Measures to assess commonly experienced symptoms for people with dementia in long-term care settings: a systematic review

BACKGROUND

High symptom burden is common in long-term care residents with dementia and results in distress and behavioral challenges if undetected. Physicians may have limited time to regularly examine all residents, particularly those unable to self-report, and may rely on reports from caregivers who are frequently in a good position to detect symptoms quickly. We aimed to identify proxy-completed assessment measures of symptoms experienced by people with dementia, and critically appraise the psychometric properties and applicability for use in long-term care settings by caregivers.

METHODS

We searched Medline, EMBASE, PsycINFO, CINAHL and ASSIA from inception to 23 June 2015, supplemented by citation and reference searches. The search strategy used a combination of terms: dementia OR long-term care AND assessment AND symptoms (e.g. pain). Studies were included if they evaluated psychometric properties of proxy-completed symptom assessment measures for people with dementia in any setting or those of mixed cognitive abilities residing in long-term care settings. Measures were included if they did not require clinical training, and used proxy-observed behaviors to support assessment in verbally compromised people with dementia. Data were extracted on study setting and sample, measurement properties and psychometric properties. Measures were independently evaluated by two investigators using quality criteria for measurement properties, and evaluated for clinical applicability in long-term settings.

RESULTS

Of the 19,942 studies identified, 40 studies evaluating 32 measures assessing pain (n = 12), oral health (n = 2), multiple neuropsychiatric symptoms (n = 2), depression (n = 8), anxiety (n = 2), psychological wellbeing (n = 4), and discomfort (n = 2) were included. The majority of studies (31/40) were conducted in long-term care settings although none of the neuropsychiatric or anxiety measures were validated in this setting. The pain assessments, PAINAD and PACSLAC had the strongest psychometric evidence. The oral health, discomfort, and three psychological wellbeing measures were validated in this setting but require further psychometric evaluation. Depression measures were poor at detecting depression in this population. All measures require further investigation into agreement, responsiveness and interpretability.

CONCLUSIONS

Measures for pain are best developed for this population and setting. All other measures require further validation. A multi-symptom measure to support comprehensive assessment and monitoring in this population is required.

Minimal Clinically Important Difference in the Physical, Emotional, and Total Symptom Distress Scores of the Edmonton Symptom Assessment System

CONTEXT

The Edmonton Symptom Assessment System (ESAS) is one of the most commonly used symptom batteries in clinical practice and research.

OBJECTIVES

We used the anchor-based approach to identify the minimal clinically important difference (MCID) for improvement and deterioration for ESAS physical, emotional, and total symptom distress scores.

METHODS

In this multicenter prospective study, we asked patients with advanced cancer to complete their ESAS at the first clinic visit and at a second visit three weeks later. The anchor for MCID determination was Patient's Global Impression regarding their physical, emotional, and overall symptom burden ("better," "about the same," or "worse"). We identified the optimal sensitivity/specificity cutoffs for both improvement and deterioration for the three ESAS scores and also determined the within-patient changes.

RESULTS

A total of 796 patients were enrolled from six centers. The ESAS scores had moderate responsiveness, with area under the receiver operating characteristic curve between 0.69 and 0.76. Using the sensitivity-specificity approach, the optimal cutoffs for ESAS physical, emotional, and total symptom distress scores were ≥3/60, ≥2/20, and ≥3/90 for improvement, and ≤-4/60, ≤-1/20, and ≤-4/90 for deterioration, respectively. These cutoffs had moderate sensitivities (59%-68%) and specificities (62%-80%). The within-patient change approach revealed the MCID cutoffs for improvement/deterioration to be 3/-4.3 for the physical score, 2.4/-1.8 for the emotional score, and 5.7/-2.9 for the total symptom distress score.

CONCLUSION

We identified the MCIDs for physical, emotional, and total symptom distress scores, which have implications for interpretation of symptom response in clinical trials.

Evaluation of two instruments of perceived symptom intensity in palliative care patients in an outpatient clinic

AIMS AND OBJECTIVES

To evaluate the test-retest stability in assessments of perceived symptom intensity on the Edmonton Symptom Assessment System-revised and the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative. The possible interchangeability between the instruments and the patients' experiences of completing the instruments were also studied.

BACKGROUND

The two instruments assess the same symptoms, but the symptom intensity is assessed on 11-point numerical scales on the Edmonton Symptom Assessment System-revised and on four-point verbal descriptive scales on the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative. Both instruments are commonly used; however, uncertainty exists about which instrument should be recommended and about the interchangeability of the instruments.

DESIGN

This study used a test-retest design with inter-scale comparisons.

METHODS

Data from 54 patients with cancer who were receiving palliative care in an oncology outpatient clinic were self-reported by the patients in the clinic, at home and when patients returned to the clinic.

