Prospective Observations of Discomfort, Pain, and Dyspnea in Nursing Home Residents With Dementia and Pneumonia

Prevalence of Opioid Use in Nursing Homes Over the Last Decade: A Systematic Literature Review

Background: Despite global concerns of an opioid epidemic, there is no systematic literature review on how frequently these drugs are used in nursing home (NH) populations, including those living with dementia. Objective: This systematic review aims to describe the prevalence and incidence of opioid use in NHs. A secondary objective is to describe the use of these drugs in a subset of NH residents, namely among persons living with dementia. Methods: A systematic literature review was carried out using MEDLINE and Scopus (PROSPERO registration number CRD42021254210). Screening of title and abstract was carried out by 2 persons independently for studies published between January 1, 2011 and May 19, 2021. The main outcomes were annual prevalence, period prevalence, and duration of opioid use. Results: From a total of 178 identified studies, 29 were considered eligible for inclusion. The annual prevalence of any opioid use among all NH residents without any selection criteria ranged from 6.3% to 50% with a median annual prevalence of 22.9% (Q25-Q75: 19.5%-30.2%), based on 17 studies. Five studies measured the annual prevalence in NH residents living with dementia, finding that this ranged from 10% to 39.6%. Conclusions: More evidence is needed quantifying opioid use in NH, especially among persons living with dementia. Given that opioid use in NH is still a problem, implementation of a pain management protocol in NH or nationally would help improve clinical outcomes.

Pneumonia-associated Emergency Transfers, Functional Decline, and Mortality in Nursing Home Residents

OBJECTIVE

To describe nursing home residents (NHRs) transferred to the emergency department (ED) with pneumonia, and investigate the association of pneumonia with functional ability and mortality.

DESIGN

Case-control observational multicenter study.

SETTING AND PARTICIPANTS

Participants of the FINE study, including 1037 NHRs presenting to 17 EDs in France over 4 nonconsecutive weeks (1 per season) in 2016, mean age 87.2 years ± 7.1, 68.4% women.

METHODS

Activities of daily living (ADL) performance evolution between (1) 15 days before transfer and (2) within 7 days after discharge back to the nursing home was compared in NHRs with or without pneumonia. The association of pneumonia with functional evolution was investigated by a mixed-effect linear regression of ADL and mortality was compared by a χ² test.

RESULTS

NHRs with pneumonia (n = 232; 22.4%) were more likely to have a lower ADL performance than NHRs without pneumonia (n = 805, 77.6%). They presented with a more severe clinical condition, were more likely to be hospitalized after ED and to stay longer in ED and in hospital. They showed a 0.5 decline in median ADL performance after transfer and a significantly higher mortality than NHRs without pneumonia (24.1% and 8.7%, respectively). Post-ED functional evolution did not differ significantly between NHRs with or without pneumonia.

CONCLUSIONS AND IMPLICATIONS

Pneumonia-associated ED transfers resulted in longer care pathways and higher mortality, but no significant difference in functional decline. This study identified a suggestive course of symptoms that could facilitate early identification of NHRs developing pneumonia and early management to prevent ED transfer.

Antibiotic use for respiratory tract infections among older adults living in long-term care facilities: a systematic review and meta-analysis

BACKGROUND

Antibiotics are commonly prescribed for respiratory tract infections (RTIs) among older adults in long-term care facilities (LTCFs), and this contributes to the emergence of antimicrobial resistance. The objective of this study was to determine the antibiotic prescribing rate for RTIs among LTCF residents, and to analyse the antibiotic consumption patterns with the AwaRe monitoring tool, developed by the World Health Organization.

METHODS

MEDLINE, EMBASE and CINAHL were searched from inception to March 2022. Original articles reporting antibiotic use for RTIs in LTCFs were included in this review. Study quality was assessed using the Joanna Briggs Institute's Critical Appraisal Checklist for Prevalence Data. A random-effects meta-analysis was employed to calculate the pooled estimates. Subgroup analysis was conducted by type of RTI, country, and study start year.

RESULTS

In total, 47 articles consisting of 50 studies were included. The antibiotic prescribing rate ranged from 21.5% to 100% (pooled estimate 69.8%, 95% confidence interval 55.2-82.6%). The antibiotic prescribing rate for lower respiratory tract infections (LRTIs) was higher than the rates for viral and general RTIs. Compared with Italy, France and the USA, the Netherlands had lower antibiotic use for LRTIs. A proportion of viral RTIs were treated with antibiotics, and all the antibiotics were from the Watch group. Use of antibiotics in the Access group was higher in the Netherlands, Norway, Switzerland and Slovenia compared with the USA and Australia.

CONCLUSION

The antibiotic prescribing rate for RTIs in LTCFs was high, and AWaRe antibiotic use patterns varied by type of RTI and country. Improving antibiotic use may require coordination efforts.

Utilization of Point-of-Care Ultrasound in a Specialist Palliative Care Team Across Multiple Care Settings: A Retrospective Chart Review

BACKGROUND

Technological advancements have rapidly increased the use of point-of-care ultrasound (POCUS) across various medical disciplines, leading to real-time information for clinicians at the bed side. However, literature reveals scant evidence of POCUS use in palliative care. The objective of this study was to examine the use of POCUS in a specialist palliative care setting.

METHODS

A retrospective chart review was conducted from January 2018 to June 2019 in Brampton, Canada, to evaluate characteristics of patients for whom POCUS was utilized. Patients were identified through pre-existing logs and descriptive information was collected from electronic health records, including demographic information, life-limiting diagnosis, patient assessment location, diagnosis made with POCUS, and, if applicable, volume of fluid drained.

