Highlighted Reviews

The following selected systematic reviews have been reviewed by the CareSearch team to highlight the relevance of this research to palliative care practice and the Australian context where appropriate.  For the full list of new reviews added to the CareSearch Systematic Review collection visit the Latest Reviews page.

6 November 2019

Does Deprescribing Improve Quality of Life? A Systematic Review of the Literature.

Pruskowski JA, Springer S, Thorpe CT, Klein-Fedyshin M, Handler SM. Does Deprescribing Improve Quality of Life? A Systematic Review of the Literature. Drugs Aging. 2019 Oct 9. doi: 10.1007/s40266-019-00717-1. [Epub ahead of print]
Reducing the number of medications older people with a life-limiting condition are prescribed may be of benefit in harm reduction and cost to the person. Of 13 studies included in this systematic review of deprescribing only two were able to demonstrate improved quality or life, and none showed reduced hospitalisation rates. However, there was considerable study variation in the combination of medications and settings of care. Additionally, the patient needs to be willing to deprescribe the targeted medication and adverse drug withdrawal events likely impact on hospitalisation rates. In terms of practice, it is suggested that successful deprescribing is achieved when targeted to an individual person’s needs and specific medications.

6 November 2019

Does inpatient palliative care consultation impact outcomes following hospital discharge? A narrative systematic review.

Scott M, Shaver N, Lapenskie J, Isenberg SR, Saunders S, Hsu AT, Tanuseputro P. Does inpatient palliative care consultation impact outcomes following hospital discharge? A narrative systematic review. Palliat Med. 2019 Oct 4:269216319870649. doi: 10.1177/0269216319870649. [Epub ahead of print]
Discharge from an acute hospital when you are dying can be difficult. This review of 15 studies found that in-patient palliative care consultation leads to more patients being discharged into the community and reduces readmission rates by 4.5% to 17%. In practice this suggests that effective transitions to a community setting are supported through palliative care consultations including development of discharge plans, identification of goals of care and symptom management advice.

6 November 2019

Comparative Efficacy of Interventions for Aggressive and Agitated Behaviors in Dementia: A Systematic Review and Network Meta-analysis.

Watt JA, Goodarzi Z, Veroniki AA, Nincic V, Khan PA, Ghassemi M, Thompson Y, Tricco AC, Straus SE. Comparative Efficacy of Interventions for Aggressive and Agitated Behaviors in Dementia: A Systematic Review and Network Meta-analysis. Ann Intern Med. 2019 Oct 15. doi: 10.7326/M19-0993. [Epub ahead of print]
Many people with dementia will experience behavioural and psychological symptoms. Based on 163 studies this review ranks non-pharmacological and pharmacological interventions in managing physical and verbal agitation and aggression in people with dementia. From a practice perspective the findings support greater promotion of non-pharmacological interventions. A visual plot of intervention rankings in this article can be used to quickly identify the most appropriate approach for different behaviours. Also highlighted is the importance of multidisciplinary assessment to identify the underlying cause.

30 September 2019

Systematic review of natural and miscellaneous agents for the management of oral mucositis in cancer patients and clinical practice guidelines-part 1: vitamins, minerals, and nutritional supplements

Yarom N, Hovan A, Bossi P, Ariyawardana A, Jensen SB, Gobbo M, et al. Systematic review of natural and miscellaneous agents for the management of oral mucositis in cancer patients and clinical practice guidelines-part 1: vitamins, minerals, and nutritional supplements. Support Care Cancer. 2019 Oct;27(10):3997-4010. doi: 10.1007/s00520-019-04887-x. Epub 2019 Jul 8.
Oral mucositis can be a distressing and difficult to treat side effect of cancer treatments. This systematic review was undertaken as part of a larger project to update clinical practice guidelines for the management of oral mucositis in cancer patients. While not specifically reviewing literature in a palliative care setting this study may be applicable to some patients. 78 studies were included in the review which examined a number of vitamins, minerals and nutritional supplements. Based on this review some recommendations in the guideline have been updated. There is evidence to recommend not using parenteral glutamine to prevent oral mucositis in haematopoietic stem cell transplantation. A new recommendation supports the use of oral glutamine in head and neck cancer patients treated with both radiotherapy and chemotherapy. The authors were unable to make a positive recommendation for the use of zinc as the evidence remains conflicting and so have made a recommendation against its use in patients with head and neck cancer. New studies were reviewed examining the use of vitamin E, selenium, folinic acid and calcitrol but there is limited evidence to make recommendation about using any of these. There is a growing area of research around vitamins, minerals and nutritional supplements and recommendations about their use in the clinical setting are evolving.

30 September 2019

Observational Pain Assessment Instruments for Use With Nonverbal Patients at the End-of-life: A Systematic Review.

Tapp D, Chenacher S, Gérard NPA, Bérubé-Mercier P, Gelinas C, Douville F, et al. Observational Pain Assessment Instruments for Use With Nonverbal Patients at the End-of-life: A Systematic Review. J Palliat Care. 2019 Jan 13:825859718816073. doi: 10.1177/0825859718816073. [Epub ahead of print]
Pain is the most common symptom experienced by patients at the end of life. Assessing pain in patients who cannot speak is a challenge and a number of tools have been developed in a number of settings to help clinicians assess pain in non-verbal patients. This review examined the utility and validity of some of these tools for use in a palliative care setting. Four tools met the authors inclusion criteria – the Pain in Advanced Dementia (PAINAD), the Abbey Pain Scale, both developed for use in people with dementia, the Critical Care Pain Observation Tool (CPOT), developed for use in ventilated patients and the Multidimensional Objective Pain Assessment Tool (MOPAT) which is the only tool developed for the palliative care setting. Some of these tools have been validated for use in other settings, the PAINAD in people with dementia and the CPOT in intensive care patients. All four tools have been partially validated for use in an end-of life clinical setting, but none have been fully validated. This presents a gap in the research evidence and the authors are unable to make a clear recommendation on which tool to use. This study highlights the importance of using validated tools in any setting and the fact that many tools being used today have not been validated for use in palliative care. The CPOT may be the most useful tool to validate in the palliative care setting.

30 September 2019

Evaluating the effects of the pharmacological and nonpharmacological interventions to manage delirium symptoms in palliative care patients: systematic review.

Skelton L, Guo P. Evaluating the effects of the pharmacological and nonpharmacological interventions to manage delirium symptoms in palliative care patients: systematic review. Curr Opin Support Palliat Care. 2019 Sep 3. doi: 10.1097/SPC.0000000000000458. [Epub ahead of print]
Delirium is becoming more prevalent in the palliative care setting and managing it can be difficult. This systematic review examined studies to evaluate the effectiveness of pharmacological and non-pharmacological approaches to managing delirium in the palliative care setting. Six studies were included, three were set in hospitals, and three set in hospices. Four of the studies were RCTs, one a controlled trial and one was a comparative cohort study, including 1958 patients, nearly all of whom had cancer. The treatment approaches examined in the studies were haloperidol, risperidone, olanzapine, lorazepam, aripiprazole and the non-pharmacological approach as a multi-component intervention, which included patient orientation, patient cognitive stimulation, education for staff, and supportive advice for families. The authors acknowledge there is limited research in this area but despite this they are able to make some recommendations. They recommend the implementation of non-pharmacological techniques in mild delirium. For moderate to severe delirium a pharmacological approach is advised and the authors found no one medication superior to another and so recommend an individual approach to management. In agitated delirium, particularly for patients moving towards the terminal phase, there is a role for benzodiazepines along with haloperidol.