RESULTS

The assessments on the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative verbal rating scales showed a higher level of test-retest stability than the assessments on the Edmonton Symptom Assessment System-revised numerical scoring scales, indicating higher reliability. The correspondence between the verbal categories and the numerical scores of symptom intensity were low because different verbal categories were used by patients who assessed the same numerical score.

CONCLUSIONS

The test-retest stability in the assessments was higher on the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative and the results show that assessments on the two instruments could not be used interchangeably. Therefore, the symptom instrument chosen must be specified and unchanged within a patient to improve efficacy in clinical practice.

RELEVANCE TO CLINICAL PRACTICE

The Edmonton Symptom Assessment System-revised or the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative can be used for initial assessments of patients, but should not be compared or used interchangeably. It is vitally important to have individual follow-up for all patients who score an instrument.

Validation of an Arabic Questionnaire for Symptom Assessment

BACKGROUND

Impeccable assessment of symptoms is central to palliative care (PC) practice.

OBJECTIVES

The study objectives are (1) to test the validity of the Arabic Questionnaire for Symptom Assessment (AQSA) as a self-administered (SA) tool for assessing the severity of the listed symptoms among PC patients and (2) to test the validity of AQSA when completed by a proxy.

METHODS

The AQSA is a tool for assessing the severity of 11 symptoms in addition to the overall suffering experience on a 0 to 10 numeric scale. Symptom scores on the SA AQSA were compared to scores obtained through interviews with patients. The same procedure was repeated with patients' sitters to explore the validity of using the tool for symptom assessment by proxy.

RESULTS

The study involved 107 pairs (a patient and a sitter, each) with a mean age of 46.3 years (females 59.8%) for patients and 35.9 years (females 65.7%) for sitters. The correlation coefficient ( r) for agreement between SA and interview-based (IB) scores for patients ranged from .65 ( P < .0001) for drowsiness to .86 ( P < .0001) for pain. The SA AQSA showed positive correlation between sitters' and patients' scores, with r ranging from .28 ( P = .004) for depression to .62 ( P ≤ .0001) for vomiting.

CONCLUSIONS

The strong positive correlation between SA and IB AQSA indicates that the former is a valid tool. When the SA AQSA is used by proxy, it showed moderate to strong positive correlation with patients' actual scores for most of the symptoms.

Psychometric Properties of the Icelandic Version of the Revised Edmonton Symptom Assessment Scale

CONTEXT

The Edmonton Symptom Assessment Scale (ESAS) is a symptom assessment tool commonly used in both research and clinical practice. A revised version of the tool (ESAS-r) was published in 2011.

OBJECTIVES

To evaluate the psychometric properties and feasibility of the Icelandic version of ESAS-r.

METHODS

The study was cross-sectional, and 359 cancer patients were screened for participation at inpatient and outpatient settings. The ESAS-r, M. D. Anderson Symptom Inventory (MDASI), demographic and feasibility questions were completed by 143 patients. The psychometric properties assessed for ESAS-r were internal consistency (Cronbach alpha) and concurrent validity (Pearson correlation).

RESULTS

Reliability analysis of the ESAS-r showed good internal consistency (Cronbach alpha = 0.85). Validity analysis showed significant moderate-to-strong correlations between seven matching symptom scores on the ESAS-r and MDASI, ranging from r = 0.64-0.86. The majority of patients rated both tools easy to understand, but on the whole, significantly more patients found ESAS-r easier to complete and preferred its use over the MDASI.

CONCLUSION

The Icelandic version of ESAS-r is a valid and reliable tool for symptom screening in Icelandic cancer patients in both inpatient and outpatient settings.

Assessment of Sexual Dysfunction Symptoms in Female Drug Users: Standardized vs. Unstandardized Methods

AIMS

The aim of this study is to evaluate whether there is a difference in the identified prevalence between the assessment of symptoms of sexual dysfunction in female drug users using a standardized scale and by means of a nonstandardized set of questions about sexual dysfunctions.

METHOD

A cross-sectional study was conducted with two groups of substance-dependent women using the Drug Abuse Screening Test, the Short Alcohol Dependence Data questionnaire, the Fagerström Test for Nicotine Dependence for the evaluation of the severity of dependence, and the Arizona Sexual Experience Scale.

FINDINGS

In both groups, the severity of dependence and the prevalence of symptoms of sexual dysfunctions in women were similar.

CONCLUSION

The use of standardized and nonstandardized instruments to assess sexual dysfunction symptoms is an essential resource for the provision of good-quality care to this clientele.

Validation of the Japanese Version of the Edmonton Symptom Assessment System-Revised

CONTEXT

The Edmonton Symptom Assessment System-revised (ESAS-r) is a brief and widely used symptom measurement tool.

OBJECTIVES

To validate the Japanese version of the ESAS-r in Japanese patients with cancer.

METHODS

We assessed the internal consistency, test-retest reliability, concurrent validity, and known-group validity in 292 Japanese adult patients with cancer. They completed Japanese versions of the ESAS-r, M. D. Anderson Symptom Inventory, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30.

