151
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Tible OP, Riese F, Savaskan E, von Gunten A. Best practice in the management of behavioural and psychological symptoms of dementia. Ther Adv Neurol Disord 2017; 10:297-309. [PMID: 28781611 PMCID: PMC5518961 DOI: 10.1177/1756285617712979] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/24/2017] [Indexed: 12/12/2022] Open
Abstract
Behavioural and psychological symptoms of dementia (BPSD) occur in most patients with dementia. They cause great suffering in patients and caregivers, sometimes more so than the cognitive and functional decline inherent to dementia. The clinical features of BPSD include a wide variety of affective, psychotic and behavioural symptoms and signs. The causes and risk factors for BPSD are multiple and include biological, psychological and environmental variables. Frequently, their combination, rather than any specific factor, explains the occurrence of BPSD in an individual patient. Thus, a sound etiopathogenetic investigation including the patient and the family or care team is essential. The aim is to develop an individualized treatment plan using a therapeutic decision tree modified by the individual and environmental risk profile. Still, treatment may be difficult and challenging. Clinical empiricism often steps in where evidence from controlled studies is lacking. Psychosocial treatment approaches are pivotal for successful treatment of BPSD. Often a combination of different non-pharmacological approaches precedes drug treatment (most of which is off-label). Regular assessments of the treatment plan and any prescriptions must be carried out to detect signs of relapse and to stop any medicines that may have become inappropriate. Even with optimal management, BPSD will not disappear completely in some cases and will remain challenging for all involved parties. This article is a narrative review based closely on the interprofessional Swiss recommendations for the treatment of BPSD. To establish the recommendations, a thorough research of the literature has been carried out. Evidence-based data were provided through searches of Medline, Embase, ISI and Cochrane-Database research. Evidence categories of the World Federation of Biological Societies were used. Additionally, the clinical experience of Swiss medical experts was considered.
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Affiliation(s)
- Olivier Pierre Tible
- Department of Psychiatry, Service Universitaire de Psychiatrie de l'Age Avancé (SUPAA), Lausanne University Hospital, CH-1008 Prilly, Switzerland
| | - Florian Riese
- Department of Geriatric Psychiatry, University Hospital of Psychiatry, Zurich, Switzerland University Research Priority Programme 'Dynamics of Healthy Aging', University of Zurich, Zurich, Switzerland
| | - Egemen Savaskan
- Department of Geriatric Psychiatry, University Hospital of Psychiatry, Zurich, Switzerland
| | - Armin von Gunten
- Department of Psychiatry, Service Universitaire de Psychiatrie de l'Age Avancé (SUPAA), Lausanne University Hospital, Prilly, Switzerland
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152
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Gong WY, Wang R, Liu Y, Jin H, Zhao ZW, Wang YL, Li HY, Zhang X, Ni JX. Chronic Monoarthritis Pain Accelerates the Processes of Cognitive Impairment and Increases the NMDAR Subunits NR2B in CA3 of Hippocampus from 5-month-old Transgenic APP/PS1 Mice. Front Aging Neurosci 2017; 9:123. [PMID: 28553223 PMCID: PMC5427068 DOI: 10.3389/fnagi.2017.00123] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/12/2017] [Indexed: 01/09/2023] Open
Abstract
Many factors impact cognitive impairment; however, the effects of chronic pain and the mechanisms underlying these effects on cognitive impairment are currently unknown. Here we tested the hypothesis that chronic pain accelerates the transition from normal cognition to mild cognitive impairment (MCI) in 5-month-old transgenic APP/PS1 mice, an animal model of Alzheimer’s disease (AD), and that neurotoxicity induced by N-methyl-D-aspartic acid receptor (NMDAR) subunits may be involved in this process. Chronic monoarthritis pain was induced in transgenic APP/PS1 mice and 5-month-old wild-type (WT) mice by intra- and pre-articular injections of Freund’s complete adjuvant (FCA) into one knee joint. Pain behavior, learning and memory function, and the distribution and quantity of NMDAR subunits (NR1, NR2A and NR2B) in hippocampal CA1 and CA3 regions were assessed. Our results showed that although persistent and robust monoarthritis pain was induced by the FCA injections, only the transgenic APP/PS1 mice with chronic monoarthritis pain exhibited marked learning and memory impairments. This result suggested that chronic monoarthritis pain accelerated the cognitive impairment process. Furthermore, only transgenic APP/PS1 mice with chronic monoarthritis pain exhibited an overexpression of NR2B and an increased NR2B/NR2A ratio in the hippocampus CA3. These findings suggest that chronic pain is a risk factor for cognitive impairment and that increased neurotoxicity associated with NMDAR subunit activation may underpin the impairment. Thus, NMDARs may be a therapeutic target for the prevention of chronic pain-induced cognitive impairment.
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Affiliation(s)
- Wei-Yi Gong
- Central Laboratory, Xuanwu Hospital of Capital Medical University, Laboratory for Neurodegenerative Disease of Ministry of Education, Center of Alzheimer's Disease, Beijing Institute for Brain DisordersBeijing, China.,Department of Pain Management, Xuanwu Hospital, Capital Medical UniversityBeijing, China.,Department of Anesthesiology, Fujian Medical University Union HospitalFuzhou, China
| | - Rong Wang
- Central Laboratory, Xuanwu Hospital of Capital Medical University, Laboratory for Neurodegenerative Disease of Ministry of Education, Center of Alzheimer's Disease, Beijing Institute for Brain DisordersBeijing, China
| | - Yuan Liu
- Central Laboratory, Xuanwu Hospital of Capital Medical University, Laboratory for Neurodegenerative Disease of Ministry of Education, Center of Alzheimer's Disease, Beijing Institute for Brain DisordersBeijing, China
| | - He Jin
- Central Laboratory, Xuanwu Hospital of Capital Medical University, Laboratory for Neurodegenerative Disease of Ministry of Education, Center of Alzheimer's Disease, Beijing Institute for Brain DisordersBeijing, China
| | - Zhi-Wei Zhao
- Central Laboratory, Xuanwu Hospital of Capital Medical University, Laboratory for Neurodegenerative Disease of Ministry of Education, Center of Alzheimer's Disease, Beijing Institute for Brain DisordersBeijing, China
| | - Yu-Lan Wang
- Central Laboratory, Xuanwu Hospital of Capital Medical University, Laboratory for Neurodegenerative Disease of Ministry of Education, Center of Alzheimer's Disease, Beijing Institute for Brain DisordersBeijing, China
| | - Hong-Yan Li
- Central Laboratory, Xuanwu Hospital of Capital Medical University, Laboratory for Neurodegenerative Disease of Ministry of Education, Center of Alzheimer's Disease, Beijing Institute for Brain DisordersBeijing, China.,Department of Pain Management, Xuanwu Hospital, Capital Medical UniversityBeijing, China
| | - Xu Zhang
- Central Laboratory, Xuanwu Hospital of Capital Medical University, Laboratory for Neurodegenerative Disease of Ministry of Education, Center of Alzheimer's Disease, Beijing Institute for Brain DisordersBeijing, China
| | - Jia-Xiang Ni
- Department of Pain Management, Xuanwu Hospital, Capital Medical UniversityBeijing, China
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153
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Epidemiology of Pain in People With Dementia Living in Care Homes: Longitudinal Course, Prevalence, and Treatment Implications. J Am Med Dir Assoc 2017; 18:453.e1-453.e6. [DOI: 10.1016/j.jamda.2017.01.024] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 01/30/2017] [Accepted: 01/31/2017] [Indexed: 01/08/2023]
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154
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Rombolà L, Tridico L, Scuteri D, Sakurada T, Sakurada S, Mizoguchi H, Avato P, Corasaniti MT, Bagetta G, Morrone LA. Bergamot Essential Oil Attenuates Anxiety-Like Behaviour in Rats. Molecules 2017; 22:molecules22040614. [PMID: 28398260 PMCID: PMC6154596 DOI: 10.3390/molecules22040614] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 04/07/2017] [Accepted: 04/09/2017] [Indexed: 11/16/2022] Open
Abstract
Preclinical studies have recently highlighted that bergamot essential oil (BEO) is endowed with remarkable neurobiolological effects. BEO can affect synaptic transmission, modulate electroencephalographic activity and it showed neuroprotective and analgesic properties. The phytocomplex, along with other essential oils, is also widely used in aromatherapy to minimize symptoms of stress-induced anxiety and mild mood disorders. However, only limited preclinical evidences are actually available. This study examined the anxiolytic/sedative-like effects of BEO using an open field task (OFT), an elevated plus-maze task (EPM), and a forced swimming task (FST) in rats. This study further compared behavioural effects of BEO to those of the benzodiazepine diazepam. Analysis of data suggests that BEO induces anxiolytic-like/relaxant effects in animal behavioural tasks not superimposable to those of the DZP. The present observations provide further insight to the pharmacological profile of BEO and support its rational use in aromatherapy.
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Affiliation(s)
- Laura Rombolà
- Department of Pharmacy, Health and Nutritional Sciences, Section of Preclinical and Translational Pharmacology, University of Calabria, 87036 Rende, Italy.
| | - Laura Tridico
- Department of Pharmacy, Health and Nutritional Sciences, Section of Preclinical and Translational Pharmacology, University of Calabria, 87036 Rende, Italy.
| | - Damiana Scuteri
- Department of Pharmacy, Health and Nutritional Sciences, Section of Preclinical and Translational Pharmacology, University of Calabria, 87036 Rende, Italy.
| | - Tsukasa Sakurada
- First Department of Pharmacology, Daiichi College of Pharmaceutical Sciences, 815-8511 Fukuoka, Japan.
| | - Shinobu Sakurada
- Department of Physiology and Anatomy, Tohoku Pharmaceutical University, 981-8558 Sendai, Japan.
| | - Hirokazu Mizoguchi
- Department of Physiology and Anatomy, Tohoku Pharmaceutical University, 981-8558 Sendai, Japan.
| | - Pinarosa Avato
- Department of Pharmacy-Drug Sciences, University of Bari Aldo Moro, IT-70125 Bari, Italy.
| | | | - Giacinto Bagetta
- Department of Pharmacy, Health and Nutritional Sciences, Section of Preclinical and Translational Pharmacology, University of Calabria, 87036 Rende, Italy.
| | - Luigi Antonio Morrone
- Department of Pharmacy, Health and Nutritional Sciences, Section of Preclinical and Translational Pharmacology, University of Calabria, 87036 Rende, Italy.
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155
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Aromatherapy and Aromatic Plants for the Treatment of Behavioural and Psychological Symptoms of Dementia in Patients with Alzheimer's Disease: Clinical Evidence and Possible Mechanisms. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2017; 2017:9416305. [PMID: 28465709 PMCID: PMC5390566 DOI: 10.1155/2017/9416305] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 03/02/2017] [Indexed: 12/03/2022]
Abstract
The treatment of agitation and aggression, typical Behavioural and Psychological Symptoms of Dementia (BPSDs) of Alzheimer's Disease (AD), is one of the most complicated aspects of handling patients suffering from dementia. Currently, the management of these symptoms often associated with an increased pain perception, which notably reduces the patients' quality of life (QoL), relies on the employment of antipsychotic drugs. Unfortunately, the use of these pharmacological agents has some limits: in the long term, they do not result in being equally effective as in the first weeks of treatment and they present important side effects. Therefore, there is growing interest, supported by clinical evidence, in aromatherapy for the control of agitation, aggression, and psychotic symptoms. Some molecular mechanisms have been proposed to explain the behavioural effects of essential oils, as the whole phytocomplex or the single components, but important basic research effort is still needed. For this reason, rigorous preclinical studies are necessary in order to understand the pharmacological basis of aromatherapy in the treatment of BPSDs and to widen the cluster of effective essential oils in pharmacotherapeutic practice.
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156
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Prevalence of Pain in Nursing Home Residents: The Role of Dementia Stage and Dementia Subtypes. J Am Med Dir Assoc 2017; 18:522-527. [PMID: 28236607 DOI: 10.1016/j.jamda.2016.12.078] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 12/29/2016] [Accepted: 12/30/2016] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To study pain prevalence, pain type, and its pharmacological treatment in Dutch nursing home residents in relation to dementia subtype and dementia severity. DESIGN Data were collected as part of the PAINdemiA study, an observational cross-sectional study conducted between May 2014 and December 2015. SETTING Ten nursing homes in the Netherlands. PARTICIPANTS A total of 199 nursing home residents in various stages of dementia. MEASUREMENTS We collected data on pain (by observation: MOBID-2 Pain Scale and by self-report scales), pain type, pain medication, dementia subtype, dementia severity (GDS), and demographic features. RESULTS In the whole sample, the prevalence of pain was 43% (95% confidence interval 36%-50%) using the MOBID-2 Pain Scale. Regardless of regularly scheduled analgesics, approximately one-third of the residents with pain suffered from moderate to severe pain. Pain assessment with the MOBID-2 Pain Scale showed no difference in pain between dementia subtypes, but residents with more severe dementia experienced pain more often than those with less severe dementia (27% vs 15%). The prevalence of self-reported pain was significantly higher in residents with vascular dementia (VaD) (54%) compared with those with Alzheimer disease (18%) and other dementia subtypes (14%). Nociceptive pain was the predominant type of pain (72%) followed by mixed pain (25%). Acetaminophen was the most prescribed analgesic (80%). CONCLUSION Most of the participating nursing home residents had no pain; however, pain was observed more often in residents with severe dementia, whereas residents in the early stages of VaD self-reported pain more often that those with other dementia subtypes. As one-third of the residents with clinically relevant pain had moderate to severe pain regardless of using pain medication, more focus should be on how pain management could use more tailored approaches and be regularly adjusted to individual needs.
