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Tay R, Tan JY, Lim B, Hum AY, Simpson J, Preston N. Factors associated with the place of death of persons with advanced dementia: A systematic review of international literature with meta-analysis. Palliat Med 2024:2692163241265231. [PMID: 39092850 DOI: 10.1177/02692163241265231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
BACKGROUND Many individuals with advanced dementia die in hospital, despite preferring home death. Existing evidence of factors affecting their place of death is inconsistent. To inform policies/practices for meeting needs/preferences, systematically establishing the evidence is pertinent, particularly given the exponential rise in advanced dementia prevalence. AIM To identify factors influencing where people with advanced dementia die. DESIGN AND DATA SOURCES This systematic review with meta-analysis was registered on PROSPERO (CRD42022366722). Medline, CINAHL, PsycINFO, SocINDEX and a grey literature database, Overton, were searched on 21/12/2022, supplemented by hand-searching/citation tracking. Papers reporting quantitative data on factors associated with place of death in advanced dementia were included and appraised using QualSyst. Data were analysed using random effects with the certainty of evidence determined using the GRADE criteria. RESULTS Thirty-three papers involving >5 million individuals (mean age = 89.2 years) were included. Long-term care setting deaths were relatively common but hospice deaths were rarer. Marriage's association with home death underscores social networks' importance, while younger age's and male gender's associations with hospital death demonstrate patients' and families' interdependency. Pneumonia/COPD's opposing effects on hospital deaths with cancer/functional impairment highlight the challenges of advanced dementia care. Unlike hospital/nursing home bed availability's lack of effect, capitated funding (fixed-amount-per-patient-per-period) decreased hospital death likelihood. CONCLUSION This comprehensive review of place of death determinants highlight the profound challenges of advanced dementia end-of-life care. Given that bed capacity did not affect place of death, a capitation-based, integrated palliative care model would appear more likely to meet patients' needs in a resource-constrained environment.
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Affiliation(s)
- RiYin Tay
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
- The Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
- Dover Park Hospice, Singapore, Singapore
| | - Joyce Ys Tan
- The Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - BinYan Lim
- The Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
- Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore, Singapore
| | - Allyn Ym Hum
- The Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jane Simpson
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Nancy Preston
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
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2024 Alzheimer's disease facts and figures. Alzheimers Dement 2024; 20:3708-3821. [PMID: 38689398 PMCID: PMC11095490 DOI: 10.1002/alz.13809] [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] [Indexed: 05/02/2024]
Abstract
This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.
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Abstract
This article describes the public health impact of Alzheimer's disease, including prevalence and incidence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report examines the patient journey from awareness of cognitive changes to potential treatment with drugs that change the underlying biology of Alzheimer's. An estimated 6.7 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, and Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated by the COVID-19 pandemic in 2020 and 2021. More than 11 million family members and other unpaid caregivers provided an estimated 18 billion hours of care to people with Alzheimer's or other dementias in 2022. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $339.5 billion in 2022. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the paid health care workforce are involved in diagnosing, treating and caring for people with dementia. In recent years, however, a shortage of such workers has developed in the United States. This shortage - brought about, in part, by COVID-19 - has occurred at a time when more members of the dementia care workforce are needed. Therefore, programs will be needed to attract workers and better train health care teams. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2023 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $345 billion. The Special Report examines whether there will be sufficient numbers of physician specialists to provide Alzheimer's care and treatment now that two drugs are available that change the underlying biology of Alzheimer's disease.
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Zhu Y, Olchanski N, Cohen JT, Freund KM, Faul JD, Fillit HM, Neumann PJ, Lin PJ. Life-Sustaining Treatments Among Medicare Beneficiaries with and without Dementia at the End of Life. J Alzheimers Dis 2023; 96:1183-1193. [PMID: 37955089 PMCID: PMC10777481 DOI: 10.3233/jad-230692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND Older adults with dementia including Alzheimer's disease may have difficulty communicating their treatment preferences and thus may receive intensive end-of-life (EOL) care that confers limited benefits. OBJECTIVE This study compared the use of life-sustaining interventions during the last 90 days of life among Medicare beneficiaries with and without dementia. METHODS This cohort study utilized population-based national survey data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Our sample included Medicare fee-for-service beneficiaries aged 65 years or older deceased between 2000 and 2016. The main outcome was receipt of any life-sustaining interventions during the last 90 days of life, including mechanical ventilation, tracheostomy, tube feeding, and cardiopulmonary resuscitation. We used logistic regression, stratified by nursing home use, to examine dementia status (no dementia, non-advanced dementia, advanced dementia) and patient characteristics associated with receiving those interventions. RESULTS Community dwellers with dementia were more likely than those without dementia to receive life-sustaining treatments in their last 90 days of life (advanced dementia: OR = 1.83 [1.42-2.35]; non-advanced dementia: OR = 1.16 [1.01-1.32]). Advance care planning was associated with lower odds of receiving life-sustaining treatments in the community (OR = 0.84 [0.74-0.96]) and in nursing homes (OR = 0.68 [0.53-0.86]). More beneficiaries with advanced dementia received interventions discordant with their EOL treatment preferences. CONCLUSIONS Community dwellers with advanced dementia were more likely to receive life-sustaining treatments at the end of life and such treatments may be discordant with their EOL wishes. Enhancing advance care planning and patient-physician communication may improve EOL care quality for persons with dementia.
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Affiliation(s)
- Yingying Zhu
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Natalia Olchanski
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Joshua T. Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Karen M. Freund
- Center for Health Equity Research, Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Jessica D. Faul
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | | | - Peter J. Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Pei-Jung Lin
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
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Olvera CE, Levin ME, Fleisher JE. Community-based neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:49-66. [PMID: 36599515 DOI: 10.1016/b978-0-12-824535-4.00001-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Community-based palliative care is defined as palliative care delivered outside of the hospital and outpatient clinics. These settings include the home, nursing homes, day programs, volunteer organizations, and support groups. There is strong evidence outside of the neuropalliative context that community-based palliative care can reduce hospital costs and admissions at the end of life. Research that focuses on specialized community-based palliative care for neurologic disease have similar findings, although with significant variability across conditions and geographic locations. Several of these studies have investigated home-based care for neurologic conditions including dementia, Parkinson's disease, multiple sclerosis, brain tumors, and motor neuron disease. Other work has focused on incorporating palliative care models into the treatment of patients with neurologic diseases within nursing home settings. Similar to nonneurologic community-based palliative care, little has been published on patient and caregiver quality-of-life outcomes in such models of care, although the emerging data are generally positive. Future studies should explore how best to provide comprehensive, cost-effective, scalable, and replicable models of community-based neuropalliative care, patient and caregiver outcomes in such models, and how care can be adapted between and within specific patient populations and healthcare systems.