RESULTS

Cronbach's alpha coefficient of the Japanese version of the ESAS-r was 0.87. The intraclass correlation coefficient in the test-retest examination ranged from 0.82 to 0.91 for each symptom score and was 0.90 for the total score. Pearson correlation coefficients of each ESAS-r symptom score with corresponding M. D. Anderson Symptom Inventory and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 items ranged from 0.45 to 0.80. The total score of the ESAS-r was significantly higher in patients with an Eastern Cooperative Oncology Group performance status of 2-4 than in those with a performance status of 0 and 1 (P < 0.0001).

CONCLUSION

The Japanese version of the ESAS-r is a reliable and valid tool for measuring symptoms in Japanese adult patients with cancer.

Tools to Assess Pain or Lack of Comfort in Dementia: A Content Analysis

CONTEXT

There is need for tools to help detect pain or lack of comfort in persons unable to communicate. However, pain and (dis)comfort tools have not been compared, and it is unclear to what extent they discriminate between pain and other possible sources of discomfort, or even if items differ.

OBJECTIVES

To map and compare items in tools that assess pain and the broader notion of discomfort or comfort in people with severe dementia or at the end of life.

METHODS

Using qualitative content analysis with six classifications, we categorized each item of four thoroughly tested observational pain tools (Pain Assessment in Advanced Dementia [PAINAD], Pain Assessment Checklist for Seniors with Limited Ability to Communicate [PACSLAC], Doloplus-2, and draft Pain Assessment in Impaired Cognition [PAIC]), and four discomfort tools (including distress, comfort, and quality of life in severe dementia or at the end of life; Discomfort Scale-Dementia Alzheimer Type [DS-DAT], Disability Distress Assessment Tool [DisDAT], End-of-Life in Dementia-Comfort Assessment in Dying with Dementia [EOLD-CAD], and Quality of Life in Late-Stage Dementia [QUALID] scale). We calculated median proportions to compare distributions of categories of pain and discomfort tools.

RESULTS

We found that, despite variable content across tools, items from pain and discomfort tools overlapped considerably. For example, positive elements such as smiling and spiritual items were more often included in discomfort tools but were not unique to these. Pain tools comprised more "mostly descriptive" (median 0.63 vs. 0.44) and fewer "highly subjective" items (0.06 vs. 0.18); some used time inconsistently, mixing present and past observations.

CONCLUSION

This analysis may inform a more rigorous theoretical underpinning and (re)development of pain and discomfort tools and calls for empirical testing of a broad item pool for sensitivity and specificity in detecting and discriminating pain from other sources of discomfort.

Hospitalist attitudes toward the assessment and management of dyspnea in patients with acute cardiopulmonary diseases

BACKGROUND

Dyspnea is a common symptom in patients hospitalized with acute cardiopulmonary diseases. Routine assessment of dyspnea severity is recommended by clinical guidelines based on the evidence that patients are not treated consistently for dyspnea relief.

OBJECTIVE

To evaluate attitudes and beliefs of hospitalists regarding the assessment and management of dyspnea.

DESIGN

Cross-sectional survey.

SETTINGS

Nine hospitals in the United States.

MEASUREMENTS

Survey questions assessed the following domains regarding dyspnea: importance in clinical care, potential benefits and challenges of implementing a standardized assessment, current approaches to assessment, and how awareness of severity affects management. A 5-point Likert scale was used to assess the respondent's level of agreement; strongly agree and agree were combined into a single category.

RESULTS

Of the 255 hospitalists invited to participate, 69.8% completed the survey; 77.0% agreed that dyspnea relief is an important goal when treating patients with cardiopulmonary conditions. Approximately 90% of respondents stated that awareness of dyspnea severity influences their decision to intensify treatment, to pursue additional diagnostic testing, and the timing of discharge. Of the respondents, 61.0% agreed that standardized assessment of dyspnea should be part of the vital signs, and 64.6% agreed that awareness of dyspnea severity influences their decision to prescribe opioids. Hospitalists who appreciated the importance of dyspnea in clinical practice were more likely to support the implementation of a standardized scale.

CONCLUSIONS

Most hospitalists believe that routine assessment of dyspnea severity would enhance their clinical decision making and patient care. Measurement and documentation of dyspnea severity may represent an opportunity to improve dyspnea management.