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157
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Smith IL, Brown S, McGinnis E, Briggs M, Coleman S, Dealey C, Muir D, Nelson EA, Stevenson R, Stubbs N, Wilson L, Brown JM, Nixon J. Exploring the role of pain as an early predictor of category 2 pressure ulcers: a prospective cohort study. BMJ Open 2017; 7:e013623. [PMID: 28110286 PMCID: PMC5253581 DOI: 10.1136/bmjopen-2016-013623] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To explore pressure area related pain as a predictor of category ≥2 pressure ulcer (PU) development. DESIGN Multicentre prospective cohort study. SETTING UK hospital and community settings. PARTICIPANTS INCLUSION Consenting acutely ill patients aged ≥18 years, defined as high risk (Braden bedfast/chairfast AND completely immobile/very limited mobility; pressure area related pain or; category 1 PU). EXCLUSION Patients too unwell, unable to report pain, 2 or more category ≥2 PUs. FOLLOW-UP Twice weekly for 30 days. PRIMARY AND SECONDARY OUTCOME MEASURES Development and time to development of one or more category ≥2 PUs. RESULTS Of 3819 screened, 1266 were eligible, 634 patients were recruited, 32 lost to follow-up, providing a 602 analysis population. 152 (25.2%) developed one or more category ≥2 PUs. 464 (77.1%) patients reported pressure area related pain on a healthy, altered or category 1 skin site of whom 130 (28.0%) developed a category ≥2 PU compared with 22 (15.9%) of those without pain. Full stepwise variable selection was used throughout the analyses. (1) Multivariable logistic regression model to assess 9 a priori factors: presence of category 1 PU (OR=3.25, 95% CI (2.17 to 4.86), p<0.0001), alterations to intact skin (OR=1.98, 95% CI (1.30 to 3.00), p=0.0014), pressure area related pain (OR=1.56, 95% CI (0.93 to 2.63), p=0.0931). (2) Multivariable logistic regression model to account for overdispersion: presence of category 1 PU (OR=3.20, 95% CI (2.11 to 4.85), p<0.0001), alterations to intact skin (OR=1.90, 95% CI (1.24 to 2.91), p=0.0032), pressure area related pain (OR=1.85, 95% CI (1.07 to 3.20), p=0.0271), pre-existing category 2 PU (OR=2.09, 95% CI (1.35 to 3.23), p=0.0009), presence of chronic wound (OR=1.66, 95% CI (1.06 to 2.62), p=0.0277), Braden activity (p=0.0476). (3) Accelerated failure time model: presence of category 1 PU (AF=2.32, 95% CI (1.73 to 3.12), p<0.0001), pressure area related pain (AF=2.28, 95% CI (1.59 to 3.27), p<0.0001). (4) 2-level random-intercept logistic regression model: skin status which comprised 2 levels (versus healthy skin); alterations to intact skin (OR=4.65, 95% CI (3.01 to 7.18), p<0.0001), presence of category 1 PU (OR=17.30, 95% CI (11.09 to 27.00), p<0.0001) and pressure area related pain (OR=2.25, 95% CI (1.53 to 3.29), p<0.0001). CONCLUSIONS This is the first study to assess pain as a predictor of category ≥2 PU development. In all 4 models, pain emerged as a risk factor associated with an increased probability of category ≥2 PU development.
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Affiliation(s)
- Isabelle L Smith
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sarah Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Elizabeth McGinnis
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Michelle Briggs
- Division of Nursing, Midwifery & Social Work, & Central Manchester University Hospitals NHS Foundation Trust (CMFT), Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Susanne Coleman
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Carol Dealey
- School of Health & Population Sciences, University of Birmingham, Birmingham, UK
| | - Delia Muir
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rebecca Stevenson
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Nikki Stubbs
- Department of Tissue Viability, Leeds Community Healthcare NHS Trust, Leeds, UK
| | - Lyn Wilson
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Mid Yorkshire Hospital NHS Trust, Wakefield, UK
| | - Julia M Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jane Nixon
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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158
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Kutschar P, Bauer Z, Gnass I, Osterbrink J. Does item overlap render measured relationships between pain and challenging behaviour trivial? Results from a multicentre cross-sectional study in 13 German nursing homes. Nurs Inq 2017; 24. [DOI: 10.1111/nin.12182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Patrick Kutschar
- Institute of Nursing Science and Practice; Paracelsus Medical University; Salzburg Austria
| | - Zsuzsa Bauer
- Institute of Nursing Science and Practice; Paracelsus Medical University; Salzburg Austria
| | - Irmela Gnass
- Institute of Nursing Science and Practice; Paracelsus Medical University; Salzburg Austria
| | - Jürgen Osterbrink
- Institute of Nursing Science and Practice; Paracelsus Medical University; Salzburg Austria
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159
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Parsons C. Polypharmacy and inappropriate medication use in patients with dementia: an underresearched problem. Ther Adv Drug Saf 2017; 8:31-46. [PMID: 28203365 PMCID: PMC5298466 DOI: 10.1177/2042098616670798] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Multimorbidity and polypharmacy are increasingly prevalent across healthcare systems and settings as global demographic trends shift towards increased proportions of older people in populations. Numerous studies have demonstrated an association between polypharmacy and potentially inappropriate prescribing (PIP), and have reported high prevalence of PIP across settings of care in Europe and North America and, as a consequence, increased risk of adverse drug reactions, healthcare utilization, morbidity and mortality. These studies have not focused specifically on people with dementia, despite the high risk of adverse drug reactions and PIP in this patient cohort. This narrative review considers the evidence currently available in the area, including studies examining prevalence of PIP in older people with dementia, how appropriateness of prescribing is assessed, the medications most commonly implicated, the clinical consequences, and research priorities to optimize prescribing for this vulnerable patient group. Although there has been a considerable research effort to develop criteria to assess medication appropriateness in older people in recent years, the majority of tools do not focus on people with dementia. Of the limited number of tools available, most focus on the advanced stages of dementia in which life expectancy is limited. The development of tools to assess medication appropriateness in people with mild to moderate dementia or across the full spectrum of disease severity represents an important gap in the research literature and is beginning to attract research interest, with recent studies considering the medication regimen as a whole, or misprescribing, overprescribing or underprescribing of certain medications/medication classes, including anticholinergics, psychotropics, antibiotics and analgesics. Further work is required in development and validation of criteria to assess prescribing appropriateness in this vulnerable patient population, to determine prevalence of PIP in large cohorts of people with the full spectrum of dementia variants and severities, and to examine the impact of PIP on health outcomes.
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Affiliation(s)
- Carole Parsons
- Queen’s University Belfast, 97 Lisburn Road, Belfast, Northern Ireland BT9 7BL, UK
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160
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Corbett A, Nunez KM, Smeaton E, Testad I, Thomas AJ, Closs SJ, Briggs M, Clifton L, Gjestsen MT, Lawrence V. The landscape of pain management in people with dementia living in care homes: a mixed methods study. Int J Geriatr Psychiatry 2016; 31:1354-1370. [PMID: 26898542 DOI: 10.1002/gps.4445] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/26/2015] [Accepted: 01/20/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The aim of this study is to explore the current landscape of pain management in people with dementia living in care home settings. Pain is extremely common in this patient group, yet there is very limited guidance for healthcare professionals. METHODS Triangulation of stakeholder consultation and quality review of pain management guidance were performed. A review of existing pain management guidance was conducted using published quality criteria adapted for the field. Three focus group discussions were held with care home staff and two focus group discussions and an online survey with family carers. Data were subjected to thematic analysis to identify themes and sub-themes. Outcomes were reviewed by an expert panel, which gave recommendations. RESULTS Fifteen existing guidelines were identified, of which three were designed for use in dementia and none were tailored for care home settings. Thematic analysis revealed six major themes in current pain management in dementia: importance of person-centredness, current lack of pain awareness in staff, communication as a core element, disparities in staff responsibility and confidence, the need for consistency of care and current lack of staff training. In addition to the needs for practice, the expert panel identified promising pharmacological treatment candidates, which warrant clinical evaluation. CONCLUSIONS The findings of this study clearly articulate a need for an evidence-based pain management programme for care homes, which is informed by stakeholder input and based within a conceptual framework for this setting. There are novel opportunities for clinical trials of alternative analgesics for use in this patient group. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Anne Corbett
- Wolfson Centre for Age-Related Diseases, King's College London, London, UK.
| | | | - Emily Smeaton
- Wolfson Centre for Age-Related Diseases, King's College London, London, UK
| | - Ingelin Testad
- Centre for Age-Related Medicine (SESAM), Stavanger University, Stavanger, Norway
| | - Alan J Thomas
- Institute for Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - S Jose Closs
- School of Healthcare, University of Leeds, Leeds, UK
| | - Michelle Briggs
- Centre for Pain Research, Faculty of Health and Social Sciences, Leeds Beckett University, Leeds, UK
| | - Lei Clifton
- Centre for Statistics in Medicine (CSM), University of Oxford, UK
| | | | - Vanessa Lawrence
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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161
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Hamina A, Taipale H, Tanskanen A, Tolppanen AM, Tiihonen J, Hartikainen S. Differences in analgesic use in community-dwelling persons with and without Alzheimer's disease. Eur J Pain 2016; 21:658-667. [PMID: 27862681 DOI: 10.1002/ejp.969] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND There are conflicting findings about analgesic use among persons with cognitive impairment compared to cognitively intact older persons. The objective of our study was to investigate the prevalence of analgesic use in community-dwelling persons with and without Alzheimer's disease (AD), within six months after AD diagnosis and to find out factors associated with the use of analgesics and specific analgesic groups. METHOD We utilized data from register based MEDALZ (Medication use and Alzheimer's disease) cohort consisting of all community-dwelling persons diagnosed with AD during 2005-2011 in Finland and their matched comparison persons without AD. Altogether, 67,215 persons with AD and one comparison person for each case were included. Drug use data were collected from the Prescription Register and comorbidities from Special Reimbursement and Hospital Discharge Registers. RESULTS Statistically significant (p < 0.001) yet mostly small differences were found for analgesics use: analgesics were used by 34.9% and 33.5% of persons with and without AD, respectively. Paracetamol was the most frequently used analgesic both among persons with (25.0%) and without AD (19.1%). Persons with AD used less frequently NSAIDs (Nonsteroidal Anti-inflammatory Drugs) (13.2% vs. 17.3%) and mild opioids (5.0% vs. 7.1%), while the use of strong opioids was more common in comparison to persons without AD (1.3% vs. 1.1%, respectively). Analgesic users were more likely women, aged ≥80 years, had asthma/COPD, cardiovascular disease, diabetes, cancer, hip fracture, osteoporosis, rheumatoid arthritis, and lower socioeconomic position. CONCLUSION Further studies are needed to evaluate the adequateness of pain relief in older persons with and without AD. SIGNIFICANCE Persons with Alzheimer's disease (AD) used more frequently paracetamol and less frequently NSAIDs and mild opioids. A decreasing trend of NSAID use was observed among persons with AD during the study period.
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Affiliation(s)
- A Hamina
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - H Taipale
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Research Centre for Comparative Effectiveness and Patient Safety (RECEPS), University of Eastern Finland, Kuopio, Finland
| | - A Tanskanen
- National Institute for Health and Welfare, Helsinki, Finland.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
| | - A-M Tolppanen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Research Centre for Comparative Effectiveness and Patient Safety (RECEPS), University of Eastern Finland, Kuopio, Finland
| | - J Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
| | - S Hartikainen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Department of Psychiatry, Kuopio University Hospital, Kuopio, Finland
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162
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Wright R, Malec M, Shega JW, Rodriguez E, Kulas J, Morrow L, Rodakowski J, Semla T, Weiner DK. Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part XI: Dementia. PAIN MEDICINE (MALDEN, MASS.) 2016; 17:1993-2002. [PMID: 27880650 PMCID: PMC6388877 DOI: 10.1093/pm/pnw247] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE : To present the 11th in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of 12 important contributions to pain and disability in older adults with CLBP. This article focuses on dementia. METHODS A modified Delphi technique was used to develop an algorithm for an approach to treatment for older adults living with CLBP and dementia. A panel of content experts on pain and cognition in older adults developed the algorithm through an iterative process. Though developed using resources available within Veterans Health Administration (VHA) facilities, the algorithm is applicable across all health care settings. A case taken from the clinical practice of one of the contributors demonstrates application of the algorithm. RESULTS We present an evidence-based algorithm and biopsychosocial rationale to guide providers evaluating CLBP in older adults who may have dementia. The algorithm considers both subtle and overt signs of dementia, dementia screening tools to use in practice, referrals to appropriate providers for a complete a workup for dementia, and clinical considerations for persons with dementia who report pain and/or exhibit pain behaviors. A case of an older adult with CLBP and dementia is presented that highlights how an approach that considers the impact of dementia on verbal and nonverbal pain behaviors may lead to more appropriate and successful pain management. CONCLUSIONS Comprehensive pain evaluation for older adults in general and for those with CLBP in particular requires both a medical and a biopsychosocial approach that includes assessment of cognitive function. A positive screen for dementia may help explain why reported pain severity does not improve with usual or standard-of-care pain management interventions. Pain reporting in a person with dementia does not always necessitate pain treatment. Pain reporting in a person with dementia who also displays signs of pain-associated suffering requires concerted pain management efforts targeted to improving function while avoiding harm in these vulnerable patients.Key Words. Dementia; Chronic Pain; Low Back Pain; Lumbar; Primary Care.
