Delirium is highly prevalent in patients receiving palliative care, with up to 4 in 10 people having delirium on admission to a palliative care unit, and higher rates seen at the end of life.¹ Symptom relief is important to reduce the known distress associated with delirium; thus, effective, evidence-based management strategies that optimally balance benefits and risks are needed.²

Purpose: The anesthetic ketamine is widely used for pain related to cancer, but the evidence to support its use in this setting is weak. This study aimed to determine whether ketamine is more effective than placebo when used in conjunction with opioids and standard adjuvant therapy in the management of chronic uncontrolled cancer pain. Ketamine would be considered of net benefit if it provided clinically relevant improvement in pain with limited breakthrough analgesia and acceptable toxicity. Patients and Methods: In this multisite, dose-escalation, double-blind, randomized, placebo-controlled phase III trial, ketamine or placebo was delivered subcutaneously over 3 to 5 days. Results: In all, 185 participants were included in the primary analysis. There was no significant difference between the proportion of positive outcomes (0.04; 95% CI, −0.10 to 0.18; P = .55) in the placebo and intervention arms (response rates, 27% [25 of 92] and 31% [29 of 93]). Pain type (nociceptive v neuropathic) was not a predictor of response. There was almost twice the incidence of adverse events worse than baseline in the ketamine group after day 1 (incidence rate ratio, 1.95; 95% CI, 1.46 to 2.61; P < .001) and throughout the study. Those receiving ketamine were more likely to experience a more severe grade of adverse event per day (odds ratio, 1.09; 95% CI, 1.00 to 1.18; P = .039). The number of patients needed to treat for one additional patient to have a positive outcome from ketamine was 25 (95% CI, six to ∞). The number needed to harm, because of toxicity-related withdrawal, was six (95% CI, four to 13). Conclusion: Ketamine does not have net clinical benefit when used as an adjunct to opioids and standard coanalgesics in cancer pain.

Background: efficient strategies are needed to provide specialist advice in nursing homes to ensure quality medical care. We describe a case conference intervention involving a multidisciplinary team of health professionals. Objectives: to evaluate the impact of multidisciplinary case conferences on the appropriateness of medications and on patient behaviours in high-level residential aged care facilities. Design: cluster-randomised controlled trial. Setting: ten high-level aged care facilities. Participants: 154 residents with medication problems and/or challenging behaviours were selected for case conference by residential care staff. Intervention: two multidisciplinary case conferences involving the resident's general practitioner, a geriatrician, a pharmacist and residential care staff were held at the nursing home for each resident. Measurements: outcomes were assessed at baseline and 3 months. The primary outcome was the Medication Appropriateness Index (MAI). The behaviour of each resident was assessed via the Nursing Home Behaviour Problem Scale. Results: 45 residents died before follow-up. Medication appropriateness improved in the intervention group [MAI mean change 4.1, 95% confidence interval (CI) 2.1–6.1] compared with the control group (MAI mean change 0.4, 95% CI −0.4−1.2; P < 0.001). There was a significant reduction in the MAI for benzodiazepines (mean change control −0.38, 95% CI −1.02−0.27 versus intervention 0.73, 95% CI 0.16–1.30; P = 0.017). Resident behaviours were unchanged after the intervention and the improved medication appropriateness did not extend to other residents in the facility. Conclusion: multidisciplinary case conferences in nursing homes can improve care. Outreach specialist services can be delivered without direct patient contact and achieve improvements in prescribing.

What is Known and objective Hot days are increasingly common and are often associated with increased morbidity and mortality, especially in the elderly. Most heat‐related illness and heat‐related deaths are preventable. Comment Medicines may accentuate the risk of dehydration and heat‐related illness, especially in elderly people taking multiple medicines, through the following mechanisms: diuresis and electrolyte imbalance, sedation and cognitive impairment, changed thermoregulation, reduced thirst recognition, reduced sweat production, and hypotension and reduced cardiac output. What is new and conclusion Commonly used medicines that may significantly increase the risk include diuretics, especially when combined with an angiotensin converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB), anticholinergics and psychotropics. Initiation of individualized preventive measures prior to the start of the hot weather season, which includes a review of the patient and their medicines to identify thermoregulatory issues, may reduce the risk of heat‐related illness or death.