Symptoms and Symptom Clusters Identified by Adolescents and Young Adults With Cancer Using a Symptom Heuristics App

Adolescents and young adults (AYAs) with cancer experience multiple distressing symptoms during treatment. Because the typical approach to symptom assessment does not easily reflect the symptom experience of individuals, alternative approaches to enhancing communication between the patient and provider are needed. We developed an iPad-based application that uses a heuristic approach to explore AYAs' cancer symptom experiences. In this mixed-methods descriptive study, 72 AYAs (13-29 years old) with cancer receiving myelosuppressive chemotherapy used the Computerized Symptom Capture Tool (C-SCAT) to create images of the symptoms and symptom clusters they experienced from a list of 30 symptoms. They answered open-ended questions within the C-SCAT about the causes of their symptoms and symptom clusters. The images generated through the C-SCAT and accompanying free-text data were analyzed using descriptive, content, and visual analyses. Most participants (n = 70) reported multiple symptoms (M = 8.14). The most frequently reported symptoms were nausea (65.3%), feeling drowsy (55.6%), lack of appetite (55.6%), and lack of energy (55.6%). Forty-six grouped their symptoms into one or more clusters. The most common symptom cluster was nausea/eating problems/appetite problems. Nausea was most frequently named as the priority symptom in a cluster and as a cause of other symptoms. Although common threads were present in the symptoms experienced by AYAs, the graphic images revealed unique perspectives and a range of complexity of symptom relationships, clusters, and causes. Results highlight the need for a tailored approach to symptom management based on how the AYA with cancer perceives his or her symptom experience.

Symptom Expression in the Last Seven Days of Life Among Cancer Patients Admitted to Acute Palliative Care Units

CONTEXT

The symptom burden in the last week of life of patients with advanced cancer has not been well characterized.

OBJECTIVES

To examine the frequency, intensity, and predictors for symptoms in the last seven days of life among patients who were able to communicate and died in an acute palliative care unit (APCU).

METHODS

We systematically documented the Edmonton Symptom Assessment System (ESAS) daily and 15 symptoms twice daily on consecutive advanced cancer patients admitted to APCUs at MD Anderson Cancer Center (U.S.) and Barretos Cancer Hospital (Brazil) from admission to death or discharge in 2010/2011. We examined the frequency and intensity of the symptoms from death backward.

RESULTS

A total of 203 of 357 patients died. The proportion of patients able to communicate decreased from 80% to 39% over the last seven days of life. ESAS anorexia (P = 0.001 in longitudinal analyses), drowsiness (P < 0.0001), fatigue (P < 0.0001), poor well-being (P = 0.01), and dyspnea (P < 0.0001) increased in intensity closer to death. In contrast, ESAS depression (P = 0.008) decreased over time. Dysphagia to solids (P = 0.01) and liquids (P = 0.005) as well as urinary incontinence (P = 0.0002) also were present in an increasing proportion of patients in the last few days of life. In multivariate analyses, female sex, non-Hispanic race, and lung cancer were significantly associated with higher ESAS symptom expression (odds ratio > 1).

CONCLUSION

Despite intensive management in APCUs, some cancer patients continue to experience high symptom burden as they approached death.

Assessment of the Lower Urinary Tract Microbiota during Symptom Flare in Women with Urologic Chronic Pelvic Pain Syndrome: A MAPP Network Study

PURPOSE

We compared culture independent assessment of microbiota of the lower urinary tract in standard culture negative female patients with urological chronic pelvic pain syndrome who reported symptom flare vs those who did not report a flare.

MATERIALS AND METHODS

Initial stream (VB1) and midstream (VB2) urine specimens (233 patients with urological chronic pelvic pain syndrome) were analyzed with Ibis T-5000 Universal Biosensor system technology for comprehensive identification of microorganism species. Differences between flare and nonflare groups for presence or number of different species within a higher level group (richness) were examined by permutational multivariate analysis of variance and logistic regression.

RESULTS

Overall 81 species (35 genera) were detected in VB1 and 73 (33) in VB2. Mean (SD) VB1 and VB2 species count per person was 2.6 (1.5) and 2.4 (1.5) for 86 flare cases and 2.8 (1.3) and 2.5 (1.5) for 127 nonflare cases, respectively. Overall the species composition did not significantly differ between flare and nonflare cases at any level (p=0.14 species, p=0.95 genus in VB1 and VB2, respectively) in multivariate analysis for richness. Univariate analysis, unadjusted as well as adjusted, confirmed a significantly greater prevalence of fungi (Candida and Saccharomyces) in the flare group (15.7%) compared to the nonflare group in VB2 (3.9%) (p=0.01). When adjusted for antibiotic use and menstrual phase, women who reported a flare remained more likely to have fungi present in VB2 specimens (OR 8.3, CI 1.7-39.4).

CONCLUSIONS

Among women with urological chronic pelvic pain syndrome the prevalence of fungi (Candida and Saccharomyces sp.) was significantly greater in those who reported a flare compared to those who did not.

Linguistic Validation of the M. D. Anderson Symptom Inventory in Persian-Speaking Iranian Cancer Patients

CONTEXT

Various symptoms frequently affect cancer patients' quality of life. Appropriate assessment of these symptoms provides valuable data for cancer management.

OBJECTIVES

This study aimed to validate the Persian version of the M. D. Anderson Symptom Inventory (MDASI-P).