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Affiliation(s)
- Caroline E Olvera
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States; Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL, United States
| | - Melissa E Levin
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States; Chicago Medical School-Rosalind Franklin University, North Chicago, IL, United States
| | - Jori E Fleisher
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States.
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Abstract
This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report discusses consumers' and primary care physicians' perspectives on awareness, diagnosis and treatment of mild cognitive impairment (MCI), including MCI due to Alzheimer's disease. An estimated 6.5 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available. Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States in 2019 and the seventh-leading cause of death in 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. More than 11 million family members and other unpaid caregivers provided an estimated 16 billion hours of care to people with Alzheimer's or other dementias in 2021. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $271.6 billion in 2021. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the dementia care workforce have also been affected by COVID-19. As essential care workers, some have opted to change jobs to protect their own health and the health of their families. However, this occurs at a time when more members of the dementia care workforce are needed. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2022 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $321 billion. A recent survey commissioned by the Alzheimer's Association revealed several barriers to consumers' understanding of MCI. The survey showed low awareness of MCI among Americans, a reluctance among Americans to see their doctor after noticing MCI symptoms, and persistent challenges for primary care physicians in diagnosing MCI. Survey results indicate the need to improve MCI awareness and diagnosis, especially in underserved communities, and to encourage greater participation in MCI-related clinical trials.
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Carpenter JG, Hanson LC, Hodgson N, Murray A, Hippe DS, Polissar NL, Ersek M. Implementing Primary Palliative Care in Post-acute nursing home care: Protocol for an embedded pilot pragmatic trial. Contemp Clin Trials Commun 2021; 23:100822. [PMID: 34381919 PMCID: PMC8340123 DOI: 10.1016/j.conctc.2021.100822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 07/10/2021] [Accepted: 07/24/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Older adults with serious illness frequently receive post-acute rehabilitative care in nursing homes (NH) under the Part A Medicare Skilled Nursing Facility (SNF) Benefit. Treatment is commonly focused on disease-modifying therapies with minimal consideration for goals of care, symptom relief, and other elements of palliative care. INTERVENTION The evidence-based Primary Palliative Care in Post-Acute Care (PPC-PAC) intervention for older adults is delivered by nurse practitioners (NP). PPC-PAC NPs assess and manage symptoms, conduct goals of care discussions and assist with decision making; they communicate findings with NH staff and providers. Implementation of PPC-PAC includes online and face-to-face training of NPs, ongoing facilitation, and a template embedded in the NH electronic health record to document PPC-PAC. OBJECTIVES The objectives of this pilot pragmatic clinical trial are to assess the feasibility, acceptability, and preliminary effectiveness of the PPC-PAC intervention and its implementation for 80 seriously ill older adults newly admitted to a NH for post-acute care. METHODS Design is a two-arm nonequivalent group multi-site pilot pragmatic clinical trial. The unit of assignment is at the NP and unit of analysis is NH patients. Recruitment occurs at NHs in Pennsylvania, New Jersey, Delaware, and Maryland. Effectiveness (patient quality of life) data are collected at two times points-baseline and 14-21 days. CONCLUSION This will be the first study to evaluate the implementation of an evidence-based primary palliative care intervention specifically designed for older adults with serious illness who are receiving post-acute NH care.
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Affiliation(s)
- Joan G. Carpenter
- University of Maryland School of Nursing, Baltimore, MD, USA
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Laura C. Hanson
- Division of Geriatric Medicine & Palliative Care Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nancy Hodgson
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Andrew Murray
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Daniel S. Hippe
- The Mountain Whisper Light Statistics $ Data Science, Seattle, WA, USA
| | - Nayak L. Polissar
- The Mountain Whisper Light Statistics $ Data Science, Seattle, WA, USA
| | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Chiong W, Tsou AY, Simmons Z, Bonnie RJ, Russell JA. Ethical Considerations in Dementia Diagnosis and Care: AAN Position Statement. Neurology 2021; 97:80-89. [PMID: 34524968 DOI: 10.1212/wnl.0000000000012079] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 03/08/2021] [Indexed: 11/15/2022] Open
Abstract
Alzheimer disease and other dementias present unique practical challenges for patients, their families, clinicians, and health systems. These challenges reflect not only the growing public health effect of dementia in an aging global population, but also more specific ethical complexities including early loss of patients' capacity to make decisions regarding their own care, the stigma often associated with a dementia diagnosis, the difficulty of balancing concern for patients' welfare with respect for patients' remaining independence, and the effect on the physical, emotional, and financial well-being of family caregivers. Caring for patients with dementia requires respecting patient autonomy while acknowledging progressively diminishing decisional capacity and continuing to provide care in accordance with other core ethical principles (beneficence, justice, and nonmaleficence). Whereas these ethical principles remain unchanged, neurologists must reconsider how to apply them given changes across multiple domains including our understanding of disease, clinical and legal tools for addressing manifestations of illness, our expanding awareness of the crucial role of family caregivers in providing care and maintaining patient quality of life, and societal conceptions of dementia and individuals' personal expectations for aging. This revision to the American Academy of Neurology's 1996 position statement summarizes ethical considerations that often arise in caring for patients with dementia; although it addresses how such considerations influence patient management, it is not a clinical practice guideline.
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Affiliation(s)
- Winston Chiong
- From the Department of Neurology (W.C.), University of California San Francisco; Evidence-Based Practice Center (A.Y.T.), ECRI, Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Neurology (Z.S.), The Pennsylvania State University, Hershey; School of Law (R.J.B.), University of Virginia, Charlottesville; and Department of Neurology (J.A.R.), Lahey Medical Center, Burlington, MA.
| | - Amy Y Tsou
- From the Department of Neurology (W.C.), University of California San Francisco; Evidence-Based Practice Center (A.Y.T.), ECRI, Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Neurology (Z.S.), The Pennsylvania State University, Hershey; School of Law (R.J.B.), University of Virginia, Charlottesville; and Department of Neurology (J.A.R.), Lahey Medical Center, Burlington, MA
| | - Zachary Simmons
- From the Department of Neurology (W.C.), University of California San Francisco; Evidence-Based Practice Center (A.Y.T.), ECRI, Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Neurology (Z.S.), The Pennsylvania State University, Hershey; School of Law (R.J.B.), University of Virginia, Charlottesville; and Department of Neurology (J.A.R.), Lahey Medical Center, Burlington, MA
| | - Richard J Bonnie
- From the Department of Neurology (W.C.), University of California San Francisco; Evidence-Based Practice Center (A.Y.T.), ECRI, Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Neurology (Z.S.), The Pennsylvania State University, Hershey; School of Law (R.J.B.), University of Virginia, Charlottesville; and Department of Neurology (J.A.R.), Lahey Medical Center, Burlington, MA
| | - James A Russell
- From the Department of Neurology (W.C.), University of California San Francisco; Evidence-Based Practice Center (A.Y.T.), ECRI, Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Neurology (Z.S.), The Pennsylvania State University, Hershey; School of Law (R.J.B.), University of Virginia, Charlottesville; and Department of Neurology (J.A.R.), Lahey Medical Center, Burlington, MA
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Abstract
Chronic brain failure, also known as dementia or major neurocognitive disorder, is a syndrome of progressive functional decline characterized by both cognitive and neuropsychiatric symptoms. It can be conceptualized like other organ failure syndromes and its impact on quality of life can be mitigated with proper treatment. Dementia is a risk factor for delirium, and their symptoms can be similar. Patients with dementia can present with agitation that can lead to injury. Logic and reason are rarely successful when attempting to redirect someone with advanced dementia. Interactions that offer a sense of choice are more likely to succeed.
