death.


In 2008, 370 Dutch physicians filled out a questionnaire and reported on their last patient who received continuous sedation until death. The potential life-shortening effect of continuous sedation was estimated through a direct approach (question: Did continuous sedation, according to your estimation, hasten the patient's death? If yes: by how much time?) and an indirect approach (estimated life expectancy minus duration of sedation). The intrarater agreement between both approaches was determined with a weighted κ.


According to the direct approach, sedation might have had a life-shortening effect in 51% of the cases and according to the indirect approach in 84%. The intrarater agreement between both approaches was fair (weighted κ=0.38). In 10% of all cases, the direct approach yielded higher estimates of the extent to which life had been shortened; in 58% of the cases, the indirect approach yielded higher estimates.


The results show a discrepancy between different approaches to estimate the potential life-shortening effect of continuous sedation until death.

Palliative sedation in nursing anesthesia.


Central Wisconsin Anesthesia Associates, Berlin, Wisconsin, USA.

AANA J. 2013 Apr;81(2):113-7.


Palliative sedation is a technique of providing a sedative for end-of-life care to patients with intractable pain. The literature discusses the techniques and use of palliative sedation.

 Numerous articles have been written regarding the issues surrounding its use, but no literature has discussed the prescription or administration of palliative sedation by a nurse anesthetist. 

 By understanding the concept and ethics involved in its use and providing nursing care that is theory based, the author argues that the involvement of nursing anesthesia is appropriate and within the scope of practice.

 Few other healthcare disciplines can provide the patient care and empirical knowledge that is imperative in the care of the dying patient. 
This article discusses the concept and ethics of palliative sedation and presents a case of providing palliative sedation to a terminally ill patient by an experienced nurse anesthetist. 
Palliative sedation should be understood, embraced, and utilized as an area of expertise suited for nursing anesthesia.
Balsam helps terminally ill live life to the fullest

A Balsam team member provides palliative care for a patient.
A Balsam team member provides palliative care for a patient.

BEIRUT: By its very nature, the medical system is focused on curing illness. But this can mean that the concerns of patients with chronic or terminal disease, who often live for relatively long periods in pain, are forgotten or set aside.
This is why family physician Hibah Osman founded the Lebanese Center for Palliative Care in 2011. 
Known as Balsam, the center works to comfort patients with chronic and terminal illnesses, as well as their families.
“When my patients started getting very sick and I didn’t have the resources to support them when they were sick and dying ... the [idea] of palliative care opened up to me,” Osman says.
“We needed to create something so that when patients have serious illnesses, we are able to support them and take care of them because they’re still there, they are still alive and they’re suffering.”
When she initially became interested in the subject, Osman knew little about palliative care. “I didn’t really know what it was about until I was probably 10 years into my practice as a family doctor,” she says, lamenting that this lack of knowledge was common in the Lebanese medical community.
“So I stumbled into it [while] trying to make my patients more comfortable and noticed that there was nothing in palliative care in Lebanon. This is where the idea of Balsam came from.”
Balsam was registered in 2011, but the non-governmental organization’s team has been working together since 2010. Balsam and SANAD, another NGO, are the only two organizations providing palliative care in Lebanon.
Speaking to The Daily Star in Balsam’s Hamra headquarters, Osman details the types of support her organization provides to patients.
“We focus on relieving suffering in the physical sense, in the psychological sense [manifested] by the depression and anxiety associated with serious illness, and in the social and spiritual [senses] as well,” she says.
“Social support includes things like providing equipment, hospital beds, walkers, [and] wheel chairs. If somebody is still undergoing chemotherapy or radiation, [it means] helping them arrange transport to the hospital and from the hospital.”
Balsam provides all its services for free and relies mainly on donations.
“We believe very strongly that death with dignity and relieving suffering is something that everybody should have access to,” Osman says, explaining that Balsam does not charge for its services because it wants them to be accessible to all.
“A big part of what we do is raising awareness, changing legislation, [and] training ... What we hope to do is train health providers to provide this kind of care,” she said.
“Now we are involved in setting medical curricula for medical students and nurses.”
Balsam held a fundraiser at Beirut’s Sky Bar earlier this month, and is asking people to run on its behalf in the November Beirut Marathon.
“We have wonderful supporters, we have a few key anchor donors who have been providing a lot of the support, [but] it is always a struggle,” she says, pointing to rising costs as the staff increases.
Osman says that with a huge demand for the kind of care Balsam offers, the organization is growing quickly.
“It is estimated that about 25,000 people die in Lebanon each year ... of those about 10 percent die suddenly ... the other 90 percent die after chronic illness, whether that is cancer or something else,” says Osman.
“The estimate is that about 60 percent of those people could benefit significantly from receiving palliative care,” she adds.
Balsam has cared for around 50 people since it opened, at first working with one or two patients at once. Now, Osman says the staff – which includes two part-time and one full-time nurse – takes on 10 patients at a time.
Osman notes that Balsam played an active role in pushing for the establishment of the National Committee for Pain and Palliative Care, formed under the Health Ministry in May 2010.
This committee is working to develop a national strategy for palliative care, so that it is both incorporated in the education of doctors and nurses.
Balsam provides constant support for those patients who are relatively close to its Beirut center, Osman said.
“If they are far ... we provide partial support ... We do maybe one visit and help them figure out what their needs are ... and then, for instance, we can provide telephone support.”
Osman says that the reaction of the patients and families who have received palliative care from Balsam has been “extremely positive.”
“Palliative care is not about dying, it is about living life to the fullest despite your illness,” she says. “It’s about saying, ‘I can still participate in life and I can still sit with the family at the dinner table.’”