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Affiliation(s)
| | - Monica Malec
- Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Joseph W Shega
- VITAS Healthcare, Miami, Florida
- University of Central Florida, Orlando, Florida
| | | | - Joseph Kulas
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine New Haven, Connecticut
| | | | - Juleen Rodakowski
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences
| | - Todd Semla
- US Department of Veterans Affairs, National Pharmacy Benefits Management Services, Hines, Illinois
- Departments of Psychiatry
- Behavioral Sciences, Northwestern University, Chicago, Illinois
| | - Debra K Weiner
- Geriatric Research, Education & Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of Geriatric Medicine
- Yale School of Medicine New Haven, Connecticut
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
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Closs SJ, Dowding D, Allcock N, Hulme C, Keady J, Sampson EL, Briggs M, Corbett A, Esterhuizen P, Holmes J, James K, Lasrado R, Long A, McGinnis E, O’Dwyer J, Swarbrick C, Lichtner V. Towards improved decision support in the assessment and management of pain for people with dementia in hospital: a systematic meta-review and observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04300] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BackgroundPain and dementia are common in older people, and impaired cognitive abilities make it difficult for them to communicate their pain. Pain, if poorly managed, impairs health and well-being. Accurate pain assessment in this vulnerable group is challenging for hospital staff, but essential for appropriate management. Robust methods for identifying, assessing and managing pain are needed.Aims and objectivesTwo studies were undertaken to inform the development of a decision support tool to aid hospital staff in the recognition, assessment and management of pain. The first was a meta-review of systematic reviews of observational pain assessment instruments with three objectives: (1) to identify the tools available to assess pain in adults with dementia; (2) to identify in which settings they were used and with what patient populations; and (3) to assess their reliability, validity and clinical utility. The second was a multisite observational study in hospitals with four objectives: (1) to identify information currently used by clinicians when detecting and managing pain in patients with dementia; (2) to explore existing processes for detecting and managing pain in these patients; (3) to identify the role (actual/potential) of carers in this process; and (4) to explore the organisational context in which health professionals operate. Findings also informed development of health economics data collection forms to evaluate the implementation of a new decision support intervention in hospitals.MethodsFor the meta-review of systematic reviews, 12 databases were searched. Reviews of observational pain assessment instruments that provided psychometric data were included. Papers were quality assessed and data combined using narrative synthesis. The observational study used an ethnographic approach in 11 wards in four UK hospitals. This included non-participant observation of 31 patients, audits of patient records, semistructured interviews with 52 staff and four carers, informal conversations with staff and carers and analysis of ward documents and policies. Thematic analysis of the data was undertaken by the project team.ResultsData from eight systematic reviews including 28 tools were included in the meta-review. Most tools showed moderate to good reliability, but information about validity, feasibility and clinical utility was scarce. The observational study showed complex ward cultures and routines, with variations in time spent with patients, communication patterns and management practices. Carer involvement was rare. No pain decision support tools were observed in practice. Information about pain was elicited in different ways, at different times, by different health-care staff and recorded in separate documents. Individual staff made sense of patients’ pain by creating their own ‘overall picture’ from available information.LimitationsGrey literature and non-English-language papers were excluded from the meta-review. Sample sizes in the observational study were smaller than planned owing to poor documentation of patients’ dementia diagnoses, gatekeeping by staff and difficulties in gaining consent/assent. Many patients had no or geographically distant carers, or a spouse who was too unwell and/or reluctant to participate.ConclusionsNo single observational pain scale was clearly superior to any other. The traditional linear concept of pain being assessed, treated and reassessed by single individuals did not ‘fit’ with clinical reality. A new approach enabling effective communication among patients, carers and staff, centralised recording of pain-related information, and an extended range of pain management interventions is proposed [Pain And Dementia Decision Support (PADDS)]. This was not tested with users, but a follow-on study aims to codesign PADDS with carers and clinicians, then introduce education on staff/patient/carer communications and use of PADDS within a structured implementation plan. PADDS will need to be tested in differing ward contexts.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- S José Closs
- School of Healthcare, University of Leeds, Leeds, UK
| | - Dawn Dowding
- School of Nursing, Columbia University, New York, NY, USA
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY, USA
| | - Nick Allcock
- Clinical Specialist, Pain Management Solutions, Nottingham, UK
| | - Claire Hulme
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - John Keady
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Michelle Briggs
- School of Health and Community Studies, Leeds Beckett University, Leeds, UK
| | - Anne Corbett
- Wolfson Centre for Age-Related Diseases, King’s College London, London, UK
| | | | - John Holmes
- Leeds Institute of Medical Education, University of Leeds, Leeds, UK
| | - Kirstin James
- School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley, UK
| | - Reena Lasrado
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Andrew Long
- School of Healthcare, University of Leeds, Leeds, UK
| | | | - John O’Dwyer
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Caroline Swarbrick
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
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Gregory J. Initial testing of a behavioural pain assessment tool within trauma units. Int J Orthop Trauma Nurs 2016; 24:3-11. [PMID: 27919714 DOI: 10.1016/j.ijotn.2016.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 08/18/2016] [Accepted: 08/31/2016] [Indexed: 10/21/2022]
Abstract
Pain is common in trauma patients who may be older and also may have cognitive impairment leading to reduced communication about their pain. A number of observational pain assessment tools are available and have been found to have limited clinical usefulness. The Bolton Pain Assessment Tool (BPAT) was developed following a trial of three established tools and includes a section to involve family and/or close carers in the pain assessment process. The aim of this paper is to present the findings of initial testing of BPAT. BPAT was used and evaluated by clinical staff in four trauma units in the UK. Forty-six staff evaluations were completed and 98% indicated it was easy to use; it took between one and two minutes to complete by 69.5% and led to pain management interventions by 93.5% of the respondents. It was rated highly by the clinical staff, but the involvement of families and close carers in the assessment process was different at each unit, with one unit not involving the family/close carer. There remains the need for a simple and practical way of assessing pain. This initial testing of the clinical feasibility of BPAT suggests that it is easy to use and helps to identify pain, but further testing of its reliability and validity is required.
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Affiliation(s)
- Julie Gregory
- School of Nursing, Midwifery and Social Work, University of Manchester, Jean MacFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
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165
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Stubbs B, Thompson T, Solmi M, Vancampfort D, Sergi G, Luchini C, Veronese N. Is pain sensitivity altered in people with Alzheimer's disease? A systematic review and meta-analysis of experimental pain research. Exp Gerontol 2016; 82:30-8. [DOI: 10.1016/j.exger.2016.05.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/19/2016] [Accepted: 05/30/2016] [Indexed: 11/24/2022]
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Lichtner V, Dowding D, Allcock N, Keady J, Sampson EL, Briggs M, Corbett A, James K, Lasrado R, Swarbrick C, Closs SJ. The assessment and management of pain in patients with dementia in hospital settings: a multi-case exploratory study from a decision making perspective. BMC Health Serv Res 2016; 16:427. [PMID: 27553364 PMCID: PMC4995653 DOI: 10.1186/s12913-016-1690-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 08/18/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain is often poorly managed in people who have a dementia. Little is known about how this patient population is managed in hospital, with research to date focused mainly on care homes. This study aimed to investigate how pain is recognised, assessed and managed in patients with dementia in a range of acute hospital wards, to inform the development of a decision support tool to improve pain management for this group. METHODS A qualitative, multi-site exploratory case study. Data were collected in four hospitals in England and Scotland. Methods included non-participant observations, audits of patient records, semi-structured interviews with staff and carers, and analysis of hospital ward documents. Thematic analysis was performed through the lens of decision making theory. RESULTS Staff generally relied on patients' self-report of pain. For patients with dementia, however, communication difficulties experienced because of their condition, the organisational context, and time frames of staff interactions, hindered patients' ability to provide staff with information about their pain experience. This potentially undermined the trials of medications used to provide pain relief to each patient and assessments of their responses to these treatments. Furthermore, given the multidisciplinary environment, a patient's communication about their pain involved several members of staff, each having to make sense of the patient's pain as in an 'overall picture'. Information about patients' pain, elicited in different ways, at different times and by different health care staff, was fragmented in paper-based documentation. Re-assembling the pieces to form a 'patient specific picture of the pain' required collective staff memory, 'mental computation' and time. CONCLUSIONS There is a need for an efficient method of eliciting and centralizing all pain-related information for patients with dementia, which is distributed in time and between personnel. Such a method should give an overall picture of a patient's pain which is rapidly accessible to all involved in their care. This would provide a much-needed basis for making decisions to support the effective management of the pain of older people with dementia in hospital.
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Affiliation(s)
| | - Dawn Dowding
- Columbia University School of Nursing, New York, NY 10032 USA
- Center for Home Care Policy and Research, Visiting Nursing Service of New York, New York, NY USA
| | - Nick Allcock
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - John Keady
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Michelle Briggs
- Centre for Pain Research, Leeds Beckett University, Leeds, UK
| | - Anne Corbett
- Wolfson Centre for Age-Related Diseases, King’s College London, London, UK
| | - Kirstin James
- School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley, UK
| | - Reena Lasrado
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Caroline Swarbrick
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - S. José Closs
- School of Healthcare, University of Leeds, Leeds, UK
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167
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Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of End-of-Life Care Provided to Patients With Different Serious Illnesses. JAMA Intern Med 2016; 176:1095-102. [PMID: 27367547 PMCID: PMC5470549 DOI: 10.1001/jamainternmed.2016.1200] [Citation(s) in RCA: 228] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Efforts to improve end-of-life care have focused primarily on patients with cancer. High-quality end-of-life care is also critical for patients with other illnesses. OBJECTIVE To compare patterns of end-of-life care and family-rated quality of care for patients dying with different serious illnesses. DESIGN, SETTING, AND PARTICIPANTS A retrospective cross-sectional study was conducted in all 146 inpatient facilities within the Veteran Affairs health system among patients who died in inpatient facilities between October 1, 2009, and September 30, 2012, with clinical diagnoses categorized as end-stage renal disease (ESRD), cancer, cardiopulmonary failure (congestive heart failure or chronic obstructive pulmonary disease), dementia, frailty, or other conditions. Data analysis was conducted from April 1, 2014, to February 10, 2016. MAIN OUTCOMES AND MEASURES Palliative care consultations, do-not-resuscitate orders, death in inpatient hospices, death in the intensive care unit, and family-reported quality of end-of-life care. RESULTS Among 57 753 decedents, approximately half of the patients with ESRD, cardiopulmonary failure, or frailty received palliative care consultations (adjusted proportions, 50.4%, 46.7%, and 43.7%, respectively) vs 73.5% of patients with cancer and 61.4% of patients with dementia (P < .001). Approximately one-third of patients with ESRD, cardiopulmonary failure, or frailty (adjusted proportions, 32.3%, 34.1%, and 35.2%, respectively) died in the intensive care unit, more than double the rates among patients with cancer and those with dementia (13.4% and 8.9%, respectively) (P < .001). Rates of excellent quality of end-of-life care reported by 34 005 decedents' families were similar for patients with cancer and those with dementia (adjusted proportions, 59.2% and 59.3%; P = .61), but lower for patients with ESRD, cardiopulmonary failure, or frailty (54.8%, 54.8%, and 53.7%, respectively; all P ≤ .02 vs patients with cancer). This quality advantage was mediated by palliative care consultation, setting of death, and a code status of do-not-resuscitate; adjustment for these variables rendered the association between diagnosis and overall end-of-life care quality nonsignificant. CONCLUSIONS AND RELEVANCE Family-reported quality of end-of-life care was significantly better for patients with cancer and those with dementia than for patients with ESRD, cardiopulmonary failure, or frailty, largely owing to higher rates of palliative care consultation and do-not-resuscitate orders and fewer deaths in the intensive care unit among patients with cancer and those with dementia. Increasing access to palliative care and goals of care discussions that address code status and preferred setting of death, particularly for patients with end-organ failure and frailty, may improve the overall quality of end-of-life care for Americans dying of these illnesses.