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Abstract
This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the challenges of providing equitable health care for people with dementia in the United States. An estimated 6.2 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available, making Alzheimer's the sixth-leading cause of death in the United States and the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated in 2020 by the COVID-19 pandemic. More than 11 million family members and other unpaid caregivers provided an estimated 15.3 billion hours of care to people with Alzheimer's or other dementias in 2020. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $256.7 billion in 2020. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2021 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $355 billion. Despite years of efforts to make health care more equitable in the United States, racial and ethnic disparities remain - both in terms of health disparities, which involve differences in the burden of illness, and health care disparities, which involve differences in the ability to use health care services. Blacks, Hispanics, Asian Americans and Native Americans continue to have a higher burden of illness and lower access to health care compared with Whites. Such disparities, which have become more apparent during COVID-19, extend to dementia care. Surveys commissioned by the Alzheimer's Association recently shed new light on the role of discrimination in dementia care, the varying levels of trust between racial and ethnic groups in medical research, and the differences between groups in their levels of concern about and awareness of Alzheimer's disease. These findings emphasize the need to increase racial and ethnic diversity in both the dementia care workforce and in Alzheimer's clinical trials.
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Loomer L, Ogarek JA, Mitchell SL, Volandes AE, Gutman R, Gozalo PL, McCreedy EM, Mor V. Impact of an Advance Care Planning Video Intervention on Care of Short-Stay Nursing Home Patients. J Am Geriatr Soc 2020; 69:735-743. [PMID: 33159697 DOI: 10.1111/jgs.16918] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVES To assess whether an advance care planning (ACP) video intervention impacts care among short-stay nursing home (NH) patients. DESIGN PRagmatic trial of Video Education in Nursing Homes (PROVEN) was a pragmatic cluster randomized clinical trial. SETTING A total of 360 NHs (N = 119 intervention, N = 241 control) owned by two healthcare systems. PARTICIPANTS A total of 2,538 and 5,290 short-stay patients with advanced dementia or cardiopulmonary disease (advanced illness) in the intervention and control arms, respectively; 23,302 and 50,815 short-stay patients without advanced illness in the intervention and control arms, respectively. INTERVENTION Five ACP videos were available on tablets or online. Designated champions at each intervention facility were instructed to offer a video to patients (or proxies) on admission. Control facilities used usual ACP practices. MEASUREMENTS Follow-up time was at most 100 days for each patient. Outcomes included hospital transfers per 1000 person-days alive and the proportion of patients experiencing more than one hospital transfer, more than one burdensome treatment (tube-feeding, parenteral therapy, invasive mechanical intervention, and intensive care unit admission), and hospice enrollment. Champions recorded whether a video was offered in the patients' electronic medical record. RESULTS There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention versus control groups with advanced illness (rate (95% confidence interval (CI)), 12.3 (11.6-13.1) vs 13.2 (12.5-13.7); rate difference: -0.8; 95% CI = -1.8-0.2)). There was a nonsignificant reduction in hospital transfers per 1000 person-days alive in the intervention versus control among short-stay patients without advanced illness. Secondary outcomes did not differ between groups among patients with and without advanced illness. Based on champion only reports 14.2% and 15.3% of eligible short-stay patients with and without advanced illness were shown videos, respectively. CONCLUSION An ACP video program did not significantly reduce hospital transfers, burdensome treatment, or hospice enrollment among short-stay NH patients; however, fidelity to the intervention was low.
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Affiliation(s)
- Lacey Loomer
- Department of Economics, Labovitz School of Business and Economics, Duluth, Minnesota, USA
| | - Jessica A Ogarek
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, 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
| | - Angelo E Volandes
- General Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Section of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Roee Gutman
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Pedro L Gozalo
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
| | - Ellen M McCreedy
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Vincent Mor
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
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12
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Impact of Dementia on Health Service Use in the Last 2 Years of Life for Women with Other Chronic Conditions. J Am Med Dir Assoc 2020; 21:1651-1657.e1. [DOI: 10.1016/j.jamda.2020.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 02/21/2020] [Accepted: 02/21/2020] [Indexed: 01/17/2023]
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Abstract
This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the future challenges of meeting care demands for the growing number of people living with Alzheimer's dementia in the United States with a particular emphasis on primary care. By mid-century, the number of Americans age 65 and older with Alzheimer's dementia may grow to 13.8 million. This represents a steep increase from the estimated 5.8 million Americans age 65 and older who have Alzheimer's dementia today. Official death certificates recorded 122,019 deaths from AD in 2018, the latest year for which data are available, making Alzheimer's the sixth leading cause of death in the United States and the fifth leading cause of death among Americans age 65 and older. Between 2000 and 2018, deaths resulting from stroke, HIV and heart disease decreased, whereas reported deaths from Alzheimer's increased 146.2%. In 2019, more than 16 million family members and other unpaid caregivers provided an estimated 18.6 billion hours of care to people with Alzheimer's or other dementias. This care is valued at nearly $244 billion, but its costs extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2020 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $305 billion. As the population of Americans living with Alzheimer's dementia increases, the burden of caring for that population also increases. These challenges are exacerbated by a shortage of dementia care specialists, which places an increasing burden on primary care physicians (PCPs) to provide care for people living with dementia. Many PCPs feel underprepared and inadequately trained to handle dementia care responsibilities effectively. This report includes recommendations for maximizing quality care in the face of the shortage of specialists and training challenges in primary care.
