How Morphine Can Help in Heart Failure at the End of Life

Morphine is most often used as a pain reliever.  But for heart patients, it is often used for shortness of breath.  There are several ways that morphine interrupts the cycle of breathlessness.

• Morphine lowers the breathing rate in the brain’s respiratory center. This means the heart doesn’t have to work so hard to supply blood to the chest muscles for breathing.  It reduces excessive breathing drive.
• Morphine widens blood vessels in the arms and legs.  Pooling blood in the extremities reduces the amount of blood that returns to the heart.  This means the heart doesn’t have to pump as often—it can rest more.  When the heart doesn’t have to pump so hard, it also needs less oxygen—so the resident doesn’t have to breathe as hard.
• It eases anxiety, and when a resident is less anxious, he or she will breathe more calmly.  If you breathe more slowly, you are less anxious.
• When we are in pain, we tend to breathe faster and harder.  So relieving pain also reduces respiratory rate.

Used correctly, morphine is safe.  Addiction is very, very rare.  The chance of becoming addicted is so small that it is considered unethical to withhold morphine because of a fear of addiction.

But if we don’t know how opioids like morphine, fentanyl, Vicodin or Dilaudid work, we may mistake initial responses.  If an opiod is new to a person, he or she may be sleepy for the first 2 or 3 days—especially if they have not been sleeping well (maybe because of shortness of breath or pain).  When symptoms are relieved, the resident may want to “catch up” on sleep.  After a few days, the sleepiness wears off.

At the end of life, morphine is the most important medicine for providing comfort to heart patients.  It reduces the breathless feeling that can be so frightening to people at the end of life.

Antidepressants in Dementia

As many as 20% of patients with dementia may also have depression.  The usual treatment is a selective serotonin reuptake inhibitor or a noradrenergic and specific serotonergic antidepressant.  But some research has questioned the effectiveness of these treatments.

In a study published in The Lancet, (volume 378, Issue 9789, pages 403 - 411, 30 July 2011), Sube Banerjee MD, a London-based expert in old age psychiatry, and his colleagues concluded that because there was an absence of benefit compared with placebo and increased risk of adverse events, the practice of using these antidepressants should be reevaluated.

“Depression is one of the most important co-morbidities in dementia.  It is a source of great distress yet the treatments we use are not proven,” said Dr. Banerjee.

In their parallel-group, double-blind, placebo-controlled study of more than 326 patients with Alzheimer’s dementia, decreases in depression scores at 13 and 39 weeks did not differ between 111 controls and 107 participants allocated to receive sertraline (Zoloft) or 108 who received mirtazapine (Remeron).

“I am surprised by just how unequivocal our findings are,” said lead author Banerjee, professor of mental health and aging at King’s College London, Institute of Psychiatry, United Kingdom.  “The present practice of use of these antidepressants with usual care for first-line treatment of depression in Alzheimer’s disease should be reconsidered,” write the authors.

“The message is to think before using antidepressants for depression in dementia.  It may well be that these symptoms will resolve with the problem-solving and information-giving that is implicit in good-quality dementia care,” added Dr. Banerjee. The investigators suggest that antidepressants be reserved for “individuals whose depression has not resolved within 3 months of referral, apart from those in whom drug treatment is indicated by risk or extreme severity.”

Funding for this study was provided by the UK National Institute of Health Research HTA Programme.

Vitamin & Supplement Risks

Contrary to what many might believe, vitamins and minerals may be risky.  Risks associated with the use of common dietary vitamin and mineral supplements in older women may include higher mortality rates.

Researchers examined vitamin and mineral supplement use in relation to total mortality in 38,772 older women (mean age 61.6 years at baseline in 1986).  Vitamin B6, folic acid, iron, magnesium, zinc, and copper were all associated to some extent with increased risk of mortality when compared with non-use.  The association was strongest with supplemental iron, but in contrast to other findings, calcium was associated with decreased risk.

For more information, the research is part of the Iowa Women’s Health Study and was reported in the Archives of Internal Medicine,  2011; 171(18):1625-33 (ISSN: 1538-3679)

CT Scans in Lung Cancer Screening

New recommendations from the National Comprehensive Cancer Network (NCCN) say that patients determined to be at high risk for lung cancer should have regular screening with low-dose CT scans.

The NCCN guidelines define high-risk patients as:

• Age 55-74 plus ≥30 pack-year smoking history plus smoking cessation <15 years or
• Age ≥50 and ≥20 pack-year history of smoking and other risk factors besides second-hand smoke

A negative scan should be followed by annual low-dose CT scans for three years and then periodically until age 74.  If the baseline image reveals one lung nodule, the patient should have close follow up with additional low-dose CT scans, with the scan interval determined by the nodule’s characteristics.

According to the guidelines, a solid or partly solid nodule ≤4 mm requires annual screening with low-dose CT for three years and until age 74. Larger nodules have shorter screening intervals, ranging to follow-up CT in one month for patients with solid endobronchial nodules. Patients who have nodules with a ground-glass appearance require follow-up CT at intervals ranging from three to six months to 12 months, depending on nodule size.

Patients with a low or moderate risk for lung cancer do not need routine lung cancer screening.  The NCCN defines moderate-risk patients as age ≥50, a smoking history of ≥20 pack-years, and no additional risk factors. A low-risk patients is younger than 50 and has less than a 20 pack-year smoking history.

“Lung cancer screening with CT should be part of a program of care and should not be performed in isolation as a free-standing test,” according to the guidelines available on the NCCN website.

“Given the high percentage of false-positive results and the downstream management that ensues for many patients, the risks and benefits of lung cancer screening should be discussed with the individual before doing a screening low-dose CT.

“It is recommended that institutions performing lung cancer screening use a multidisciplinary approach that may include specialties such as radiology, pulmonary medicine, internal medicine, thoracic oncology, and thoracic surgery. Management of downstream testing and follow up of small nodules are imperative and may require establishment of administrative processes to ensure the adequacy of follow up.”

The NCCN offers additional guidance for solid and ground-glass nodules, based on specific nodule characteristics.

NCCN is a consortium of major US cancer centers.   

Yogurt & Colorectal Cancer

Yogurt may confer some degree of protection against colorectal cancer (CRC) according to a prospective study done in Italy.  Yogurt intake was found to be inversely associated with CRC risk.

More than 45,000 volunteers participated by completing dietary questionnaires that included specific questions about yogurt intake.  In the following 12 years 289 participants were diagnosed with CRC.  High yogurt intake was significantly associated with decreased CRC risk, suggesting that yogurt should be part of a diet to prevent the disease.

The protective effect of yogurt was evident in the entire cohort, but was stronger in the 14,178 men in the study.

The study, done at Fondazione IRCSS Istituto Nazionale Tumori, Milano, Italy, was published in the International Journal of Cancer.  2011; 129(11):2712-9 (ISSN: 1097-0215)