Advanced dementia research in the nursing home: the CASCADE study

The quality of advanced dementia care in the nursing home: the role of special care units

BACKGROUND

The quality of nursing home care for residents with advanced dementia has been described as suboptimal. One relatively understudied factor is the impact of special care units (SCUs) for dementia for residents at the end stage of this disease.

OBJECTIVE

To examine the association between residence in an SCU and the quality of end-of-life care for nursing home residents with advanced dementia.

RESEARCH DESIGN

This study used longitudinal data on 323 nursing home residents with advanced dementia living in 22 Boston-area facilities. Using multivariate methods, we analyzed the association between residence in an SCU and measures of quality of end-of-life care including: treatment of pain and dyspnea, prevalence of pressure ulcers, hospitalization, tube feeding, antipsychotic drug use, advance care planning, and health care proxy (HCP) satisfaction with care.

RESULTS

A total of 43.7% residents were cared for in an SCU. After multivariate adjustment, residents in SCUs were more likely to receive treatment for dyspnea, had fewer hospitalizations, were less likely to be tube fed, and more likely to have a do-not-hospitalize order, compared with non-SCU residents. However, non-SCU residents were more likely to be treated for pain, had fewer pressure ulcers, and less frequent use of antipsychotic drugs than SCU residents. HCPs of SCU residents reported greater satisfaction with care than HCPs of non-SCU residents.

CONCLUSIONS

Residence in an SCU is associated with some, but not all, markers of better quality end-of-life care among nursing home residents with advanced dementia.

Selection bias in family reports on end of life with dementia in nursing homes

BACKGROUND

Selective participation in retrospective studies of families recruited after the patient's death may threaten generalizability of reports on end-of-life experiences.

OBJECTIVES

To assess possible selection bias in retrospective study of dementia at the end of life using family reports.

METHODS

Two physician teams covering six nursing home facilities in the Netherlands reported on 117 of 119 consecutive decedents within two weeks after death unaware of after-death family participation in the study. They reported on characteristics; treatment and care; overall patient outcomes such as comfort, nursing care, and outcomes; and their own perspectives on the experience. We compared results between decedents with and without family participation.

RESULTS

The family response rate was 55%. There were no significant differences based on participation versus nonparticipation in demographics and other nursing home resident characteristics, treatment and care, or overall resident outcome. However, among participating families, physicians perceived higher-quality aspects of nursing care and outcome, better consensus between staff and family on treatment, and a more peaceful death. Participation was less likely with involvement of a new family member in the last month.

CONCLUSIONS

Families may be more likely to participate in research with more harmonious teamwork in end-of-life caregiving. Where family participation is an enrollment criterion, comparing demographics alone may not capture possible selection bias, especially in more subjective measures. Selection bias toward more positive experiences, which may include the physician's and probably also the family's experiences, should be considered if representativeness is aimed for. Future work should address selection bias in other palliative settings and countries, and with prospective recruitment.

Sampling challenges in nursing home research

BACKGROUND

Research on end-of-life care in nursing homes is hampered by challenges in retaining facilities in samples through study completion. Large-scale longitudinal studies in which data are collected on-site can be particularly challenging.

OBJECTIVES

To compare characteristics of nursing homes that dropped from the study to those that completed the study.

METHODS

One hundred two nursing homes in a large geographic 2-state area were enrolled in a prospective study of end-of-life care of residents who died in the facility. The focus of the study was the relationship of staff communication, teamwork, and palliative/end-of-life care practices to symptom distress and other care outcomes as perceived by family members. Data were collected from public data bases of nursing homes, clinical staff on site at each facility at 2 points in time, and from decedents' family members in a telephone interview.

RESULTS

Seventeen of the 102 nursing homes dropped from the study before completion. These non-completer facilities had significantly more deficiencies and a higher rate of turnover of key personnel compared to completer facilities. A few facilities with a profile typical of non-completers actually did complete the study after an extraordinary investment of retention effort by the research team.

CONCLUSION

Nursing homes with a high rate of deficiencies and turnover have much to contribute to the goal of improving end-of-life care, and their loss to study is a significant sampling challenge. Investigators should be prepared to invest extra resources to maximize retention.

Older people dying with dementia: a nationwide study

BACKGROUND

Large-scale nationwide data describing the end-of-life characteristics of older people with dementia are lacking. This paper describes the dying process and end-of-life care provided to elderly people with mild or severe dementia in Belgium. It compares with elderly people dying without dementia.

METHODS

A nationwide retrospective mortality study was conducted, via representative network of general practitioners (GPs) in 2008 in Belgium, with weekly registration of all deaths (aged ≥ 65) using a standardized form. GPs reported on diagnosis and severity of dementia, aspects of end-of-life care and communication, and on the last week of life in terms of symptoms that caused distress as judged by the GP, and the patients' physical and cognitive abilities.

RESULTS

Thirty-one percent of our sample (1,108 deaths) had dementia (43% mildly, 57% severely). Of those, 26% died suddenly, 59% in care home, and 74% received palliative treatment, versus 37%, 19%, and 55% in people without dementia. GP-patient conversations were less frequent among those with (45%) than those without (73%) dementia, and 11% of both groups had a proxy decision-maker. During the last week of life, physical and psychological distress was common in both groups. Of older people with dementia, 83% were incapable of decision-making and 83% were bedridden; both significantly higher percentages than found in the group without dementia (24% and 52%).