RESULTS

We identified 126 uses of POCUS in 89 unique patients. Sixty-two patients (69.7%) had a cancer diagnosis, with patients most commonly suffering from gastrointestinal, lung, and breast pathologies. Sixty-one POCUS cases (48.4%) were in the outpatient setting. Eighty-one POCUS cases (64.3%) revealed a diagnosis of ascites and 21 POCUS cases (16.7%) revealed a diagnosis of pleural effusion. Other diagnoses made with POCUS included bowel obstruction, pneumonia, and congestive heart failure. During the study period, 52 paracentesis and 7 thoracentesis procedures were performed using POCUS guidance.

CONCLUSION

We identified multiple indications in our specialist palliative care setting where POCUS aided in diagnosis/management of patients in both inpatient and outpatient settings. Further studies can be conducted to identify the potential benefits in symptom burden, patient and caregiver satisfaction, and health care utilization in palliative care patients receiving POCUS.

Terminal care in oldest old dying from COVID-19 in the acute hospital : A multicenter study describing pharmacological treatment in the last 24 h

Background

Coronavirus disease 2019 (COVID-19) has a high mortality, especially in the oldest old. Dying from COVID-19 is often characterized by symptoms such as breathlessness and agitation but data concerning medical treatment in the dying phase are limited.

Objective

This study describes the administration of oxygen, opioids and benzodiazepines in the last 24 h before death in patients 80 years or older dying from COVID-19 on acute hospital wards.

Material and methods

In this multi-centric retrospective study, patients, 80 years and older, admitted to the acute hospital in March and April 2020 were recruited from 10 acute Belgian hospitals. They all were diagnosed with COVID-19 and died on non-ICU wards with COVID-19. Administration of oxygen, opioids and benzodiazepines in the last 24 h before death was registered.

Results

Eighty-five percent of patients received oxygen, half of them even by means of a mask providing at least 10l oxygen per minute. The majority (84.3%) of patients were treated with opioids (morphine). Mean dosage of SC morphine equivalent was 31.3 mg/24 h (range 2–120 mg; SD 21.6 mg). More than half of patients (52.8%) received benzodiazepines, mostly midazolam. Mean dosage of midazolam was 20.4 mg/24 h (range 1–100 mg; SD 15.4 mg). Dosages of morphine and midazolam did not differ depending on frailty or comorbidities. Older COVID-19 patients dying with respiratory failure had higher midazolam dosage (p 0.002) but not morphine dosage (p 0.11).

Conclusion

A high proportion of patients 80 years and older and dying with COVID-19 in the hospital, were treated with oxygen, opioids and benzodiazepines in the last 24 h before death. With this descriptive study, we hope to contribute to the discussion and further research on the optimization of symptom control in an older population dying from/with COVID-19.

Improving Dyspnoea Symptom Control of Patients in Palliative Care Using a Smart Patch-A Proof of Concept Study

The world of healthcare constantly aims to improve the lives of people while nurturing their health and comfort. Digital health and wearable technologies are aimed at making this possible. However, there are numerous factors that need to be addressed such as aging, disabilities, and health hazards. These factors are intensified in palliative care (PC) patients and limited hospital capacities make it challenging for health care providers (HCP) to handle the crisis. One of the most common symptoms reported by PC patients with severe conditions is dyspnoea. Monitoring devices with sufficient comfort could improve symptom control of patients with dyspnoea in PC. In this article, we discuss the proof-of-concept study to investigate a smart patch (SP), which monitors the pulmonary parameters: (a) breathing rate (BR) and inspiration to expiration ratio (I:E); markers for distress: (b) heart rate (HR) and heart rate variability (HRV), and (c) transmits real-time data securely to an adaptable user interface, primarily geared for palliative HCP but scalable to specific needs. The concept is verified by measuring and analyzing physiological signals from different electrode positions on the chest and comparing the results achieved with the gold standard Task Force Monitor (TFM).

[A systematic review of distress due to pneumonia experienced by older people with end-stage dementia]

AIM

Many older people with end-stage dementia die of pneumonia, but the details of their distress have been unclear. The present study clarified the distress experienced by such individuals due to pneumonia.

METHODS

We searched for literature corresponding to 5 clinical questions (CQs) concerning including "What distress is experienced by older people with end-stage dementia due to pneumonia (CQ1) ?" using a search formula with the Web version of the Central Medical Magazine, MEDLINE (STN)/EMBASE (STN), Cochrane Library, and extracted 604 articles. Forty-two articles corresponding to 5 CQs were extracted by primary screening using abstracts, and 17 articles were adopted after the secondary screening. A total of six articles corresponding to CQ1 were ultimately analyzed.

RESULTS

Older people with end-stage dementia who died of pneumonia reported more discomfort and dyspnea than those who died of dehydration. Their main symptoms were respiratory symptoms, such as cough, sputum, and dyspnea, a fever and somnolence. Distress such as dyspnea and discomfort among older people with end-stage dementia recovering from pneumonia peaked on the day of the diagnosis. Furthermore, in older people with end-stage dementia dying of pneumonia, distresses began approximately one week before death and peaked on the day before death. A few days before death, several distressing symptoms, such as pain, dyspnea and restlessness/agitation, were often observed at the same time.

