Objective: To illustrate and investigate the use of oral morphine for management of behavioral symptoms associated with severe dementia.
Design: A case series of patients with severe dementia.
Methods: Cases were collected through referrals from residential aged care facilities, and from health workers, including medical practitioners, who worked in these facilities. One author (SEK) contacted or visited the Director of Nursing at each facility to collect data about each patient.
Results: 39 patients (14 males, 25 females; mean age 79.3years) participated, and all were living in residential aged care facilities providing high levels of care. The main indication for the use of morphine was agitation in 16 patients, aggression in 10, inappropriate vocalization in 8, and distress in 5. All patients had been treated with at least 1 psychotropic medication before morphine was commenced. The median starting dose of morphine was 2.5mg, with an initial daily total dose of 12.5mg, and the median maximum dose was 25mg per day. The morphine was continued for a median of 6 months (range 1 to 45 months). A satisfactory response, that is a substantial reduction in target symptoms, was reported in 37 of the 39 patients. Nursing reports included words such as “more contented,” happy,” “settled,” and “more relaxed.” In a number of cases family members also commented on symptom improvement and were supportive of the treatment being continued to maintain quality of life. No side-effects were reported in 20 patients, while reports of constipation were made for 5 patients, drowsiness in 9 patients, and nausea or vomiting was reported for a further 5 patients. For the side-effect analysis only the most significant side-effect is reported for each patient. Four deaths occurred during the data collection period whilst patients were taking morphine. Causes of death were reported as aspiration pneumonia, urinary tract sepsis, stroke, and influenza.
Conclusion: This case series suggests that morphine is a promising treatment for distressing behavioral symptoms in patients with severe dementia. In a high percentage of cases symptoms were effectively controlled using small to moderate dosages of morphine with limited side-effects. There was no need for a major increase in dose to maintain symptom control over medium to long periods of time. A case series is subject to many potential biases. The major bias is a tendency for informants to preferentially report patients with a good response to morphine. The next step in investigating this new indication for morphine is a prospective case series with standardized outcome measures.
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