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Esteban-Burgos AA, Hueso-Montoro C, Mota-Romero E, Montoya-Juarez R, Gomez-Batiste X, Garcia-Caro MP. The prognostic value of the NECPAL instrument, Palliative Prognostic Index, and PROFUND index in elderly residents of nursing homes with advanced chronic condition. BMC Geriatr 2023; 23:715. [PMID: 37924015 PMCID: PMC10623722 DOI: 10.1186/s12877-023-04409-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 10/15/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND It is essential to assess the need for palliative care and the life prognosis of elderly nursing home residents with an advanced chronic condition, and the NECPAL ICO-CCOMS©4.0 prognostic instrument may be adequate for both purposes. The objective of this study was to examine the predictive capacity of NECPAL, the Palliative Prognosis Index, and the PROFUND index in elderly residents with advanced chronic condition with and without dementia, comparing their results at different time points. METHODS This prospective observational study was undertaken in eight nursing homes, following the survival of 146 residents with advanced chronic condition (46.6% with dementia) at 3, 6, 12, and 24 months. The capacity of the three instruments to predict mortality was evaluated by calculating the area under the receiver operating characteristic curve (AUC), with 95% confidence interval, for the global population and separately for residents with and without dementia. RESULTS The mean age of residents was 84.63 years (± 8.989 yrs); 67.8% were female. The highest predictive capacity was found for PROFUND at 3 months (95%CI: 0.526-0.756; p = 0.016), for PROFUND and NECPAL at 12 months (non-significant; AUC > 0.5), and NECPAL at 24 months (close-to-significant (AUC = 0.624; 95% CI: 0.499-0.750; p = 0.053). The highest capacity at 12 months was obtained using PROFUND in residents with dementia (AUC = 0.698; 95%CI: 0.566-0.829; p = 0.003) and NECPAL in residents without dementia (non-significant; AUC = 0.649; 95%CI: 0.432-0.867; p = 0.178). Significant differences in AUC values were observed between PROFUND at 12 (p = 0.017) and 24 (p = 0.028) months. CONCLUSIONS PROFUND offers the most accurate prediction of survival in elderly care home residents with advanced chronic condition overall and in those with dementia, especially over the short term, whereas NECPAL ICO-CCOMS©4.0 appears to be the most useful to predict the long-term survival of residents without dementia. These results support early evaluation of the need for palliative care in elderly care home residents with advanced chronic condition.
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Affiliation(s)
- Ana Alejandra Esteban-Burgos
- Departamento de Enfermería, Universidad de Jaén, Jaén, Spain
- Instituto Investigación Biosanitaria Granada (IBS), Granada, Spain
- Programa de Doctorado en Medicina Clínica y Salud Pública, Universidad de Granada, Granada, Spain
| | - César Hueso-Montoro
- Departamento de Enfermería, Universidad de Jaén, Jaén, Spain
- Instituto Investigación Biosanitaria Granada (IBS), Granada, Spain
| | - Emilio Mota-Romero
- Instituto Investigación Biosanitaria Granada (IBS), Granada, Spain
- Centro de Salud Salvador Caballero. Distrito Sanitario Granada-Metropolitano. Servicio Andaluz de Salud, Granada, Spain
- Departamento de Enfermería, Universidad de Granada, Granada, Spain
| | - Rafael Montoya-Juarez
- Instituto Investigación Biosanitaria Granada (IBS), Granada, Spain.
- Departamento de Enfermería, Universidad de Granada, Granada, Spain.
- Centro de Investigación Mente, Cerebro y Comportamiento (CIMCYC), Universidad de Granada, Granada, Spain.