METHODS

This cross-sectional study was conducted at four cancer treatment centers in two cities in Iran. Breast cancer and colorectal cancer patients aged 18 years and older were consecutively included in the study. The standard forward-backward translation method was applied. Patients completed the MDASI-P along with the previously validated Persian version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). Construct validity (factor analysis), criterion validity (against the EORTC QLQ-C30), and reliability (Cronbach's alpha) were analyzed.

RESULTS

A total of 146 breast cancer and 94 colorectal cancer patients were studied. Factor analysis for the symptom severity items resulted in a three-factor solution, further reduced to a two-factor solution: general symptoms and gastrointestinal symptoms. Correlation of the MDASI-P symptom severity items with corresponding EORTC QLQ-C30 symptom items (r = 0.48-0.75) and MDASI-P interference items with corresponding EORTC QLQ-C30 functioning domains (r = -0.46 to -0.23) supported the criterion validity. Cronbach's alpha was 0.90, 0.88, and 0.77 for the total questionnaire, symptom severity items, and the interference subscale, respectively.

CONCLUSION

The MDASI-P is a feasible, valid, and reliable instrument for evaluation of symptoms in Persian-speaking cancer patients and can be used to improve symptom management in these patients.

Is excessive daytime sleepiness a separate manifestation in Parkinson's disease?

BACKGROUND

Excessive daytime sleepiness (EDS) is common in Parkinson's disease (PD), but its role and relation to other PD features is less well understood.

OBJECTIVE

To investigate potential predictors of EDS in PD and to explore how EDS relates to other motor and non-motor PD features.

METHODS

118 consecutive persons with PD (54% men; mean age, 64) were assessed regarding EDS using the Epworth Sleepiness Scale (ESS) and a range of motor and non-motor symptoms. Variables significantly associated with ESS scores in bivariate analyses were used in multiple regression analyses with ESS scores as the dependent variable. Principal component analysis (PCA) was conducted to explore the interrelationships between ESS scores and other motor and non-motor PD aspects.

RESULTS

Among 114 persons with complete ESS data, significant independent associations were found between ESS scores and axial/postural/gait impairment, depressive symptoms, and pain (R2, 0.199). ESS scores did not load significantly together with any other PD features in the PCA.

CONCLUSIONS

Only a limited proportion of the variation in EDS could be accounted for by other symptoms, and EDS did not cluster together with any other PD features in PCAs. This suggests that EDS is a separate manifestation differing from, for example, poor sleep quality and fatigue.

Generation and optimization of the self-administered bleeding assessment tool and its validation as a screening test for von Willebrand disease

INTRODUCTION/AIM

Our aim was to generate, optimize and validate a self-administered bleeding assessment tool (self-BAT) for von Willebrand disease (VWD).

METHODS

In Phase 1, medical terminology in the expert-administered International Society on Thrombosis and Haemostasis (ISTH)-BAT was converted into a Grade 4 reading level to produce the first version of the Self-BAT which was then optimized to ensure agreement with the ISTH-BAT. In Phase 2, the normal range of bleeding scores (BSs) was determined and test-retest reliability analysed. In Phase 3, the optimized Self-BAT was tested as a screening tool for first time referrals to the Haematology clinic.

RESULTS

Bleeding score from the final optimized version of the Self-BAT showed an excellent intra-class correlation coefficient (ICC) of 0.87 with ISTH-BAT BS in Phase 1. In Phase 2, the normal range of BSs for the optimized Self-BAT was determined to be 0 to +5 for females and 0 to +3 for males and excellent test-retest reliability was shown (ICC = 0.95). In Phase 3, we showed that a positive Self-BAT BS (≥6 for females, ≥4 for males) has a sensitivity of 78%, specificity of 23%, positive predictive value (PPV) of 0.15 and negative predictive value (NPV) of 0.86 for VWD; these figures improved when just the females were analysed; sensitivity of 100%, specificity of 21%, PPV = 0.17 and NPV = 1.0.

CONCLUSION

We show an optimized Self-BAT can generate comparable BS to the expert-administered ISTH-BAT and is a reliable, effective screening tool to incorporate into the assessment of individuals, particularly women, referred for a possible bleeding disorder.

Minimal clinically important differences in the Edmonton Symptom Assessment Scale in cancer patients: A prospective, multicenter study

BACKGROUND

The Edmonton Symptom Assessment Scale (ESAS) is widely used for symptom assessment in clinical and research settings. A sensitivity-specificity approach was used to identify the minimal clinically important difference (MCID) for improvement and deterioration for each of the 10 ESAS symptoms.

METHODS

This multicenter, prospective, longitudinal study enrolled patients with advanced cancer. ESAS was measured at the first clinic visit and at a second visit 3 weeks later. For each symptom, the Patient's Global Impression ("better," "about the same," or "worse") was assessed at the second visit as the external criterion, and the MCID was determined on the basis of the optimal cutoff in the receiver operating characteristic (ROC) curve. A sensitivity analysis was conducted through the estimation of MCIDs with other approaches.