CONCLUSIONS

If older people with end-stage dementia contract pneumonia and die from it, attentive palliative care is needed to manage their severe discomfort, dyspnea and other sources of distress.

Attitudes toward withholding antibiotics from people with dementia lacking decisional capacity: findings from a survey of Canadian stakeholders

Background

Healthcare professionals and surrogate decision-makers often face the difficult decision of whether to initiate or withhold antibiotics from people with dementia who have developed a life-threatening infection after losing decisional capacity.

Methods

We conducted a vignette-based survey among 1050 Quebec stakeholders (senior citizens, family caregivers, nurses and physicians; response rate 49.4%) to (1) assess their attitudes toward withholding antibiotics from people with dementia lacking decisional capacity; (2) compare attitudes between dementia stages and stakeholder groups; and (3) investigate other correlates of attitudes, including support for continuous deep sedation (CDS) and medical assistance in dying (MAID). The vignettes feature a woman moving along the dementia trajectory, who has refused in writing all life-prolonging interventions and explicitly requested that a doctor end her life when she no longer recognizes her loved ones. Two stages were considered after she had lost capacity: the advanced stage, where she likely has several more years to live, and the terminal stage, where she is close to death.

Results

Support for withholding antibiotics ranged from 75% among seniors and caregivers at the advanced stage, to 98% among physicians at the terminal stage. Using the generalized estimating equation approach, we found stakeholder group, religiosity, and support for CDS and MAID, to be associated with attitudes toward antibiotics.

Conclusions

Findings underscore the importance for healthcare professionals of discussing underlying values and treatment goals with people at an early stage of dementia and their relatives, to help them anticipate future care decisions and better prepare surrogates for their role. Findings also have implications for the scope of MAID laws, in particular in Canada where the extension of MAID to persons lacking decisional capacity is currently being considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00689-1.

Palliative Care in Advanced Dementia: Comparison of Strategies in Three Countries

Palliative care including hospice care is appropriate for advanced dementia, but policy initiatives and implementation have lagged, while treatment may vary. We compare care for people with advanced dementia in the United States (US), The Netherlands, and Israel. We conducted a narrative literature review and expert physician consultation around a case scenario focusing on three domains in the care of people with advanced dementia: (1) place of residence, (2) access to palliative care, and (3) treatment. We found that most people with advanced dementia live in nursing homes in the US and The Netherlands, and in the community in Israel. Access to specialist palliative and hospice care is improving in the US but is limited in The Netherlands and Israel. The two data sources consistently showed that treatment varies considerably between countries with, for example, artificial nutrition and hydration differing by state in the US, strongly discouraged in The Netherlands, and widely used in Israel. We conclude that care in each country has positive elements: hospice availability in the US, the general palliative approach in The Netherlands, and home care in Israel. National Dementia Plans should include policy regarding palliative care, and public and professional awareness must be increased.

Frailty, Complexity, and Priorities in the Use of Advanced Palliative Care Resources in Nursing Homes

Background and objectives: This study aimed to determine the frailty, prognosis, complexity, and palliative care complexity of nursing home residents with palliative care needs and define the characteristics of the cases eligible for receiving advanced palliative care according to the resources available at each nursing home. Materials and Methods: In this multi-centre, descriptive, and cross-sectional study, trained nurses from eight nursing homes in southern Spain selected 149 residents with palliative care needs. The following instruments were used: the Frail-VIG index, the case complexity index (CCI), the Diagnostic Instrument of Complexity in Palliative Care (IDC-Pal), the palliative prognosis index, the Barthel index (dependency), Pfeiffer's test (cognitive impairment), and the Charlson comorbidity index. A consensus was reached on the complexity criteria of the Diagnostic Instrument of Complexity in Palliative Care that could be addressed in the nursing home (no priority) and those that required a one-off (priority 2) or full (priority 1) intervention of advanced palliative care resources. Non-parametric tests were used to compare non-priority patients and patients with some kind of priority. Results: A high percentage of residents presented frailty (80.6%), clinical complexity (80.5%), and palliative care complexity (65.8%). A lower percentage of residents had a poor prognosis (10.1%) and an extremely poor prognosis (2%). Twelve priority 1 and 14 priority 2 elements were identified as not matching the palliative care complexity elements that had been previously identified. Of the studied cases, 20.1% had priority 1 status and 38.3% had priority 2 status. Residents with some kind of priority had greater levels of dependency (p < 0.001), cognitive impairment (p < 0.001), and poorer prognoses (p < 0.001). Priority 1 patients exhibited higher rates of refractory delirium (p = 0.003), skin ulcers (p = 0.041), and dyspnoea (p = 0.020). Conclusions: The results indicate that there are high levels of frailty, clinical complexity, and palliative care complexity in nursing homes. The resources available at each nursing home must be considered to determine when advanced palliative care resources are required.

Reliability of nonlocalizing signs and symptoms as indicators of the presence of infection in nursing-home residents

Antibiotics are among the most common medications prescribed in nursing homes. The annual prevalence of antibiotic use in residents of nursing homes ranges from 47% to 79%, and more than half of antibiotic courses initiated in nursing-home settings are unnecessary or prescribed inappropriately (wrong drug, dose, or duration). Inappropriate antibiotic use is associated with a variety of negative consequences including Clostridioides difficile infection (CDI), adverse drug effects, drug-drug interactions, and antimicrobial resistance. In response to this problem, public health authorities have called for efforts to improve the quality of antibiotic prescribing in nursing homes.