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Affiliation(s)
- Melissa W Wachterman
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts2Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts3Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer
| | - Corey Pilver
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts5Tufts Health Plan, Watertown, Massachusetts
| | - Dawn Smith
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Mary Ersek
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania7University of Pennsylvania School of Nursing, Philadelphia
| | - Stuart R Lipsitz
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nancy L Keating
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts8Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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168
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La Frenais F, Stone P, Sampson EL. Analgesic prescribing in care home residents: how epidemiological studies may inform clinical practice. Pain Manag 2016; 6:561-568. [PMID: 27383004 DOI: 10.2217/pmt-2016-0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Care home residents are often frail with multiple comorbidities and cognitive impairment, most commonly caused by dementia. This population is under-represented in clinical trials, leading to a lack of valid and reliable evidence to inform clinicians' prescribing practice. This paper summarizes how epidemiological research conducted in similar populations can inform pain management by describing pain prevalence, risk factors, typical features and functional consequences. This evidence can help overcome the numerous barriers to optimal pain management in care home residents.
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Affiliation(s)
- Francesca La Frenais
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.,Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.,Barnet Enfield & Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, Sterling Way, London, N18 1QX, UK
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169
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Bauer U, Pitzer S, Schreier MM, Osterbrink J, Alzner R, Iglseder B. Pain treatment for nursing home residents differs according to cognitive state - a cross-sectional study. BMC Geriatr 2016; 16:124. [PMID: 27317390 PMCID: PMC4912815 DOI: 10.1186/s12877-016-0295-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/31/2016] [Indexed: 11/23/2022] Open
Abstract
Background Communication skills are known to decrease with advancing cognitive impairment. Analgesic treatment in long-term care may be deficient due to the residents’ impaired ability to communicate their pain and needs. Undertreated pain frequently leads to rising BPSD in residents with cognitive impairment, resulting in a treatment with antipsychotics. Aim of this study was the analysis of differences in assessment and pharmacological treatment of pain in nursing home residents relative to their cognitive state and ability to articulate pain. Methods Data stems from the baseline of a non-experimental pre-post-study in 12 Austrian nursing homes. Residents’ pain prevalence in relation to pain assessment and cognitive decline was assessed, data on medical diagnoses and prescriptions were retrieved from the nursing homes’ documentation (n = 425). Residents were first divided into two groups: Residents with MMSE ≥ 18 were selected into group CUS (cognitively unimpaired/slightly impaired), residents with MMSE ≤ 17 were selected into group CI (cognitively moderately to severely impaired). CI residents were then sub-grouped according to their ability to communicate pain via the Verbal Rating Scale (VRS) (i.e. group CI-V, group CI-NV). Pain behavior of CI residents was assessed with a modified German version of PAINAD. Group differences were tested with ANOVA and H-test, 95 % confidence intervals were calculated and associations were tested with log-binomial regression. Results Pain prevalence in CI residents irrespective of their ability to communicate pain was 80 % and exceeded the CUS group prevalence significantly by 14 %. CI residents had significantly less analgesic prescriptions. Furthermore, CI residents have a significantly higher risk of getting no analgesics when in pain than CUS residents (CI-V: RR =2.6, CI-NV: RR =3.4). Use of antipsychotics was high in all groups (49 – 65 %) with more prescriptions in the cognitively impaired group. Conclusion Results point toward an underuse of pain medication in cognitively impaired residents, especially those unable to communicate pain verbally. The implementation of standardized pain assessments adapted to the cognitive abilities of residents may foster the recognition of pain, warrant optimized pain management, reduce inadequate medication and consequently raise the chance of equally effective pain treatment regardless of cognitive state.
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Affiliation(s)
- Ulrike Bauer
- Institute of Nursing Science and Practice, Paracelsus Medical University Salzburg, Strubergasse 21, A-5020, Salzburg, Austria.
| | - Stefan Pitzer
- Institute of Nursing Science and Practice, Paracelsus Medical University Salzburg, Strubergasse 21, A-5020, Salzburg, Austria
| | - Maria Magdalena Schreier
- Institute of Nursing Science and Practice, Paracelsus Medical University Salzburg, Strubergasse 21, A-5020, Salzburg, Austria
| | - Jürgen Osterbrink
- Institute of Nursing Science and Practice, Paracelsus Medical University Salzburg, Strubergasse 21, A-5020, Salzburg, Austria
| | - Reinhard Alzner
- Department of Geriatric Medicine, Christian Doppler Klinik, Paracelsus Medical University, Ignaz-Harrer-Straße 79, A-5020, Salzburg, Austria
| | - Bernhard Iglseder
- Department of Geriatric Medicine, Christian Doppler Klinik, Paracelsus Medical University, Ignaz-Harrer-Straße 79, A-5020, Salzburg, Austria
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170
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Tan EC, Visvanathan R, Hilmer SN, Vitry A, Emery T, Robson L, Pitkälä K, Ilomäki J, Bell JS. Analgesic use and pain in residents with and without dementia in aged care facilities: A cross-sectional study. Australas J Ageing 2016; 35:180-7. [PMID: 27256958 DOI: 10.1111/ajag.12295] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIM To investigate analgesic use and pain in people with and without dementia in Australian residential aged are facilities. METHODS A cross-sectional study of 383 residents of six residential aged are facilities was conducted. Nurses assessed self-reported and clinician-observed pain. Analgesic use data were extracted from medication charts. Logistic regression was used to investigate factors associated with analgesic use. RESULTS Analgesics were administered to 291 (76.0%) residents in the previous 24 hours. The prevalence of analgesic use was similar among residents with and without dementia (79.3% vs 73.4%, P = 0.20). Residents with dementia had a higher prevalence of self-reported pain than those without dementia but similar prevalence of clinician-observed pain. In residents with dementia, high care residence and dementia severity were associated with analgesic use. CONCLUSION The prevalence of analgesic use was similar among residents with and without dementia. Both self-reported and clinician-observed measures are needed in regular pain assessments.
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Affiliation(s)
- Edwin Ck Tan
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia.
| | - Renuka Visvanathan
- Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, School of Medicine, University of Adelaide, South Australia, Australia.,Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, South Australia, Australia
| | - Sarah N Hilmer
- Kolling Institute of Medical Research, Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, New South Wales, Australia
| | - Agnes Vitry
- Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Tina Emery
- Resthaven Incorporated, Adelaide, South Australia, Australia
| | - Leonie Robson
- Resthaven Incorporated, Adelaide, South Australia, Australia
| | - Kaisu Pitkälä
- Department of General Practice, Unit of Primary Health Care, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia.,NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, New South Wales, Australia.,Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
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172
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Timmons S, O'Shea E, O'Neill D, Gallagher P, de Siún A, McArdle D, Gibbons P, Kennelly S. Acute hospital dementia care: results from a national audit. BMC Geriatr 2016; 16:113. [PMID: 27245979 PMCID: PMC4886443 DOI: 10.1186/s12877-016-0293-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 05/27/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Admission to an acute hospital can be distressing and disorientating for a person with dementia, and is associated with decline in cognitive and functional ability. The objective of this audit was to assess the quality of dementia care in acute hospitals in the Republic of Ireland. METHODS Across all 35 acute public hospitals, data was collected on care from admission through discharge using a retrospective chart review (n = 660), hospital organisation interview with senior management (n = 35), and ward level organisation interview with ward managers (n = 76). Inclusion criteria included a diagnosis of dementia, and a length of stay greater than 5 days. RESULTS Most patients received physical assessments, including mobility (89 %), continence (84 %) and pressure sore risk (87 %); however assessment of pain (75 %), and particularly functioning (36 %) was poor. Assessment for cognition (43 %) and delirium (30 %) was inadequate. Most wards have access at least 5 days per week to Liaison Psychiatry (93 %), Geriatric Medicine (84 %), Occupational Therapy (79 %), Speech & Language (81 %), Physiotherapy (99 %), and Palliative Care (89 %) Access to Psychology (9 %), Social Work (53 %), and Continence services (34 %) is limited. Dementia awareness training is provided on induction in only 2 hospitals, and almost half of hospitals did not offer dementia training to doctors (45 %) or nurses (48 %) in the previous 12 months. Staff cover could not be provided on 62 % of wards for attending dementia training. Most wards (84 %) had no dementia champion to guide best practice in care. Discharge planning was not initiated within 24 h of admission in 72 % of cases, less than 40 % had a single plan for discharge recorded, and 33 % of carers received no needs assessment prior to discharge. Length of stay was significantly greater for new discharges to residential care (p < .001). CONCLUSION Dementia care relating to assessment, access to certain specialist services, staffing levels, training and support, and discharge planning is sub-optimal, which may increase the risk of adverse patient outcomes and the cost of acute care. Areas of good practice are also highlighted.
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Affiliation(s)
- Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, The Bungalow, Block 13, St. Finbarr's Hospital, Douglas Road, Cork, Ireland
| | - Emma O'Shea
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, The Bungalow, Block 13, St. Finbarr's Hospital, Douglas Road, Cork, Ireland.
| | - Desmond O'Neill
- Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin, Ireland
| | - Paul Gallagher
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, The Bungalow, Block 13, St. Finbarr's Hospital, Douglas Road, Cork, Ireland
| | - Anna de Siún
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, The Bungalow, Block 13, St. Finbarr's Hospital, Douglas Road, Cork, Ireland
| | - Denise McArdle
- Quality and Patient Safety Audit Services, Health Service Executive, Dublin, Ireland
| | - Patricia Gibbons
- Quality and Patient Safety Audit Services, Health Service Executive, Dublin, Ireland
| | - Sean Kennelly
- Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin, Ireland
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173
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Booker SQ, Herr KA, Tripp-Reimer T. Culturally Conscientious Pain Measurement in Older African Americans. West J Nurs Res 2016; 38:1354-73. [PMID: 27174228 DOI: 10.1177/0193945916648952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite considerable pain disparities across the care continuum, pain is an understudied health problem in older ethnic minority groups, such as African Americans. Quality pain measurement is a core task in pain management and a mechanism by which pain disparities may be reduced. Pain measurement includes the methods (e.g., assessment approaches, tools) and metrics that researchers and clinicians use to understand the characteristics of pain. However, there are significant issues and gaps that negatively affect pain measurement in older African Americans. Of concern is insufficient representation in pain research, which impedes the testing and refinement of many standardized self-report, behavioral and surrogate report, physiological, and composite measures of pain. The purposes for this article are to discuss the status of pain measurement and factors that affect our knowledge on pain measurement in older African Americans, and to provide guidance for culturally conscientious pain measurement using the available literature.
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174
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Tang MM, Wollsen MG, Aagaard L. Pain monitoring and medication assessment in elderly nursing home residents with dementia. J Res Pharm Pract 2016; 5:126-31. [PMID: 27162807 PMCID: PMC4843582 DOI: 10.4103/2279-042x.179578] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective: To monitor pain intensity, pain symptoms, and medication use in elderly with dementia. Methods: Nursing home residents above 65 years of age, diagnosed with dementia, and showing pain symptoms were included in the study. The patients’ mental status was monitored through a mini-mental state examination score and observations of pain symptoms using Part 1 of the Mobilization-Observation-Behaviour-Intensity-Dementia-2 (MOBID-2) pain scale. Community pharmacists reviewed the patients’ medication use, and the prescriptions were compared with guidelines for treatment of geriatric patients. Alterations to the patients’ medicine use were forwarded to the general practitioners. Findings: Sixty-one nursing home residents diagnosed with dementia were identified, 15 of these fulfilled the inclusion criteria, and 12 agreed to participate in the study. The mean age was 87 years of age (range: 77-96), and 42% of the residents were males. The patients’ overall pain intensity was 83% for observations on the numeric pain rating scale (NRS) >0 and 67% for NRS ≥3. Most painful were the situations in which the residents were to mobilize their legs, turn around to both sides of the bed, and when sitting on the bed. The medication reviews identified a total of 95 individual prescriptions, and 33% of these were for nervous system medications, followed by medicines for the treatment of alimentary tract and metabolism disorders (31% of total). Eleven prescriptions for pain medicine were identified; the majority of these were for paracetamol and opioids. Seventeen proposals to patients’ medication use were suggested, but the general practitioners accepted only 6% of these. Conclusion: This study indicates that the MOBID-2 pain scale in combination with medication reviews can be used as a tool for optimization of patients’ medication use. However, we recommend the conduction of a larger-scale study in multiple settings, to validate our results and the generalizability of the findings.