| | - Xavier Gomez-Batiste
- Cátedra de Cuidados Paliativos, Universitat de Vic-Universitat Central de Catalunya (UVIC-UCC), Barcelona, Spain
| | - María Paz Garcia-Caro
- Instituto Investigación Biosanitaria Granada (IBS), Granada, Spain
- Departamento de Enfermería, Universidad de Granada, Granada, Spain
- Centro de Investigación Mente, Cerebro y Comportamiento (CIMCYC), Universidad de Granada, Granada, Spain
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Malhotra C, Balasubramanian I. Instability in Caregivers' Perception of Dementia as a Terminal Disease. J Am Med Dir Assoc 2023; 24:1427-1432. [PMID: 37567244 DOI: 10.1016/j.jamda.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/29/2023] [Accepted: 07/02/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVES Family caregivers' perception that dementia is a terminal disease influence end-of-life (EoL) care of persons with severe dementia (PwSDs). Yet, this perception and the extent to which it changes over time is underexplored. We assessed PwSD caregivers' perception of dementia as a terminal disease and changes in this perception over time. DESIGN Prospective cohort. SETTING AND PARTICIPANTS Two hundred fifteen primary informal caregivers of community-dwelling PWSDs in Singapore were surveyed every 4 months over a period of 16 months. METHODS We assessed the proportion of caregivers who perceived that dementia is a terminal disease and the extent to which it changed between the previous time points. Using mixed effects multinomial regression models, we assessed factors associated with caregivers' perception and changes in perception between consecutive time points. RESULTS At baseline, only 26% of the caregivers reported correctly that dementia is a terminal disease. This changed over time, not necessarily toward a correct perception. Caregivers of PwSDs with an acute medical condition in the last 4 months (risk ratio [RR] 2.19, 95% CI 1.21, 3.97) and those with higher functional dependence (RR 1.11, 95% CI 1.01,1.22) were more likely and those of older PwSDs were less likely (RR 0.87, 95% CI 0.81, 0.93) to perceive dementia as a terminal disease. Caregivers of PwSDs who had experienced an acute medical problem in the last 4 months (RR 1.58, 95% CI 1.00, 2.49) were also more likely to shift their perception toward being correct. Caregivers of PwSDs who had more agitation behaviors were more likely to shift their perception toward being incorrect (RR 1.04, 95% CI 1.00,1.07) CONCLUSIONS AND IMPLICATIONS: Few caregivers perceived dementia as terminal, and this perception changed over time and differed according to age and the health status of PwSD. Results have implications regarding the frequency of prognostic discussions.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore; Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore.
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Volle D. Dementia Care at the End of Life: A Clinically Focused Review. Am J Geriatr Psychiatry 2023; 31:291-303. [PMID: 36456444 DOI: 10.1016/j.jagp.2022.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
With the geriatric population in the United States growing rapidly, the prevalence of dementia is expected to rise concomitantly. As dementia is an invariably progressive and terminal illness, planning for and managing end of life care in dementia is an important part of the overall process of dementia care. Unfortunately, this is often neglected outside of formal palliative and hospice medicine training programs and geriatric psychiatrists are left without preparation on how to manage, as well as counsel patients and families on, this important phase of dementia care. This review aims to explore the potential contributors to this historic disparity in geriatric education and care delivery, as well as its impact, while also attempting to shift the field's focus toward a palliative approach to dementia care. To begin to accomplish this, this review explores the natural illness history/disease trajectory of the various dementing illnesses, as well as the topic of prognostication as it pertains to the end of life for patients with dementia and how this information can be used in advanced care planning and symptom management.
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Affiliation(s)
- Dax Volle
- Department of Psychiatry (DV), Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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4
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Arahata M, Asakura H, Morishita E, Minami S, Shimizu Y. Identification and Prognostication of End-of-Life State Using a Japanese Guideline-Based Diagnostic Method: A Diagnostic Accuracy Study. Int J Gen Med 2023; 16:23-36. [PMID: 36636714 PMCID: PMC9830418 DOI: 10.2147/ijgm.s392963] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/26/2022] [Indexed: 01/05/2023] Open
Abstract
Purpose Prognostic uncertainty can be a barrier to providing palliative care. Accurate prognostic estimation for patients at the end of life is challenging. This study aimed to evaluate the accuracy of end-of-life diagnosis using our unique diagnostic method. Patients and Methods A retrospective longitudinal observational study was conducted through collaboration among three medical facilities in a rural super-aged community in Japan. In 2007, we established a unique end-of-life diagnostic process comprising (1) physicians' judgement, (2) disclosure to patients, and (3) discussion at an end-of-life case conference (EOL-CC), based on Japanese end-of-life-related guidelines. Research subjects were consecutive patients discussed in EOL-CC between January 1, 2010, and September 30, 2017. The primary outcome was mortality within 6 months after the initial EOL-CC decision. Sensitivity, specificity, and diagnostic odds ratio were calculated using EOL-CC diagnosis (end-of-life or non-end-of-life) as an index test and overall survival (<6 months or ≥6 months) as a reference standard. Results In total, 315 patients were eligible for survival analysis (median age 89, range 54-107). The study population was limited to patients with severe conditions such as advanced cancer, organ failures, advanced dementia with severe deterioration in functioning. EOL-diagnosis by our methods was associated with much lower survival rate at 6 months after EOL-CC than non-EOL-diagnosis (6.9% vs 43.5%; P < 0.001). Of the patients, 297 were eligible for diagnostic accuracy analysis (median age 89, range 54-107). The EOL-diagnosis showed high sensitivity (0.95; 95% confidence interval [CI] 0.92-0.97) but low specificity (0.35; 95% CI 0.20-0.53) against the outcomes. It also showed a high diagnostic odds ratio (10.32; 95% CI 4.08-26.13). Conclusion The diagnostic process using the Japanese end-of-life guidelines had tolerable accuracy in identification and prognostication of end of life.