Comfort and clinical events at the end of life of nursing home residents with and without dementia: The six-country epidemiological PACE study

OBJECTIVES

We aimed to investigate the occurrence rates of clinical events and their associations with comfort in dying nursing home residents with and without dementia.

METHODS

Epidemiological after-death survey was performed in nationwide representative samples of 322 nursing homes in Belgium, Finland, Italy, the Netherlands, Poland, and England. Nursing staff reported clinical events and assessed comfort. The nursing staff or physician assessed the presence of dementia; severity was determined using two highly discriminatory staff-reported instruments.

RESULTS

The sample comprised 401 residents with advanced dementia, 377 with other stages of dementia, and 419 without dementia (N = 1197). Across the three groups, pneumonia occurred in 24 to 27% of residents. Febrile episodes (unrelated to pneumonia) occurred in 39% of residents with advanced dementia, 34% in residents with other stages of dementia and 28% in residents without dementia (P = .03). Intake problems occurred in 74% of residents with advanced dementia, 55% in residents with other stages of dementia, and 48% in residents without dementia (P < .001). Overall, these three clinical events were inversely associated with comfort. Less comfort was observed in all resident groups who had pneumonia (advanced dementia, P = .04; other stages of dementia, P = .04; without dementia, P < .001). Among residents with intake problems, less comfort was observed only in those with other stages of dementia (P < .001) and without dementia (P = .003), while the presence and severity of dementia moderated this association (P = .03). Developing "other clinical events" was not associated with comfort.

CONCLUSIONS

Discomfort was observed in dying residents who developed major clinical events, especially pneumonia, which was not specific to advanced dementia. It is crucial to identify and address the clinical events potentially associated with discomfort in dying residents with and without dementia.

Comfort and Satisfaction With Care of Home-Dwelling Dementia Patients at the End of Life

CONTEXT

Despite the preference to pass away at home, many dementia patients die in institutions, resulting in a paucity of studies examining end-of-life care outcomes in the home setting.

OBJECTIVE

The objective of this study was to identify modifiable factors associated with the comfort of dementia patients dying at home and families' satisfaction with care.

METHODS

This is a prospective cohort study conducted from October 2014 to April 2019 in Singapore. Dementia patients at Stage 7 on the Functional Assessment Staging Scale, with albumin <35 g/L, enteral feeding, or pneumonia, were recruited from a palliative homecare program. Independent variables included demographics, medical information, and care preferences. The Comfort Assessment in Dying with Dementia scale assessed dying patients' comfort, whereas the Satisfaction with Care at the End-of-Life in Dementia scale evaluated family caregivers' satisfaction two months after bereavement. Gamma regression identified factors independently associated with comfort and satisfaction.

RESULTS

The median age of 202 deceased patients whose comfort was assessed was 88 years. Anti-cholinergic prescription (60.4% of patients) [β (95% CI) = 1.823 (0.660-2.986), P = 0.002] was positively associated with comfort, whereas opioid prescription (89.6%) [β (95% CI) = -2.179 (-4.107 to -0.251), P = 0.027] and >1 antibiotic courses used in the last two weeks of life (77.2%) [β (95% CI) = -1.968 (-3.196 to -0.740), P = 0.002] were negatively associated. Independent factors associated with families' satisfaction with care were comfort [β (95% CI) = 0.149 (0.012-0.286), P = 0.033] and honoring of medical intervention preferences (96.0%) [β (95% CI) = 3.969 (1.485-6.453), P = 0.002].

CONCLUSION

Achieving comfort and satisfaction with care for dementia patients dying at home involves an interplay of modifiable factors. Honoring medical intervention preferences, such as those with palliative intent associated with patients' comfort, determined families' satisfaction with care.

Namaste care in the home setting: developing initial realist explanatory theories and uncovering unintended outcomes

INTRODUCTION

The End-of-Life Namaste Care Program for People with Dementia, challenges the misconception that people with dementia are a 'shell'; it provides a holistic approach using the five senses, which can provide positive ways of communicating and emotional responses. It is proposed Namaste Care can improve communication and the relationships families and friends have with the person with dementia. Previously used in care homes, this study is the first to explore the pioneering use of Namaste Care in people's own homes.

OBJECTIVE

To develop initial programme theories detailing if, how and under which circumstances Namaste Care works when implemented at home.

DESIGN

A qualitative realist approach following the RAMESES II guidelines was employed to understand not only whether Namaste Care has positive outcomes, but also how these are generated, for whom they happen and in which circumstances.

SETTING

A hospice in the North East of England, operating in the community, through volunteers.

PARTICIPANTS

Programme theories were developed from three focus groups with volunteers implementing Namaste Care (n=8; n=8; n=11) and eight interviews with family carers (n=8).

RESULTS

Four refined explanatory theories are presented: increasing engagement, respite for family carers, importance of matched volunteers and increasing social interaction. It was identified that while Namaste Care achieved some of the same goals in the home setting as it does in the care home setting, it could also function in a different way that promoted socialisation.

CONCLUSIONS

Namaste Care provides holistic and personalised care to people with both moderate and advanced dementia, improving engagement and reducing social isolation. In the present study carers often chose to use Namaste Care sessions as respite. This was often linked to their frustration of the unavoidable dominance of task-focussed care in daily life. Individualised Namaste Care activities thus led to positive outcomes for both those with dementia and their carers.

A group intervention to improve quality of life for people with advanced dementia living in care homes: the Namaste feasibility cluster RCT

BACKGROUND

People with advanced dementia who live and die in nursing homes experience variable quality of life, care and dying. There is a need to identify appropriate, cost-effective interventions that facilitate high-quality end-of-life care provision.