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Stephens CE, Halifax E, David D, Bui N, Lee SJ, Shim J, Ritchie CS. "They Don't Trust Us": The Influence of Perceptions of Inadequate Nursing Home Care on Emergency Department Transfers and the Potential Role for Telehealth. Clin Nurs Res 2020; 29:157-168. [PMID: 31007055 PMCID: PMC10242499 DOI: 10.1177/1054773819835015] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
In this descriptive, qualitative study, we conducted eight focus groups with diverse informal and formal caregivers to explore their experiences/challenges with nursing home (NH) to emergency department (ED) transfers and whether telehealth might be able to mitigate some of those concerns. Interviews were transcribed and analyzed using a grounded theory approach. Transfers were commonly viewed as being influenced by a perceived lack of trust in NH care/capabilities and driven by four main factors: questioning the quality of NH nurses' assessments, perceptions that physicians were absent from the NH, misunderstandings of the capabilities of NHs and EDs, and perceptions that responses to medical needs were inadequate. Participants believed technology could provide "the power of the visual" permitting virtual assessment for the off-site physician, validation of nursing assessment, "real time" assurance to residents and families, better goals of care discussions with multiple parties in different locations, and family ability to say goodbye.
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Affiliation(s)
- Caroline E. Stephens
- Department of Community Health Systems, University of California, San Francisco, CA, USA
| | - Elizabeth Halifax
- Department of Physiological Nursing, University of California, San Francisco, CA, USA
| | - Daniel David
- Department of Community Health Systems, University of California, San Francisco, CA, USA
| | - Nhat Bui
- Asian Health Services, Oakland, CA, USA
| | - Sei J. Lee
- Division of Geriatrics, University of California, San Francisco, CA, USA
- San Francisco VA Healthcare System, San Francisco, CA, USA
| | - Janet Shim
- Department of Social and Behavioral Sciences, University of California, San Francisco, CA, USA
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Gonella S, Campagna S, Basso I, De Marinis MG, Di Giulio P. Mechanisms by which end-of-life communication influences palliative-oriented care in nursing homes: A scoping review. PATIENT EDUCATION AND COUNSELING 2019; 102:2134-2144. [PMID: 31278036 DOI: 10.1016/j.pec.2019.06.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 06/05/2019] [Accepted: 06/18/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE End-of-life communication has been largely recognized to promote quality end-of-life care in nursing home (NHs) by increasing residents' likelihood of receiving comfort-oriented care. This scoping review summarizes what is known about the potential mechanisms by which end-of-life communication may contribute to palliative-oriented care in NHs. METHODS Using the framework proposed by Arksey and O'Malley and refined by the Joanna Briggs Institute methodology, five literature databases were searched. We extracted 2159 articles, 11 of which met the inclusion criteria: seven quantitative, three qualitative, and one mixed-methods study. RESULTS Three mechanisms were identified: a) promotion of family carers' understanding about their family member's health condition, prognosis, and treatments available; b) fostering of shared decision-making between health care professionals (HCPs) and residents/family carers; and c) using and improving knowledge about residents' preferences. CONCLUSION Family carers' understanding, shared decision-making, and knowledge of residents' preferences contribute to palliative-oriented care in NHs. PRACTICE IMPLICATIONS Discussions about end-of-life should take place early in a resident's disease trajectory to allow time for family carers to understand the condition and participate in subsequent, mindful, shared decision-making. HCPs should conduct systematic and thorough discussions about end-of-life treatment options with all cognitively competent residents to promote informed advance directives.
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Affiliation(s)
- Silvia Gonella
- Department of Biomedicine and Prevention, University of Roma Tor Vergata, Via Montpellier 1, 00133, Roma, Italy; Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Corso Bramante 88-90, 10126, Torino, Italy.
| | - Sara Campagna
- Department of Public Health and Pediatrics, University of Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Ines Basso
- Department of Public Health and Pediatrics, University of Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Maria Grazia De Marinis
- Nursing Research Unit, University Campus Bio Medico of Roma, Via Alvaro del Portillo 200, 00128, Roma, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Torino, Via Santena 5 bis, 10126, Torino, Italy
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Temkin-Greener H, Lee T, Caprio T, Cai S. Rehabilitation Therapy for Nursing Home Residents at the End-of-Life. J Am Med Dir Assoc 2018; 20:476-480.e1. [PMID: 30287262 DOI: 10.1016/j.jamda.2018.07.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/31/2018] [Accepted: 07/31/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Ultrahigh therapy use has increased in SNFs without concomitant increases in residents' characteristics. It has been suggested that this trend may also have influenced the provision of high-intensity rehabilitation therapies to residents who are at the end of life (EOL). Motivated by lack of evidence, we examined therapy use and intensity among long-stay EOL residents. DESIGN An observational study covering a time period 2012-2016. SETTING AND PARTICIPANTS New York State nursing homes (N = 647) and their long-stay decedent residents (N = 55,691). METHODS Data sources included Minimum Data Set assessments, vital statistics, Nursing Home Compare website, LTCfocus, and Area Health Resource File. Therapy intensity in the last month of life was the outcome measure. Individual-level covariates were used to adjust for health conditions. Facility-level covariates were the key independent variables of interest. Multinomial logistic regression models with facility random effects were estimated. RESULTS Overall, 13.6% (n = 7600) of long-stay decedent residents had some therapy in the last month of life, 0% to 45% across facilities. Of those, almost 16% had very high/ultrahigh therapy intensity (>500 minutes) prior to death. Adjusting for individual-level covariates, decedents in the for-profit facilities had 18% higher risk of low/medium therapy [relative risk ratio (RRR) = 1.182, P < .001], and more than double the risk of high/ultrahigh therapy (RRR = 2.126, P < .001), compared to those with no therapy use in the last month of life. In facilities with higher physical therapy staffing, decedents had higher risk (RRR = 16.180, P = .002) of high/ultrahigh therapy, but not of low/medium therapy intensity. The use of high/ultrahigh therapy in this population has increased over time. CONCLUSIONS AND RELEVANCE This is a first study to empirically demonstrate that facility characteristics are associated with the provision of therapy intensity to EOL residents. Findings suggest that facilities with a for-profit mission, and with higher staffing of therapists, may be more incentivized to maximize therapy use, even among the sickest of the residents.