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Affiliation(s)
- Masahisa Arahata
- Department of General Medicine, Nanto Municipal Hospital, Nanto, Toyama, Japan,Department of Internal Medicine, Nanto Municipal Hospital, Nanto, Toyama, Japan,Correspondence: Masahisa Arahata, Department of Internal Medicine, Nanto Municipal Hospital, 938 Inami, Nanto, Toyama, 932-0211, Japan, Tel +81 763 82 1475, Fax +81 763 82 1853, Email
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Eriko Morishita
- Department of Clinical Laboratory Science, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Shinji Minami
- Department of Internal Medicine, Nanto Municipal Hospital, Nanto, Toyama, Japan
| | - Yukihiro Shimizu
- Department of Internal Medicine, Nanto Municipal Hospital, Nanto, Toyama, Japan
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Arendts G, Chenoweth L, Hayes BJ, Campbell E, Agar M, Etherton-Beer C, Spilsbury K, Howard K, Braitberg G, Cubitt M, Sheehan C, Magann L, Sudharshan T, Schnitker LM, Pearce J, Gilmore I, Cerra N, duPreez J, Jaworski R, Soh SC, Celenza A. CELPI: trial protocol for a randomised controlled trial of a Carer End of Life Planning Intervention in people dying with dementia. BMC Geriatr 2022; 22:869. [PMID: 36384478 PMCID: PMC9670369 DOI: 10.1186/s12877-022-03534-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background Dementia is a leading cause of death in developed nations. Despite an often distressing and symptom laden end of life, there are systematic barriers to accessing palliative care in older people dying of dementia. Evidence exists that 70% of people living with severe dementia attend an emergency department (ED) in their last year of life. The aim of this trial is to test whether a Carer End of Life Planning Intervention (CELPI), co-designed by consumers, clinicians and content specialists, improves access to end of life care for older people with severe dementia, using an ED visit as a catalyst for recognising unmet needs and specialist palliative care referral where indicated. Methods A randomised controlled trial (RCT) enrolling at six EDs across three states in Australia will be conducted, enrolling four hundred and forty dyads comprising a person with severe dementia aged ≥ 65 years, and their primary carer. Participants will be randomly allocated to CELPI or the control group. CELPI incorporates a structured carer needs assessment and referral to specialist palliative care services where indicated by patient symptom burden and needs assessment. The primary outcome measure is death of the person with dementia in the carer-nominated preferred location. Secondary outcomes include carer reported quality of life of the person dying of dementia, hospital bed day occupancy in the last 12 months of life, and carer stress. An economic evaluation from the perspective of a health funder will be conducted. Discussion CELPI seeks to support carers and provide optimal end of life care for the person dying of dementia. This trial will provide high level evidence as to the clinical and cost effectiveness of this intervention. Trial registration ACTRN12622000611729 registered 22/04/2022. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03534-1.