OBJECTIVES

To establish the feasibility and acceptability to staff and family of conducting a cluster randomised controlled trial of the Namaste Care intervention for people with advanced dementia in nursing homes.

DESIGN

The study had three phases: (1) realist review and (2) intervention refinement to inform the design of (3) a feasibility cluster randomised controlled trial with a process evaluation and economic analysis. Clusters (nursing homes) were randomised in a 3 : 1 ratio to intervention or control (usual care). The nature of the intervention meant that blinding was not possible.

SETTING

Nursing homes in England providing care for people with dementia.

PARTICIPANTS

Residents with advanced dementia (assessed as having a Functional Assessment Staging Test score of 6 or 7), their informal carers and nursing home staff.

INTERVENTION

Namaste Care is a complex group intervention that provides structured personalised care in a dedicated space, focusing on enhancements to the physical environment, comfort management and sensory engagement.

MAIN OUTCOME MEASURES

The two contender primary outcome measures were Comfort Assessment in Dying - End of Life Care in Dementia for quality of dying (dementia) and Quality of Life in Late Stage Dementia for quality of life. The secondary outcomes were as follows: person with dementia, sleep/activity (actigraphy), neuropsychiatric symptoms, agitation and pain; informal carers, satisfaction with care at the end of life; staff members, person-centred care assessment, satisfaction with care at the end of life and readiness for change; and other data - health economic outcomes, medication/service use and intervention activity.

RESULTS

Phase 1 (realist review; 86 papers) identified that a key intervention component was the activities enabling the development of moments of connection. In phase 2, refinement of the intervention enabled the production of a user-friendly 16-page A4 booklet. In phase 3, eight nursing homes were recruited. Two homes withdrew before the intervention commenced; four intervention and two control homes completed the study. Residents with advanced dementia (n = 32) were recruited in intervention (n = 18) and control (n = 14) homes. Informal carers (total, n = 12: intervention, n = 5; control, n = 7) and 97 staff from eight sites (intervention, n = 75; control, n = 22) were recruited over a 6-month period. Recruitment is feasible. Completion rates of the primary outcome questionnaires were high at baseline (100%) and at 4 weeks (96.8%). The Quality of Life in Late Stage Dementia was more responsive to change over 24 weeks. Even where economic data were missing, these could be collected in a full trial. The intervention was acceptable; the dose varied depending on the staffing and physical environment of each care home. Staff and informal carers reported changes for the person with dementia in two ways: increased social engagement and greater calm. No adverse events related to the intervention were reported.

CONCLUSIONS

A subsequent definitive trial is feasible if there are amendments to the recruitment process, outcome measure choice and intervention specification.

FUTURE WORK

In a full trial, consideration is needed of the appropriate outcome measure that is sensitive to different participant responses, and of clear implementation principles for this person-centred intervention in a nursing home context.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14948133.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 6. See the NIHR Journals Library website for further project information.

Predicting Mortality in Nursing Home Residents With Dementia and Pneumonia Treated With Antibiotics: Validation of a Prediction Model in a More Recent Population

BACKGROUND

We aimed to find the best predictive model for 14-day mortality in antibiotic-treated nursing home residents with dementia and pneumonia by first applying an existing model to the recent PneuMonitor study. Second, we evaluated whether model performance improved by revising variables or adding variables related to recent changes in the care for older people.

METHODS

The original prognostic model included gender, respiratory rate, respiratory difficulty, pulse rate, decreased alertness, fluid intake, eating dependency, and pressure sores. This model was applied to 380 recent pneumonia episodes in nursing home residents with dementia, updated by considering revising and/or adding variables, internally validated using bootstrapping, and transformed into a simplified risk score that can be used in clinical practice. Model performance was evaluated by Hosmer-Lemeshow statistics and calibration graphs to assess calibration; and area under the receiver operating characteristic curve (AUC) to assess discrimination.

RESULTS

The newer cohort had lower 14-day mortality and was less often dehydrated or malnourished. Median AUC of the original model over the imputed datasets was 0.76 (interquartile range: 0.76-0.77), compared to 0.80 in the old cohort. Extending the model with dehydration, bowel incontinence, increase in eating dependency and cardiovascular history, while removing pressure sores, improved AUC: 0.80 (interquartile range: 0.80-0.81) after internal validation. Calibration remained adequate (Hosmer-Lemeshow statistic: p = .67).

CONCLUSIONS

In the newer cohort with less severe illness, model performance of the existing model was adequate, but a new extended model distinguished better between residents at low and high mortality risk.

Responding to Varying Levels of Certainty about Pain in People with Dementia after Initial Pain Assessment

Introduction

Pain is still inadequately treated in people with dementia (PWD) due to the complexity of assessing it. Pain assessment in PWD is still challenging because of patient-related or nurse-related factors. The patient-related factors have been studied extensively. However, the nurse-related factors, e.g., nurses' certainty regarding suspected pain in PWD, have been given little attention by researchers.

Purpose

This study aims to investigate how the degree of nurses' certainty is compromised after pain assessment and how this affects levels of pain and agitation in PWD.

Method

A descriptive, correlational design was used, and a convenience sample of 104 nursing home residents with dementia were recruited.

Results

This study found that nurses' certainty after the pain assessment mediates the relationship between the type of pain assessment and patient outcomes when the nurses had a high initial certainty. When nurses had a low initial certainty, their certainty after the assessment and the type of assessment predicted the levels of pain and agitation in PWD.