CONCLUSIONS

Several areas of end-of-life care provision could be improved. Early communication and exploration of wishes and appointment of proxy decision-makers are important components of an early palliative care approach which appears to be initiated too infrequently.

The study of pathogen resistance and antimicrobial use in dementia: study design and methodology

Advanced dementia is characterized by the onset of infections and antimicrobial use is extensive. The extent to which this antimicrobial use is appropriate and contributes to the emergence of antimicrobial resistant bacteria is not known. The object of this report is to present the methodology established in the Study of Pathogen Resistance and Exposure to Antimicrobials in Dementia (SPREAD), and describe how challenges specific to this research were met. SPREAD is an ongoing, federally funded, 5-year prospective cohort study initiated in September 2009. Subjects include nursing home residents with advanced dementia and their proxies recruited from 31 Boston-area facilities. The recruitment and data collection protocols are described. Characteristics of participant facilities are presented and compared to those nationwide. To date, 295 resident/proxy dyads have been recruited. Baseline and selected follow-up data demonstrate successful recruitment of subjects and repeated collection of complex data documenting infections, decision-making for these infections, and antimicrobial bacteria resistance among the residents. SPREAD integrates methods in dementia, palliative care and infectious diseases research. Its successful implementation further establishes the feasibility of conducting rigorous, multi-site NH research in advanced dementia, and the described methodology serves as a detailed reference for subsequent publications emanating from the study.

Communicating with clinicians: the experiences of surrogate decision-makers for hospitalized older adults

OBJECTIVES

To describe communication experiences of surrogates who had recently made a major medical decision for a hospitalized older adult.

DESIGN

Semistructured interviews about a recent hospitalization.

SETTING

Two hospitals affiliated with one large medical school: an urban public hospital and a university-affiliated tertiary referral hospital.

PARTICIPANTS

Surrogates were eligible if they had recently made a major medical decision for a hospitalized individual aged 65 and older and were available for an interview within 1 month (2-5 months if the patient died).

MEASUREMENTS

Interviews were audio-recorded, transcribed, and analyzed using methods of grounded theory.

RESULTS

Thirty-five surrogates were interviewed (80% female, 44% white, 56% African American). Three primary themes emerged. First, it was found that the nature of surrogate-clinician relationships was best characterized as a relationship with a "team" of clinicians rather than individual clinicians because of frequent staff changes and multiple clinicians. Second, surrogates reported their communication needs, including frequent communication, information, and emotional support. Surrogates valued communication from any member of the clinical team, including nurses, social workers, and physicians. Third, surrogates described trust and mistrust, which were formed largely through surrogates' communication experiences.

CONCLUSION

In the hospital, surrogates form relationships with a "team" of clinicians rather than with individuals, yet effective communication and expressions of emotional support frequently occur, which surrogates value highly. Future interventions should focus on meeting surrogates' needs for frequent communication and high levels of information and emotional support.

Mapping health status measures to a utility measure in a study of nursing home residents with advanced dementia

BACKGROUND

Nursing home residents with advanced dementia commonly experience burdensome and costly interventions (eg, hospitalization) of questionable clinical benefit. To facilitate cost-effectiveness analyses of these interventions, utility-based measures are needed in order to estimate quality-adjusted outcomes.

METHODS

Nursing home residents with advanced dementia in 22 facilities were followed for 18 months (N=319). Validated health status measures ascertained from nurses at baseline, quarterly, and death (N=1702 assessments) were mapped to the Health Utilities Index Mark 2 [range, 1 (perfect health) to 0 (death); scores below 0 indicate states worse than death]. To assess validity, utility scores were compared between residents who did and did not receive burdensome interventions (parenteral therapy, percutaneous endoscopic gastrostomy tubes, and hospital transfers), residents with and without pneumonia, and residents who did and did not die at the last assessment.

RESULTS

Mean (±SD) Health Utilities Index Mark 2 utility score for the cohort was 0.165±0.060 (range, -0.005 to 0.215). Residents spent an average of 15.5% of their days with utilities <0.10. Lower utility scores were found among residents who received burdensome interventions (0.152±0.067 vs. 0.171±0.056; P=0.0003); had pneumonia (0.147±0.066 vs. 0.170±0.057; P=0.003); and were dying (0.163±0.057 vs. 0.180±0.055; P=0.006).

CONCLUSIONS

It is feasible to map health status measures to utility-based measures for advanced dementia. This work will facilitate future cost-effectiveness analyses aimed at quantifying the cost of interventions relative to quality-based outcomes for patients with this condition.

Hospital transfers of nursing home residents with advanced dementia

OBJECTIVES

To describe diagnoses and factors associated with hospital transfer in nursing home (NH) residents with advanced dementia.

DESIGN

Prospective cohort study.

SETTING

Twenty-two Boston, Massachusetts-area NHs.

PARTICIPANTS

Three hundred twenty-three NH residents with advanced dementia.