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Kosaka M, Miyatake H, Kotera Y, Masunaga H, Arita S, Tsunetoshi C, Nishikawa Y, Ozaki A, Beniya H. The survival time of end-of-life home care patients in Fukui prefecture, Japan: A retrospective observational study. Medicine (Baltimore) 2021; 100:e27225. [PMID: 34559116 PMCID: PMC10545356 DOI: 10.1097/md.0000000000027225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 08/10/2021] [Accepted: 08/23/2021] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT End-of-life advance care planning (ACP) has become increasingly important in home care setting. In facilitating ACP discussion in home care setting, accurate understanding of patients' survival would be beneficial because it would facilitate healthcare professionals to individualize ACP discussion. However, little is known about survival outcome of home care patients. This study aimed to clarify the outcome of patients and identify factors to better predict the survival outcome of home care patients with the focus on patients' primary diseases.We conducted a retrospective analysis using data from 277 patients managed at a home care clinic in Japan and first treated in 2017 or 2018. Data regarding sociodemographic and clinical characteristics, and clinical outcome on December 31, 2019 were extracted. Using Kaplan-Meier product-limit method, we estimated the overall 30 days, 90 days, 1 year, and 3 year survival probabilities among the entire patients and their differences according to their primary disease. We also evaluated whether outcomes differed based on the primary disease or other factors using the hazard ratio and Cox proportional hazards regression.The overall survival probability was 82.5% at 30 days, 67.8% at 90 days, 52.7% at 1 year, and 39.1% at 3 years. The survival rates at 30 days, 90 days, 1 year, and 3 years were 64.6%, 33.4%, 9.5%, and 4.1% among cancer patients; 91.9%, 86.4%, 78.1%, and 47.0% among dementia patients; and 91.9%, 86.4%, 78.1%, and 47.0% among patients with other nervous and cerebrovascular diseases, respectively. Cox proportional hazard regression clarified that cancer patients (hazard ratio 6.53 [95% CI 4.16-10.28]) and older adults (hazard ratio 1.01 [95% CI 1.00-1.02]) were significantly more likely to die than dementia patients and young patients, respectively.Primary disease had a significant influence on the prediction of survival time and could be a useful indicator to individualize ACP in home care setting.
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Affiliation(s)
- Makoto Kosaka
- Orange Home-Care Clinic, Fukui City, Fukui Prefecture, Japan
| | | | | | | | - Satoshi Arita
- Orange Home-Care Clinic, Fukui City, Fukui Prefecture, Japan
| | - Chie Tsunetoshi
- Orange Home-Care Clinic, Fukui City, Fukui Prefecture, Japan
| | - Yoshitaka Nishikawa
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Akihiko Ozaki
- Orange Home-Care Clinic, Fukui City, Fukui Prefecture, Japan
- Department of Breast Surgery, Jyoban Hospital of Tokiwa Foundation, Iwaki City, Fukushima Prefecture, Japan
| | - Hiroyuki Beniya
- Orange Home-Care Clinic, Fukui City, Fukui Prefecture, Japan
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7
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Schlögl M, Iyer AS, Riese F, Blum D, O'Hare L, Kulkarni T, Pautex S, Schildmann J, Swetz KM, Kumar P, Jones CA. Top Ten Tips Palliative Care Clinicians Should Know About Prognostication in Oncology, Dementia, Frailty, and Pulmonary Diseases. J Palliat Med 2021; 24:1391-1397. [PMID: 34264746 DOI: 10.1089/jpm.2021.0327] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Prognostication has been described as "Medicine's Lost Art." Taken with diagnosis and treatment, prognostication is the third leg on which medical care rests. As research leads to additional beneficial treatments for vexing conditions like cancer, dementia, and lung disease, prognostication becomes even more difficult. This article, written by a group of palliative care clinicians with backgrounds in geriatrics, pulmonology, and oncology, aims to offer a useful framework for consideration of prognosis in these conditions. This article will serve as the first in a three-part series on prognostication in adults and children.