RESULTS

For the 796 participants, the median duration between the 2 study visits was 21 days (interquartile range, 18-28 days). The area under the ROC curve varied from 0.70 to 0.87, and this suggested good responsiveness. For all 10 symptoms, the optimal cutoff was ≥1 point for improvement and ≤-1 point for deterioration, with sensitivities of 59% to 85% and specificities of 69% to 85%. With other approaches, the MCIDs varied from 0.8 to 2.2 for improvement and from -0.8 to -2.3 for deterioration in the within-patient analysis, from 1.2 to 1.6 with the one-half standard deviation approach, and from 1.3 to 1.7 with the standard error of measurement approach.

CONCLUSIONS

ESAS was responsive to change. The optimal cutoffs were ≥1 point for improvement and ≤-1 point for deterioration for each of the 10 symptoms. Our findings have implications for sample size calculations and response determination.

Do negative symptoms of schizophrenia change over time? A meta-analysis of longitudinal data

BACKGROUND

Negative symptoms are a core component of schizophrenia which can severely impact quality of life and functional outcomes. These symptoms are understood to be highly stable but this has not been tested in a meta-analysis, despite the wealth of longitudinal data available.

METHOD

A systematic review of the literature was conducted, with eligible studies pooled into a random-effects meta-analysis. Planned meta-regressions were conducted to evaluate the impact of factors known to induce secondary negative symptoms, in addition to other possible sources of heterogeneity.

RESULTS

The main analysis included 89 samples from 41 studies, totalling 5944 participants. Negative symptoms were found to significantly reduce in all treatment interventions, including in placebo and treatment as usual conditions, with a medium effect size (ES) present across all study conditions (ES = 0.66, 95% confidence interval 0.56-0.77, I(2) = 94.0%). In a multivariate meta-regression, only the type of scale used was found to significantly influence negative symptom change. No difference in outcome was found between studies that excluded patients with a high level of positive or depressive symptoms, compared to those that did not.

CONCLUSIONS

Negative symptoms were found to reduce in almost all schizophrenia outpatient samples. A reduction was found across all conditions, with effect sizes ranging from small to large depending upon the condition type. These findings challenge the convention that negative symptoms are highly stable and suggest that they may improve to a greater extent than what has previously been assumed.

Identifying Residents' Health Issues Six Weeks after the Great East Japan Earthquake

OBJECTIVE

The aim of this study was to identify the characteristics and health issues of residents in need of assistance in a town affected by the Great East Japan Earthquake, six weeks after the disaster, through an outreach initiative.

DESIGN AND SAMPLE

A cross-sectional qualitative design was used. Public health nurses conducted comprehensive semi-structured interviews during home visits with residents. A total of 5,082 residents from the affected town.

MEASURES

These included demographic information, public records of the extent of the damages, and qualitative interview data to determine the urgency of the necessary interventions.

RESULTS

A total of 281 residents needed some kind of assistance and were identified as "requiring early intervention (within two weeks)" or "requiring assistance (within 12 weeks)." The most common health issue requiring early intervention was "interruption of treatment" (25.0%), followed by "need for mental care." The most frequent health issue requiring assistance within 12 weeks was the "need for mental health care" (39.7%), followed by "interruption of treatment," and "need for nursing care."

CONCLUSIONS

During a disaster, it is imperative to identify cases requiring early intervention. Home-visit interviews were necessary to identify existing health concerns to prevent the development of more serious health problems.

Fatigue two months after myocardial infarction and its relationships with other concurrent symptoms, sleep quality and coping strategies

AIMS AND OBJECTIVES

To explore fatigue levels two months after myocardial infarction and examine the associations with other concurrent symptoms, sleep quality and coping strategies.

BACKGROUND

Fatigue has been found to be the most frequent and bothersome symptom after myocardial infarction, influencing health-related quality of life negatively.

DESIGN

The present study was explorative and cross-sectional. The focus was on fatigue two months postmyocardial infarction, complemented with a comparative analysis of fatigue dimension levels.

METHODS

The sample included 142 persons (mean age 63 years), treated for myocardial infarction, who responded to a questionnaire package measuring fatigue, depression, health complaints (symptoms), sleep quality and coping strategies.

RESULTS

The main results showed that a global fatigue score two months postmyocardial infarction was associated with concurrent symptoms, such as breathlessness and stress, and coping strategies such as change in values, intrusion and isolation. In comparisons of present fatigue dimension levels (general fatigue, physical fatigue, reduced activity and mental fatigue) two months postmyocardial infarction with baseline measurements (first week in hospital), the results showed that levels of fatigue dimensions had decreased. In comparisons with levels of fatigue four months postmyocardial infarction in a reference group, we found lower levels of fatigue two months postmyocardial infarction.

CONCLUSION

The present findings indicated that postmyocardial infarction fatigue is lowest two months postmyocardial infarction. This may thus be the right time to identify persons experiencing postmyocardial infarction fatigue, as timely fatigue relief support may prevent progression into a state of higher levels of fatigue.