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Affiliation(s)
- Mette Marie Tang
- Section for Clinical Pharmacology, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Morten Gill Wollsen
- Centre for Energy Informatics, University of Southern Denmark, Odense, Denmark
| | - Lise Aagaard
- Section for Clinical Pharmacology, Institute of Public Health, University of Southern Denmark, Odense, Denmark
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175
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The Interactive Relationship between Pain, Psychosis, and Agitation in People with Dementia: Results from a Cluster-Randomised Clinical Trial. Behav Neurol 2016; 2016:7036415. [PMID: 27247487 PMCID: PMC4876223 DOI: 10.1155/2016/7036415] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 03/29/2016] [Indexed: 11/17/2022] Open
Abstract
Background. Neuropsychiatric symptoms are common in people with dementia, and pain is thought to be an important underlying factor. Pain has previously been associated with agitation, and pain treatment has been shown to ameliorate agitated behaviour. So far, the association between pain and psychosis and the effect of pain treatment on psychotic symptoms is unclear. Furthermore, the impact of opioid treatment on psychosis is not established. Aim. To investigate the efficacy of a stepwise protocol for treating pain (SPTP) on psychosis and agitation measured with the Neuropsychiatric Inventory, Nursing Home version, and to explore the impact of opioid analgesics on psychosis. Method. Secondary analyses are from a cluster-randomised controlled trial including 352 patients with advanced dementia and agitation from 18 nursing homes in Western Norway. The intervention group received pain treatment according to SPTP. Results. Pain was associated with disinhibition (adjusted OR: 1.21, 95% CI: 1.10–1.34) and irritability (adjusted OR: 1.10, 95% CI: 1.01–1.21) at baseline. Pain treatment reduced agitation (p < 0.001, df = 1; 300) and aberrant motor behaviour (p = 0.017, df = 1; 300). Psychosis was reduced in people with at least one symptom at baseline (p = 0.034, df = 1; 135). The use of opioid analgesics did not increase psychotic symptoms. Study Registration. This trial is registered with ClinicalTrials.gov (NCT01021696), Norwegian Medicines Agency, EudraCT (EudraCTnr: 2008-007490-20).
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176
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Greenblatt HK, Greenblatt DJ. Use of Antipsychotics for the Treatment of Behavioral Symptoms of Dementia. J Clin Pharmacol 2016; 56:1048-57. [PMID: 26953213 DOI: 10.1002/jcph.731] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 02/29/2016] [Indexed: 01/08/2023]
Abstract
Antipsychotic medications are widely used in the management of behavioral and psychological symptoms of dementia. While nonpharmacological interventions should be the first-line treatment for behavioral symptoms of dementia, these are often unfeasible and/or ineffective. Conventional and atypical antipsychotic agents appear to have modest to moderate clinical efficacy in the treatment of these symptoms, though it is unclear which individual agents are most effective. No conclusive evidence exists that any available alternative medications are safer and more effective than antipsychotics. A number of studies have shown an increased risk of mortality associated with antipsychotics in patients with behavioral symptoms of dementia, though the observed risk increase may be partially confounded by illness severity and/or preexisting health determinants. The mechanisms of increased mortality risk are not fully established, but are likely to involve cardiovascular events. It is probable, though not certain, that conventional antipsychotics are associated with a greater number of poor outcomes than atypical antipsychotics. In certain patients with refractory behavioral symptoms, antipsychotics are a viable treatment option. Key considerations for antipsychotic prescribing for this population are published in regulatory guidelines, and include minimization of dosage and duration of treatment, continuous reevaluation of symptoms, and involvement of caregivers.
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Affiliation(s)
- H Karl Greenblatt
- Program in Pharmacology and Experimental Therapeutics, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
| | - David J Greenblatt
- Program in Pharmacology and Experimental Therapeutics, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
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177
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Ersek M, Neradilek MB, Herr K, Jablonski A, Polissar N, Du Pen A. Pain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial. J Am Med Dir Assoc 2016; 17:348-56. [PMID: 26897592 PMCID: PMC4988793 DOI: 10.1016/j.jamda.2016.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 01/04/2016] [Accepted: 01/05/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To enhance pain practices in nursing homes (NHs) using pain assessment and management algorithms and intense diffusion strategies. DESIGN A cluster, randomized controlled trial. The intervention consisted of intensive training and support for the use of recommended pain assessment and management practices using algorithms (ALGs). Control facilities received pain education (EDU) only. SETTING Twenty-seven NHs in the greater Puget Sound area participated. Facilities were diverse in terms of size, quality, and ownership. PARTICIPANTS Data were collected from 485 NH residents; 259 for the intervention and 226 for the control group. MEASUREMENTS Resident outcomes were nursing assistant (proxy) report and self-reported resident pain intensity. Process outcomes were adherence to recommended pain practices. Outcomes were measured at baseline, completion of the intervention (ALG) or training (EDU), and again 6 months later. RESULTS Among 8 comparisons of outcome measures between ALG and EDU (changes in 4 primary pain measures compared at 2 postintervention time points) there was only 1 statistically significant but small treatment difference in proxy- or self-reported pain intensity. Resident-reported worst pain decreased by an average of 0.8 points from baseline to 6 months among the EDU group and increased by 0.2 points among the ALG (P = .005), a clinically nonsignificant difference. There were no statistically significant differences in adherence to clinical guideline practice recommendations between ALG and EDU following the intervention. CONCLUSIONS Future research needs to identify and test effective implementation methods for changing complex clinical practices in NHs, including those to reduce pain.
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Affiliation(s)
- Mary Ersek
- Professor of Palliative Care, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, University of Pennsylvania School of Nursing, 418 Curie Blvd., Room 329, Philadelphia, PA 19104-6096, Phone: (215) 746-3563, Fax: (215) 222-2592
| | - Moni Blazej Neradilek
- The Mountain-Whisper-Light Statistics, 1827 23rd Ave. East, Seattle, WA 98112-2913, Phone: (206) 329-9325, Fax: (206) 324-5915
| | - Keela Herr
- Professor & Chair, Adult & Gerontology Nursing, College of Nursing, University of Iowa, 101 Nursing Building, 50 Newton Road, Iowa City, IA 52242-1121, Phone: (319) 335-7080
| | - Anita Jablonski
- Associate Professor, College of Nursing, Seattle University, 410 Garrand, Seattle, WA 98122, Phone: (206) 296-5679
| | - Nayak Polissar
- The Mountain-Whisper-Light Statistics, 1827 23rd Ave. East, Seattle, WA 98112-2913, Phone: (206) 329-9325, Fax: (206) 324-5915
| | - Anna Du Pen
- Retired, 14555 Wild Swan NE, Bainbridge Island, WA 98110-4102, Phone: (206) 780-8373
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178
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van der Leeuw G, Eggermont LHP, Shi L, Milberg WP, Gross AL, Hausdorff JM, Bean JF, Leveille SG. Pain and Cognitive Function Among Older Adults Living in the Community. J Gerontol A Biol Sci Med Sci 2016; 71:398-405. [PMID: 26433218 PMCID: PMC5013972 DOI: 10.1093/gerona/glv166] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 08/31/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pain related to many age-related chronic conditions is a burdensome problem in elderly adults and may also interfere with cognitive functioning. The purpose of this study was to examine the cross-sectional relationship between measures of pain severity and pain interference and cognitive performance in community-living older adults. METHODS We studied 765 participants in the Maintenance of Balance Independent Living Intellect and Zest (MOBILIZE) Boston Study, a population-based study of persons aged 70 and older. Global pain severity and interference were measured using the Brief Pain Inventory subscales. The neuropsychological battery included measures of attentional capacity (Trail Making Test A, WORLD Test), executive function (Trail Making Test B and Delta, Clock-in-a-Box, Letter Fluency), memory (Hopkins Verbal Learning Test), and a global composite measure of cognitive function. Multivariable linear regression models were used to analyze the relationship between pain and cognitive functioning. RESULTS Elderly adults with more severe pain or more pain interference had poorer performance on memory tests and executive functioning compared to elders with none or less pain. Pain interference was also associated with impaired attentional capacity. Additional adjustment for chronic conditions, behaviors, and psychiatric medication resulted in attenuation of many of the observed associations. However, the association between pain interference and general cognitive function persisted. CONCLUSIONS Our findings point to the need for further research to understand how chronic pain may contribute to decline in cognitive function and to determine strategies that may help in preventing or managing these potential consequences of pain on cognitive function in older adults.
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Affiliation(s)
| | - Laura H P Eggermont
- Department of Clinical Neuropsychology, Vrije University, Amsterdam, The Netherlands
| | - Ling Shi
- College of Nursing and Health Sciences, University of Massachusetts Boston
| | - William P Milberg
- Geriatric Neuropsychology Laboratory, Geriatric, Research, Education and Clinical Center, Brockton/West Roxbury Department of Veterans Affairs Medical Center, Boston, Massachusetts. Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Alden L Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins Center on Aging and Health, Baltimore, Maryland
| | - Jeffrey M Hausdorff
- Laboratory for Gait and Neurodynamics, Movement Disorders Unit, Department of Neurology, Tel-Aviv Sourasky Medical Center, Israel. Department of Physical Therapy, Sackler Faculty of Medicine, and Sagol School of Neuroscience, Tel Aviv University, Israel
| | - Jonathan F Bean
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Massachusetts. New England Geriatric, Research, Education and Clinical Center, Boston Veterans Administration Health System, Massachusetts. Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Suzanne G Leveille
- College of Nursing and Health Sciences, University of Massachusetts Boston. Department of Medicine, Harvard Medical School, Boston, Massachusetts. Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
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179
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Sandvik R, Selbaek G, Kirkevold O, Aarsland D, Husebo BS. Analgesic prescribing patterns in Norwegian nursing homes from 2000 to 2011: trend analyses of four data samples. Age Ageing 2016; 45:54-60. [PMID: 26764395 DOI: 10.1093/ageing/afv184] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND the analgesic drug use has been reported to increase in general in nursing home patients. However, there is insufficient evidence in terms of what agents are used, variations of use over time and to whom these drugs are prescribed. OBJECTIVE we investigated the prescribing patterns of scheduled analgesic drugs in Norwegian nursing home patients from 2000 to 2011, with the association to age, gender, cognitive function and type of nursing home unit. DESIGN secondary analyses of four study samples (three observational studies and one randomised controlled trial). SETTING AND SUBJECTS nursing home patients included in study samples from 2000 (n = 1,926), 2004 (n = 1,163), 2009 (n = 850) and 2011 (n = 1,858) located in 14 Norwegian counties. METHODS trend analyses of analgesic drug prescriptions. Percentages were described using t-test, χ(2) and Mann-Whitney U test and multivariate logistic regression. RESULTS the odds ratio for receiving any pain medication in 2011 compared with 2000 was 2.6 (95% CI 2.23-2.91), this is corresponding to a 65% increase from 34.9 to 57.6%. The paracetamol prescription increased by 113%, from 22.7% in 2000 to 48.4% in 2011. Strong opioids (fentanyl, buprenorphine, morphine, oxycodone) increased from 1.9% in 2000 to 17.9% in 2011 (P < 0.001), whereas non-steroidal anti-inflammatory drug prescription decreased, from 6.8 to 3.2%. In 2000, 2004 and 2009, people with dementia received fewer analgesics compared with patients without dementia; no differences in analgesic drug use between the groups were found in 2011. CONCLUSIONS the analgesic drug prescription increased significantly from 2000 to 2011, especially the use of paracetamol and strong opioids. We also highlight a possible change from under-prescription of analgesic medication in people with dementia, to an equal amount compared with patients without cognitive impairment.
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Affiliation(s)
- Reidun Sandvik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Geir Selbaek
- National Advisory Unit on Ageing and Health, Oslo Universitetssykehus HF, Oslo, Norway
| | - Oyvind Kirkevold
- National Advisory Unit on Ageing and Health, Oslo Universitetssykehus HF, Oslo, Norway The Alzheimer's Society Systematic Review Group
| | - Dag Aarsland
- Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
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180
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Dowding D, Lichtner V, Allcock N, Briggs M, James K, Keady J, Lasrado R, Sampson EL, Swarbrick C, José Closs S. Using sense-making theory to aid understanding of the recognition, assessment and management of pain in patients with dementia in acute hospital settings. Int J Nurs Stud 2016; 53:152-62. [DOI: 10.1016/j.ijnurstu.2015.08.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 07/07/2015] [Accepted: 08/21/2015] [Indexed: 11/26/2022]
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181
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Husebo BS, Achterberg W, Flo E. Identifying and Managing Pain in People with Alzheimer's Disease and Other Types of Dementia: A Systematic Review. CNS Drugs 2016; 30:481-97. [PMID: 27240869 PMCID: PMC4920848 DOI: 10.1007/s40263-016-0342-7] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Pain in patients with Alzheimer's disease is a complex issue; these patients suffer from the common causes of acute and chronic pain, and some also have neuropathic or nociceptive pain. Whatever the mechanism of pain in these patients, their pain will require careful assessment and management, to insure the correct type and level of analgesia is given. The objective of this systematic review was the identification of studies that have investigated the efficacy of different analgesics on pain intensity or pain-related behavior during nursing home stay and at the end of life. METHODS A search using pain, pain treatment, and dementia MESH terms and keywords was conducted (October 15, 2015) in MEDLINE, EMBASE, PsychINFO, CINAHL, and Cochrane libraries. RESULTS Our search yielded 3138 unique hits, published between 1990 and October 2015. We read titles and abstracts, identified 124 papers for full-text evaluation, and included 12 papers to reflect and synthesize the following questions: (1) Which pain assessment tools for people with dementia are responsive to change in pain intensity scores? (2) Which analgesics are efficacy-tested by controlled trials including people with dementia living in nursing homes, including at the end of life? (3) Which outcome measures have been used to identify pain, pain behavior, and/or treatment efficacy in people with dementia? CONCLUSION Despite increased use of analgesics, pain is still prevalent in people with dementia. Validated pain tools are available but not implemented and not fully tested on responsiveness to treatment. Official guidelines for pain assessment and treatment addressing people with dementia living in a nursing home are lacking. The efficacy of analgesic drug use on pain or neuropsychiatric behavior related to dementia has been hardly investigated.
