Pain in the Geriatric Patient with Advanced Chronic Disease

Effects of timely case conferencing between general practitioners and specialist palliative care services on symptom burden in patients with advanced chronic disease: results of the cluster-randomised controlled KOPAL trial

BACKGROUND

Patients with advanced chronic non-malignant conditions often experience significant symptom burden. Therefore, overcoming barriers to interprofessional collaboration between general practitioners (GPs) and specialist palliative home care (SPHC) teams is essential to facilitate the timely integration of palliative care elements. The KOPAL trial aimed to examine the impact of case conferences between GPs and SPHC teams on symptom burden and pain in patients with advanced chronic heart failure, chronic obstructive pulmonary disease, and dementia.

METHODS

The cluster-randomised controlled trial compared a structured palliative care nurse visit followed by an interprofessional case conference to usual care. Data were collected from GPs at baseline and 48 weeks, while standardised patient interviews were conducted at baseline, 6, 12, 24, and 48 weeks.

RESULTS

We analysed 172 patients from 49 German GP practices. Both groups showed marginal improvement in symptom burden; however, no statistically significant between-group difference was found ([Formula: see text]=-0.561, 95% CI: -3.201-2.079, p = .68). Patients with dementia experienced a significant pain reduction ([Formula: see text]=2.187, 95% CI: 0.563-3.812, p = .009). Conversely, the intervention did not have a significant effect on pain severity ([Formula: see text]=-0.711, 95% CI: -1.430 - 0.008, p=.053) or pain interference ([Formula: see text]=-0.036, 95% CI:-0.797 - 0.725, p=.926) in other patient groups.

CONCLUSIONS

The intervention showed promise in the timely introduction of palliative care elements to address pain management in patients with dementia. Further studies are needed to identify and effectively address symptom burden and pain in other patient groups.

TRIAL REGISTRATION

German Clinical Trials Register: https://www.drks.de/DRKS00017795 (Registration date: 9th January 2020).

Worst Pain Severity Profiles of Oncology Patients Are Associated With Significant Stress and Multiple Co-Occurring Symptoms

Little is known about the associations between pain, stress, and co-occurring symptoms in oncology patients. Purpose was to identify subgroups of patients with distinct worst pain profiles and evaluate for differences among the subgroups in demographic and clinical characteristics, as well as stress and symptom scores. Oncology outpatients (n = 1305) completed questionnaires prior to their second or third chemotherapy cycle. Worst pain intensity was assessed 6 times over 2 chemotherapy cycles using a 0 to 10 numeric rating scale. The 371 patients (28.4%) who had ≤1 occurrence of pain over the 6 assessments were classified as the None class. For the remaining 934 patients whose data were entered into the latent profile analysis, 3 distinct worst pain profiles were identified (ie Mild [12.5%], Moderate [28.6%], Severe [30.5%]). Compared to None class, Severe class had fewer years of education and a lower annual income; were less likely to be employed and married; less likely to exercise on a regular basis, had a higher comorbidity burden, and a worse functional status. Compared to None class, Severe class reported higher levels of general, disease-specific, and cumulative life stress and lower levels of resilience, as well as higher levels of depressive symptoms, anxiety, fatigue, sleep disturbance, and cognitive dysfunction. This study is the first to identify distinct worst pain profiles in a large sample of oncology patients receiving chemotherapy and associated risk factors. PERSPECTIVE: Unrelieved pain remains a significant problem for oncology patients receiving chemotherapy. High levels of stress and co-occurring symptoms contribute to a more severe pain profile in these patients.

Chronic Conditions, Persistent Pain, and Psychological Distress Among the Rural Older Adults: A Path Analysis in Shandong, China

Psychological distress were found to be associated with chronic conditions and persistent pain. However, few studies explored the underlying pathways between them. This study aimed to analyze the path of chronic conditions and persistent pain on psychological distress through sleep quality and self-rated health. A total of 2,748 rural older people in Shandong, China were included in this study. Path analysis was performed by using Mplus 8.3 to examine the associations between chronic conditions, persistent pain, sleep quality, self-rated health, and psychological distress after adjusting for age, gender, education, and household income. The prevalence of psychological distress among the older adults in this study was 47.49%. Chronic conditions and persistent pain were indirectly associated with psychological distress through six mediating pathways: (1) the path from chronic conditions to psychological distress through sleep quality (β = 0.041, 95%CI: 0.015-0.067) and self-rated health (β = 0.064, 95%CI: 0.038-0.091), respectively, and a chain mediation existed (β = 0.007, 95% CI: 0.000-0.014); (2) the path of persistent pain and psychological distress through sleep quality (β = 0.058, 95% CI: 0.014-0.102) and self-rated health (β = 0.048, 95% CI: 0.000-0.096), respectively, also the chain mediation found (β = 0.009, 95% CI: 0.005-0.014). Psychological distress was associated with chronic conditions and persistent pain through decreased sleep quality and self-rated health among Chinese rural older people. Multi-pronged targeted intervention should be taken for older adults with chronic conditions and persistent pain.

Glimpsing the raging seas that stop swans: A qualitative look at living with multimorbidity and pain in patients from a tertiary care service

Multimorbidity requires complex and ongoing care. Understanding the subjective illness experience is critical to effective care. Literature isn't clear about illness perception in patients with multimorbidity followed in services of high complexity. This study aims to investigate the illness experience based on narratives about daily living and symptoms of patients with multimorbidity and pain in a tertiary health care service.

Methods

Qualitative narrative inquiry design with framework analysis from semi-structured interviews at a tertiary internal medicine outpatient clinic. Patients with Elixhauser comorbidity index ≧3 or and pain during the last week were included. Framework analysis was performed using 3 main patterns of illness experience from a previous study: "Gliding swan" (Resilience); "Stormy Seas" (Vulnerability); and "Stuck adrift" (Disruption); and identifying subthemes. One case study was selected from each main category. 43 patients, 14 classified as "gliding swan," 12 as "stormy seas" and 17 as "stuck adrift." Within the "gliding swan" group, positive examples of how to navigate through physical and emotional factors to sustain their wellbeing based on comprehension; In the "stormy seas" group, themes revolved around vulnerability, burden and ambiguity in relation to the health team. In the "stuck adrift" group the main content was about overwhelmed feelings and limitations.

Conclusions

Narratives brought the content about lacking personalized understanding of diseases, with great emotional repercussion. Some meaningful anchors were highlighted. This study reinforces multimorbidity and pain interact and that healthcare professional should be aware of the turbulences that can disturb navigation in the raging seas of long-term multimorbid conditions.