The rising prevalence of dementia will have an impact on acute hospitals. Extra resources will be required for intermediate and palliative care and mental health liaison services.

Summary Uncontrolled studies have reported that fatigue is a common symptom among patients with advanced cancer. It is also a frequent complaint among the general population. Simply asking cancer patients whether or not they feel fatigued does not distinguish between the 'background' level of this symptom in the community and any 'excess' arising as a result of illness. The aim of this study was to determine the prevalence of fatigue among palliative care inpatients in comparison with a control group of age and sex-matched volunteers without cancer. In addition, the correlates of fatigue were investigated. The prevalence of 'severe subjective fatigue' (defined as fatigue greater than that experienced by 95% of the control group) was found to be 75%. Patients were malnourished, had diminished muscle function and were suffering from a number of physical and mental symptoms. The severity of fatigue was unrelated to age, sex, diagnosis, presence or site of metastases, anaemia, dose of opioid or steroid, any of the haematological or biochemical indices (except urea), nutritional status, voluntary muscle function, or mood. A multivariate analysis found that fatigue severity was significantly associated with pain and dypnoea scores in the patients, and with the symptoms of anxiety and depression in the controls. The authors conclude that subjective fatigue is both prevalent and severe among patients with advanced cancer. The causes of this symptom remain obscure. Further work is required in order to determine if the associations reported between fatigue and pain and between fatigue and dyspnoea are causal or coincidental.Keywords: fatigue; asthenia; neoplasms; palliative care; quality of life 1479British Journal of Cancer (1999) 79(9/10), 1479-1486 © 1999 Cancer Research Campaign Article no. bjoc.1998 Received SUBJECTS AND METHODSInpatients with advanced cancer were recruited from three palliative care units between April 1996 and January 1997. Radiotherapy or chemotherapy within the previous 4 weeks, clinically apparent confusion, poor English language skills, disability or pain affecting the non-dominant hand or an estimated prognosis of less than 2 weeks were all exclusion criteria. The principal investigator visited each of the participating units weekly and approached all patients identified as being eligible to enter the study. In the absence of the principal investigator, due to holidays or illness, recruitment was suspended. Thus, although the patient group did not represent a consecutive series of eligible patients (i.e. it was a convenience sample), there is no reason to suspect a systematic bias in patient selection. Control subjects were age and sex-matched volunteers without cancer. They were recruited from the 'League of Friends' at the respective units and were subjected to the same inclusion and exclusion criteria as the patients. The protocol was approved by the relevant Scientific and Ethics Committees.After informed consent had been obtained, the patients were asked to undergo a number of assessme...

A prospective validation study was conducted in 171 consenting patients from oncology and palliative care outpatient clinics to validate the Distress Thermometer (DT) against the Hospital Anxiety and Depression Scale (HADS), General Health Questionnaire-12 (GHQ-12) and Brief Symptom Inventory-18 (BSI-18) at baseline, four weeks and eight weeks. Receiver Operating Characteristic analysis was used to examine the sensitivity and specificity of the DT scores against the clinically significant cut-off scores of the criterion measures reporting 95% confidence intervals. Standardised response means were used to compare DT scores with criterion measures over time. For a cut-off of 4 vs 5, sensitivity against HADS was 79%, specificity 81%; against GHQ-12, sensitivity was 63%, specificity 83%; and against BSI-18, sensitivity was 88%, specificity 74%. At both four and eight weeks, DT scores tended to change significantly in the same direction as the criterion measures. Ninety-five percent of patients found completing the DT acceptable. The DT is valid and acceptable for use as a rapid screening instrument for patients in the UK with cancer. Our results indicate that it can be used to monitor change in psychological distress over time, but further work is needed to confirm this.

Patients with advanced dementia often receive poor end-of-life care. We aimed to design and pilot a palliative care and advance care plan (ACP) intervention. Patients had undergone emergency hospital admission and had severe dementia. The intervention consisted of a palliative care patient assessment which informed an ACP discussion with the carer, who was offered the opportunity to write an ACP for the person with dementia. Carer-patient dyads were randomized to 'usual care' or the intervention. Carer-related outcome measures included the Kessler Distress Scale, Decision Satisfaction Inventory, Client Satisfaction Questionnaire and the Euroqol-5D, measured at baseline, six weeks, six months and three months after bereavement. The Satisfaction with End of Life Care in Dementia Scale was completed if the patient died. The 32 patient participants were physically frail and in the advanced stages of dementia: 62% had pressure damage to the skin, all needed feeding assistance and 95% were in pain. Nearly 50% died during the six-month follow-up period. Carers were difficult to recruit during acute admission; 33 patients and carers entered the study (22 intervention arm; 11 control arm). Only seven carers made ACPs. The care planning discussion was well received, but few carers wrote an ACP, despite intensive support from an experienced nurse specialist. Advance care planning is, in theory, a necessary intervention for people with severe dementia; the reluctance of carers to write plans needs to be explored further.

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