MEASUREMENTS

Data were collected quarterly for up to 18 months. Data regarding transfers were collected with regard to hospitalization or emergency department (ED) visit, diagnosis, and duration of inpatient admission. Information on the occurrence of any acute medical event (pneumonia, febrile episode, or other acute illness) in the prior 90 days was obtained quarterly. Logistic regression conducted at the level of the acute medical event identified characteristics associated with hospital transfer.

RESULTS

The entire cohort experienced 74 hospitalizations and 60 ED visits. Suspected infections were the most common reason for hospitalization (44, 59%), most frequently attributable to a respiratory source (30, 41%). Feeding tube-related complications accounted for 47% of ED visits. In adjusted analysis conducted on acute medical events, younger resident age, event type (pneumonia or other event vs febrile episode), chronic obstructive pulmonary disease, and the lack of a do-not-hospitalize (DNH) order (adjusted odds ratio = 5.22, 95% confidence interval = 2.31-11.79) were associated with hospital transfer.

CONCLUSION

The majority of hospitalizations of NH residents with advanced dementia were due to infections and thus were potentially avoidable, because infections are often treatable in the NH. Feeding tube-related complications accounted for almost half of all ED visits, representing a common but underrecognized burden of this intervention. Advance care planning in the form of a DNH order was the only identified modifiable factor associated with avoiding hospitalization.

CoMPASs: IOn programme (Care Of Memory Problems in Advanced Stages of dementia: Improving Our Knowledge): protocol for a mixed methods study

INTRODUCTION

Approximately 700 000 people in the UK have dementia, rising to 1.2 million by 2050; one-third of people aged over 65 will die with dementia. Good end-of-life care is often neglected, and detailed UK-based research on symptom burden and needs is lacking. Our project examines these issues from multiple perspectives using a rigorous and innovative design, collecting data which will inform the development of pragmatic interventions to improve care.

METHODS AND ANALYSIS

To define in detail symptom burden, service provision and factors affecting care pathways we shall use mixed methods: prospective cohort studies of people with advanced dementia and their carers; workshops and interactive interviews with health professionals and carers, and a workshop with people with early stage dementia. Interim analyses of cohort data will inform new scenarios for workshops and interviews. Final analysis will include cohort demographics, the symptom burden and health service use over the follow-up period. We shall explore the level and nature of unmet needs, describing how comfort and quality of life change over time and differences between those living in care homes and those remaining in their own homes. Data from workshops and interviews will be analysed for thematic content assisted by textual grouping software. Findings will inform the development of a complex intervention in the next phase of the research programme.

ETHICS AND DISSEMINATION

Ethical approval was granted by National Health Service ethical committees for studies involving people with dementia and carers (REC refs. 12/EE/0003; 12/LO/0346), and by university ethics committee for work with healthcare professionals (REC ref. 3578/001). We shall present our findings at conferences, and in peer-reviewed journals, prepare detailed reports for organisations involved with end-of-life care and dementia, publicising results on the Marie Curie website. A summary of the research will be provided to participants if requested.

Measuring the quality of dying and quality of care when dying in long-term care settings: a qualitative content analysis of available instruments

CONTEXT

Long-term care (LTC) settings have become a significant site for end-of-life care; consequently, instruments that assess the quality of dying and care may be useful in these settings.

OBJECTIVES

To evaluate the content of available measurement instruments to assess the quality of dying and care when dying.

METHODS

Qualitative content analysis to categorize items as structure of care, process of care, satisfaction with health care (the first three representing quality of care and its evaluation), quality of dying, or patient factors.

RESULTS

Instruments that measure mostly quality of care and its evaluation are the Family Perception of Physician-Family Caregiver Communication, End-of-Life in Dementia (EOLD) Satisfaction With Care, Family Perception of Care Scale, Toolkit of Instruments to Measure End-of-Life Care after-death bereaved family member interview (nursing home version), and the Family Assessment of Treatment at the End-of-Life Short version. Instruments measuring quality of dying are the EOLD-Comfort Assessment in Dying, EOLD-Symptom Management, Mini-Suffering State Examination, and Palliative Care Outcome Scale. The Quality of Dying in Long-Term Care measures care and dying. The Minimum Data Set-Palliative Care measures mostly dying and patient factors. The instruments differ in dementia specificity, time of administration, and respondent.

CONCLUSION

Instruments that assess quality when dying differ in several ways and most do not measure a single construct, which is relevant to guiding and evaluating care. Comparing psychometric properties and usefulness of instruments that measure similar constructs is the next step in determining which are best suited for use in LTC.

Psychometric properties of instruments to measure the quality of end-of-life care and dying for long-term care residents with dementia

Purpose

Quality of care for long-term care (LTC) residents with dementia at the end-of-life is often evaluated using standardized instruments that were not developed for or thoroughly tested in this population. Given the importance of using appropriate instruments to evaluate the quality of care (QOC) and quality of dying (QOD) in LTC, we compared the validity and reliability of ten available instruments commonly used for these purposes.

Methods

We performed prospective observations and retrospective interviews and surveys of family (n = 70) and professionals (n = 103) of LTC decedents with dementia in the Netherlands.