RELEVANCE TO CLINIC PRACTICE

Measuring fatigue two months postmyocardial infarction would enable healthcare professionals to identify persons experiencing fatigue and to introduce fatigue relief support. Tailored rehabilitation support should include stress management and breathlessness relief support. If maladaptive use of the coping strategies isolation and intrusion is observed, these strategies could be discussed together with the patient.

Correlation of esophageal clearance and dysphagia symptom assessment after treatment for achalasia

BACKGROUND

Early relapse after treatment of achalasia occurs in 10-32 % of patients. The best method to follow up these patients is not known. Symptoms often do not correlate with esophageal clearance: some patients are oligosymptomatic despite persistent esophageal stasis/dilatation.

AIM

The aim was to compare two methods of measurement of esophageal clearance (impedance manometry with barium swallow) in achalasia patients following treatment. Symptom assessment (Eckardt score/detailed dysphagia questions) was correlated with objective measurements of esophageal stasis (barium swallow and impedance manometry) in achalasia patients following treatment.

METHODS

Post-treatment patients were followed up after median 38.4 months (median range 1-144 months). Symptoms were quantified using the Eckardt score and detailed dysphagia questions. Timed barium swallow quantified distal esophageal retention 0.5, 1, 3, and 5 minutes after oral contrast and impedance manometry assessed total and segmental esophageal clearance during water/viscous swallows and free drinking (200 mL).

RESULTS

Thirty-two patients (7 women, age 48.3; range 20-74) completed all investigations. Bolus retention in the distal esophagus assessed by impedance correlated well with barium swallow. There were no differences in impedance and timed barium swallow parameters between patients with Eckardt score 0-2 points or ≥3 points. Nine (28%) patients had an Eckardt score ≥3 points and 21 (66%) had ≥1 point in the detailed dysphagia questions. Patients without any dysphagia history had lower barium column height and width at 3 and 5 minutes compared to those with ≥1 positive answer in the detailed dysphagia questions. Correlation between the Eckardt score and detailed dysphagia questions was moderately good (r = 0.546; p = 0.001).

CONCLUSION

A detailed history of esophageal dysphagia rather than the Eckardt score is more sensitive to detect oligosymptomatic patients with disturbed esophageal clearance. Impedance manometry correlates well with the timed-barium swallow examination and represents an alternative objective assessment as it avoids radiation exposure.

Intensity cut-points for the Respiratory Distress Observation Scale

BACKGROUND

The Respiratory Distress Observation Scale(©) is an innovative solution to assessment when a dyspnea report cannot be elicited. The Respiratory Distress Observation Scale has acceptable reliability and validity psychometrics.

AIM

To identify distress-intensity cut-points of the Respiratory Distress Observation Scale.

DESIGN

Receiver operating characteristic curve analysis was conducted with inpatients stratified by four levels of respiratory distress-none, mild, moderate, or severe. Patients provided three self-report measures of dyspnea: dichotomous (yes/no); a ranking of none, mild, moderate, or severe; and a numerical rating scale. Respiratory distress was assessed using the Respiratory Distress Observation Scale instrument.

SETTING/PARTICIPANTS

Participants were 136 adult inpatients, mean age 61.8 years (standard deviation = 13.18 years), 89.7% African American, and 56.6% female, who were recruited from an urban, tertiary care hospital in the Midwest of the United States.

RESULTS

In all, 47% (n = 64) self-reported dyspnea (yes/no). Ranking was distributed as follows: none = 36, mild = 35, moderate = 40, and severe = 25. Numerical rating scale scores ranged from 0 to 10, mean = 4.99 (standard deviation = 2.9). Respiratory Distress Observation Scale scores ranged from 0 to 7, median (interquartile range) = 2 (1-3). Receiver operating characteristic curve analysis-determined Respiratory Distress Observation Scale score of 0-2 suggests little or no respiratory distress; score ≥3 signified moderate to severe distress.

CONCLUSION

A Respiratory Distress Observation Scale score ≥3 signifies a patient's need for palliation of respiratory distress. An end-point for identifying responsiveness to treatment, in other words, respiratory comfort, is Respiratory Distress Observation Scale <3. Because patients with imminent respiratory failure, as typified by dying patients, were not represented yielding lower than expected Respiratory Distress Observation Scale scores, further substantiation is needed to determine moderate or severe cut-points.

Fatigue in child chronic health conditions: a systematic review of assessment instruments

BACKGROUND AND OBJECTIVE

Fatigue is common in chronic health conditions in childhood, associated with decreased quality of life and functioning, yet there are limited data to compare assessment instruments across conditions and childhood development. Our objective was to describe fatigue assessment instruments used in children with chronic health conditions and critically appraise the evidence for the measurement properties of identified instruments.