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Affiliation(s)
- Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Tiffany Lee
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Thomas Caprio
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
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Sampson EL, Candy B, Davis S, Gola AB, Harrington J, King M, Kupeli N, Leavey G, Moore K, Nazareth I, Omar RZ, Vickerstaff V, Jones L. Living and dying with advanced dementia: A prospective cohort study of symptoms, service use and care at the end of life. Palliat Med 2018; 32:668-681. [PMID: 28922625 PMCID: PMC5987852 DOI: 10.1177/0269216317726443] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Increasing number of people are dying with advanced dementia. Comfort and quality of life are key goals of care. AIMS To describe (1) physical and psychological symptoms, (2) health and social care service utilisation and (3) care at end of life in people with advanced dementia. DESIGN 9-month prospective cohort study. SETTING AND PARTICIPANTS Greater London, England, people with advanced dementia (Functional Assessment Staging Scale 6e and above) from 14 nursing homes or their own homes. MAIN OUTCOME MEASURES At study entry and monthly: prescriptions, Charlson Comorbidity Index, pressure sore risk/severity (Waterlow Scale/Stirling Scale, respectively), acute medical events, pain (Pain Assessment in Advanced Dementia), neuropsychiatric symptoms (Neuropsychiatric Inventory), quality of life (Quality of Life in Late-Stage Dementia Scale), resource use (Resource Utilization in Dementia Questionnaire and Client Services Receipt Inventory), presence/type of advance care plans, interventions, mortality, place of death and comfort (Symptom Management at End of Life in Dementia Scale). RESULTS Of 159 potential participants, 85 were recruited (62% alive at end of follow-up). Pain (11% at rest, 61% on movement) and significant agitation (54%) were common and persistent. Aspiration, dyspnoea, septicaemia and pneumonia were more frequent in those who died. In total, 76% had 'do not resuscitate' statements, less than 40% advance care plans. Most received primary care visits, there was little input from geriatrics or mental health but contact with emergency paramedics was common. CONCLUSION People with advanced dementia lived with distressing symptoms. Service provision was not tailored to their needs. Longitudinal multidisciplinary input could optimise symptom control and quality of life.
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Affiliation(s)
- Elizabeth L Sampson
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,2 Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
| | - Bridget Candy
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Sarah Davis
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Anna Buylova Gola
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Jane Harrington
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Michael King
- 3 Division of Psychiatry, University College London, London, UK
| | - Nuriye Kupeli
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Gerry Leavey
- 4 The Bamford Centre for Mental Health and Wellbeing, Ulster University, Coleraine, UK
| | - Kirsten Moore
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Irwin Nazareth
- 5 Department of Primary Care and Population Health, University College London, London, UK
| | - Rumana Z Omar
- 6 Department of Statistical Science, University College London, London, UK
| | - Victoria Vickerstaff
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,5 Department of Primary Care and Population Health, University College London, London, UK
| | - Louise Jones
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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Hunt LJ, Lee SJ, Harrison KL, Smith AK. Secondary Analysis of Existing Datasets for Dementia and Palliative Care Research: High-Value Applications and Key Considerations. J Palliat Med 2017; 21:130-142. [PMID: 29265949 DOI: 10.1089/jpm.2017.0309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To provide a guide to researchers selecting a dataset pertinent to the study of palliative care for people with dementia and to aid readers who seek to critically evaluate a secondary analysis study in this domain. BACKGROUND The impact of dementia at end-of-life is large and growing. Secondary dataset analysis can play a critical role in advancing research on palliative care for people with dementia. METHODS We conducted a broad search of a variety of resources to: 1. identity datasets that include information germane to dementia and palliative care research; 2. review relevant applications of secondary dataset analysis in the published literature; and 3. explore potential validity and reliability concerns. RESULTS We synthesize findings regarding: 1. Methodological approaches for determining the presence of dementia; 2. Inclusion and measurement of key palliative care items as they relate to people with dementia; and 3. Sampling and study design issues, including the role and implications of proxy-respondents. We describe and compare a selection of high-value existing datasets relevant to palliative care and dementia research. DISCUSSION While secondary analysis of existing datasets requires consideration of key limitations, it can be a powerful tool for efficiently enhancing knowledge of palliative care needs among people with dementia.
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Affiliation(s)
- Lauren J Hunt
- 1 Department of Physiological Nursing, University of California , San Francisco, San Francisco, California.,2 San Francisco Veterans Affairs Medical Center , San Francisco, California
| | - See J Lee
- 2 San Francisco Veterans Affairs Medical Center , San Francisco, California.,3 Division of Geriatrics, Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Krista L Harrison
- 2 San Francisco Veterans Affairs Medical Center , San Francisco, California.,3 Division of Geriatrics, Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Alexander K Smith
- 2 San Francisco Veterans Affairs Medical Center , San Francisco, California.,3 Division of Geriatrics, Department of Medicine, University of California , San Francisco, San Francisco, California
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Miller SC, Lima JC, Intrator O, Martin E, Bull J, Hanson LC. Specialty Palliative Care Consultations for Nursing Home Residents With Dementia. J Pain Symptom Manage 2017; 54:9-16.e5. [PMID: 28438589 PMCID: PMC5663286 DOI: 10.1016/j.jpainsymman.2017.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/20/2017] [Accepted: 03/17/2017] [Indexed: 12/22/2022]
Abstract
CONTEXT U.S. nursing home (NH) residents with dementia have limited access to specialty palliative care beyond Medicare hospice. OBJECTIVES The objective of this study was to examine the value of expanded palliative care access for NH residents with moderate-to-very severe dementia. METHODS We merged palliative care consultation data in 31 NHs in two states to Medicare data to identify residents with consultations, moderate-to-very severe dementia, and deaths in 2006-2010. Initial palliative consultations were identified as occurring later and earlier (1-30 days and 31-180 days before death, respectively). Three controls for each consultation recipient were selected using propensity score matching. Weighted multivariate analyses evaluated the effect of consultations on hospital or acute care use seven and 30 days before death and on (potentially) burdensome transitions (i.e., hospital or hospice admission three days before death or two plus acute care transitions 30 days before death). RESULTS With earlier consultation (vs. no consultation), hospitalization rates in the seven days before death were on average 13.2 percentage points lower (95% confidence interval [CI] -21.8%, -4.7%) and with later consultation 5.9 percentage points lower (95% CI -13.7%, +4.9%). For earlier consultations (vs. no consultations), rates were 18.4 percentage points lower (95% CI -28.5%, -8.4%) for hospitalizations and 11.9 lower (95% CI -20.7%, -3.1%) for emergency room visits 30 days before death; they were 20.2 percentage points lower (95% CI -28.5%, -12.0%) for burdensome transitions. CONCLUSION Consultations appear to reduce acute care use and (potentially) burdensome transitions for dying residents with dementia. Reductions were greater when consultations were earlier.