Conclusion

Understanding how nurses' certainty can be compromising after pain assessment and how this relates to pain management in PWD is crucial.

Fact Box decision support tools reduce decisional conflict about antibiotics for pneumonia and artificial hydration in advanced dementia: a randomized controlled trail

Background

fact Boxes are decision support tools that can inform about treatment effects.

Objectives

to test whether Fact Box decision support tools impacted decisional conflict, knowledge and preferences about the use of antibiotics and artificial hydration in advanced dementia.

Design

randomized controlled trial.

Setting

Swiss-German region of Switzerland.

Subjects

two hundred thirty-two participants (64 physicians, 100 relatives of dementia patients, 68 professional guardians) randomly allocated to intervention (N = 114) or control (N = 118).

Intervention

two-page Fact Box decision support tools on antibiotics for pneumonia and artificial hydration in advanced dementia (at 1-month).

Methods

participants were mailed questionnaires at baseline and one month later that asked questions about treatments based on hypothetical scenarios. The primary outcome was change in decisional conflict (DCS-D; range 0 < 100) about treatment decisions. Secondary outcomes included knowledge about treatments (range 0 < 7) and preferences to forego treatments.

Results

participants were: mean age, 55.6 years; female, 62.8%. Relative to control participants, intervention participants experienced less decisional conflict about using antibiotics (unstandardized beta (b) = -8.35, 95% Confidence Interval (CI), -12.43, -4.28) and artificial hydration (b = -6.02, 95% CI, -9.84, -2.20) at 1-month compared to baseline. Intervention participants displayed greater knowledge about the use of antibiotics (b = 2.24, 95% CI, 1.79, 2.68) and artificial hydration (b = 3.01, 95% CI, 2.53, 3.49), and were significantly more likely to prefer to forego antibiotics (odds ratio, 2.29, 95% CI, 1.08, 4.84) but not artificial hydration.

Conclusions

fact Box decision support tools reduced decisional conflict, increased knowledge and promoted preferences to forego antibiotics in advanced dementia among various decision-makers.

Trial registration

FORSbase (12091).

Pneumonia, Intake Problems, and Survival Among Nursing Home Residents With Variable Stages of Dementia in the Netherlands: Results From a Prospective Observational Study

OBJECTIVES

We explored how pneumonia and intake problems affect survival in nursing home residents in variable stages of dementia.

METHODS

In a longitudinal observational study (372 residents) with up to 3.5 years of follow-up, we examined relationships between dementia severity, the development of pneumonia, intake problems, and mortality using joint modeling, Cox models, and mediation analyses. Dementia severity was measured semiannually with the Bedford Alzheimer Nursing Severity-Scale (BANS-S).

RESULTS

The median BANS-S score at baseline was 13 (range, 7 to 28). Pneumonia occurred in 103 (28%) and intake problems in 126 (34%) of 367 residents with complete registration of pneumonia and intake problems. Compared with dementia severity, incident pneumonia and, even more so, incident intake problems were more strongly associated with mortality risk. Pneumonia and intake problems both mediated the relationship between more severe dementia and mortality.

DISCUSSION

Developing pneumonia and intake problems affects survival, and this is not limited to advanced dementia. The occurrence of pneumonia and intake problems are important signals to consider a palliative care approach in nursing home residents with dementia, and an active focus on advance care planning is needed. Future studies should investigate whether this is also relevant for patients in primary care.

Association of hospice utilization and publicly reported outcomes following hospitalization for pneumonia or heart failure: a retrospective cohort study

Background

The Center for Medicare and Medicaid Services (CMS) and the Hospital Quality Alliance began collecting and reporting United States hospital performance in the treatment of pneumonia and heart failure in 2008. Whether the utilization of hospice might affect CMS-reported mortality and readmission rates is not known.

Methods

Hospice utilization (mean days on hospice per decedent) for 2012 from the Dartmouth Atlas (a project of the Dartmouth Institute that reports a variety of public health and policy-related statistics) was merged with hospital-level 30-day mortality and readmission rates for pneumonia and heart failure from CMS. The association between hospice use and outcomes was analyzed with multivariate quantile regression controlling for quality of care metrics, acute care bed availability, regional variability and other measures.

Results

2196 hospitals reported data to both CMS and the Dartmouth Atlas in 2012. Higher rates of hospice utilization were associated with lower rates of 30-day mortality and readmission for pneumonia but not for heart failure. Higher quality of care was associated with lower rates of mortality for both pneumonia and heart failure. Greater acute care bed availability was associated with increased readmission rates for both conditions (p < 0.05 for all).

Conclusions

Higher rates of hospice utilization were associated with lower rates of 30-day mortality and readmission for pneumonia as reported by CMS. While causality is not established, it is possible that hospice referrals might directly affect CMS outcome metrics. Further clarification of the relationship between hospice referral patterns and publicly reported CMS outcomes appears warranted.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2801-3) contains supplementary material, which is available to authorized users.

End-of-life treatment decisions in nursing home residents dying with dementia in the Netherlands

OBJECTIVE

The objective was to describe end-of-life treatment decisions for patients dying with dementia in various stages of dementia in long-term care facilities in the Netherlands with elderly care physicians responsible for treatment and care.

METHODS

We present data collected in the nationally representative Dutch End of Life in Dementia study (2007-2011). Within 2 weeks after death, 103 physicians completed questionnaires about the last phase of life in 330 residents with dementia who resided in 1 of 34 participating long-term care facilities. We used descriptive statistics.