Results

Instruments within the constructs QOC and QOD were highly correlated, and showed moderate to high correlation with overall assessments of QOC and QOD. Prospective and retrospective ratings using the same instruments differed little. Concordance between family and professional scores was low. Cronbach’s alpha was mostly adequate. The EOLD–CAD showed good fit with pre-assumed factor structures. The EOLD–SWC and FPCS appear most valid and reliable for measuring QOC, and the EOLD–CAD and MSSE for measuring QOD. The POS performed worst in this population.

Conclusions

Our comparative study of psychometric properties of instruments allows for informed selection of QOC and QOD measures for LTC residents with dementia.

Mental health and exposure to patient distress among families of nursing home residents with advanced dementia

CONTEXT

The effect of suffering among patients with advanced dementia on their family members' mental health has not been investigated.

OBJECTIVES

To describe family members' exposure to distressing symptoms among nursing home (NH) residents with advanced dementia and associations between such exposure and family members' mental health.

METHODS

Data were obtained from an 18-month prospective cohort study of NH residents with advanced dementia and their family member health care proxies (HCPs). Exposure to resident symptoms and associated fear and helplessness was measured quarterly using the Stressful Caregiving Adult Reactions to Experiences of Dying (SCARED) scale (range 0-120). HCP mental health was assessed quarterly using the Composite International Diagnostic Interview Short Form (CIDI-SF) (depression), K6 (psychological distress, range 0-24), and SF-12(®) mental health subscale.

RESULTS

Seven hundred seventy-nine SCARED scale assessments were completed by 225 HCPs. The most frequent distressing symptoms were the following: feeling the resident had had enough (33.2%), choking (21.1%), and pain (18.9%). The symptoms eliciting the greatest fear were thinking the resident was dead and seeing them choke. A sense of helplessness was highest when the resident was observed to be in pain or choking. Family members with SCARED scores >0 were more likely to meet criteria for depression on the CIDI-SF (adjusted odds ratio [AOR] 2.59, 95% confidence interval [CI] 1.14, 5.85), have a K6 score >0 (AOR 2.31, 95% CI 1.55, 3.43), and have lower SF-12 scores (adjusted parameter estimate -1.51, 95% CI -2.56, -0.47).

CONCLUSION

Family member exposure to distressing symptoms experienced by their loved ones with advanced dementia is not uncommon and is associated with worse mental health.

End-of-life issues in caring for patients with dementia: the case for palliative care in management of terminal dementia

The number of people suffering with dementia is increasing in the general population and the trend is projected to continue as people live longer, especially in countries with developed economies. The most common cause of dementia (among the many other causes) is Alzheimer's dementia, which is considered a terminal illness. The disease could eventually lead to death, or death could occur as a consequence of co-morbid physical complications. The problem of end of life (EOL) care for patients suffering from dementia though spoken of and written about, does not get the attention and system support as for example patients suffering from cancer receive. Many reasons have been advanced for the current state of affairs where EOL issues for patients suffering from dementia are concerned. This article attempts to revisit the issues, and the reasons, that may contribute to this. Some guidelines on palliative management in cases of patients suffering from severe dementia exist; the evidence base for these guidelines though is relatively weak. The ethical and legal issues that may influence or impact on the decision to initiate the palliative care pathway in the management of EOL issues for dementia patients in the terminal or end stage of the illness is highlighted. Initiatives by the department of health in England and Wales, and other bodies with interest in dementia issues and palliative care in the United Kingdom to ensure good and acceptable EOL pathways for patients with dementia are mentioned.

Grief among family members of nursing home residents with advanced dementia

OBJECTIVES

To describe preloss and postloss grief symptoms among family members of nursing home (NH) residents with advanced dementia, and to identify predictors of greater postloss grief symptoms.

DESIGN

Prospective cohort study.

SETTING

22 NHs in the greater Boston area.

PARTICIPANTS

123 family members of NH residents who died with advanced dementia.

MEASUREMENTS

Preloss grief was measured at baseline, and postloss grief was measured 2 and 7 months postloss using the Prolonged Grief Disorder Scale. Independent variables included resident and family member sociodemographic characteristics, resident comfort, acute illness, acute care prior to death, family member depression, and family member understanding of dementia and of resident's prognosis.

RESULTS

Levels of preloss and postloss grief were relatively stable from baseline to 7 months postloss. Feelings of separation and yearning were the most prominent grief symptoms. After multivariable adjustment, greater preloss grief and the family member having lived with the resident prior to NH admission were the only factors independently associated with greater postloss grief 7 months after resident death.

CONCLUSIONS

The pattern of grieving for some family members of NH residents with advanced dementia is prolonged and begins before resident death. Identification of family members at risk for postloss grief during the preloss period may help guide interventions aimed at lessening postloss grief.

Medicare expenditures among nursing home residents with advanced dementia

BACKGROUND

Nursing home residents with advanced dementia commonly experience burdensome and costly interventions (eg, tube feeding) that may be of limited clinical benefit. To our knowledge, Medicare expenditures have not been extensively described in this population.

