Pain and delirium in people with dementia in the acute general hospital setting

Role of nursing associates in addressing the needs of people with dementia in hospital

It is estimated that people with dementia comprise about one quarter of all inpatients in acute hospital wards, although this could be an underestimate. Healthcare assistants often lack the training and skills, and nurses often lack the time, to provide optimal care for these patients. As a result, the needs of hospital inpatients with dementia are often unmet, they may have suboptimal outcomes compared with inpatients who do not have dementia, and they may experience significantly reduced well-being and quality of life. Nursing associates have a hands-on role in patient care, and their training should equip them with the skills required to overcome communication barriers and identify patients' needs. This article explores the potential role of nursing associates in addressing the needs of inpatients with dementia.

Dementia Severity Associated With Increased Risk of Potentially Preventable Readmissions During Home Health Care

OBJECTIVES

Approximately 14% of Medicare beneficiaries are readmitted to a hospital within 30 days of home health care admission. Individuals with dementia account for 30% of all home health care admissions and are at high risk for readmission. Our primary objective was to determine the association between dementia severity at admission to home health care and 30-day potentially preventable readmissions (PPR) during home health care. A secondary objective was to develop a dementia severity scale from Outcome and Assessment Information Set (OASIS) items based on the Functional Assessment Staging Tool (FAST).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Home health care; 126,292 Medicare beneficiaries receiving home health care (July 1, 2013-June 1, 2015) diagnosed with dementia (ICD-9 codes).

MEASURES

30-day PPR during home health care. Dementia severity categorized into 6 levels (nonaffected to severe).

RESULTS

The overall rate of 30-day PPR was 7.6% [95% confidence interval (CI) 7.4, 7.7] but varied by patient and health care utilization characteristics. After adjusting for sociodemographic and clinical characteristics, the odds ratio (OR) for dementia severity category 6 was 1.37 (95% CI 1.29, 1.46) and the OR for category 7 was 1.94 (95% CI 1.64, 2.31) as compared to dementia severity category 1/2.

CONCLUSIONS AND IMPLICATIONS

Dementia severity in the later stages is associated with increased risk for potentially preventable readmissions. Our findings suggest that individuals admitted to home health during the later stages of Alzheimer's disease and related dementias may require greater supports and specialized care to minimize negative outcomes such as readmissions. Development of a dementia severity scale based on OASIS items and the FAST is feasible. Future research is needed to determine effective strategies for decreasing potentially preventable readmissions of individuals with severe dementia who receive home health care. Future research is also needed to validate the proposed dementia severity categories used in this study.

Pain Screening in the Older Adult With Delirium

BACKGROUND

In patients with cognitive impairments who are unable to self-report pain, nurses must rely on behavioral observation tools to assess and manage pain. Although frequently employed in medical-surgical units, evidence supporting the psychometric efficacy of the Pain in Advanced Dementia (PAINAD) for pain screening in older adults with delirium is lacking.

AIM

To examine the psychometrics of the PAINAD for older adults with delirium in medical-surgical settings.

DESIGN

A descriptive repeated measures design.

SETTING

Medical-surgical units in an urban tertiary care hospital.

PARTICIPANTS

Sixty-eight older adults with delirium.

METHODS

Patients with delirium unable to self-report pain were screened by two data collectors with the PAINAD and the Critical Care Pain Observation Tool (CPOT). Patients with a PAINAD score ≥3 or a CPOT score ≥2 received a pain intervention. Pain assessments were repeated 30 minutes post baseline or pain intervention.

RESULTS

Patients were predominately female (58.8%) with dementia (71%). Thirty-nine patients screened positive for pain and received a pain intervention. PAINAD reliability was strong (Cronbach's α = 0.81-0.87; interrater intraclass coefficients [ICC] = 0.91-0.94; test-retest ICC = 0.76-0.77). Construct validity was supported by a statistically significant interaction effect between time (baseline versus follow-up) and condition (pain intervention versus no pain group; Rater 1: F(1,66) = 8.31, p = 0.005, η_p² = 0.11; Rater 2: F(1,66) = 8.22, p = 0.006, η_p² = 0.11.

CONCLUSIONS

The PAINAD is a reliable and valid tool for pain screening for older adults with delirium in medical-surgical settings.

CLINICAL IMPLICATIONS

Pain and delirium frequently co-occur in the older adult population. Best practices require a holistic assessment for contributing pain and non-pain factors in patients exhibiting distress.

