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Medication Needs Vary for Terminally Ill Vietnam Era Veterans With and Without a Diagnosis of PTSD

American Journal of Hospice & Palliative Medicine® 1-8 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909115586556 ajhpm.sagepub.com

Esther Kelley-Cook, BS1, George Nguyen, DO2, Shuko Lee, MS3, Tressia M. Edwards, MLS3, and Sandra Sanchez-Reilly, MD1,3

Abstract This retrospective pilot study aims to evaluate the clinical impact of palliative care in the treatment of terminally ill Vietnam Veterans with a history of posttraumatic stress disorder (PTSD) versus those without PTSD, as it pertains to medications for symptom control at the end of life (EOL). Active prescriptions for benzodiazepines, hypnotics, antidepressants, and antipsychotic medications at the EOL were recorded. During EOL care, 28 (72%) participants with PTSD used these medications versus 55 (40%) of the non-PTSD participants (P ¼ .0005). There was significant correlation between a lifetime diagnosis of PTSD with antidepressant use (P ¼ .0002) and hypnotics (P ¼ .0085) during EOL care but not with benzodiazepines or antipsychotics. The higher utilization of certain medication classes among participants with PTSD may indicate that PTSD treatment should continue at the EOL to improve care. Keywords posttraumatic stress disorder (PTSD), end of life, Vietnam Veterans, palliative care, terminal care, pharmacotherapy

Introduction The Diagnostic and Statistical Manual of Mental Disorders (fifth edition) defines post traumatic stress disorder (PTSD) in accordance with the development of distinguishing symptoms after exposure to trauma. The PTSD symptoms can be grouped into 4 symptom clusters: intrusion, avoidance, negativity, and hyperarousal. Lifetime prevalence of PTSD in the general population of the United States is estimated to be 7.8%, with chronic symptoms affecting >33% even after many years.1 These symptoms are bothersome not only to patients but also to families. The family members had reported bothersome intrusive symptoms of PTSD in 17% of dying Veterans with a previous diagnosis of PTSD. These PTSD symptoms were associated with decreased satisfaction with care and poorer communication with providers.2 The lifetime prevalence of PTSD in the Veteran population is even higher. Lifetime prevalence of PTSD for Vietnam Veterans is estimated to be between 18.7% and 30.9%.3 Posttraumatic stress disorder greatly affects the participant’s environment and relationships. The PTSD is correlated with higher rates of aggression. Studies looking at the incidence of aggressive behavior in male Veteran populations with PTSD found that approximately 75% of this group had been involved in destruction of property, threats of violence or physical fighting over a period of one year.4 Not surprisingly, intimate partner violence is also higher among Veterans with PTSD. Veterans

engage in intimate partner violence at higher rates than civilians,5 and Veterans with PTSD have even higher rates than other Veterans. Studies have shown that over a period of one year, 33% of Vietnam Veterans with PTSD perpetrated intimate partner violence compared to 13% in those Veterans without PTSD.4,5 Symptoms of PTSD robustly predict partner aggression even when other factors are controlled for.4 The PTSD is also associated with greater suicide rates among Veterans: The disorder most associated with Veteran suicide is PTSD. Vietnam Veterans who have PTSD are four times more likely to have completed suicides than those without PTSD. Within the Veterans Affairs (VA) system, Vietnam Veterans are the largest group with a PTSD diagnosis, accounting for approximately 50% of the total PTSD diagnoses within the VA system.6 Symptoms of PTSD in dying Veterans with a diagnosis of PTSD were associated with decreased satisfaction with care

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The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA 2 Baylor Scott & White Health Care System, Temple, TX, USA 3 South Texas Veterans Health Care System, San Antonio, TX, USA Corresponding Author: Sandra Sanchez-Reilly, MD, The University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System GRECC (182), 7400 Merton Minter Blvd, San Antonio, TX 78229, USA. Email: [email protected]

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American Journal of Hospice & Palliative Medicine®

2 and poor communication with providers. However, a palliative care (PC) consult was associated with lower discomfort ratings attributed to PTSD symptoms as reported by the families.2 This pilot study found that terminally ill Vietnam Veterans with a PC consult and a diagnosis of PTSD were more likely to be prescribed hypnotics and antidepressants than their counterparts without PTSD. This may be relevant for future research to determine why PC consults are associated with lower rates of discomfort due to PTSD symptoms at the end of life (EOL).