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Affiliation(s)
- Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.
- Section for Nursing Home Medicine, Municipality of Bergen, Bergen, Norway.
| | - Wilco Achterberg
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Elisabeth Flo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
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182
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Ability of the Pain Recognition and Treatment (PRT) Protocol to Reduce Expressions of Pain among Institutionalized Residents with Dementia: A Cluster Randomized Controlled Trial. Pain Manag Nurs 2015; 17:14-24. [PMID: 26584896 DOI: 10.1016/j.pmn.2015.08.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 08/04/2015] [Accepted: 08/20/2015] [Indexed: 11/20/2022]
Abstract
Many strategies have been used to improve pain management in institutionalized care settings, but there is no consensus on the effects of these methods. The study purpose was to compare the effect of a Pain Recognition and Treatment (PRT) protocol coupled with basic pain education (experimental group) versus basic pain education alone (control group) in (1) improving the pain management performance of registered nurses (RNs) and (2) reducing pain-related expressions of residents with dementia postintervention and at 3-month follow up. A double-blind cluster randomized controlled trial with a 3-month follow-up period was conducted with 195 residents of six dementia special-care units. The weekly pain management performance of RNs (e.g., use of pharmacologic and nonpharmacologic strategies, use of referral) was recorded and weekly average scores of the pain-related expressions of residents were assessed using the following: the Verbal Descriptor Scale (VDS), Pain Assessment in Advanced Dementia Scale (PAINAD), and the Cohen-Mansfield Agitation Inventory (CMAI). The generalized linear mixed model analysis showed that, after intervention, the experimental group had significantly more weekly nonpharmacologic pain relief strategies and weekly referrals for pain management than the control group. Residents in the experimental group had significantly fewer verbal and behavioral expressions of pain compared to those in the control group. However, the groups did not differ significantly in the use of pharmacological strategies or the agitated behaviors expressed by residents. The PRT protocol is effective and is recommended for routine use in residents with dementia to improve the quality of pain care.
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183
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Husebo BS, Flo E, Aarsland D, Selbaek G, Testad I, Gulla C, Aasmul I, Ballard C. COSMOS--improving the quality of life in nursing home patients: protocol for an effectiveness-implementation cluster randomized clinical hybrid trial. Implement Sci 2015; 10:131. [PMID: 26374231 PMCID: PMC4572450 DOI: 10.1186/s13012-015-0310-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 08/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nursing home patients have complex mental and physical health problems, disabilities and social needs, combined with widespread prescription of psychotropic drugs. Preservation of their quality of life is an important goal. This can only be achieved within nursing homes that offer competent clinical conditions of treatment and care. COmmunication, Systematic assessment and treatment of pain, Medication review, Occupational therapy, Safety (COSMOS) is an effectiveness-implementation hybrid trial that combines and implements organization of activities evidence-based interventions to improve staff competence and thereby the patients' quality of life, mental health and safety. The aim of this paper is to describe the development, content and implementation process of the COSMOS trial. METHODS/DESIGN COSMOS includes a 2-month pilot study with 128 participants distributed among nine Norwegian nursing homes, and a 4-month multicenter, cluster randomized effectiveness-implementation clinical hybrid trial with follow-up at month 9, including 571 patients from 67 nursing home units (one unit defined as one cluster). Clusters are randomized to COSMOS intervention or current best practice (control group). The intervention group will receive a 2-day education program including written guidelines, repeated theoretical and practical training (credited education of caregivers, physicians and nursing home managers), case discussions and role play. The 1-day midway evaluation, information and interviews of nursing staff and a telephone hotline all support the implementation process. Outcome measures include quality of life in late-stage dementia, neuropsychiatric symptoms, activities of daily living, pain, depression, sleep, medication, cost-utility analysis, hospital admission and mortality. DISCUSSION Despite complex medical and psychosocial challenges, nursing home patients are often treated by staff possessing low level skills, lacking education and in facilities with a high staff turnover. Implementation of a research-based multicomponent intervention may improve staff's knowledge and competence and consequently the quality of life of nursing home patients in general and people with dementia in particular. TRIAL REGISTRATION ClinicalTrials.gov NCT02238652.
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Affiliation(s)
- Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly - and Nursing Home Medicine, University of Bergen, Kalfarveien 31, N-5020, Bergen, Norway.
- Centre for Elderly and Nursing Home Medicine, Stavanger University Hospital, Stavanger, Norway.
| | - Elisabeth Flo
- Department of Global Public Health and Primary Care, Centre for Elderly - and Nursing Home Medicine, University of Bergen, Kalfarveien 31, N-5020, Bergen, Norway.
| | - Dag Aarsland
- Centre for Elderly and Nursing Home Medicine, Stavanger University Hospital, Stavanger, Norway.
- Karolinska Institutet (KI), Department of Neurobiology, Care Sciences and Society, KI-Alzheimer Disease Research Center, Stockholm, Sweden.
| | - Geir Selbaek
- Norwegian National Advisory Unit of Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway.
- Centre for Old Age Psychiatry Research, Innlandet Hospital Trust, Ottestad, Norway.
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Ingelin Testad
- Centre for Elderly and Nursing Home Medicine, Stavanger University Hospital, Stavanger, Norway.
| | - Christine Gulla
- Department of Global Public Health and Primary Care, Centre for Elderly - and Nursing Home Medicine, University of Bergen, Kalfarveien 31, N-5020, Bergen, Norway.
| | - Irene Aasmul
- Department of Global Public Health and Primary Care, Centre for Elderly - and Nursing Home Medicine, University of Bergen, Kalfarveien 31, N-5020, Bergen, Norway.
| | - Clive Ballard
- Centre for Elderly and Nursing Home Medicine, Stavanger University Hospital, Stavanger, Norway.
- The Wolfson Wing & Hodgkin Building Guys Campus, Kings College, London, SE1 1UL, UK.
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Nixon J, Nelson EA, Rutherford C, Coleman S, Muir D, Keen J, McCabe C, Dealey C, Briggs M, Brown S, Collinson M, Hulme CT, Meads DM, McGinnis E, Patterson M, Czoski-Murray C, Pinkney L, Smith IL, Stevenson R, Stubbs N, Wilson L, Brown JM. Pressure UlceR Programme Of reSEarch (PURPOSE): using mixed methods (systematic reviews, prospective cohort, case study, consensus and psychometrics) to identify patient and organisational risk, develop a risk assessment tool and patient-reported outcome Quality of Life and Health Utility measures. PROGRAMME GRANTS FOR APPLIED RESEARCH 2015. [DOI: 10.3310/pgfar03060] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BackgroundThe Pressure UlceR Programme Of reSEarch (PURPOSE) consisted of two themes. Theme 1 focused on improving our understanding of individuals’ and organisational risk factors and on improving the quality of risk assessments (work packages 1–3) and theme 2 focused on developing patient-reported outcome measures (work packages 4 and 5).MethodsThe programme comprised 21 individual pieces of work. Pain: (1) multicentre pain prevalence study in acute hospitals, (2) multicentre pain prevalence study in community localities incorporating (3) a comparison of case-finding methods, and (4) multicentre, prospective cohort study. Severe pressure ulcers: (5) retrospective case study, (6) patient involvement workshop with the Pressure Ulcer Research Service User Network for the UK (PURSUN UK) and (7) development of root cause analysis methodology. Risk assessment: (8) systematic review, (9) consensus study, (10) conceptual framework development and theoretical causal pathway, (11) design and pretesting of draft Risk Assessment Framework and (12) field test to assess reliability, validity, data completeness and clinical usability. Quality of life: (13) conceptual framework development (systematic review, patient interviews), (14 and 15) provisional instrument development, with items generated from patient interviews [from (1) above] two systematic reviews and experts, (16) pretesting of the provisional Pressure Ulcer Quality of Life (PU-QOL) instrument using mixed methods, (17) field test 1 including (18) optimal mode of administration substudy and item reduction with testing of scale formation, acceptability, scaling assumptions, reliability and validity, and (19) field test 2 – final psychometric evaluation to test scale targeting, item response categories, item fit, response bias, acceptability, scaling assumptions, reliability and validity. Cost–utility: (20) time trade-off task valuations of health states derived from selected PU-QOL items, and (21) validation of the items selected and psychometric properties of the new Pressure Ulcer Quality of Life Utility Index (PUQOL-UI).Key findingsPain: prevalence studies – hospital and community patients experience both pressure area-related and pressure ulcer pain; pain cohort study – indicates that pain is independently predictive of category 2 (and above) pressure ulcer development. Severe pressure ulcers: these were more likely to develop in contexts in which clinicians failed to listen to patients/carers or recognise/respond to high risk or the presence of an existing pressure ulcer and services were not effectively co-ordinated; service users found the interactive workshop format valuable; including novel components (interviews with patients and carers) in root cause analysis improves the quality of the insights captured. Risk assessment: we developed a Pressure Ulcer Risk Assessment Framework, the PURPOSE-T, incorporating the Minimum Data Set, a screening stage, a full assessment stage, use of colour to support decision-making, and decision pathways that make a clear distinction between patients with an existing pressure ulcer(s) (or scarring from previous ulcers) who require secondary prevention and treatment and those at risk who require primary prevention (http://medhealth.leeds.ac.uk/accesspurposet). Quality of life: the final PU-QOL instrument consists of 10 scales to measure pain, exudate, odour, sleep, vitality, mobility/movement, daily activities, emotional well-being, self-consciousness and appearance, and participation (http://medhealth.leeds.ac.uk/puqol-ques). Cost–utility: seven items were selected from the PU-QOL instrument for inclusion in the PUQOL-UI (http://medhealth.leeds.ac.uk/puqol-ui); secondary study analysis indicated that item selection for the PUQOL-UI was appropriate and that the index was acceptable to patients and had adequate levels of validity.ConclusionsThe PURPOSE programme has provided important insights for pressure ulcer prevention and treatment and involvement of service users in research and development, with implications for patient and public involvement, clinical practice, quality/safety/health service management and research including replication of the pain risk factor study, work exploring ‘best practice’ settings, the impact of including skin status as an indicator for escalation of preventative interventions, further psychometric evaluation of PU-QOL and PUQOL-UI the measurement of ‘disease attribution.’FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Jane Nixon
- Clinical Trials Research Unit, School of Medicine, University of Leeds, Leeds, UK
| | | | - Claudia Rutherford
- Clinical Trials Research Unit, School of Medicine, University of Leeds, Leeds, UK
| | - Susanne Coleman
- Clinical Trials Research Unit, School of Medicine, University of Leeds, Leeds, UK
| | - Delia Muir
- Clinical Trials Research Unit, School of Medicine, University of Leeds, Leeds, UK
| | - Justin Keen
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Christopher McCabe
- Department of Emergency Medicine, University of Alberta Hospital, Edmonton, AB, Canada
| | - Carol Dealey
- Research and Development Team, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Nursing, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Michelle Briggs
- School of Health and Community Studies, Leeds Beckett University, Leeds, UK
| | - Sarah Brown
- Clinical Trials Research Unit, School of Medicine, University of Leeds, Leeds, UK
| | - Michelle Collinson
- Clinical Trials Research Unit, School of Medicine, University of Leeds, Leeds, UK
| | - Claire T Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - David M Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Elizabeth McGinnis
- Department of Tissue Viability, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Malcolm Patterson
- Sheffield University Management School, University of Sheffield, Sheffield, UK
| | - Carolyn Czoski-Murray
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Lisa Pinkney
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Isabelle L Smith
- Clinical Trials Research Unit, School of Medicine, University of Leeds, Leeds, UK
| | - Rebecca Stevenson
- Clinical Trials Research Unit, School of Medicine, University of Leeds, Leeds, UK
| | - Nikki Stubbs
- Wound Prevention and Management Service, Leeds Community Healthcare NHS Trust, Leeds, UK
| | - Lyn Wilson
- Clinical Trials Research Unit, School of Medicine, University of Leeds, Leeds, UK
- Research and Development Department, The Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Julia M Brown
- Clinical Trials Research Unit, School of Medicine, University of Leeds, Leeds, UK
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Abstract
Up to 80% of nursing home residents may be experiencing pain; however, in many cases their pain is not diagnosed and/or treated. People with moderate to severe dementia may have impaired communication, and this can impact on their self-report of pain. Drug treatment should be used cautiously. --This report is adapted from paineurope 2015; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be viewed via the Web site: www.paineurope.com , at which health professionals can find links to the original articles and request copies of the quarterly publication and access additional pain education and pain management resources.