Acute and Chronic Pain Learning and Teaching in Medical School-An Observational Cross-Sectional Study Regarding Preparation and Self-Confidence of Clinical and Pre-Clinical Medical Students

Background and objectives: Adequate pain management is a major challenge of public health. The majority of students graduating from medical schools has insufficient education and experience with patients suffering pain. Not enough is being taught regarding pain in non-verbal patients (children, critically ill in the intensive care unit, demented). Chronic pain is the most difficult to optimize and requires appropriate preparation at the level of medical school. Our aim was to evaluate attitudes, expectations and the actual knowledge of medical students at different levels of their career path regarding the assessment and treatment of acute and chronic pain. Materials and Methods: We performed an observational cross-sectional study that was based on a survey distributed among medical students of pre-clinical and post-clinical years at the Pomeranian Medical University in Szczecin, Poland. The survey included: demographic data, number of hours of formal pain teaching, actual knowledge of pain assessment, and pain treatment options in adults and children. Results: We received responses from 77/364 (21.15%) students and 79.2% of them rated the need to obtain knowledge regarding pain as very important (10/10 points). Post-clinical group declared having on average 11.51 h of acute pain teaching as compared to the 7.4 h reported by the pre-clinical group (p = 0.012). Graduating students also reported having significantly more classes regarding the treatment of chronic pain (6.08 h vs. 3.79 h, p = 0.007). The average level of comfort in the post-clinical group regarding treatment of acute pain was higher than in the pre-clinical group (6.05 vs. 4.26, p = 0.006), similarly with chronic pain treatment in adults (4.33 vs. 2.97, p = 0.021) and with pain treatment in children (3.14 vs. 1.97, p = 0.026). Conclusions: This study shows that education about pain management is a priority to medical students. Despite this, there continues to be a discrepancy between students’ expectations and the actual teaching and knowledge regarding effective pain management, including the vulnerable groups: chronic pain patients, children, and critically ill people.

The Role of Delirium and Other Risk Factors on Mortality in Elderly Patients with Critical Limb Ischemia Undergoing Major Lower Limb Amputation

BACKGROUND

Delirium in patients with critical limb ischemia (CLI) is associated with increased mortality. The main goal of this study was to investigate the association between delirium and mortality in patients undergoing major lower limb amputation for CLI. In addition, other risk factors associated with mortality were analyzed.

METHODS

An observational cohort study was conducted including all patients aged ≥70 years with CLI undergoing a major lower limb amputation between January 2014 and July 2017. Delirium was scored using the Delirium Observation Screening Score in combination with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Risk factors for mortality were analyzed by calculating hazard ratios using a Cox proportional hazards model.

RESULTS

In total, 95 patients were included; of which, 29 (31%) patients developed a delirium during admission. Delirium was not associated with an increased risk of mortality (hazard ratio [HR] = 0.84; 95 % confidence interval [CI]: 0.51-1.73; P = 0.84). Variables independently associated with an increased risk of mortality were age (HR 1.1; 95% CI 1.0-1.1), cardiac history (HR 3.3; 95% CI 1.8-6.1), current smoking (HR 2.9; 95% CI 1.6-5.5), preoperative anemia (HR 2.8; 95% CI 1.1-7.2), and living in a nursing home (HR 2.2; 95% CI 1.1-4.4).

CONCLUSION

Delirium was not associated with an increased mortality risk in elderly patients with CLI undergoing a major lower limb amputation. Factors related to an increased mortality risk were age, cardiac history, current smoking, preoperative anemia, and living in a nursing home.

[Types and frequencies of complications associated with midline catheters and PICCs in a South Tyrolean district hospital: a retrospective cohort study]

Types and frequencies of complications associated with midline catheters and PICCs in a South Tyrolean district hospital: a retrospective cohort study Abstract.

BACKGROUND

Specialized registered nurses play a key role in the insertion and management of peripherally inserted central catheters (PICCs) and midline catheters in Anglo-Saxon countries. From the German-speaking area no data on the use of PICCs and midline catheters are available.

AIM

The aim of this study was to describe the types and frequencies of complications of PICCs and midline catheters which were inserted by specialized registered nurses in a South Tyrolean district hospital.

METHODS

We performed a retrospective cohort study of PICCs and midline catheters inserted between 2013 and 2015 in one surgical unit in the district hospital Bruneck (South Tyrol / Italy).

RESULTS

Data from 900 catheters (421 midline catheters and 479 PICCs) inserted in 686 adult patients (404 women, 282 men) were analysed. The cumulative incidence was 29.2 % complications for midline catheters (incidence rate: 13 complications / 1000 catheter days) and 16.0 % for PICCs (incidence rate: 3 complications / 1000 catheter days). The most frequent complication was the removal of the catheter by the patients (PICCs: 6.7 %, midline catheters: 15.7 %). Other less frequent complications were mechanical complications, occlusions, infections and thromboses.

CONCLUSIONS

This study in one district hospital revealed similar types and frequencies of complications as previous international studies. Specialized and clinically competent nurses in German-speaking countries could develop advanced roles in the insertion and management of PICCs and midline catheters.