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Affiliation(s)
- Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
| | - Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Department of Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Department of Medicine, Center for Outcomes and Effectiveness Research and Education, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Florian Riese
- University Research Priority Program "Dynamics of Healthy Aging," University of Zurich, Zurich, Switzerland
| | - David Blum
- Department of Radiation Oncology, Competence Center for Palliative Care, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Lanier O'Hare
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tejaswini Kulkarni
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sophie Pautex
- Division of Palliative Medicine, Department of Geriatrics and Rehabilitation, University of Geneva, University Hospital Geneva, Geneva, Switzerland
| | - Jan Schildmann
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University, Halle-Wittenberg, Germany
| | - Keith M Swetz
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Pallavi Kumar
- Division of Hematology Oncology, Department of Medicine, Ruth and Raymond Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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8
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Ansari AA, Pomerantz DH, Abedini N, Jayes RL, Matti-Orozco B, Havyer RD. Clinical Progress Note: Addressing Prognosis in Advanced Dementia. J Hosp Med 2020; 15:678-680. [PMID: 31634101 DOI: 10.12788/jhm.3316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 08/23/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Aziz A Ansari
- Division of Hospital Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Daniel H Pomerantz
- Division of General Internal Medicine and Department of Family Medicine (Palliative Care), Albert Einstein College of Medicine, Bronx, New York
- Department of Medicine, Montefiore New Rochelle Hospital, New Rochelle, New York
| | - Nauzley Abedini
- Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan
- National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan
| | - Robert L Jayes
- Division of Geriatrics and Palliative Medicine, George Washington University Medical Faculty Associates, Washington, DC
| | - Brenda Matti-Orozco
- Division of General Internal Medicine & Palliative Medicine, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Rachel D Havyer
- Division of Community Internal Medicine and Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota
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Bicknell R, Lim WK, Maier AB, LoGiuidice D. A study protocol for the development of a multivariable model predicting 6- and 12-month mortality for people with dementia living in residential aged care facilities (RACFs) in Australia. Diagn Progn Res 2020; 4:17. [PMID: 33033746 PMCID: PMC7538167 DOI: 10.1186/s41512-020-00085-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 09/23/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND For residential aged care facility (RACF) residents with dementia, lack of prognostic guidance presents a significant challenge for end of life care planning. In an attempt to address this issue, models have been developed to assess mortality risk for people with advanced dementia, predominantly using long-term care minimum data set (MDS) information from the USA. A limitation of these models is that the information contained within the MDS used for model development was not collected for the purpose of identifying prognostic factors. The models developed using MDS data have had relatively modest ability to discriminate mortality risk and are difficult to apply outside the MDS setting. This study will aim to develop a model to estimate 6- and 12-month mortality risk for people with dementia from prognostic indicators recorded during usual clinical care provided in RACFs in Australia. METHODS A secondary analysis will be conducted for a cohort of people with dementia from RACFs participating in a cluster-randomized trial of a palliative care education intervention (IMPETUS-D). Ten prognostic indicator variables were identified based on a literature review of clinical features associated with increased mortality for people with dementia living in RACFs. Variables will be extracted from RACF files at baseline and mortality measured at 6 and 12 months after baseline data collection. A multivariable logistic regression model will be developed for 6- and 12-month mortality outcome measures using backwards elimination with a fractional polynomial approach for continuous variables. Internal validation will be undertaken using bootstrapping methods. Discrimination of the model for 6- and 12-month mortality will be presented as receiver operating curves with c statistics. Calibration curves will be presented comparing observed and predicted event rates for each decile of risk as well as flexible calibration curves derived using loess-based functions. DISCUSSION The model developed in this study aims to improve clinical assessment of mortality risk for people with dementia living in RACFs in Australia. Further external validation in different populations will be required before the model could be developed into a tool to assist with clinical decision-making in the future.