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Baeta-Corral R, Defrin R, Pick CG, Giménez-Llort L. Tail-flick test response in 3×Tg-AD mice at early and advanced stages of disease. Neurosci Lett 2015; 600:158-63. [DOI: 10.1016/j.neulet.2015.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 05/26/2015] [Accepted: 06/02/2015] [Indexed: 12/15/2022]
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Stacpoole M, Hockley J, Thompsell A, Simard J, Volicer L. The Namaste Care programme can reduce behavioural symptoms in care home residents with advanced dementia. Int J Geriatr Psychiatry 2015; 30:702-9. [PMID: 25338971 DOI: 10.1002/gps.4211] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 08/12/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate the effects of the Namaste Care programme on the behavioural symptoms of residents with advanced dementia in care homes and their pain management. METHODS Six dementia care homes collaborated in an action research study-one withdrew. Inclusion criteria were a dementia diagnosis and a Bedford Alzheimer's Nursing Severity Scale score of >16. Primary research measures were the Neuropsychiatric Inventory-Nursing Homes (NPI-NH) and Doloplus-2 behavioural pain assessment scale for the elderly. Measures were recorded at baseline and at three 1-2 monthly intervals after Namaste Care started. RESULTS Management disruption occurred across all care homes. The severity of behavioural symptoms, pain and occupational disruptiveness (NPI-NH) decreased in four care homes. Increased severity of behavioural symptoms in one care home was probably related to poor pain management, reflected in increased pain scores, and disrupted leadership. Comparison of NPI-NH scores showed that severity of behavioural symptoms and occupational disruptiveness were significantly lower after initiation of Namaste Care (n = 34, p < 0.001) and after the second interval (n = 32, p < 0.001 and p = 0.003). However, comparison of these measures in the second and third intervals revealed that both were slightly increased in the third interval (n = 24, p < 0.001 and p = 0.001). CONCLUSIONS Where there are strong leadership, adequate staffing, and good nursing and medical care, the Namaste Care programme can improve quality of life for people with advanced dementia in care homes by decreasing behavioural symptoms. Namaste is not a substitute for good clinical care.
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Affiliation(s)
| | - Jo Hockley
- Care Home Project Team, St Christopher's Hospice, London, UK
| | | | - Joyce Simard
- School of Nursing and Midwifery, University of Western Sydney, Sydney, Australia
| | - Ladislav Volicer
- School of Ageing Studies, University of South Florida, Tampa, Florida, USA
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Flo E, Gulla C, Husebo BS. Effective pain management in patients with dementia: benefits beyond pain? Drugs Aging 2015; 31:863-71. [PMID: 25373921 DOI: 10.1007/s40266-014-0222-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This current opinion aims to provide a literature overview of the associations between pain and neuropsychiatric symptoms and the efficacy of pain management for both pain and neuropsychiatric symptoms in patients with dementia. In addition, international guidelines and recommendations for pain management have been collated, and important developing research areas are highlighted. Pain is, in general, under-recognized and undertreated in people with dementia and may therefore trigger or exacerbate neuropsychiatric symptoms. While there is an abundance of pain assessment instruments intended for people with dementia, few have been adequately tested for their feasibility, reliability and validity. In patients with dementia, vocalizations, facial expressions and body movements may be the only valid expressions of pain. Further, pain has been related to the neuropsychiatric symptoms of agitation, aggression, mood syndrome and sleep problems. Unfortunately, health personnel may misinterpret these symptoms as neuropsychiatric symptoms of dementia. A differential assessment of dementia, its presenting neuropsychiatric symptoms and the potential presence of pain is crucial to provide the correct treatment. To achieve this, use of pain assessment tools that are responsive to change and are validated for use in patients with dementia is a prerequisite. To date, there have been few studies, with inconsistent findings on the association between pain and neuropsychiatric symptoms. To ensure a better differential assessment of pain and neuropsychiatric symptoms, and consequently more accurate treatment for patients with dementia, studies with adequate statistical power and high-quality study designs, including randomized controlled trials, are needed.
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Affiliation(s)
- Elisabeth Flo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Pbox 7800, 5020, Bergen, Norway,
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Fin de vie et démence dans les établissements d’hébergement pour personnes âgées dépendantes. MÉDECINE PALLIATIVE : SOINS DE SUPPORT - ACCOMPAGNEMENT - ÉTHIQUE 2015. [DOI: 10.1016/j.medpal.2015.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Lee KH, McConnell ES, Knafl GJ, Algase DL. Pain and psychological well-being among people with dementia in long-term care. PAIN MEDICINE (MALDEN, MASS.) 2015; 16:1083-9. [PMID: 25800276 PMCID: PMC4478238 DOI: 10.1111/pme.12739] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine the relationship between self-reported pain and psychological well-being of people with dementia (PWD) living in residential long-term care as indicated by displays of observed emotional expression over the daytime period. DESIGN Secondary analysis using repeated measures of self-report and observational data. SETTING AND SUBJECTS A total of 177 PWD were included from 17 nursing homes and six assisted living facilities in Michigan and Pennsylvania. METHODS Negative emotional expression was used as an indicator of reduced psychological well-being. Pain was assessed through PWD's response to a question about presence of pain obtained at each observation. Cognitive impairment was assessed using the Mini-Mental Status Examination. Linear mixed models were used that accounted for correlation of negative emotional expression measurements over time for each participant and between participants within the same facility. RESULTS Among 171 participants who were able to express their pain, 44% of PWD reported pain once or more during the daytime period. Severity of cognitive impairment was related to expression of negative emotion. PWD with pain displayed more negative emotional expression than PWD without pain. CONCLUSIONS Routine pain assessment is feasible among PWD with moderate to severe dementia and positive report of pain is associated with greater observed negative emotional expression, an indicator of reduced psychological well-being. Improving pain management holds potential for enhancing psychological well-being among PWD living in residential long-term care.
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Affiliation(s)
- Kyung Hee Lee
- Boston College, Connell School of Nursing, Chestnut Hill, MA, USA
| | - Eleanor S McConnell
- Duke University, School of Nursing, Clinical Nurse Researcher, Geriatric Research, Education and Clinical Center (GRECC), Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - George J Knafl
- University of North Carolina, Chapel Hill, School of Nursing, Chapel Hill, NC, USA
| | - Donna L Algase
- University of Michigan, School of Nursing, Ann Arbor, MI, USA
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Rodger KTM, Greasley-Adams C, Hodge Z, Reynish E. Expert opinion on the management of pain in hospitalised older patients with cognitive impairment: a mixed methods analysis of a national survey. BMC Geriatr 2015; 15:56. [PMID: 25928876 PMCID: PMC4419491 DOI: 10.1186/s12877-015-0056-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 04/22/2015] [Indexed: 11/14/2022] Open
Abstract
Background Hospitalised older patients are complex. Comorbidity and polypharmacy complicate frailty. Significant numbers have dementia and/or cognitive impairment. Pain is highly prevalent. The evidence base for pain management in cognitively impaired individuals is sparse due to methodological issues. A wealth of expert opinion is recognised potentially providing a useful evidence base for guiding clinical practice. The study aimed to gather expert opinion on pain management in cognitively impaired hospitalised older people. Methods Consultant Geriatricians listed as dementia leads in the National Dementia Audit were contacted electronically and invited to respond. The questionnaire sought information on their role, confidence and approach to pain management in cognitively impaired hospitalised patients. Responses were analysed using a mixed methods approach. Results Respondents considered themselves very confident in the clinical field. Awareness of potential to do harm was highly evident. Unequivocally responses suggested paracetamol is safe and should be first choice analgesic, newer opiates should be used preferentially in renal impairment and nefopam is unsafe. A grading of the safety profile of specific medications became apparent, prompting requirement for further evaluation and holistic assessment. Conclusion The lack of consensus reached highlights the complexity of this clinical field. The use of paracetamol first line, newer opiates in renal impairment and avoidance of nefopam are immediately transferrable to clinical practice. Further review, evaluation and comparison of the risks associated with other specific analgesics are necessary before a comprehensive clinical guideline can be produced. Electronic supplementary material The online version of this article (doi:10.1186/s12877-015-0056-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kirsty T M Rodger
- Department of Geriatric Medicine, NHS Fife, Victoria Hospital, Hayfield Road, Kirkcaldy, KY2 5AH, UK.
| | - Corinne Greasley-Adams
- School of Applied Social Science, University of Stirling, Colin Bell Building, Stirling, FK9 4LA, UK.
| | - Zoe Hodge
- Acute Pain Service, NHS Fife, Victoria Hospital, Hayfield Road, Kirkcaldy, KY2 5AH, UK.
| | - Emma Reynish
- Department of Geriatric Medicine, NHS Fife, Victoria Hospital, Hayfield Road, Kirkcaldy, KY2 5AH, UK. .,School of Applied Social Science, University of Stirling, Colin Bell Building, Stirling, FK9 4LA, UK.
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193
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van Dalen-Kok AH, Pieper MJC, de Waal MWM, Lukas A, Husebo BS, Achterberg WP. Association between pain, neuropsychiatric symptoms, and physical function in dementia: a systematic review and meta-analysis. BMC Geriatr 2015; 15:49. [PMID: 25928621 PMCID: PMC4409739 DOI: 10.1186/s12877-015-0048-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 04/01/2015] [Indexed: 12/24/2022] Open
Abstract
Background Pain, neuropsychiatric symptoms (NPS) and functional impairment are prevalent in patients with dementia and pain is hypothesized to be causal in both neuropsychiatric symptoms (NPS) and functional impairment. As the exact nature of the associations is unknown, this review examines the strength of associations between pain and NPS, and pain and physical function in patients with dementia. Special attention is paid to the description of measurement instruments and the methods used to detect pain, NPS and physical function. Methods A systematic search was made in the databases of PubMed (Medline), Embase, Cochrane, Cinahl, PsychINFO, and Web of Science. Studies were included that described associations between pain and NPS and/or physical function in patients with moderate to severe dementia. Results The search yielded 22 articles describing 18 studies, including two longitudinal studies. Most evidence was found for the association between pain and depression, followed by the association between pain and agitation/aggression. The longitudinal studies reported no direct effects between pain and NPS but some indirect effects, e.g. pain through depression. Although some association was established between pain and NPS, and pain and physical function, the strength of associations was relatively weak. Interestingly, only three studies used an observer rating scale for pain-related behaviour. Conclusions Available evidence does not support strong associations between pain, NPS and physical function. This might be due to inadequate use or lack of rating scales to detect pain-related behaviour. These results show that the relationship between pain and NPS, as well as with physical function, is complicated and warrants additional longitudinal evaluation. Electronic supplementary material The online version of this article (doi:10.1186/s12877-015-0048-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annelore H van Dalen-Kok
- Department of Public Health and Primary Care, Leiden University Medical Centre, Hippocratespad 21 Post zone V0-P, PO Box 9600, Leiden, RC, 2300, The Netherlands.
| | - Marjoleine J C Pieper
- Department of Public Health and Primary Care, Leiden University Medical Centre, Hippocratespad 21 Post zone V0-P, PO Box 9600, Leiden, RC, 2300, The Netherlands. .,Department of General Practice & Elderly Care Medicine, VU University Medical Centre Amsterdam, van der Boechorststraat 7, Amsterdam, BT, 1081, The Netherlands.
| | - Margot W M de Waal
- Department of Public Health and Primary Care, Leiden University Medical Centre, Hippocratespad 21 Post zone V0-P, PO Box 9600, Leiden, RC, 2300, The Netherlands.
| | - Albert Lukas
- Malteser Hospital Bonn/Rhein-Sieg, Centre of Geriatric Medicine, Academic Hospital University of Bonn, Von-Hompesch-Straße 1, Bonn, 53123, Germany.
| | - Bettina S Husebo
- Department of Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway. .,Stavanger University Hospital, Bergen, Norway.
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Centre, Hippocratespad 21 Post zone V0-P, PO Box 9600, Leiden, RC, 2300, The Netherlands.
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van Kooten J, Delwel S, Binnekade TT, Smalbrugge M, van der Wouden JC, Perez RSGM, Rhebergen D, Zuurmond WWA, Stek ML, Lobbezoo F, Hertogh CMPM, Scherder EJA. Pain in dementia: prevalence and associated factors: protocol of a multidisciplinary study. BMC Geriatr 2015; 15:29. [PMID: 25879681 PMCID: PMC4436741 DOI: 10.1186/s12877-015-0025-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/02/2015] [Indexed: 01/28/2023] Open
Abstract
Background Pain is a common problem in people with dementia, however the exact prevalence of pain in dementia subtypes, e.g. Alzheimer’s Disease (AD), Vascular Dementia (VaD), Frontotemporal Dementia (FTD) and dementia with Lewy Bodies (DLB), is unknown, as is the relation between pain and the different subtypes of dementia. In this study, the prevalence of pain in people with dementia will be investigated per dementia subtype and the relationship between the various subtypes of dementia and the presence of specific types of pain (i.e. musculoskeletal pain, neuropathic pain and orofacial pain) will be examined. Secondly, associations between various types of pain, cognitive functioning, neuropsychiatric symptoms and quality of life in people with dementia will be examined. A third purpose is to study the value of the assessment of autonomic responses in assessing pain in people with dementia. Finally, the effect of feedback to the attending physician on the presence of pain, based on examination by investigators with backgrounds in neuropsychology, geriatric dentistry and elderly care medicine, will be evaluated. Methods/Design A cross-sectional, partially longitudinal observational study in 400 participants with dementia, aged 60 years and older. Participants will be recruited from an outpatient memory clinic and dementia special care units. All participants will be examined by an elderly care medicine trainee, a dentist with experience in geriatric dentistry, and a neuropsychologist. The primary outcome is presence of pain. Secondary outcomes will include oral health, autonomic responses to pain stimulus, vital sensibility and gnostic sensibility, musculoskeletal examination, cognitive functioning, neuropsychiatric symptoms, and quality of life. Discussion This study will help to enhance our knowledge regarding the prevalence of different types of pain in different dementia subtypes i.e. AD, VaD, FTD and DLB. This study also aims to contribute to a better understanding of oral health status in people with dementia, the use of autonomic responses in the assessment of pain in people with dementia and the relationships between pain and cognitive symptoms, neuropsychiatric symptoms and quality of life in people with various dementia subtypes and in different stages of the disease.