Methods This is a retrospective study analyzing and reporting data obtained from electronic medical records (EMR) of a tertiary VA hospital. An initial comprehensive literature search determined what is known regarding PTSD, PTSD symptoms in a PC setting and potential factors influencing worsening of PTSD, specifically as it relates to EOL care. The question was asked: Does PTSD affect provider interventions at the EOL? Investigators chose to query Computerized Patient Record System (CPRS) (VA’s EMR system) for PC consults of inpatient participants at the Audie L. Murphy Memorial VA Hospital (a tertiary care center), who were admitted with a terminal diagnosis between November 1, 2010 and November 30, 2011. Subsequently, participants’ EMRs were screened for Vietnam era service. This research was approved by the Institutional Review Board (IRB) and the VA Research and Development Committee and was determined to be exempt by the IRB as research which involves the collection or study of existing data. The data were deidentified during collection so that after abstraction no participants could be identified. Investigators created a chart abstraction template (Table 1) and attempted to abstract the data from CPRS, as described in the variable description section of the table. Some variables were thrown out at this stage due to inability to find the result consistently in the EMR. For example, PTSD symptoms at the time of the inpatient PC consult and family meeting outcomes were not documented in CPRS in a way that could be collected reliably by researchers. Two researchers abstracted the data. Interrater reliability was not formally tested, however, chart abstraction was attempted several times during this phase, where variables were chosen and variables that could not be collected reliably were not collected. Variables collected assessed demographics, social support, comorbid illness, PC team interventions, family meeting interventions, and medications that are commonly given for symptoms at the EOL which also have an association with PTSD. Demographic variables included age, gender, length of inpatient hospital stay, history of PTSD diagnosis, and whether participants were followed by mental health as an outpatient. Whether participants were still living at the time of data collection were recorded to verify whether this was an EOL population. Whether the participant had been a prisoner of war or experienced military sexual trauma was collected, as these experiences are closely correlated with PTSD. Of note, the binary variables for female gender, prisoner of war, and military sexual trauma could not be analyzed due to insufficient sample size.

In order to account for possible social confounders, investigators gathered psychosocial information and details on the PC consult intervention, such as, if there was a next of kin (NOK) listed in the medical record, caregiver information, social work consults, previous PC consult, and whether a family meeting was held at the time of the inpatient PC consult. If the participant had a family meeting at the time of the inpatient PC consult, data were collected on what the family meetings addressed (including pain, family concerns, goals of care, disposition, symptoms, and feeding tube). Other categorical data included relationship of NOK and caregiver, discharge location, medical team, hospital floor, and consult reason. Data were analyzed comparing differences between history of PTSD diagnosis and no diagnosis of PTSD. In order to determine possible confounders, this study looked at comorbid mental and physical illnesses. In order to assess whether different pharmacologic interventions were required at the EOL for participants with a lifetime diagnosis of PTSD, investigators gathered as binary data whether the participant was taking any of the following medication classes at the time of the inpatient PC consult: benzodiazepines, antipsychotics, antidepressants, and hypnotics. Although benzodiazepines are not prominent in the evidence-based guidelines for PTSD, recent studies of prescribing habits at the VA showed that nearly 30% of PTSD participants at the VA were receiving benzodiazepines.7,8 Therefore, investigators thought it is prudent to include this measure as a PTSD-related medication.

Data Analysis All analysis were conducted by SAS V9.3 (SAS Institute Inc, Cary, North Carolina). P values of less than .05 were considered to be significantly different. The total number of participants after excluding those who did not meet the eligibility criteria was 176. The demographics and characteristics of the study including clinical laboratory and history of events were examined by frequency and percentage for discrete variables and Pearson’s Chi-square test or Fisher exact test to determine the significant difference between PTSD and non-PTSD participants, appropriately. The mean and standard deviation for continuous variables such as age and the length of hospital stay were examined by Student’s t-test.

Results This retrospective pilot study of Vietnam Veterans included a total number of 176 participants who had PC consults at the EOL. Participants with PTSD versus the non-PTSD participants (control group) were analyzed. Number of PTSD participants was 39, and number of control group was 137. The mean age at consult was 65.12. This was an EOL population with 79.55% deceased by the time chart reviews were conducted in summer 2012. As expected, this population of Veterans was predominantly (99%) male. Of note, only two participants had been prisoners of war, and only three participants had been victims of military sexual trauma as documented in the EMR, so we did not

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Table 1. Variables Collected. Variable collected Demographics Age Age-group Mean age at time of consult Gender Mean length of hospital stay Binary variable demographics Deceased Prisoner of war Military sexual trauma Posttraumatic stress disorder (PTSD) Service connection for PTSD Followed by outpatient mental health

Description of variable Participant age recorded as a continuous whole variable Participant age recorded as discrete variables with numeric codes given for 80. Omitted from analysis Age of the participant at the time palliative care was consulted. Recorded as a continuous whole variable Recorded as a binary variable with numeric codes given for male or female Determined by Microsoft Excel from admit date and discharge date recorded from CPRS Was the participant deceased at the time of data collection as recorded in CPRS? Was the participant service connected for being a prisoner of war? Was the participant service connected for being a victim of military sexual trauma? Did the participant have a history of PTSD listed in the problems tab of CPRS? Was the participant service connected for PTSD? Was the participant followed by a VA outpatient mental health provider at any time as evidenced by provider notes in the medical record containing psychiatry or psychology in the title when all records viewed by title name