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Affiliation(s)
- Ross Bicknell
- Department of Medicine and Aged Care, @AgeMelbourne, Melbourne Health–Royal Melbourne Hospital, University of Melbourne, 6 North Main Building, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050 Australia
| | - Wen Kwang Lim
- Department of Medicine and Aged Care, @AgeMelbourne, Melbourne Health–Royal Melbourne Hospital, University of Melbourne, 6 North Main Building, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050 Australia
| | - Andrea B. Maier
- Department of Medicine and Aged Care, @AgeMelbourne, Melbourne Health–Royal Melbourne Hospital, University of Melbourne, 6 North Main Building, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050 Australia
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Dina LoGiuidice
- Department of Medicine and Aged Care, @AgeMelbourne, Melbourne Health–Royal Melbourne Hospital, University of Melbourne, 6 North Main Building, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050 Australia
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10
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Kangasniemi H, Setälä P, Olkinuora A, Huhtala H, Tirkkonen J, Kämäräinen A, Virkkunen I, Yli‐Hankala A, Jämsen E, Hoppu S. Limiting treatment in pre-hospital care: A prospective, observational multicentre study. Acta Anaesthesiol Scand 2020; 64:1194-1201. [PMID: 32521040 DOI: 10.1111/aas.13649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/17/2020] [Accepted: 05/26/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Data are scarce on the withdrawal of life-sustaining therapies and limitation of care orders (LCOs) during physician-staffed Helicopter Emergency Medical Service (HEMS) missions. We investigated LCOs and the quality of information available when physicians made treatment decisions in pre-hospital care. METHODS A prospective, nationwide, multicentre study including all Finnish physician-staffed HEMS bases during a 6-month study period. All HEMS missions where a patient had pre-existing LCOs and/or a new LCO were included. RESULTS There were 335 missions with LCOs, which represented 5.7% of all HEMS missions (n = 5895). There were 181 missions with pre-existing LCOs, and a total of 170 new LCOs were issued. Usually, the pre-existing LCO was a do not attempt cardiopulmonary resuscitation order only (n = 133, 74%). The most frequent new LCO was 'termination of cardiopulmonary resuscitation' only (n = 61, 36%), while 'no intensive care' combined with some other LCO was almost as common (n = 54, 32%). When issuing a new LCO for patients who did not have any preceding LCOs (n = 153), in every other (49%) case the physicians thought that the patient should have already had an LCO. When the physician made treatment decisions, patients' background information from on-scene paramedics was available in 260 (78%) of the LCO missions, while patients' medical records were available in 67 (20%) of the missions. CONCLUSION Making LCOs or treating patients with pre-existing LCOs is an integral part of HEMS physicians' work, with every twentieth mission involving LCO patients. The new LCOs mostly concerned withholding or withdrawal of cardiopulmonary resuscitation and intensive care.
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Affiliation(s)
- Heidi Kangasniemi
- Research and Development Unit FinnHEMS LtdWTC Helsinki Airport Vantaa Finland
- Emergency Medical Services Tampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Piritta Setälä
- Emergency Medical Services Tampere University Hospital Tampere Finland
| | - Anna Olkinuora
- Research and Development Unit FinnHEMS LtdWTC Helsinki Airport Vantaa Finland
| | - Heini Huhtala
- Faculty of Social Sciences Tampere University Tampere Finland
| | - Joonas Tirkkonen
- Department of Intensive Care Medicine and Department of Emergency, Anaesthesia and Pain Medicine Tampere University Hospital Tampere Finland
- Intensive Care Unit Liverpool Hospital Sydney Australia
| | - Antti Kämäräinen
- Emergency Medical Services Tampere University Hospital Tampere Finland
- Department of Emergency Medicine Department of Anaesthesia Hyvinkää District Hospital Hyvinkää Finland
| | - Ilkka Virkkunen
- Research and Development Unit FinnHEMS LtdWTC Helsinki Airport Vantaa Finland
- Emergency Medical Services Tampere University Hospital Tampere Finland
| | - Arvi Yli‐Hankala
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
- Department of Anaesthesia Tampere University Hospital Tampere Finland
| | - Esa Jämsen
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
- Centre of Geriatrics Tampere University Hospital Tampere Finland
| | - Sanna Hoppu
- Emergency Medical Services Tampere University Hospital Tampere Finland
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Tark A, Estrada LV, Tresgallo ME, Quigley DD, Stone PW, Agarwal M. Palliative care and infection management at end of life in nursing homes: A descriptive survey. Palliat Med 2020; 34:580-588. [PMID: 32153248 PMCID: PMC7405898 DOI: 10.1177/0269216320902672] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Infections are common occurrences at end of life that are associated with high rates of morbidity and mortality among frail elderly individuals. The problem of infections in nursing homes has led to a subsequent overuse and misuse of antibiotics in this already-frail population. Improving palliative care in nursing homes has been proposed as a key strategy to reduce the use of antibiotics. AIM The aim of this study was to describe the current status of how nursing homes integrates palliative care and infection management at end of life across the nation. DESIGN This is a cross-sectional survey of nationally representative US nursing homes. SETTING/PARTICIPANTS Between November 2017 and October 2018, a survey was conducted with a nationally representative random sample of nursing homes and 892 surveys were completed (49% response rate). The weighted study sample represented 15,381 nursing homes across the nation. RESULTS Most nursing homes engaged in care plan documentation on what is important to residents (90.43%) and discussed spiritual needs of terminally ill residents (89.50%). In the event of aspiration pneumonia in terminally ill residents, 59.43% of nursing homes responded that resident would be transferred to the hospital. In suspected urinary tract infection among terminally ill residents, 66.62% of nursing homes responded that the resident will be treated with antibiotics. CONCLUSION The study found wide variations in nursing home palliative care practices, particularly for timing of end-of-life care discussions, and suboptimal care reported for antibiotic usage. Further education for nursing home staff on appropriate antibiotic usage and best practices to integrate infection management in palliative care at the end of life is needed.