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Affiliation(s)
- Janine van Kooten
- Department of General Practice and Elderly Care Medicine and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
| | - Suzanne Delwel
- Department of Clinical Neuropsychology VU University, Amsterdam, The Netherlands. .,Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands.
| | - Tarik T Binnekade
- Department of Clinical Neuropsychology VU University, Amsterdam, The Netherlands.
| | - Martin Smalbrugge
- Department of General Practice and Elderly Care Medicine and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
| | - Johannes C van der Wouden
- Department of General Practice and Elderly Care Medicine and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
| | - Roberto S G M Perez
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands.
| | - Didi Rhebergen
- GGZ InGeest /Department of Psychiatry and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Wouter W A Zuurmond
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands.
| | - Max L Stek
- GGZ InGeest /Department of Psychiatry and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Frank Lobbezoo
- Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands.
| | - Cees M P M Hertogh
- Department of General Practice and Elderly Care Medicine and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
| | - Erik J A Scherder
- Department of Clinical Neuropsychology VU University, Amsterdam, The Netherlands.
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195
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Trawalter S, Hoffman KM. Got Pain? Racial Bias in Perceptions of Pain. SOCIAL AND PERSONALITY PSYCHOLOGY COMPASS 2015. [DOI: 10.1111/spc3.12161] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Sophie Trawalter
- Frank Batten School of Leadership and Public Policy; University of Virginia
- Department of Psychology; University of Virginia
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196
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Hendriks SA, Smalbrugge M, Galindo-Garre F, Hertogh CMPM, van der Steen JT. From admission to death: prevalence and course of pain, agitation, and shortness of breath, and treatment of these symptoms in nursing home residents with dementia. J Am Med Dir Assoc 2015; 16:475-81. [PMID: 25736822 DOI: 10.1016/j.jamda.2014.12.016] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/18/2014] [Accepted: 12/19/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Burdensome symptoms frequently develop as part of the dementia trajectory and influence quality of life. We explore the course of symptoms and their treatment during nursing home stay to help target adequate symptom management. DESIGN Data were collected as part of the Dutch End of Life in Dementia study, a longitudinal observational study with up to 3.5 years of follow-up. Physicians performed assessments at baseline, semiannually, and shortly after death of pain, agitation, shortness of breath, and treatment provided for these symptoms. SETTING Long-term care facilities (28) in the Netherlands. PARTICIPANTS Newly admitted nursing home residents (372) in variable stages of dementia. MEASUREMENTS We described prevalence and course of symptoms, and treatment provided for these symptoms. We used generalized estimating equations to evaluate the longitudinal change in symptoms and their treatment, and the associations between the symptoms of pain and agitation, as well as between stage of dementia and symptoms. RESULTS Pain was common (varying from 47% to 68% across the semiannual assessments) and frequently persistent (36%-41% of all residents); it increased to 78% in the last week of life. Agitation was the most common symptom (57%-71%), and also frequently persistent (39%-53%), yet it decreased to 35% in the last week of life. Shortness of breath was less common (16%-26%), but it increased to 52% at the end of life. Pain was not significantly associated with agitation. Advanced dementia was associated with more pain only. Treatment changed in particular at the end of life. Pain was treated mostly with acetaminophen (34%-52%), and at the end of life with parenteral opioids (44%). Agitation was mostly treated nonpharmacologically (78%-92%), and at the end of life anxiolytics were the most frequently prescribed treatment (62%). Overall, aerosolized bronchodilators were the most frequently prescribed treatment for shortness of breath (29%-67%), but at the end of life, this was morphine (69%). CONCLUSION Pain and agitation were common and frequently persisted in residents with dementia during nursing home stay, but symptom management intensified only at the end of life. Symptom control may be suboptimal from admission, and a stronger focus on symptom control is needed at an earlier stage than the end of life.
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Affiliation(s)
- Simone A Hendriks
- Department of General Practice and Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Martin Smalbrugge
- Department of General Practice and Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Francisca Galindo-Garre
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of General Practice and Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Jenny T van der Steen
- Department of General Practice and Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
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197
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Adherence of pain assessment to the German national standard for pain management in 12 nursing homes. Pain Res Manag 2015; 19:133-40. [PMID: 24851238 DOI: 10.1155/2014/785765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pain is very common among nursing home residents. The assessment of pain is a prerequisite for effective multiprofessional pain management. Within the framework of the German health services research project, 'Action Alliance Pain-Free City Muenster', the authors investigated pain assessment adherence according to the German national Expert Standard for Pain Management in Nursing, which is a general standard applicable to all chronic⁄acute pain-affected persons and highly recommended for practice. OBJECTIVES To evaluate the state of pain assessment and to identify need for improvement in 12 nursing homes in a German city. METHODS In the present study, the authors used an ex-post-facto design (survey methodology). Available written policies for routine pain assessment in residents ≥65 years of age were reviewed and a standardized online survey completed by 151 of 349 nurses in 12 nursing home facilities was conducted between September 2010 and April 2011. RESULTS Most of the included nursing homes provided written policies for pain assessment, and the majority of nurses reported that they assess and regularly reassess pain. However, observational tools for residents with severe cognitive impairment and written reassessment schedules were lacking in many facilities or were inconsistent. CONCLUSIONS Essentially, pain assessment appeared to be feasible in the majority of the German nursing homes studied. However, the absence or inconsistency of reassessment schedules indicate that pain management guidelines should include a detailed and explicit reassessment schedule for the heterogenic needs of nursing home residents. For residents with severe cognitive impairment, assessment tools are needed that are simple to use and clearly indicate the presence or absence of pain.
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Booker S“S, Herr K. The State-of-“Cultural Validity” of Self-Report Pain Assessment Tools in Diverse Older Adults: Table 1. PAIN MEDICINE 2015; 16:232-9. [DOI: 10.1111/pme.12496] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lichtner V, Dowding D, Esterhuizen P, Closs SJ, Long AF, Corbett A, Briggs M. Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools. BMC Geriatr 2014; 14:138. [PMID: 25519741 PMCID: PMC4289543 DOI: 10.1186/1471-2318-14-138] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 12/11/2014] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is evidence of under-detection and poor management of pain in patients with dementia, in both long-term and acute care. Accurate assessment of pain in people with dementia is challenging and pain assessment tools have received considerable attention over the years, with an increasing number of tools made available. Systematic reviews on the evidence of their validity and utility mostly compare different sets of tools. This review of systematic reviews analyses and summarises evidence concerning the psychometric properties and clinical utility of pain assessment tools in adults with dementia or cognitive impairment. METHODS We searched for systematic reviews of pain assessment tools providing evidence of reliability, validity and clinical utility. Two reviewers independently assessed each review and extracted data from them, with a third reviewer mediating when consensus was not reached. Analysis of the data was carried out collaboratively. The reviews were synthesised using a narrative synthesis approach. RESULTS We retrieved 441 potentially eligible reviews, 23 met the criteria for inclusion and 8 provided data for extraction. Each review evaluated between 8 and 13 tools, in aggregate providing evidence on a total of 28 tools. The quality of the reviews varied and the reporting often lacked sufficient methodological detail for quality assessment. The 28 tools appear to have been studied in a variety of settings and with varied types of patients. The reviews identified several methodological limitations across the original studies. The lack of a 'gold standard' significantly hinders the evaluation of tools' validity. Most importantly, the samples were small providing limited evidence for use of any of the tools across settings or populations. CONCLUSIONS There are a considerable number of pain assessment tools available for use with the elderly cognitive impaired population. However there is limited evidence about their reliability, validity and clinical utility. On the basis of this review no one tool can be recommended given the existing evidence.
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Affiliation(s)
| | - Dawn Dowding
- />Columbia University School of Nursing, 617 West 168th Street, New York, NY 10032 USA
- />Center for Home Care Policy and Research, Visiting Nurse Service of New York, 5 Penn Plaza, New York, NY 10001 USA
| | | | - S José Closs
- />School of Healthcare, University of Leeds, Leeds, UK
| | - Andrew F Long
- />School of Healthcare, University of Leeds, Leeds, UK
| | - Anne Corbett
- />Wolfson Centre for Age-Related Diseases, King’s College London, London, SE1 1UL UK
| | - Michelle Briggs
- />Institute of Health and Wellbeing, Leeds Beckett University, Leeds, UK
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Corbett A, Achterberg W, Husebo B, Lobbezoo F, de Vet H, Kunz M, Strand L, Constantinou M, Tudose C, Kappesser J, de Waal M, Lautenbacher S. An international road map to improve pain assessment in people with impaired cognition: the development of the Pain Assessment in Impaired Cognition (PAIC) meta-tool. BMC Neurol 2014; 14:229. [PMID: 25726717 PMCID: PMC4279897 DOI: 10.1186/s12883-014-0229-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 11/19/2014] [Indexed: 11/11/2022] Open
Abstract
Background Pain is common in people with dementia, yet identification is challenging. A number of pain assessment tools exist, utilizing observation of pain-related behaviours, vocalizations and facial expressions. Whilst they have been developed robustly, these often lack sufficient evidence of psychometric properties, like reliability, face and construct validity, responsiveness and usability, and are not internationally implemented. The EU-COST initiative “Pain in impaired cognition, especially dementia” aims to combine the expertise of clinicians and researchers to address this important issue by building on previous research in the area, identifying existing pain assessment tools for dementia, and developing consensus for items for a new universal meta-tool for use in research and clinical settings. This paper reports on the initial phase of this collaboration task. Methods All existing observational pain behaviour tools were identified and elements categorised using a three-step reduction process. Selection and refinement of items for the draft Pain Assessment in Impaired Cognition (PAIC) meta-tool was achieved through scrutiny of the evidence, consensus of expert opinion, frequency of use and alignment with the American Geriatric Society guidelines. The main aim of this process was to identify key items with potential empirical, rather than theoretical value to take forward for testing. Results 12 eligible assessment tools were identified, and pain items categorised according to behaviour, facial expression and vocalisation according to the AGS guidelines (Domains 1 – 3). This has been refined to create the PAIC meta-tool for validation and further refinement. A decision was made to create a supporting comprehensive toolkit to support the core assessment tool to provide additional resources for the assessment of overlapping symptoms in dementia, including AGS domains four to six, identification of specific types of pain and assessment of duration and location of pain. Conclusions This multidisciplinary, cross-cultural initiative has created a draft meta-tool for capturing pain behaviour to be used across languages and culture, based on the most promising items used in existing tools. The draft PAIC meta-tool will now be taken forward for evaluation according to COSMIN guidelines and the EU-COST protocol in order to exclude invalid items, refine included items and optimise the meta-tool. Electronic supplementary material The online version of this article (doi:10.1186/s12883-014-0229-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anne Corbett
- Wolfson Centre for Age-Related Diseases, Kings College London, London, UK.
| | - Wilco Achterberg
- Department of Public Health and Primary care medicine, Leiden University Medical Center & EU COST Vice-Chair, Leiden, The Netherlands.
| | - Bettina Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway. .,Center for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway.
| | - Frank Lobbezoo
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands.
| | - Henrica de Vet
- Department of Epidemiology & Biostatistics, EMGO Institute for Health and Care Research, VU University medical center, Amsterdam, The Netherlands.
| | - Miriam Kunz
- Department of Physiological Psychology, University of Bamberg, Bamberg, Germany.
| | - Liv Strand
- Department of Global Public Health and Primary Care, Physiotherapy Research Group, University of Bergen, Bergen, Norway.
| | - Marios Constantinou
- Social Sciences Department & Center for Cognitive and Behavioral Psychology (CCBP), University of Nicosia, Nicosia, Cyprus.
| | - Catalina Tudose
- Department of Neurology, Neurosurgery and Psychiatry, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.
| | - Judith Kappesser
- Department of Clinical Psychology, University of Giessen, Giessen, Germany.
| | - Margot de Waal
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.
| | - Stefan Lautenbacher
- Department of Physiological Psychology, University of Bamberg, Bamberg, Germany.
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