374 Vol. 43 No. 2 February 2012Schedule With Abstracts

no religious affiliation, 83% described them-selves as spiritual but not religious, 33% re-ported unmet spiritual needs, and 60%wanted help meeting their spiritual needs.The Cronbach’s a for the total SNAP was 0.89and for the subscales was: psychosocial ¼ 0.58,spiritual ¼ 0.83, and religious needs ¼ 0.90.Test-retest correlation coefficients were: totalSNAP ¼ 0.72, psychosocial needs ¼ 0.43, spiri-tual needs ¼ 0.73, and religious needs ¼ 0.72.Unmet spiritual needs, as assessed through a sin-gle-item question were not associated with high-er SNAP scores in contrast to results of theEnglish SNAP.

Conclusion. The Chinese SNAP is a reliable in-strument for measuring spiritual needs.

Implications for research, policy, or practice.Lack of correlation between the SNAP and thesingle-item question on unmet spiritual needssuggests that the SNAP may capture patientneeds that Chinese patients would not readilydescribe as spiritual whether due to cultural dif-ferences or educational level.

Benzodiazepines and the Management ofDyspnea in Palliative Care Patients (411-A)Patama Gomutbutra, MD, University ofCaliforniaSan Francisco, San Francisco, CA. DavodO’Riordan, PhD, University of California SanFrancisco, San Francisco, CA. Kathleen Kerr, BA,University of California San Francisco, San Fran-cisco, CA. Stevem Pantilat, MD, University of Cal-ifornia San Francisco, San Francisco, CA.(All authors listed above for this session have dis-closed no relevant financial relationships.)

Objectives1. Describe of the impact of BZD in improving

dyspnea of chronically ill patients.2. Describe dyspnea management in palliative

care setting.

Background. Benzodiazepines (BZD) are com-monly prescribed for relief of dyspnea, yet thereis little evidence describing the efficacy of thetreatment of dyspnea in chronically ill patients.

Research objective. To describe the impact ofBZD in improving dyspnea of chronically illpatients.

Method. A retrospective chart review was under-taken of adults with dyspnea seen by the UCSFPalliative Care Service (PCS) during 2005-2010.Dyspnea was assessed using a four-point

categorical scale (0 ¼ none, 1 ¼ mild, 3 ¼ mod-erate, 4 ¼ severe).

Result. We reviewed charts for 93.6% (308/330)of eligible cases. Patients were 66 years old, male(52%), white (52%), and diagnosed with lungcancer (40%), heart failure ([HF]¼24%), orCOPD (19%). At baseline, most patients had ei-ther mild (53%), moderate (28%), or severe(19%) dyspnea. BZD were prescribed to 37%(n ¼ 113) of patients, with 66% (n ¼ 75) receiv-ing BZD in the first 24 hours of being referred tothe PCS. In multivariate logistic regression, vari-ables associated with receiving BDZ includedconcurrent opioid use (OR ¼ 4.8, 95% CI ¼2.2, 10.3), gender (female: OR ¼ 1.7, 95%CI ¼ 1.1, 3.3), and age (OR ¼ 0.9, 95% CI ¼0.96, 0.99). Overall 56% (n ¼ 172) had a clini-cally meaningful improvement (1-point) in dysp-nea at 24 hours, 38% (n ¼ 117) had noimprovement, and 7% (n ¼ 20) got worse. Amultivariate logistic regression indentified thatthe strongest predictors of a clinically meaning-ful improvement in dyspnea were age (OR ¼1.02, 95% CI ¼ 1.0, 1.03), and being prescribedBDZ (2.3, 95% CI ¼ 1.2, 4.2).

Conclusion. BZD were associated with improve-ments in dyspnea among patients seen in a PCS.

Implications for research, policy, or practice.BZD maybe an appropriate adjuvant treatmentfor dyspnea.

Rapid Treatments for Depression andAnxiety (411-B)Scott Irwin, MD PhD, The Institute for PalliativeMedicine at San Diego Hospice, San Diego, CA.(Irwin has disclosed no relevant financialrelationships.)

Objectives1. Recognize the significance of depression

near the end of life.2. Recognize new data suggesting ketamine and

methylphenidate may rapidly ameliorate de-pression in patients receiving hospice care.

3. Discuss further investigation of ketamine andmethylphenidate for the rapid treatment ofdepression in medically ill patients.

Background. Depression is prevalent and under-treated in patients receiving hospice care. Stan-dard antidepressants do not work rapidly oroften enough to benefit most of these patients.Ketamine and methylphenidate may provide via-ble alternatives in this population.

