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Chronic microaspiration and diffuse aspiration bronchiolitis may account for some otherwise unexplained frailty in nursing home patients.

Tardive dyskinesia (TD) is a chronic and often irreversible movement disorder that usually evolves after years of neuroleptic use but can sometimes develop over a much shorter time frame. Paradoxically, a higher dose of the neuroleptic agent that causes TD can often temporarily suppress the movement disorder. This is generally an inadvisable approach, though, as its effectiveness is probably limited to only a matter of weeks and as it will worsen the problem in the long run. We describe a patient with widely metastatic squamous cell carcinoma of the lung who developed severe TD when treated with chlorpromazine for severe hiccups. As his prognosis was only days to weeks, we were able to effectively suppress his TD with haloperidol. Hospice care emphasizes relief of suffering at the end of life, often at the expense of attention to long-range adverse effects, and this approach may be a viable management strategy for patients with TD and very limited prognosis.

Persistent or intractable hiccups are not uncommon at the end of life, occurring in approximately 4% to 9% of patients, and can cause considerable suffering, including difficulties in eating, drinking, and speaking, insomnia, pain, fatigue, and depression. In palliative practice, the etiology of hiccups is often either unknown or untreatable, and empirical pharmacologic treatment is the norm. Unfortunately, many of the agents reported as effective for hiccups can cause undesirable sedation. The authors describe a patient with end-stage vascular dementia and a 4-year history of idiopathic intractable hiccups who responded dramatically to amantadine, a nonsedating dopamine agonist. The role of dopamine in hiccups is somewhat ambiguous and likely not central to their cause or treatment. Amantadine may be a reasonable option for patients with distressing hiccups who cannot tolerate a sedating agent.

Clinicians commonly encounter dysphagia and constipation in a skilled nursing population. Increasing the viscosity of liquids, usually with a starch- or xanthan gum-based thickener, serves as a key intervention for patients with dysphagia. We report a newly identified and potentially dangerous interaction between polyethylene glycol 3350 laxative (PEG) and starch-thickened liquids. A patient requiring nectar-thickened liquids became constipated, and medical staff prescribed PEG for constipation. His nurse observed that the thickened apple juice immediately thinned to near-water consistency when PEG was added. She obtained the same results with thickened water and coffee. We quantified this phenomenon by isothermal rotational rheology. Results confirmed a precipitous loss of thickening when PEG was added to starch-based thickeners but not with xanthan gum-based thickeners. Clinicians and front-line staff should be aware of this potentially critical interaction between PEG- and starch-based thickeners. Although confirmatory studies are needed, our preliminary data suggest that PEG may be compatible with xanthan gum-- based thickeners.

Nausea and vomiting are common and often highly distressing symptoms in advanced cancer and in hospice and palliative medicine practice. Nausea and vomiting generally respond well to correction of the underlying etiology (when possible) and appropriate selection of antiemetic medication, but up to 7% of patients will have refractory symptoms. Dronabinol is extensively studied for chemotherapy-related nausea and vomiting, but there are only a few case reports of its use in nausea and vomiting unrelated to chemotherapy. We report a patient with end-stage ovarian cancer with peritoneal carcinomatosis and refractory nausea and vomiting who responded dramatically to addition of dronabinol. Dronabinol is usually well tolerated and may have several novel mechanisms of antiemetic action; further study of its scope of efficacy is warranted.

Ischemic fasciitis is a rare reactive, non-neoplastic proliferation of atypical fibroblasts typically seen in older debilitated patients at pressure points. We describe the case of an 85-year-old female nursing home resident with a past medical history of advanced dementia and immobility who developed an enlarging nodule on the posterior aspect of her right shoulder. A needle biopsy was performed under ultrasound guidance, and the histology was consistent with ischemic fasciitis. Surgical resection of the lesion was performed and anatomical pathology was consistent with ischemic fasciitis. Ischemic fasciitis has been described in association with immobility and debilitation in elderly patients. It is usually located over a bony prominence and should be recognized and differentiated from other skin conditions, such as pressure ulcers or soft tissue sarcoma. It is diagnosed by biopsy and treated by surgical resection. A high degree of clinical suspicion and appropriate management will help to avoid delay in care and medical complications.