Social support variables Next of kin (NOK) Relationship of NOK to participant Primary caregiver

Was there a NOK listed in CPRS? Collected as a binary variable How was the NOK related to the participant? Collected as discrete variables with numeric codes given for: No NOK listed, parent, sibling, child, friend, spouse, other relative Did the participant have a primary caregiver as evidenced by medical record provider notes or family meeting notes referring to a primary caregiver? Relationship of primary caregiver How was the caregiver (as discussed in participant medical record physician notes or family meeting with participant notes referring to the primary caregiver) related to the participant? Collected as discrete variables with numeric codes given for caregiver not listed, grandparent, parent, sibling, child, friend, spouse, and other relative NOK and caregiver are the same Was the NOK listed in CPRS the same person as discussed in participant medical record physician notes person or family meeting notes referring to the primary caregiver? Collected as a binary variable Discharge location Where was the participant discharged to upon leaving the hospital? Collected as discrete variables with numeric codes given for inpatient psychiatry, home, nursing home, death during hospitalization, rehabilitation facility, and inpatient hospice Comorbid illness binary variables Schizophrenia Did the participant have a history of schizophrenia listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Bipolar disorder Did the participant have a history of hypertension listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Hallucinations Did the participant have a history of hallucinations listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Panic disorder Did the participant have a history of panic disorder listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Anxiety Did the participant have a history of anxiety listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Depression Did the participant have a history of depression listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Nonalcohol substance abuse Did the participant have a history of nonalcohol substance abuse listed in the problems tab of CPRS or evidenced by provider note documenting substance abuse in the participant’s history and physical examination? Alcohol abuse Did the participant have a history of alcohol abuse listed in the problems tab of CPRS or evidenced by provider note documenting alcohol abuse in the participant’s history and physical examination? Tobacco use Did the participant have a history of tobacco use listed in the problems tab of CPRS or evidenced by provider note documenting tobacco use in the participant’s history and physical examination? (continued)

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American Journal of Hospice & Palliative Medicine®

4 Table 1. (continued) Variable collected

Description of variable

Insomnia

Did the participant have a history of Insomnia listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Did the participant have a history of sleep disorders other than insomnia listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Did the participant have a history of failure to thrive listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Did the participant have a history of cancer listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Did the participant have a history of dementia listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Did the participant have a history of heart disease listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Did the participant have a history of seropositivity for human immunodeficiency virus listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Did the participant have a history of any liver pathology listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Did the participant have a history of any lung pathology listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Did the participant have a history of any neurological pathology listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Did the participant have a history of any renal pathology listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed? Did the participant have a history of stroke listed in the problems tab of CPRS or evidenced by medication list with corresponding medical record physician note documenting why the medication was prescribed?

Sleep disorder other than insomnia Failure to thrive

Cancer

Dementia

Heart disease

HIV seropositive

Liver disease

Pulmonary disease

Neurologic disease

Renal disease

Stroke

Medications binary variables Any of the following medications

Benzodiazepines Antipsychotics Antidepressants Hypnotics

Palliative consult variables Palliative care consult Consult number

Total number of consults Prior palliative care consult

Was the participant taking any of the following medications at the time of the inpatient palliative care consult: benzodiazepines, antipsychotics, antidepressants, or hypnotics as evidenced by the taking of one of the four medications being positive? Was the participant taking any benzodiazepine at the time of the inpatient palliative care consult? Was the participant taking any typical or atypical antipsychotic at the time of the inpatient palliative care consult? Was the participant taking any antidepressant medication at the time of the inpatient palliative care consult? Was the participant taking any nonbenzodiazepine hypnotic medication at the time of the inpatient palliative care consult or any antidepressant commonly used to aid sleep (trazodone, mirtazapine) with corresponding medical record provider note documenting the medication was prescribed to aid sleep? Did the participant have a palliative care consult during the inpatient hospitalization? This was an inclusion criteria determined by looking in the consults tab of CPRS. Collected as a binary variable. Palliative care consults were numbered chronologically as whole numbers starting at one. This field indicates whether the contact with palliative care during this hospitalization represents continuity of care throughout illness or the first contact of the participant with the palliative care team. Collected as a continuous whole variable. How many palliative care consults did the participant have recorded in CPRS? Recorded as a binary variable with numeric codes given for only one consult and more than one consult. Did the participant have a prior palliative care consult or was the initial visit from the palliative care team during this inpatient hospitalization? (continued)