METHODS

Nursing home residents with advanced dementia in 22 facilities (N = 323) were followed up for 18 months. Clinical and health services use data were collected every 90 days. Medicare expenditures were described. Multivariate analysis was used to identify factors associated with total 90-day expenditures for (1) all Medicare services and (2) all Medicare services excluding hospice.

RESULTS

Over an 18-month period, total mean Medicare expenditures were $2303 per 90 days but were highly skewed; expenditures were less than $500 for 77.1% of the 90-day assessment periods and more than $12,000 for 5.5% of these periods. The largest proportion of Medicare expenditures were for hospitalizations (30.2%) and hospice (45.6%). Among decedents (n = 177), mean Medicare expenditures increased by 65% in each of the last 4 quarters before death owing to an increase in both acute care and hospice. After multivariable adjustment, not living in a special care dementia unit was a modifiable factor associated with higher total expenditures for all Medicare services. Lack of a do-not-hospitalize order, tube feeding, and not living in a special care unit were associated with higher nonhospice Medicare expenditures.

CONCLUSIONS

Medicare expenditures among nursing home residents with advanced dementia vary substantially. Hospitalizations and hospice account for most spending. Strategies that promote high-quality palliative care may shift expenditures away from aggressive treatments for these patients at the end of life.

Interventions for improving palliative care for older people living in nursing care homes

BACKGROUND

Residents of nursing care homes for older people are highly likely to die there, making these places where palliative care is needed.

OBJECTIVES

The primary objective was to determine effectiveness of multi-component palliative care service delivery interventions for residents of care homes for older people. The secondary objective was to describe the range and quality of outcome measures.

SEARCH STRATEGY

The grey literature and the following electronic databases were searched: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness (all issue 1, 2010); MEDLINE, EMBASE, CINAHL, British Nursing Index, (1806 to February 2010), Science Citation Index Expanded & AMED (all to February 2010). Key journals were hand searched and a PubMed related articles link search was conducted on the final list of articles.

SELECTION CRITERIA

We planned to include Randomised Clinical Trials (RCTs), Controlled Clinical Trials (CCTs), controlled before-and-after studies and interrupted time series studies of multi-component palliative care service delivery interventions for residents of care homes for older people. These usually include the assessment and management of physical, psychological and spiritual symptoms and advance care planning. We did not include individual components of palliative care, such as advance care planning.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, and assessed quality and risk of bias. Meta analysis was not conducted due to heterogeneity of studies. The analysis comprised a structured narrative synthesis. Outcomes for residents and process of care measures were reported separately.

MAIN RESULTS

Two RCTs and one controlled before-and-after study were included (735 participants). All were conducted in the USA and had several potential sources of bias. Few outcomes for residents were assessed. One study reported higher satisfaction with care and the other found lower observed discomfort in residents with end-stage dementia. Two studies reported group differences on some process measures. Both reported higher referral to hospice services in their intervention group, one found fewer hospital admissions and days in hospital in the intervention group, the other found an increase in do-not-resuscitate orders and documented advance care plan discussions.

AUTHORS' CONCLUSIONS

We found few studies, and all were in the USA. Although the results are potentially promising, high quality trials of palliative care service delivery interventions which assess outcomes for residents are needed, particularly outside the USA. These should focus on measuring standard outcomes, assessing cost-effectiveness, and reducing bias.

Hospice use and outcomes in nursing home residents with advanced dementia

OBJECTIVES

To identify characteristics of nursing home (NH) residents with advanced dementia and their healthcare proxies (HCPs) associated with hospice referral and to examine the association between hospice use and the treatment of pain and dyspnea and unmet needs during the last 7 days of life.

DESIGN

Prospective cohort study.

SETTING

Twenty-two Boston-area NHs.

PARTICIPANTS

Three hundred twenty-three NH residents with advanced dementia and their HCPs.

MEASUREMENTS

Data were collected at baseline and quarterly for up to 18 months. Hospice referral, frequency of pain and dyspnea, and treatment of these symptoms was ascertained. HCPs reported unmet needs during the last 7 days of the residents' lives for communication, information, emotional support, and help with personal care.

RESULTS

Twenty-two percent of residents were referred to hospice. After multivariable adjustment, factors associated with hospice referral were nonwhite race, eating problems, HCP's perception that the resident's had less than 6 months to live, and better HCP mental health. Residents in hospice were more likely to receive scheduled opioids for pain (adjusted odds ratio (AOR)=3.16; 95% confidence interval (95% CI)=1.57-6.36) and oxygen, morphine, scopolamine, or hyoscyamine for dyspnea (AOR=3.28, 95% CI=1.37-7.86). HCPs of residents in hospice reported fewer unmet needs in all domains during the last 7 days of the residents' life.

CONCLUSION

A minority of NH residents with advanced dementia received hospice care. Hospice recipients were more likely to received scheduled opioids for pain and symptomatic treatment for dyspnea and had fewer unmet needs at the end of life.