Haloperidol for agitation in dementia.


Department of Medicine, UCSF School of Medicine, VA Medical Center, 4150 Clement St, San Francisco, California 94121, USA.



Agitation includes wandering, crying out, abusive vocalization, and assaultive behavior and occurs in up to 70% of patients with dementia. Although the neuroleptic haloperidol has been used for decades to control disruptive behavior in psychotic and demented patients, the effectiveness of this drug for agitated dementia remains in question. 
The first meta-analysis on the effectiveness of haloperidol for agitated dementia, published in 1990, was limited in scope and was unable to provide clear guidelines for the use of haloperidol for demented patients who are agitated. 

Meta-analyses in 1998 and 2000 examined haloperidol compared with other neuroleptics as well as with placebo and omitted a number of databases, including non-English language publications. To determine the effect of haloperidol, compared with placebo, in the control of agitated dementia and to make recommendations for future research in this area a more widely based, yet more highly focussed review was carried out.


The main objective was to determine whether evidence supports the use of haloperidol to treat agitation in demented patients.


The CDCIG Specialized Register was searched to identify all available reports on haloperidol treatment of agitated dementia.


We examined randomized, placebo-controlled trials, with concealed allocation, where subjects' dementia and agitation were assessed. Trials involving treatment of less than one week were not included.


1. Two reviewers extracted data from included trials. 
2. Data were pooled, where possible, and analysed using appropriate statistical methods. 
3. Odds ratios or average differences were calculated. 
4. Only 'intention to treat' data were included. Where a cross-over design was employed (Devanand, 1998), only the initial phase of the study was used to compare haloperidol versus placebo. 
5. Sensitivity analysis was applied to heterogeneity of results and to gauge the effect of the included studies of small sample size. 
6. In addition to the overall meta-analysis, individual analyses of the reports were carried out to examine the effect of degree of dementia, dose of haloperidol, and duration of therapy on agitated dementia. 
Analysis included the following groups: All patients treated with haloperidol compared with placebo.


There were five included trials. All studies stated "intention to treat" analysis of their results. Three studies were from the United States, and two studies were from Europe. Two studies examined patients with various forms of dementia, and three studies included only patients with diagnosed Alzheimer's dementia. 
1. Overall meta-analysis of the response of agitated patients to haloperidol, compared with controls, showed no improvement in agitation. There is some evidence that haloperidol helps to control aggression. Adverse reactions and dropouts were more frequent among haloperidol treated patients, compared with controls. This meta-analysis provided no information about the relationship between the degree of dementia, the kind of agitation manifested, or the dosage and duration of therapy with haloperidol and response to treatment of demented patients with agitation. 
2. The results of this meta-analysis were too broad to permit specific recommendations for treatment of agitated dementia with haloperidol. 
3. Higher dose haloperidol, or prolonged haloperidol (12 weeks compared with 3 - 6 weeks) was associated with increased side effects, largely related to Parkinsonian symptoms of rigidity and bradykinesia.


1. Haloperidol appeared to provide no improvement in agitation among demented patients compared with placebo, but side effects were frequent. 

