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Improving mental health in palliative care

Delirium and depression: conditions too often seen in the palliative care setting are distressing, not only for the patient themselves, but for family, carers and medical staff as well.

Research is currently underway into therapeutic approaches which could ease the suffering of palliative care patients with these conditions.

Using melatonin to ease delirium

Inability to focus, fluctuating conscious levels, disorientation, restlessness, altered sleep/wake cycles and hallucinations. These are some of the symptoms experienced by palliative care patients with delirium.

And it’s common.

Professor Meera Agar, Professor of Palliative Medicine at UTS explains that up to one in three people will have delirium when admitted into palliative care with a further one-in-three at risk of developing delirium after admission.

“In the palliative care setting, we see a higher rate of delirium than any other hospital setting, even in geriatric care where the rate is one-in-five patients,” Professor Agar says.

With such a high prevalence of delirium in Palliative Care, the need to find ways to ease patient suffering is critical.

“Our research is looking into whether there any therapeutic approaches that can reduce the rate of delirium and increase the time people have with normal cognition,” says Professor Agar.

Enter the melatonin study.

The “Melatonin to prevent delirium in cancer patients” study is a three-year study funded by Cancer Australia which looks at whether prevention of delirium in cancer palliative care patients is possible with a daily 2mg dose of melatonin.

Amy Chow, Staff Specialist Palliative Medicine at Braeside Hospital, one of the hospitals participating in the trial, explains that patients with delirium often have disrupted sleep/wake cycles. Because melatonin is known for its efficacy in restoring these cycles, it is hoped that taking melatonin daily will prevent the onset of delirium.

Professor Meera Agar at Braeside Hospital

Professor Agar, lead investigator of the study, explains this further.

“There are a number of symptoms that manifest in delirium that are linked to our bodies circadian rhythm. Ability to focus is one of them. Clinical and laboratory studies have identified low levels of melatonin and circadian disruption in delirium and four studies have shown melatonin as a safe agent in the hospitalised elderly.”

“We are building on the potential effect seen in these studies to apply in people with advanced cancer,” Professor Agar says.

Unlike other pharmaceutical treatments currently in use for delirium, melatonin has far less side-effects and is generally well-tolerated which is another reason the research is important.

The study is currently in its second year and will be completed by December 2020.

 

Easing depression in palliative care

For some people facing the end of their life, clinical depression occurs, and this can be particularly difficult to treat for those patients with a very poor prognosis of days to weeks.

“Oral antidepressants take several weeks to be effective and for someone who possibly has only weeks to live, there is no time to see benefits,” explains Professor Agar.

Ketamine have shown promise in rapidly improving depressive symptoms, usually within a few days. A new two-year study, led by Dr Wei Lee at University of Technology Sydney is looking at the feasibility, activity and safety of ketamine as a treatment for people in palliative care with clinical depression. The study is currently underway in Braeside Hospital in Fairfield, Calvary, Sacred Heart and Liverpool Hospital.

Dr Lee explains that people in palliative care nearing the end of life, often have difficulty swallowing therefore an injectable treatment is needed that is fast and robust enough to work. The study involves the subcutaneous infusion of ketamine via a syringe-driven pump over a two-hour period at a weekly interval for up to four weeks. Patients’ depressions symptoms are then assessed regularly during the week after treatment. Depending on the patient’s response, a decision will be made about the next most appropriate dose: an individual dose titration approach.

“Because every patient is different in the way they respond to medication, we use an individualised approach where we start at ultra-low doses. The dose is then adjusted according to the patient’s responses to optimise effect while minimising side effects,” he explains.

While the study is only in the early stages, it is hoped it will show that ketamine can provide much needed relief for people nearing the end of their lives.

“Many people suffering depression at the end of life often lose interest in things such as interacting with family. This is difficult not only for the patient but also for family who do not get the opportunity to say goodbye. With an infusion of ketamine we are hoping to improve their mood so that they will want to interact with their families even if they have just a few hours left to live,” Dr Lee explains.