[Measuring quality of life in nursing home residents with severe dementia: psychometric properties of the QUALID scale]

The Quality of Life in Late Stage Dementia (QUALID) Scale is an instrument to measure quality of life in patients with severe dementia over the last week by means of an interview with a nurse or nurse aid. We interviewed nurse aids on 48 patients with severe dementia in two nursing homes in The Netherlands to determine the psychometric properties of the Dutch translation of the QUALID. Test- retest reliability was good with an Concordance Correlation Coefficient (CCC) of 0.82, (95% Confidence Interval, CI 0.70 - 0.90); interrater reliability was moderate, with an CCC of 0.49 (CI: 0.17-0.72). There was a significant, but low correlation between QUALID ratings and discomfort ratings as observed with the Discomfort Scale-Dementia of Alzheimer Type (DS-DAT), amounting 0.32 (CI: 0.04 - 0.56). The QUALID seems appropriate for measuring quality of life in patients with advanced dementia, when one and the same rater monitors a patient over time in a longitudinal study.

Survival and comfort after treatment of pneumonia in advanced dementia

BACKGROUND

Pneumonia is common among patients with advanced dementia, especially toward the end of life. Whether antimicrobial treatment improves survival or comfort is not well understood. The objective of this study was to examine the effect of antimicrobial treatment for suspected pneumonia on survival and comfort in patients with advanced dementia.

METHODS

From 2003 to 2009, data were prospectively collected from 323 nursing home residents with advanced dementia in 22 facilities in the area of Boston, Massachusetts. Each resident was followed up for as long as 18 months or until death. All suspected pneumonia episodes were ascertained, and antimicrobial treatment for each episode was categorized as none, oral only, intramuscular only, or intravenous (or hospitalization). Multivariable methods were used to adjust for differences among episodes in each treatment group. The main outcome measures were survival and comfort (scored according to the Symptom Management at End-of-Life in Dementia scale) after suspected pneumonia episodes.

RESULTS

Residents experienced 225 suspected pneumonia episodes, which were treated with antimicrobial agents as follows: none, 8.9%; oral only, 55.1%, intramuscular, 15.6%, and intravenous (or hospitalization), 20.4%. After multivariable adjustment, all antimicrobial treatments improved survival after pneumonia compared with no treatment: oral (adjusted hazard ratio [AHR], 0.20; 95% confidence interval [CI], 0.10-0.37), intramuscular (AHR, 0.26; 95% CI, 0.12-0.57), and intravenous (or hospitalization) (AHR, 0.20; 95% CI, 0.09-0.42). After multivariable adjustment, residents receiving any form of antimicrobial treatment for pneumonia had lower scores on the Symptom Management at End-of-Life in Dementia scale (worse comfort) compared with untreated residents.

CONCLUSION

Antimicrobial treatment of suspected pneumonia episodes is associated with prolonged survival but not with improved comfort in nursing home residents with advanced dementia.

Daily medication use in nursing home residents with advanced dementia

OBJECTIVES

To describe the pattern and factors associated with daily medication use in nursing home (NH) residents with advanced dementia.

DESIGN

Prospective cohort study.

SETTING

Twenty-two Boston-area NHs.

PARTICIPANTS

NH residents with advanced dementia (N=323).

MEASUREMENTS

Data from residents' records were used to determine the number or daily medications, specific drugs prescribed, and use of drugs deemed "never appropriate" in patients with advanced dementia. Resident characteristics associated with the use of more daily medications and drugs deemed inappropriate were examined.

RESULTS

Residents were prescribed a mean of 5.9 +/- 3.0 daily medications, and 37.5% received at least one medication considered "never appropriate" in advanced dementia. Acetylcholinesterase inhibitors (15.8%) and lipid-lowering agents (12.1%) were the most common inappropriate drugs. Twenty-eight percent of residents took antipsychotics daily. Modest reductions in most daily medications occurred only during the last week of life. Factors independently associated with taking more daily medications included older age, male sex, non-white race, dementia not due to Alzheimer's disease, better cognition, cardiovascular disease, acute illness, and hospice referral. Factors independently associated with greater likelihood of taking inappropriate medications included being male, shorter NH stay, better functional status, and diabetes mellitus, whereas a do-not-hospitalize order was associated with a lower likelihood.

CONCLUSION

Questionably beneficial medications are common in advanced dementia, even as death approaches. Several characteristics can help identify residents at risk for greater medication burden. Medication use in advanced dementia should be tailored to the goals of care.

The clinical course of advanced dementia

BACKGROUND

Dementia is a leading cause of death in the United States but is underrecognized as a terminal illness. The clinical course of nursing home residents with advanced dementia has not been well described.

METHODS

We followed 323 nursing home residents with advanced dementia and their health care proxies for 18 months in 22 nursing homes. Data were collected to characterize the residents' survival, clinical complications, symptoms, and treatments and to determine the proxies' understanding of the residents' prognosis and the clinical complications expected in patients with advanced dementia.

RESULTS

Over a period of 18 months, 54.8% of the residents died. The probability of pneumonia was 41.1%; a febrile episode, 52.6%; and an eating problem, 85.8%. After adjustment for age, sex, and disease duration, the 6-month mortality rate for residents who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%. Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last 3 months of life, 40.7% of residents underwent at least one burdensome intervention (hospitalization, emergency room visit, parenteral therapy, or tube feeding). Residents whose proxies had an understanding of the poor prognosis and clinical complications expected in advanced dementia were much less likely to have burdensome interventions in the last 3 months of life than were residents whose proxies did not have this understanding (adjusted odds ratio, 0.12; 95% confidence interval, 0.04 to 0.37).