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Affiliation(s)
- Aluem Tark
- School of Nursing, Columbia University, New York, NY, USA
| | - Leah V Estrada
- School of Nursing, Columbia University, New York, NY, USA
| | | | | | | | - Mansi Agarwal
- School of Nursing, Columbia University, New York, NY, USA
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12
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Eisenmann Y, Golla H, Schmidt H, Voltz R, Perrar KM. Palliative Care in Advanced Dementia. Front Psychiatry 2020; 11:699. [PMID: 32792997 PMCID: PMC7394698 DOI: 10.3389/fpsyt.2020.00699] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/02/2020] [Indexed: 12/20/2022] Open
Abstract
Dementia syndrome is common and expected to increase significantly among older people and characterized by the loss of cognitive, psychological and physical functions. Palliative care is applicable for people with dementia, however they are less likely to have access to palliative care. This narrative review summarizes specifics of palliative care in advanced dementia. Most people with advanced dementia live and die in institutional care and they suffer a range of burdensome symptoms and complications. Shortly before dying people with advanced dementia suffer symptoms as pain, eating problems, breathlessness, neuropsychiatric symptoms, and complications as respiratory or urinary infections and frequently experience burdensome transitions. Pharmacological and nonpharmacological interventions may reduce symptom burden. Sensitive observation and appropriate assessment tools enable health professionals to assess symptoms and needs and to evaluate interventions. Due to lack of decisional capacity, proxy decision making is often necessary. Advanced care planning is an opportunity establishing values and preferences and is associated with comfort and decrease of burdensome interventions. Family carers are important for people with advanced dementia they also experience distress and are in need for support. Recommendations refer to early integration of palliative care, recognizing signs of approaching death, symptom assessment and management, advanced care planning, person-centered care, continuity of care, and collaboration of health care providers.
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Affiliation(s)
- Yvonne Eisenmann
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Heidrun Golla
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Holger Schmidt
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Clinical Trials Center (ZKS), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Health Services Research, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Klaus Maria Perrar
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
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13
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Loizeau AJ, Cohen SM, Mitchell SL, Theill N, Eicher S, Martin M, Riese F. Physician and Surrogate Agreement with Assisted Dying and Continuous Deep Sedation in Advanced Dementia in Switzerland. NEURODEGENER DIS 2019; 19:4-11. [PMID: 31013507 PMCID: PMC6692213 DOI: 10.1159/000499113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 02/18/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Assisted dying and continuous deep sedation (CDS) are controversial practices. Little is known about the perceptions of physicians and surrogates about these practices for patients with advanced dementia. OBJECTIVES To describe and compare physician and surrogate agreement with the use of assisted dying and CDS in advanced dementia. DESIGN, SETTING, SUBJECTS Physicians (n = 64) and surrogates (n = 168) of persons with advanced dementia were recruited as part of a randomized controlled trial in Switzerland that tested decision support tools in this population. METHODS At baseline, the participants were asked about their agreement with assisted dying and CDS in advanced dementia using the following response options: "completely agree," "somewhat agree," "somewhat disagree," "completely disagree," and "do not know." Multivariable logistic regressions compared the likelihood that surrogates versus physicians would completely or somewhat agree (vs. completely or somewhat disagree) with these practices. RESULTS The physicians and surrogates, respectively, had a mean age (SD) of 50.6 years (9.9) and 57.4 years (14.6); 46.9% (n = 30/64) and 68.9% (n = 115/167) were women. A total of 20.3% (n = 13/64) of the physicians and 47.0% (n = 79/168) of the surrogates agreed with assisted dying in advanced dementia. Surrogates were significantly more likely to agree with this practice than physicians (adjusted odds ratio, 3.87; 95% CI: 1.94, 7.69). With regard to CDS, 51.6% (n = 33/64) of the physicians and 41.9% (n = 70/169) of the surrogates agreed with this practice, which did not differ significantly between the groups. CONCLUSIONS The surrogates were more agreeable to considering assisted dying in the setting of advanced dementia than the physicians, and about half of the participants in both groups reported CDS to be an appropriate option for this population.