RESULTS

Advance directives were rare (4.9%). A minority was hospitalized (8.0%) in the last month (mainly for fractures) or received antibiotics (24.2%) in the last week (mainly for pneumonia). Four residents received tube feeding or rehydration therapy in the last week. In almost half of the residents (42.3%), decisions were made not to start potentially life-prolonging treatment such as hospital transfer and artificial nutrition and hydration. In more than half of the residents (53.7%), decisions were made to withdraw potentially life-prolonging treatment such as artificial nutrition and hydration and medication. Antibiotics were more frequently prescribed for residents with less advanced dementia, but otherwise there were no differences in treatment decisions between residents with advanced and less advanced dementia.

CONCLUSIONS

Physicians often withhold potentially burdensome life-prolonging treatment in nursing home residents in all stages of dementia in the Netherlands. This suggests that the physicians feel that a palliative care approach is appropriate at the end of life in dementia in long-term care. Copyright © 2016 John Wiley & Sons, Ltd. StartCopTextCopyright © 2016 John Wiley & Sons, Ltd.

Symptom relief in patients with pneumonia and dementia: implementation of a practice guideline

OBJECTIVE

This study aimed to assess the degree of implementation and barriers encountered in the use of a practice guideline for optimal symptom relief for patients with dementia and pneumonia in Dutch nursing homes.

METHODS

A process evaluation included assessment of reach, fidelity, and dose delivered using researcher's observations, and dose received was addressed in a question "use of the practice guideline," which the physicians completed for each patient included in the study. Perceived barriers were assessed with a structured questionnaire (response 69%) and semi-structured interviews (n = 14), which were subject to qualitative content analysis.

RESULTS

Of the 55 physicians involved in the intervention phase, 87% attended an implementation meeting; 20 physicians joined the study later (reach). The intervention was implemented as planned, and all intervention components were delivered by the researchers (fidelity and dose delivered). Thirty-six physicians included 109 patients. For 81% of the patients, the treating physician stated to have used the guideline (dose received). The guideline was perceived as providing a good overview of current practice, but some physicians had expected a more directive protocol or algorithm. Further, recommended regular observations of symptoms were rarely performed. Physician's often felt that "this is not different from what we usually do," and with the acute illness, there was not always enough time to (re)familiarize with the contents.

CONCLUSIONS

The physicians used the practice guideline frequently despite important barriers. Future implementation may involve strategies such as multiple interactive meetings. Further, the greatest potential to alter usual practice should be emphasized, such as using observational instruments. Copyright © 2016 John Wiley & Sons, Ltd.

Incidence of pneumonia in nursing home residents with dementia in the Netherlands: an estimation based on three differently designed studies

Pneumonia leads to considerable morbidity and mortality in nursing home residents with dementia. We assessed pneumonia incidence based on data from three different studies: (1) real-time national surveillance of healthcare-associated infections in nursing home residents in 2009-2015; (2) a randomized controlled trial in 2012-2015 to assess effects of a practical guideline in nursing home residents with dementia and pneumonia; and (3) a study in 2007-2010 to assess quality of dying in newly admitted nursing home residents with dementia. In national surveillance data, pneumonia incidence was calculated separately for psychogeriatric and somatic beds, as a proxy for residents with and without dementia. Weekly pneumonia incidence was significantly lower per 1000 psychogeriatric beds (3·9; 95% confidence interval (CI) 3·2-4·6) compared with 1000 somatic beds (5·7; 95% CI 5·1-6·3). Annual incidence per 1000 psychogeriatric beds was similar in national surveillance (range 78·9-117·1) and the trial (range 71·0-94·3), and significantly higher in newly admitted dementia residents (range 267·3-363·2). The incidence was highest during the first months after admission when compared with residents with longer stay. In conclusion, follow-up of pneumonia in newly admitted dementia residents may result in higher incidence, possibly due to higher risk in this population.

Antimicrobial Use in Patients with Dementia: Current Concerns and Future Recommendations

Infections are common in people with dementia, and antibiotic use is widespread, albeit highly variable, across healthcare settings and countries. The few studies conducted to date that consider the appropriateness of antibiotic prescribing specifically for people with dementia focus on people with advanced dementia and suggest that much of the prescribing of antibiotics for these patients may be potentially inappropriate. We suggest that clinicians must consider a number of factors to determine appropriateness of antimicrobial prescribing for people with dementia, including the risks and benefits of assessing and treating infections, the uncertainty regarding the effects of antibiotics on patient comfort, goals of care and treatment preferences, hydration status, dementia severity and patient prognosis. Future research should examine antibiotic prescribing and its appropriateness across the spectrum of common infections, dementia severities, care settings and countries, and should consider how antibiotic therapy should be considered in discussions regarding treatment preferences, goals of care and/or advance care planning between clinicians, patients and families.

Pneumonia in Nursing Home Patients With Advanced Dementia: Decisions, Intravenous Rehydration Therapy, and Discomfort

BACKGROUND

Comfort may be an appropriate goal in advanced dementia. Longitudinal studies on physician decision-making and discomfort assessed by direct observation are rare, and intravenous rehydration therapy is controversial.