CONCLUSIONS

Pneumonia, febrile episodes, and eating problems are frequent complications in patients with advanced dementia, and these complications are associated with high 6-month mortality rates. Distressing symptoms and burdensome interventions are also common among such patients. Patients with health care proxies who have an understanding of the prognosis and clinical course are likely to receive less aggressive care near the end of life.

Informed consent to research in long-term care settings

Informed consent to nursing home research is a two-tiered process that begins with obtaining the consent of a long-term care community at the institutional level and progresses to the engagement of individuals in the consent process. Drawing on a review of the literature and the authors' research experiences and institutional review board service, this article describes the practical implications of nurse investigators' obligation to ensure informed consent among participants in long-term care research. Recommendations focus on applying a community consent model to long-term care research, promoting an evidence-based approach to the protection of residents with decisional impairment, and increasing investigators' attention to ethical issues involving long-term care staff.

Ratings of symptoms and comfort in dementia patients at the end of life: comparison of nurses and families

After-death reporting by proxies on end-of-life outcomes is used in research and can also be used to target institutions directly to improve practice. We compared the scores of family caregivers and nurses on two End-of-Life in Dementia Scales (EOLD) scales: Symptom Management (SM; range 0-45) over the last 3 months of life and Comfort Assessment in Dying (CAD; range 14-42). Higher scores represent better outcomes. Four Dutch nursing homes retrospectively enrolled 48 decedents with dementia. Total mean scores for family caregivers and nurses were 28.7 (SD 9.6) versus 25.2 (SD 12.7) for the SM and 31.7 (SD 5.5) versus 32.8 (SD 8.2) for the CAD. Mean item scores also did not differ much. Concordance Correlation Coefficients were 0.42 (SM) and 0.04 (CAD). Mean evaluations of end of life with dementia corresponded reasonably well between family and professional caregivers, but correspondence of individual observations was poor to moderate, suggesting serious differences in individual ratings but little systematic difference.

Healthcare proxies of nursing home residents with advanced dementia: decisions they confront and their satisfaction with decision-making

OBJECTIVES

To describe the medical decisions confronting healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia and to identify factors associated with greater decision-making satisfaction.

DESIGN

Prospective cohort study.

SETTING

Twenty-two Boston-area NHs.

PARTICIPANTS

Three hundred twenty-three NH residents with advanced dementia and their HCPs.

MEASUREMENTS

Decisions made by HCPs over 18 months were ascertained quarterly. After making a decision, HCPs completed the Decision Satisfaction Inventory (DSI) (range 0-100). Independent variables included HCP and resident sociodemographic characteristics, health status, and advance care planning. Multivariable linear regression identified factors associated with higher DSI scores (greater satisfaction).

RESULTS

Of 323 HCPs, 123 (38.1%) recalled making at least one medical decision; 232 decisions were made, concerning feeding problems (27.2%), infections (20.7%), pain (12.9%), dyspnea (8.2%), behavior problems (6.9%), hospitalizations (3.9%), cancer (3.0%), and other complications (17.2%). Mean DSI score +/- standard deviation was 78.4 +/- 19.5, indicating high overall satisfaction. NH provider involvement in shared decision-making was the area of least satisfaction. In adjusted analysis, greater decision-making satisfaction was associated with the resident living on a special care dementia unit (P=.002), greater resident comfort (P=.004), and the HCP not being the resident's child (P=.02).

CONCLUSION

HCPs of NH patients with advanced dementia can most commonly expect to encounter medical decisions relating to feeding problems, infections, and pain. Inadequate support from NH providers is the greatest source of HCP dissatisfaction with decision-making. Greater resident comfort and care in a special care dementia unit are potentially modifiable factors associated with greater decision-making satisfaction.

Family oversight and the quality of nursing home care for residents with advanced dementia

BACKGROUND

The quality of nursing home (NH) care for residents with advanced dementia has been described as suboptimal. One relatively understudied factor in the provision of NH care is the role of private oversight and monitoring by family members and friends.

OBJECTIVE

To examine the association between private oversight and the quality of end-of-life care for NH residents with advanced dementia.

RESEARCH DESIGN

This study employed longitudinal data on 323 NH residents with advanced dementia living in 22 Boston area facilities. Using bivariate and multivariate methods, we analyzed the association between visit time by the resident's health care proxy (HCP) and measures of quality of end-of-life care.

RESULTS

The relationship between visit time and quality was nonlinear. Residents who were visited 1 to 7 h/wk had less pain, fewer pressure ulcers, less dyspnea, and fewer hospital transfers compared with residents who had no visits or who were visited >7 h/wk. After adjusting for covariates, residents who were visited >7 h/wk had more pressure ulcers, more pain, greater dyspnea, fewer do-not-hospitalize orders, and lower HCP satisfaction with care compared with residents who were visited 1 to 7 h/wk.