METHODS

Data sources included Medline, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO (using the EBSCOhost platform). Study selection included quantitative assessment of fatigue in children with health conditions. Data extraction was as follows: (1) study design, participant and fatigue instruments, (2) measurement properties of fatigue instruments, (3) methodological quality of included studies, and (4) synthesis of the quality of evidence across studies for the measurement properties of fatigue instruments.

RESULTS

Twenty fatigue assessment instruments were identified (12 child reports, 7 parent reports, 1 staff report), used in 89 studies. Fatigue was assessed in over 14 health conditions, most commonly in children with cancer and chronic fatigue syndrome. Evidence for the measurement properties of instruments varied, and overall quality was low. Two fatigue instruments demonstrated strong measurement properties for use in children with diverse health conditions and children with cancer.

CONCLUSIONS

The review is limited to children younger than 18 years and results are specific to health conditions described, limiting generalizability of findings to other populations. Evidence for the measurement properties of fatigue instruments varied according to the population in which instruments were used and informant. Further evidence is required for assessment of fatigue in younger children, and children with particular health conditions.

Part I--Evaluation of pediatric post-traumatic headaches

BACKGROUND

Brain injury is one of the most common injuries in the pediatric age group, and post-traumatic headache is one of the most common symptoms following mild traumatic brain injury in children.

METHODS

This is an expert opinion-based two-part review on pediatric post-traumatic headaches. Part I will focus on an overview and approach to the evaluation of post-traumatic headache. Part II will focus on the medical management of post-traumatic headache. Relevant articles were reviewed, and an algorithm is proposed.

RESULTS

We review the epidemiology, classification, pathophysiology, and clinical approach to evaluating patients with post-traumatic headache. A comprehensive history and physical examination are fundamental to identifying the headache type(s). Identifying the precise headache phenotype is important to help guide treatment. Most of the post-traumatic headaches are migraine or tension type, but occipital neuralgia, cervicogenic headache, and medication overuse headache also occur. Postconcussive signs often resolve within 1 month, and individuals whose signs persist longer may benefit from an interprofessional approach.

CONCLUSIONS

Rigorous evaluation and diagnosis are vital to treating post-traumatic headaches effectively. A multifaceted approach is needed to address all the possible contributing factors to the headaches and any comorbid conditions that may delay recovery or alter treatment choices.

Systematic literature review of patient-reported outcome measures used in assessment and measurement of sleep disorders in chronic obstructive pulmonary disease

BACKGROUND

Sleep problems are common in patients with chronic obstructive pulmonary disease (COPD), but the validity of patient-reported outcome measures (PROMs) that measure sleep dysfunction has not been evaluated. We have reviewed the literature to identify disease-specific and non-disease-specific sleep PROMs that have been validated for use in COPD patients. The review also examined the psychometric properties of identified sleep outcome measures and extracted point and variability estimates of sleep instruments used in COPD studies.

METHODS

The online EMBASE, MEDLINE, PsycINFO, and SCOPUS databases for all years to May 2014 were used to source articles for the review. The review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Criteria from the Medical Outcomes Trust Scientific Advisory Committee guidelines were used to evaluate the psychometric properties of all sleep PROMs identified.

RESULTS

One COPD-specific and six non-COPD-specific sleep outcome measures were identified and 44 papers met the review selection criteria. We only identified one instrument, the COPD and Asthma Sleep Impact Scale, which was developed specifically for use in COPD populations. Ninety percent of the identified studies used one of two non-disease-specific sleep scales, ie, the Pittsburgh Sleep Quality Index and/or the Epworth Sleep Scale, although neither has been tested for reliability or validity in people with COPD.

CONCLUSION

The results highlight a need for existing non-disease-specific instruments to be validated in COPD populations and also a need for new disease-specific measures to assess the impact of sleep problems in COPD.

Systematic review of sleep disorders in cancer patients: can the prevalence of sleep disorders be ascertained?

Although sleep is vital to all human functioning and poor sleep is a known problem in cancer, it is unclear whether the overall prevalence of the various types of sleep disorders in cancer is known. The purpose of this systematic literature review was to evaluate if the prevalence of sleep disorders could be ascertained from the current body of literature regarding sleep in cancer. This was a critical and systematic review of peer-reviewed, English-language, original articles published from 1980 through 15 October 2013, identified using electronic search engines, a set of key words, and prespecified inclusion and exclusion criteria. Information from 254 full-text, English-language articles was abstracted onto a paper checklist by one reviewer, with a second reviewer randomly verifying 50% (k = 99%). All abstracted data were entered into an electronic database, verified for accuracy, and analyzed using descriptive statistics and frequencies in SPSS (v.20) (North Castle, NY). Studies of sleep and cancer focus on specific types of symptoms of poor sleep, and there are no published prevalence studies that focus on underlying sleep disorders. Challenging the current paradigm of the way sleep is studied in cancer could produce better clinical screening tools for use in oncology clinics leading to better triaging of patients with sleep complaints to sleep specialists, and overall improvement in sleep quality.