METHODS

To assess treatment decisions and discomfort in patients with advanced dementia and pneumonia and to compare by intravenous rehydration therapy, we used data from the observational multicenter Italian End of Life Observatory-Prospective Study On DEmentia patients Care. We analyzed 109 episodes of pneumonia, which involved decisions in 77 nursing home patients with Functional Assessment Staging Tool stage 7. We assessed decisions, decision-making, and treatments every fortnight. Trained observers assessed discomfort with the Discomfort Scale-Dementia Alzheimer Type (DS-DAT).

RESULTS

Most decisions referred to treatment with antibiotics (90%; 98 of 109) and intravenous rehydration therapy (53%; 58 of 109), but hospitalization was rare (1%). Selecting decisions with antibiotics, with rehydration therapy, the prognosis was more frequently <15 days (34% vs 5% without rehydration therapy; P = .001), and a goal to reduce symptoms/suffering was more common (96% vs 74%; P = .005) while there was no difference in striving for life prolongation (a minority). With rehydration therapy, the decision was more often discussed with family rather than communicated only. Mean DS-DAT scores over time proximate to the first decision ranged between 9.2 and 10.5.

CONCLUSIONS

Italian nursing home patients with advanced dementia and pneumonia frequently received invasive rehydration therapy in addition to antibiotics, however, mostly with a palliative intent. Discomfort was high overall and symptom relief may be improved. Relations between invasive rehydration therapy and discomfort need further study.

Physicians' perceptions of suffering in people with dementia at the end of life

OBJECTIVE

Our aim was to describe physicians' perceptions of the suffering of their patients who are dying with dementia, many of whom are incompetent with regard to decision making and have difficulty with communicating about the source of their distress and with identifying related factors.

METHOD

We analyzed data from the nationally representative observational Dutch End-of-Life in Dementia (DEOLD) cohort study (2007-2011), which involved 34 long-term care facilities. A total of 103 physicians completed questionnaires about 330 patients with dementia who had died in a participating facility. Suffering during the last six hours of life was defined as "a patient being disturbed by or aware of symptoms," "suffering until the end or death was a struggle"-all related to objective indicators of lack of comfort. We employed generalized estimating equation models to assess associations of suffering with the characteristics of physicians and patients, the patient's death, and the decision-making process.

RESULTS

In 13.8% of cases, the physician felt that the patient had suffered. An unexpected death and death with pneumonia were strongly (an odds ratios close to 6) associated with suffering, and suffering was also independently associated with the physician's perception of worse quality of end-of-life care, death with cardiovascular disease, a less experienced physician, no palliative sedation, and a younger patient.

SIGNIFICANCE OF RESULTS

Most patients with dementia did not suffer during their final hours of life, according to their physicians. There are a number of factors associated with suffering, among them death with pneumonia and unexpected death. We may not be able to have much influence on death from pneumonia, but quality of care and an unexpected death are reasonable targets for intervention. Earlier identification of the beginning of the dying process would allow time to better prepare for approaching death, which would provide a source of comfort.

Improving comfort in people with dementia and pneumonia: a cluster randomized trial

BACKGROUND

Pneumonia in people with dementia has been associated with severe discomfort. We sought to assess the effectiveness of a practice guideline for optimal symptom relief for nursing home residents with dementia and pneumonia.

METHODS

A single-blind, multicenter, cluster randomized controlled trial was conducted in 32 Dutch nursing homes. Outcomes were assessed on the patient level. The main outcome measures were discomfort and symptoms: discomfort (DS-DAT: Discomfort Scale-Dementia of Alzheimer Type), (lack of) comfort (EOLD-CAD: End Of Life in Dementia-Comfort Assessment in Dying), pain (PAINAD: Pain Assessment in Advanced Dementia), and respiratory distress (RDOS: Respiratory Distress Observation Scale). Outcomes were scheduled daily from diagnosis until 10 days later and a final time between 13-15 days from diagnosis by trained observers who were blinded to the intervention and the residents' condition and treatment. In a pre-intervention phase, usual care was provided to all homes. In the intervention phase, matched clusters of homes were randomized to either the control (n = 16) or intervention condition (n = 16).

RESULTS

Between 1 January 2012 and 1 May 2015, 464 episodes of pneumonia were included. Outcomes were obtained for 399 episodes in 367 residents. Longitudinal multilevel linear regression analyses were performed on log-transformed outcomes, so coefficients should be interpreted as a ratio, and a coefficient of 1 means no difference. The practice guideline in the intervention phase did not reduce the level of discomfort and symptoms: DS-DAT: 1.11 (95 % CI 0.93-1.31), EOLD-CAD: 1.01 (95 % CI 0.98-1.05), PAINAD: 1.04 (95 % CI 0.93-1.15), RDOS: 1.11 (95 % CI 0.90-1.24). However, in both the intervention and control groups, lack of comfort and respiratory distress gradually decreased during the entire 3.5 years of data collection, and were lower in the intervention phase compared to the pre-intervention phase: DS-DAT: 0.93 (95 % CI 0.85-1.01), EOLD-CAD: 0.98 (95 % CI 0.97-1.00), PAINAD: 0.96 (95 % CI 0.91-1.01), RDOS: 0.92 (95 % CI 0.87-0.98).

CONCLUSIONS

When compared to usual care, the practice guideline for optimal symptom relief did not relieve discomfort and symptoms in nursing home residents with dementia and pneumonia. However, discomfort and symptoms decreased gradually throughout the data collection in both the intervention homes and the control homes. An intervention that focuses on creating awareness may be more effective than a physician practice guideline.

TRIAL REGISTRATION

The Netherlands National Trial Register (ID number NTR5071 . Registered 10 March 2015).