CONCLUSIONS

Several measures of quality of NH care for end-stage dementia exhibit a nonlinear relationship with the degree of HCP oversight, such that no visiting or very high levels of visiting are associated with worse quality. Future research will need to address whether families with greater oversight tend to make decisions that promote worse quality of care, or whether worse quality of care promotes greater family oversight.

Evaluations of end of life with dementia by families in Dutch and U.S. nursing homes

BACKGROUND

The End-of-Life in Dementia (EOLD) scales comprise the most specific set of instruments developed for evaluations of patients' end of life by their families. It is not known whether the EOLD scales are useful for cross-national comparisons.

METHODS

We used a mortality follow-back design in multi-center studies in the Netherlands (pilot study 2005-2007) and the U.S.A. (1999), and we compared EOLD Satisfaction With Care (SWC; last three months of life), Symptom Management (SM; last three months) and Comfort Assessment in Dying (CAD) scores for 54 Dutch and 76 U.S. nursing home residents.

RESULTS

SWC total scores did not differ significantly between the Dutch and U.S. studies (31.9, SD 4.7 versus 30.4, SD 6.1), but three of ten items were rated more favorable for Dutch residents, as were SM total scores (29.1, SD 9.2 versus 20.4, SD 10.6). CAD total scores did not differ (32.0, SD 5.4 versus 30.5, SD 5.9, respectively), but the "well-being" subscale was rated more favorably for Dutch residents. Results were similar after adjustment for demographics and dementia severity.

CONCLUSION

The Dutch families rated end of life with dementia in nursing homes as somewhat better than did U.S. families. Although differences were small, the observed patterns were consistent. This suggests validity of the SM and CAD to assess differences in quality of dying and possible sensitivity to differences between countries or time frames. Larger, simultaneous, cross-national studies are needed to confirm usefulness of the scales and to detect areas which need improvement in the respective countries.

Health care proxy grief symptoms before the death of nursing home residents with advanced dementia

OBJECTIVES

The loss experienced by family members of dementia patients before their actual death is known as "predeath grief." This study's objectives were to identify and describe factors associated predeath grief symptoms among health care proxies (HCPs) of nursing home (NH) residents with advanced dementia, and distinguish grief symptoms from those of depression.

DESIGN

Cross-sectional.

SETTING

Twenty-one Boston-area NHs.

PARTICIPANTS

Three hundred fifteen NH residents with advanced dementia and their HCPs.

MEASUREMENTS

Factor analysis was used to distinguish predeath grief and depression symptoms. Multivariate regression analyses identified factors associated with greater predeath grief measured on a 10-item summary scale of grief symptoms. Independent variables included sociodemographic information and health status of HCPs and residents, and depressive symptoms, physician communication, preparedness for death, and satisfaction with care of HCPs.

RESULTS

Predeath grief symptoms were distinct from depressive symptoms. The mean predeath grief scores was 15.0 +/- 5.6 (range, 10-49), suggesting relatively low levels of overall grief. Yearning (i.e., separation distress) was the most frequently experienced grief symptom (sometimes, 27%; often, 18%; or always, 15%). Variables associated with greater predeath grief included HCPs whose primary language was not English, HCPs who lived with a resident before institutionalization, more depressive symptoms of HCPs, less satisfaction with care of HCPs, and younger resident age.

CONCLUSIONS

Family members of NH residents with advanced dementia experience predeath grief symptoms, particularly separation distress. Predeath grief symptoms are associated with, but distinct from, those of depression. Several factors identified HCPs at higher risk for predeath grief and who may benefit from early interventions to reduce suffering.

Patterns of antimicrobial use among nursing home residents with advanced dementia

BACKGROUND

Nursing home residents with advanced dementia are at high risk of infections and antimicrobial exposure near the end of life. Detailed studies quantifying antimicrobial prescribing practices among these residents have not been performed.

METHODS

A cohort of 214 residents with advanced dementia from 21 Boston-area nursing homes were followed up prospectively for 18 months or until death. We analyzed antimicrobial use, including type, indication, and quantity, by days of therapy per 1000 resident-days.

RESULTS

During an average of 322 days of follow-up, 142 residents (66.4%) with advanced dementia received at least 1 course of antimicrobial therapy (mean [SD] number of courses per resident, 4.0 [3.7]). The mean (SD) number of days of therapy per 1000 resident-days for the entire cohort was 53.0 (4.3). Quinolones and third-generation cephalosporins were the most commonly prescribed antimicrobials, accounting for 38.3% and 15.2%, respectively, of 540 prescribed antimicrobial therapy courses. A respiratory tract infection was the most common indication (46.7% of all antimicrobial therapy courses). Among 99 decedents, 42 (42.4%) received antimicrobials during the 2 weeks before death, of which 30 of 72 courses (41.7%) were administered via the parenteral route. The number of decedents receiving antimicrobials (P < .001), the number of antimicrobials prescribed (P = .01), and the days of therapy per 1000 resident-days (P < .001) increased significantly as subjects approached death.

CONCLUSIONS

Persons with advanced dementia are frequently exposed to antimicrobials, especially during the 2 weeks before death. The implications of this practice from the perspective of the individual treatment burden near the end of life and its contribution to the emergence of antimicrobial resistance in the nursing home setting need further evaluation.