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Table 1. (continued) Variable collected

Description of variable

Social work visit

Chaplain visit

Psychologist visit

Level of care

Referring service Reason for palliative care consult Family meeting variables Family meeting

Family meeting number

Pain

Concerns

Goals

Disposition

Symptoms

Feeding tube

Did the participant have a social work consult during the inpatient hospitalization? As evidenced by a consult formally placed in the consults tab or social work note when records for the inpatient stay are viewed by title Did the participant have a chaplain visit during the inpatient hospitalization? As evidenced by a consult formally placed in the consults tab or chaplain note when records for the inpatient stay are viewed by title Did the participant have a psychology consult during the inpatient hospitalization? As evidenced by a consult formally placed in the consults tab or psychology inpatient note when records for the inpatient stay are viewed by title Collected as discrete variables with numeric codes given for critical care unit, medicine ward, surgery ward, intensive care unit, progressive care unit, spinal cord unit, inpatient psychiatry, and long-term care unit Collected as discrete variables with numeric codes given for internal medicine, surgery, psychiatry, and all others Collected as discrete variables with numeric codes given for goals of care, placement to nursing home, hospice, pain, and actively dying Did a family meeting take place during the participants inpatient hospital stay as evidenced by a family meeting note when records for the inpatient stay are viewed by title or provider note discussing family meeting as having occurred? Collected as a binary variable Number of family meetings that were held during the inpatient hospitalization as evidenced by a family meeting note when records for the inpatient stay are viewed by title or provider note discussing family meeting as having occurred. Collected as a continuous whole variable Was pain addressed in the family meeting as evidenced by a family meeting note when records for the inpatient stay are viewed by title or provider note discussing family meeting as having occurred? Collected as a binary variable Did the family meeting cover participant and family concerns as evidenced by a family meeting note when records for the inpatient stay are viewed by title or provider note discussing family meeting as having occurred? Collected as a binary variable Did the family meeting address goals of care as evidenced by a family meeting note when records for the inpatient stay are viewed by title or provider note discussing family meeting as having occurred? Collected as a binary variable Did the family meeting address discharge location as evidenced by a family meeting note when records for the inpatient stay are viewed by title or provider note discussing family meeting as having occurred? Collected as a binary variable Did the family meeting address participant symptoms as evidenced by a family meeting note when records for the inpatient stay are viewed by title or provider note discussing family meeting as having occurred? Collected as a binary variable Did the family meeting address feeding tube placement as evidenced by a family meeting note when records for the inpatient stay are viewed by title or provider note discussing family meeting as having occurred? Collected as a binary variable

Abbreviations: CPRS, Computerized Patient Record System; PTSD, posttraumatic stress disorder; NOK, next of kin.

have sufficient power for the analysis of these groups. Social support variables were not significantly different between PTSD participants and non-PTSD participants. For both PTSD participants and non-PTSD participants, the most frequent relationship for the NOK listed in the EMR was the participants’ spouse. Spouse was also most frequently recorded in the EMR as the primary caregiver for both PTSD and non-PTSD groups. The most common discharge location between the two groups was home. These variables were used to highlight any striking differences among social support between the groups, but none were found. Lifetime prevalence of PTSD was noted in 22% of this study population, while 27% had a diagnosis of insomnia, 30% had a diagnosis of anxiety, 44% had a history of alcohol-related substance abuse, and 47% had a history of substance abuse other

than alcohol. Lifetime diagnosis of PTSD was positively associated with a past medical history of insomnia, other sleep disorder diagnoses (such as obstructive sleep apnea or restless leg syndrome), anxiety, depression, and alcohol abuse. Participants with PTSD diagnosis were more likely to be followed by outpatient mental health than those participants without PTSD (P < .0001). In this study, population with PTSD was not associated with a Past Medical History of nonalcohol substance abuse or tobacco use. Numerous studies have shown that PTSD is associated with comorbid physical illnesses.9 However, results from this pilot study did not show a significant association between PTSD and failure to thrive, cancer, dementia, heart disease, HIV, liver diseases, pulmonary diseases, neurological diseases, renal diseases, or stroke. Of note, the findings of this pilot study

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American Journal of Hospice & Palliative Medicine®

6 Table 2. Differences in Pharmacologic Treatment Between Those With and Without PTSD. Medications binary variables Any of the following Benzodiazepines Antipsychotics Antidepressants Hypnotics

Percent positive Percent positive P value

Medication Needs Vary for Terminally Ill Vietnam Era Veterans With and Without a Diagnosis of PTSD.

This retrospective pilot study aims to evaluate the clinical impact of palliative care in the treatment of terminally ill Vietnam Veterans with a hist...
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