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Affiliation(s)
- Susan C Miller
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA; Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA.
| | - Julie C Lima
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA; Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA; Geriatrics and Extended Care Data and Analyses Center, Canandaigua Veterans Administration Medical Center, Canandaigua, New York, USA
| | - Edward Martin
- Department of Medicine, Brown University, Providence, Rhode Island, USA; Hope Hospice and Palliative Care, Providence, Rhode Island, USA
| | - Janet Bull
- Four Seasons, Flat Rock, North Carolina, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Center for Aging and Health, Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina, USA
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Cagle JG, Unroe KT, Bunting M, Bernard BL, Miller SC. Caring for Dying Patients in the Nursing Home: Voices From Frontline Nursing Home Staff. J Pain Symptom Manage 2017; 53:198-207. [PMID: 27815169 PMCID: PMC5463275 DOI: 10.1016/j.jpainsymman.2016.08.022] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/24/2016] [Accepted: 08/26/2016] [Indexed: 12/18/2022]
Abstract
CONTEXT Nursing homes are an important site for end-of-life care, yet little is known about the perspectives of the frontline staff who provide a majority of this care. OBJECTIVE To describe, from the staff perspective, positive/negative experiences related to caring for dying residents. METHODS Qualitative analysis using survey data from staff working in 52 Indiana nursing homes. RESULTS A total of 707 frontline staff who provide nursing, nurse aide, and social work services responded to open-ended prompts. Study data included responses to open-ended prompts asking participants to describe one positive experience and one negative experience caring for a dying patient. A thematic content analysis was conducted using the constant-comparative method. Respondents were largely female (93%), white (78%), 31-50 years (42%), and 53% had >5 years of nursing home work experience. Experiences were described from three perspectives: 1) first-hand experiences, 2) observed experiences of dying patients, and 3) observed experiences of family members. Selected themes for positive experiences include the following: creating close bonds; good patient care; involvement of hospice; being prepared; and good communication. Selected themes for negative experiences consisted of the following: challenging aspects of care; unacknowledged death; feeling helpless; uncertainty; absent family; painful emotions; and family discord. CONCLUSION Findings reveal the richness and many complexities of providing end-of-life care in nursing homes and have implications for improving staff knowledge, coordination of care with hospice, and social support for patients.
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Affiliation(s)
- John G Cagle
- University of Maryland, Baltimore, Maryland, USA.
| | - Kathleen T Unroe
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA; Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | | | - Brittany L Bernard
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA; Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Susan C Miller
- Brown University School of Public Health, Providence, Rhode Island, USA
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Palliative care during the final week of life of older people in nursing homes: A register-based study. Palliat Support Care 2017; 15:417-424. [DOI: 10.1017/s1478951516000948] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjective:Our aim was to explore the presence of symptoms, symptom relief, and other key aspects of palliative care during the final week of life among older people residing in nursing homes.Method:Our study employed data from the Swedish Palliative Care Register on all registered individuals aged 60 and older who had died in nursing homes during the years 2011 and 2012. Variables pertaining to monitoring and treatment of symptoms, end-of-life discussions, circumstances around the death, and the individual characteristics of deceased individuals were explored using descriptive statistics.Results:The most common underlying causes of death among the 49,172 deceased nursing home residents were circulatory diseases (42.2%) and dementia (22.7%). The most prevalent symptom was pain (58.7%), followed by rattles (42.4%), anxiety (33.0%), confusion (21.8%), shortness of breath (14.0%), and nausea (11.1%). Pain was the symptom with the highest degree of total relief (46.3%), whereas shortness of breath and confusion were totally relieved in 6.1 and 4.3% of all individuals, respectively. The use of valid instruments for symptom assessment was reported for pain in 12.3% and for other symptoms in 7.8% of subjects. The most prevalent individual prescriptions for injection PRN (pro re nata, according to circumstances) were for pain treatment (79.5%) and rattles (72.8%). End-of-life discussions were performed with 27.3% of all the deceased individuals and with 53.9% of their relatives. Of all individuals, 82.1% had someone present at death, and 15.8% died alone. Of all the nursing home resident deaths recorded, 45.3% died in their preferred place.Significance of results:There were large variations in degree of relief from different symptoms during the final week of life. Pain was the most prevalent symptom, and it was also the symptom with the highest proportion of total/partial relief. Other symptoms were less prevalent but also less well-relieved. Our results indicate a need for improvement of palliative care in nursing home settings, focusing on management of distressing symptoms and promotion of end-of-life discussions.
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Burke RE, Cumbler E, Coleman EA, Levy C. Post-acute care reform: Implications and opportunities for hospitalists. J Hosp Med 2017; 12:46-51. [PMID: 28125831 DOI: 10.1002/jhm.2673] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Nearly all practicing hospitalists have firsthand experience discharging patients to post-acute care (PAC), which is provided by inpatient rehabilitation facilities, skilled nursing facilities, or home healthcare providers. Many may not know that PAC is poised to undergo transformative change, spurred by recent legislation resulting in a range of reforms. These reforms have the potential to fundamentally reshape the relationship between hospitals and PAC providers. They have important implications for hospitalists and will open up opportunities for hospitalists to improve healthcare value. In this article, the authors explore the reasons for PAC reform and the scope of the reforms. Then they describe the implications for hospitalists and hospitalists' opportunities to Choose Wisely and improve healthcare value for the rapidly growing number of vulnerable older adults transitioning to PAC after hospital discharge.
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Affiliation(s)
- Robert E Burke
- Research Section, Denver VA Medical Center, Denver, CO, USA
- Hospital Medicine Section, Denver VA Medical Center, Denver, CO, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ethan Cumbler
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Eric A Coleman
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Cari Levy
- Research Section, Denver VA Medical Center, Denver, CO, USA
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO, USA
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Miller SC, Dahal R, Lima JC, Intrator O, Martin E, Bull J, Hanson LC. Palliative Care Consultations in Nursing Homes and End-of-Life Hospitalizations. J Pain Symptom Manage 2016; 52:878-883. [PMID: 27650008 PMCID: PMC5154868 DOI: 10.1016/j.jpainsymman.2016.05.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/20/2016] [Accepted: 05/27/2016] [Indexed: 12/25/2022]
Abstract
CONTEXT Although specialty palliative care in hospital and outpatient settings is associated with lower acute care use, its impact in U.S. nursing homes (NHs) is unknown. OBJECTIVES To understand how NH use of palliative care consults is associated with end-of-life hospitalizations. METHODS Seven consult providers in four states and 24 counties shared data on the number of consult visits and residents served (per NH) in study years 2000-2010. All NHs in the 24 counties were studied (n = 286). An NH-level longitudinal file included consult data, aggregated Medicare resident assessment and claims data, and NH characteristics. Consult introduction was "yes" when 1% of residents received consults. Volume was the number of consult visits per 100 residents, annually. Panel multivariate regression with NH fixed effects examined whether rates of hospital deaths and hospitalizations in the last 30 days of life differentially changed for NHs introducing consults, or increasing consult volume. RESULTS One hundred seventy (59%) of the 286 NHs introduced consults by 2010. NHs with consults, compared to others, had residents with higher acuity and functional impairment, and lower nurse but higher nursing assistant staffing. Controlling for covariate differences and compared to NHs without consults, NHs introducing consults had a 1% (95% CI -0.021, 0.002) greater reduction in hospital death rates and a 1.6% (95% CI -0.031, -0.002) greater reduction in hospitalizations in the last 30 days of life. No statistically significant associations between volume and study outcomes were observed. CONCLUSION The introduction of specialty palliative care consults in NHs is associated with overall reductions in end-of-life hospitalizations.