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Affiliation(s)
- Andrea Jutta Loizeau
- University Research Priority Program "Dynamics of Healthy Aging," University of Zurich, Zurich, Switzerland,
- Center for Gerontology, University of Zurich, Zurich, Switzerland,
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA,
| | - Simon M Cohen
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nathan Theill
- University Research Priority Program "Dynamics of Healthy Aging," University of Zurich, Zurich, Switzerland
- Center for Gerontology, University of Zurich, Zurich, Switzerland
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Zurich, Switzerland
| | - Stefanie Eicher
- University Research Priority Program "Dynamics of Healthy Aging," University of Zurich, Zurich, Switzerland
- Center for Gerontology, University of Zurich, Zurich, Switzerland
| | - Mike Martin
- University Research Priority Program "Dynamics of Healthy Aging," University of Zurich, Zurich, Switzerland
- Center for Gerontology, University of Zurich, Zurich, Switzerland
- Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Florian Riese
- University Research Priority Program "Dynamics of Healthy Aging," University of Zurich, Zurich, Switzerland
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Zurich, Switzerland
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14
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Saxena FE, Bronskill SE, Brown KA, Campitelli MA, Garber G, Langford B, Maxwell CJ, McCormack D, Schwartz KL, Daneman N. The Association of Resident Communication Abilities and Antibiotic Use in Long-Term Care. J Am Geriatr Soc 2019; 67:1164-1173. [PMID: 30690721 DOI: 10.1111/jgs.15771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine whether decreased communication ability among long-term care residents is associated with increased antibiotic exposure. DESIGN Retrospective cohort study. SETTING All long-term care homes in Ontario, Canada. PARTICIPANTS All adults aged 66 years or older residing in long-term care and undergoing a full assessment between January 1 and December 31, 2016 (N = 87,947). MEASUREMENTS Data were obtained from linkable, population-wide administrative data sets. Residents were identified, and characteristics were abstracted from the Resident Assessment Instrument Minimum Dataset version 2.0. The primary predictors of interest were residents' ability to make themselves understood and ability to understand others. The primary outcome was antibiotic days of treatment per 1000 resident days in the 90 days following assessment (obtained from the Ontario Drug Benefits Database). RESULTS Those who were sometimes/rarely/never able to make themselves understood received 50.7 antibiotic days per 1000 person-days of follow-up, compared to 62.1 received by those who were able to make themselves understood. Those who were sometimes/rarely/never able to understand others received 50.0 antibiotic days per 1000 person-days of follow-up, compared to 61.4 by those who were able to understand others. Multivariable Poisson regression, accounting for resident characteristics, confirmed that compared to those with highest levels of communication ability, those who could sometimes/rarely/never make themselves understood had significantly fewer days on antibiotics (rate ratio [RR] = 0.76; confidence interval [95% CI] = 0.73-0.79) as did those who could sometimes/rarely/never understand others (RR = 0.76; 95% CI = 0.74-0.79). CONCLUSION Poor resident communication ability is not a driver of antibiotic overuse in long-term care. In fact, lower ability to understand others and/or be understood by others is associated with less antibiotic exposure. Further work is needed to optimize antibiotic use in long-term care residents across the entire spectrum of communication skills.
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Affiliation(s)
| | - Susan E Bronskill
- ICES, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Kevin A Brown
- ICES, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Infection Prevention and Control, Public Health Ontario, Toronto, Ontario, Canada
| | | | - Gary Garber
- Infection Prevention and Control, Public Health Ontario, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Bradley Langford
- Infection Prevention and Control, Public Health Ontario, Toronto, Ontario, Canada
| | - Colleen J Maxwell
- ICES, Toronto, Ontario, Canada.,Schools of Pharmacy and Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | | | - Kevin L Schwartz
- ICES, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Infection Prevention and Control, Public Health Ontario, Toronto, Ontario, Canada
| | - Nick Daneman
- ICES, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,Infection Prevention and Control, Public Health Ontario, Toronto, Ontario, Canada
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