Vol. 43 No. 2 February 2012 375Schedule With Abstracts

Research objective. To provide evidence for theefficacy and safety of methylphenidate and ket-amine for the rapid treatment of depressionand anxiety in hospice patients.

Method. Data from pilot open-label trials of ket-amine and methlyphenidate for the rapid treat-ment of depression and anxiety, as well asretrospective data regarding methylphendiatewill be presented.

Result. Pilot data from an open label clinicaltrial of oral ketamine for depression showed anaverage 41% drop in depressive symptoms at60 minutes after initial dosing (n ¼ 5) whichwere sustained. In another trial of methylpheni-date, a 53% drop in depressive symptoms wasfound one day after initial dosing (n ¼ 2) whichcontinued to improve over one week. In addi-tion, ketamine also provided an average 76%drop in Anxiety Scores by 120 minutes after ini-tial dosing (n ¼ 5). Both drugs had minimal sideeffects.A retrospective chart review of 80 patients receiv-ing inpatient hospice care who were diagnosedwith a depressive disorder who received treat-ment showed that methylphenidate exhibiteda significantly better therapeutic effect thanother treatments (2.33 � 0.23 vs. 3.06 � 0.3;U ¼ 87, p < .05), but significantly more side ef-fects, still in the ‘‘do not interfere with function-ing’’ range on the CGI (1.72 � 0.23 vs. 1.13 �0.13; U ¼ 197 p < .05).

Conclusion. These pilot data suggest both ket-amine and methylphenidate are safe and effec-tive for the rapid treatment of depression inhospice patients.

Implications for research, policy, or practice.Further investigation with randomized, con-trolled clinical trials is necessary to firmly estab-lish the effectiveness of oral ketamine andmethylphenidate for the treatment of depres-sion and anxiety in patients receiving hospicecare.

‘‘ABH Gel’’ (Ativan�, Lorazepam;Benadryl�, Diphenhydramine; Haloperidol,Haldol�) Is Not Absorbed From the Skin ofNormal Volunteers So Cannot Be EffectiveAgainst Nausea (411-C)Thomas Smith, MD, Johns Hopkins HealthSystem, Baltimore, MD. Devon Fletcher, MD,Virginia Commonwealth University, Richmond,VA. Patrick Coyne, MSN APRN FAAN, Virginia

Commonwealth University, Richmond, VA.Joseph Ritter, PhD, Richmond, VA. PatriciaDodson, BSN RN MA CCRC, Virginia Common-wealth University, Richmond, VA. GwendolynParker, MS RN FNP-C, Virginia CommonwealthUniversity Health Systems/Massey Cancer Cen-ter, Richmond, VA.(All authors listed above for this session have dis-closed no relevant financial relationships.)

Objectives1. Recognize that the commonly used ‘‘ABHgel’’

(Ativan�, lorazepam; Benadryl�, diphenhy-dramine; haloperidol, Haldol�) is not ab-sorbed to therapeutic levels from skin, so itcannot be effective as an anti-nausea drug.

2. Recognize reasons why some commonly usedremedies may work due to placebo effect, re-gression to the mean, and low expectationsof benefit.

3. Recognize alternatives to use of ABH gel.

Background. Lorazepam (Ativan), diphenhydra-mine (Benadryl), haloperidol (Haldol)(‘‘ABH’’) topical gel is currently widely usedfor nausea in hospice due to perceived efficacyand low cost, and has been suggested for cancerchemotherapy. However, there are no studies ofabsorption, a prerequisite for effectiveness.

Research objective. To determine if ABH gelachieves serum concentrations necessary foreffectiveness.

Method. 10 healthy volunteers, age 25-58 (mean37), 2 African-American and 8 Caucasian-Ameri-can, applied the standard 1.0 ml dose (2 mg oflorazepam, 25 mg of diphenhydramine, and 2mg of haloperidol in a pluronic lecithin organo-gel) rubbed on the volar surface of the wrists bythe subject. Blood samples were obtained at 0,30, 60, 90, 120, 180, and 240 minutes. Plasmaconcentrations were analyzed by liquid chroma-tography-tandem mass spectrometry (LC/MS/MS) using deuterated internal standards foreach drug.

Result. No lorazepam (A) or haloperidol (H) wasdetected in any sample from any of the 10 volun-teers down to a level of 0.05 ng/ml. Diphenhydra-mine (B) was found inmultiple plasma samples atconcentrations > 0.05 ng/ml in 3 patients, withthe highest concentration 0.30 ng/ml in 1 personat 240minutes. Overall, 5 of 10 patients exhibiteddetectable B in one or more samples supportinglimited absorption. No subject noted any sideeffects.