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Affiliation(s)
- Susan C Miller
- Department of Health Services, Policy and Practice, Center for Gerontology & Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA.
| | - Roshani Dahal
- Department of Health Services, Policy and Practice, Center for Gerontology & Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Julie C Lima
- Department of Health Services, Policy and Practice, Center for Gerontology & Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Orna Intrator
- University of Rochester, Rochester, New York, USA; Canandaigua VA Medical Center, Canandaigua, New York, USA
| | - Edward Martin
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island, USA; Brown University School of Medicine, Providence, Rhode Island, USA
| | - Janet Bull
- Four Seasons, Flat Rock, North Carolina, USA
| | - Laura C Hanson
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Miller SC, Lima JC, Intrator O, Martin E, Bull J, Hanson LC. Palliative Care Consultations in Nursing Homes and Reductions in Acute Care Use and Potentially Burdensome End-of-Life Transitions. J Am Geriatr Soc 2016; 64:2280-2287. [PMID: 27641157 DOI: 10.1111/jgs.14469] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate how receipt and timing of nursing home (NH) palliative care consultations (primarily by nurse practitioners with palliative care expertise) are associated with end-of-life care transitions and acute care use DESIGN: Propensity score-matched retrospective cohort study. SETTING Forty-six NHs in two states. PARTICIPANTS Nursing home residents who died from 2006 to 2010 stratified according to days between initial consultation and death (≤7, 8-30, 31-60, 61-180). Propensity score matching identified three controls (n = 1,174) according to strata for each consultation recipient (n = 477). MEASUREMENTS Outcomes were hospitalizations in the last 7, 30, and 60 days of life; emergency department (ED) visits in the last 30 and 60 days; and any potentially burdensome care transition, defined as hospitalization or hospice admission within 3 days of death or two or more hospitalizations or ED visits within 30 days. Weighted multivariate logistic regression analyses were used to evaluate outcomes. RESULTS Residents with consultations had lower rates of hospitalization than controls, with rates lowest when initial consultations were furthest from death. For instance, in residents with initial consultations 8 to 30 days before death, the adjusted hospitalization rate in the last 7 days of life was 11.1% (95% confidence interval (CI) = 9.8-12.4%), vs 22.0% (95% CI = 20.6-23.4%) in controls, although in those with initial consultations 61 to 180 days before death, rates were 6.9% (95% CI = 5.5-8.4%), vs 22.9% (95% CI = 20.5-25.4%). Potentially burdensome transition rates were lower when consultations were 61 to 180 days before death (16.2%, 95% CI = 13.7-18.6%), vs 28.2% (95% CI = 25.8-30.6%) for controls. CONCLUSION Palliative care consultations improve end-of-life NH care by reducing acute care use and potentially burdensome care transitions.
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Affiliation(s)
- Susan C Miller
- Department of Health Services, Policy, & Practice, Brown University, Providence, Rhode Island.,Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island
| | - Julie C Lima
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York.,Geriatrics and Extended Care Data and Analyses Center, Canandaigua Veterans Administration Medical Center, Canandaigua, New York
| | - Edward Martin
- Department of Medicine, Brown University, Providence, Rhode Island.,Hope Hospice & Palliative Care, Providence, Rhode Island
| | | | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina, Chapel Hill, North Carolina.,Center for Aging and Health, University of North Carolina, Chapel Hill, North Carolina.,Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina
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Abstract
An 89-year-old male nursing home resident with a 10-year history of Alzheimer’s disease presents with a temperature of 38.3°C, a productive cough, and a respiratory rate of 28 breaths per minute. Nurses report that for the past 6 months he has been coughing at breakfast and having trouble swallowing. He has profound memory deficits, no longer recognizes his daughter (who is his health care proxy), is bedbound, is able to mumble a couple of words, and is unable to perform any activities of daily living. The nurse asks whether he should be hospitalized. How should this patient be evaluated and treated?
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Stephens C, Halifax E, Bui N, Lee SJ, Harrington C, Shim J, Ritchie C. Provider Perspectives on the Influence of Family on Nursing Home Resident Transfers to the Emergency Department: Crises at the End of Life. Curr Gerontol Geriatr Res 2015; 2015:893062. [PMID: 26379704 PMCID: PMC4561315 DOI: 10.1155/2015/893062] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/16/2015] [Indexed: 11/29/2022] Open
Abstract
Background. Nursing home (NH) residents often experience burdensome and unnecessary care transitions, especially towards the end of life. This paper explores provider perspectives on the role that families play in the decision to transfer NH residents to the emergency department (ED). Methods. Multiple stakeholder focus groups (n = 35 participants) were conducted with NH nurses, NH physicians, nurse practitioners, physician assistants, NH administrators, ED nurses, ED physicians, and a hospitalist. Stakeholders described experiences and challenges with NH resident transfers to the ED. Focus group interviews were recorded and transcribed verbatim. Transcripts and field notes were analyzed using a Grounded Theory approach. Findings. Providers perceive that families often play a significant role in ED transfer decisions as they frequently react to a resident change of condition as a crisis. This sense of crisis is driven by 4 main influences: insecurities with NH care; families being unprepared for end of life; absent/inadequate advance care planning; and lack of communication and agreement within families regarding goals of care. Conclusions. Suboptimal communication and lack of access to appropriate and timely palliative care support and expertise in the NH setting may contribute to frequent ED transfers.
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Affiliation(s)
- Caroline Stephens
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, N531E, UCSF Box 0608, San Francisco, CA 94143-0608, USA
| | - Elizabeth Halifax
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, N531E, UCSF Box 0608, San Francisco, CA 94143-0608, USA
| | - Nhat Bui
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, N531E, UCSF Box 0608, San Francisco, CA 94143-0608, USA
| | - Sei J. Lee
- Department of Geriatrics, Palliative & Extended Care, San Francisco VA Medical Center, Division of Geriatrics, School of Medicine, University of California, San Francisco, 4150 Clement Street, Building 1, Room 220F, San Francisco, CA 94121, USA
| | - Charlene Harrington
- Department of Social & Behavioral Sciences, School of Nursing, University of California, San Francisco, 3333 California Street, Suite 455, UCSF Box 0612, San Francisco, CA 94118, USA
| | - Janet Shim
- Department of Social & Behavioral Sciences, School of Nursing, University of California, San Francisco, 3333 California Street, Suite 455, UCSF Box 0612, San Francisco, CA 94118, USA
| | - Christine Ritchie
- Division of Geriatrics, School of Medicine, University of California, San Francisco, 3333 California Street, Suite 380, San Francisco, CA 94143-1265, USA
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30
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Abstract
An 89-year-old male nursing home resident with a 10-year history of Alzheimer’s disease presents with a temperature of 38.3°C, a productive cough, and a respiratory rate of 28 breaths per minute. Nurses report that for the past 6 months he has been coughing at breakfast and having trouble swallowing. He has profound memory deficits, no longer recognizes his daughter (who is his health care proxy), is bedbound, is able to mumble a couple of words, and is unable to perform any activities of daily living. The nurse asks whether he should be hospitalized. How should this patient be evaluated and treated?