2. Dropout rates were higher for haloperidol compared with placebo treated patients, suggesting that side effects led to discontinuation of treatment in some patients.

 3. Because of the wide focus of this meta-analysis, not enough information was provided to permit recommendations linking haloperidol treatment of agitated dementia to degree of dementia, manifestations of agitation, or dosage and duration of treatment of haloperidol. 

4. Individual analysis of reports indicated that higher dose haloperidol (more than 2 mg per day) may have been more effective than lower dose haloperidol (less than 2 mg per day) in controlling aggression, but not other manifestations of agitation, among patients with mild to moderate dementia.

 5. Similar analysis suggested that prolonged therapy with haloperidol (more than 3 - 6 wks) or higher dosage (more than 2 mg per day) was more likely to result in side effects than were short term therapy (3 weeks) or lower dose haloperidol (less than 2 mg per day). 

6. The reports provided too little information to permit interpretation of the effect of degree or type of dementia on response to haloperidol. Except for a favorable response of aggression to haloperidol, no other manifestations of agitated dementia were found to have improved following therapy with haloperidol, compared with controls.

Comment in

Haloperidol overdosing in the treatment of agitated hospitalized older people with delirium: a retrospective chart review from a community teaching hospital.

Drugs Aging. 2013 Aug;30(8):639-44. 


Division of Geriatrics, Crozer-Chester Medical Center, Upland, PA 19013, USA.



Practice guidelines recommend the use of low dose haloperidol when medication is needed to treat delirium with acute agitation in hospitalized older people. Despite this, high dose haloperidol may frequently be used and result in higher rates of complications.


To describe dosages and effects of haloperidol used in the initial treatment of delirium with acute agitation in hospitalized older people, and prescriber use of low and high dose haloperidol.


Retrospective chart reviews were performed from June 2008 to May 2009 in a community teaching hospital located in Upland, PA, USA. Patients aged 65 years and older with acute agitated delirium were included. Patients admitted to ICU and those with psychiatric conditions were excluded. Data were collected on haloperidol dosing, responses, sedation, length of stay, and concurrent use of lorazepam.


A total of 261 charts of patients who received haloperidol were reviewed and 56 patients met inclusion criteria (14 males, 42 females). 
The mean age of subjects was 83 years.
The recommended starting dose of haloperidol (0.5 mg) was administered to 35.7 % of the patients. 
An initial dose of more than 1 mg was received by 37.5 % of the patients. 
The remaining 26.8 % of patients received 1 mg.
The relative risk of sedation was significantly greater for subjects receiving more than 1 mg of haloperidol in 24 h. 
The length of hospitalization was not predicted by haloperidol doses or lorazepam but by the number of days of agitation.


Higher than recommended initial doses of haloperidol were frequently used in the treatment of delirium with acute agitation in hospitalized older people. We found no evidence to suggest that higher dosages were more effective in decreasing the duration of agitation or the length of hospital stay. 
Low dose haloperidol appears to be as effective as and safer than higher doses in the treatment of acute agitation in this older population.

High-Dose Neuroleptics and Neuroleptic Rotation for Agitated Delirium Near the End of Life.

Am J Hosp Palliat Care. 2013 Sep 30.


1Palliative Care Physician, Portland, OR, USA.


Reason for the study:
Agitated delirium presents unique challenges for hospice and palliative care clinicians. Haloperidol, the recommended neuroleptic, may be ineffective at low dose, or poorly tolerated at higher doses.

Main Findings:This article reports on two patients with refractory agitated delirium. Both developed extrapyramidal symptoms from haloperidol and required rotation to an alternate neuroleptic. 
Patient #1 received 2000 mg/day oral chlorpromazine. Patient #2 received greater than 200 mg/day sublingual olanzapine. 

Control of agitation was achieved, though the doses were substantially higher than has previously reported in the literature. 
Each patient experienced considerable sedation, though this was an acceptable side effect for the family. 
Each patient was transferred from the acute care hospital to a location of family preference. 
There they died within a week of transfer.


Agitated delirium is a palliative care emergency. 
High doses of neuroleptic medications, with rotation to an alternate neuroleptic when side effects occur with standard haloperidol, may effectively palliate agitated delirium.
 This remedy can provide the patient with a peaceful dying in a place of their choosing.


agitated delirium, chlorpromazine, end-of-life care, olanzapine, palliative sedation, terminal delirium