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Miller SC, Lima JC, Thompson SA. End-of-Life Care in Nursing Homes with Greater versus Less Palliative Care Knowledge and Practice. J Palliat Med 2015; 18:527-34. [PMID: 25774449 PMCID: PMC4519050 DOI: 10.1089/jpm.2014.0393] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Many older adults in nursing homes (NHs) lack palliative care (PC) access; but little is known about whether access to PC knowledge and practice (beyond hospice) impacts residents' care. OBJECTIVE The study objective was to evaluate how differing levels of NH PC knowledge and practice are associated with residents' end-of-life health care use. METHODS In 2009/10 we surveyed a stratified random sample of U.S. NHs and asked directors of nursing (DONs) PC knowledge and practice questions from Thompson and colleagues' validated PC Survey. This study includes 1981 NHs with complete survey responses and the 58,876 residents who died in these facilities between July 2009 and June 2010. Medicare resident assessment (minimum data set [MDS]) and claims data from July 2009 through June 2010 were used to determine outcomes and a NH's hospice use. Multivariate logistic regressions examined whether residing in NHs with higher PC scores was associated with documented six-month prognoses and receipt of aggressive treatments, including hospital and emergency room (ER) use in the last 30 days of life. RESULTS Controlling for NH hospice use, being in a NH with higher PC care knowledge scores was associated with residents having a higher likelihood of documented six-month prognoses and lower likelihoods of having feeding tubes, injections, restraints, suctioning, and end-of-life hospital and ER use. Being in a NH with higher PC practice scores was associated with a lower likelihood of having feeding tubes and ER visits. CONCLUSION Policies and advocacy promoting the development of NH PC knowledge and practices could potentially improve care and reduce hospital and ER use.
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Affiliation(s)
- Susan C. Miller
- Department of Health Services, Policy and Practice, Center for Gerontology & Health Care Research, Brown University School of Public Health, Providence, Rhode Island
| | - Julie C. Lima
- Department of Health Services, Policy and Practice, Center for Gerontology & Health Care Research, Brown University School of Public Health, Providence, Rhode Island
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Dying in a nursing home: treatable symptom burden and its link to modifiable features of work context. J Am Med Dir Assoc 2015; 16:515-20. [PMID: 25805625 DOI: 10.1016/j.jamda.2015.02.007] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 02/10/2015] [Accepted: 02/11/2015] [Indexed: 11/22/2022]
Abstract
IMPORTANCE High-quality care at the end of life supports freedom from pain and other potentially burdensome symptoms. Lowering symptom burden at the end of life is an urgent and achievable goal in delivering services in nursing home settings. Few published reports describe symptom burden among older adults in nursing homes; none examine links between symptom burden and modifiable features of nursing home organizational context (work environment). OBJECTIVES To examine the influence of organizational context on symptom burden and to compare symptom burden in the last year of life between nursing home residents with and without dementia. DESIGN Retrospective analysis of longitudinal survey data. SETTING A stratified random sample of 36 nursing homes in the Canadian provinces of Alberta, Manitoba, and Saskatchewan. PARTICIPANTS A total of 2635 residents with dementia and 1012 without dementia; 1381 front-line care staff. MEASUREMENTS (1) Trajectories of 6 symptoms (dyspnea, pain, pressure ulcers, urinary tract infections, challenging behavior, delirium), assessed with the Resident Assessment Instrument-Minimum Data Set, version 2.0, between 2008 and 2012. All residents received assessments in each quarter of the year before death. (2) Modifiable organizational context, assessed with the Alberta Context Tool. Hierarchical mixed model, repeated measures regression, to simultaneously evaluate effects of time, dementia, and context on symptom trajectories. RESULTS For all residents, prevalence of symptoms increased over time. In the last quarter before death, challenging behavior was the most frequent symptom in the dementia group (40.2%), delirium the most frequent symptom in the nondementia group (31.0%), and urinary tract infections least frequent (9.0% to 10.0%). Facilities with more favorable context had significantly higher prevalence of challenging behavior and delirium and significantly lower use of antipsychotics without diagnosis of psychosis. CONCLUSION Symptom burden increases as the end of life approaches but differs between high- and low-context facilities and between residents with and without dementia. Trajectories of treatable, burdensome symptoms at the end of life in nursing homes should be a priority focus for quality improvement. Modifiable features of organizational context that are linked to symptom burden offer new potential strategies and interventions for quality improvement.
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Håkanson C, Cronfalk BS, Henriksen E, Norberg A, Ternestedt BM, Sandberg J. First-Line Nursing Home Managers in Sweden and their Views on Leadership and Palliative Care. Open Nurs J 2015; 8:71-8. [PMID: 25628769 PMCID: PMC4303953 DOI: 10.2174/1874434601408010071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 07/23/2014] [Accepted: 08/09/2014] [Indexed: 11/22/2022] Open
Abstract
The aim of this study was to investigate first-line nursing home managers’ views on their leadership and related to that, palliative care. Previous research reveals insufficient palliation, and a number of barriers towards implementation of palliative care in nursing homes. Among those barriers are issues related to leadership quality. First-line managers play a pivotal role, as they influence working conditions and quality of care. Nine first-line managers, from different nursing homes in Sweden participated in the study. Semi-structured interviews were conducted and analysed using qualitative descriptive content analysis. In the results, two categories were identified: embracing the role of leader and being a victim of circumstances, illuminating how the first-line managers handle expectations and challenges linked to the leadership role and responsibility for palliative care. The results reveal views corresponding to committed leaders, acting upon demands and expectations, but also to leaders appearing to have resigned from the leadership role, and who express powerlessness with little possibility to influence care. The first line managers reported their own limited knowledge about palliative care to limit their possibilities of taking full leadership responsibility for implementing palliative care principles in their nursing homes. The study stresses that for the provision of high quality palliative care in nursing homes, first-line managers need to be knowledgeable about palliative care, and they need supportive organizations with clear expectations and goals about palliative care. Future action and learning oriented research projects for the implementation of palliative care principles, in which first line managers actively participate, are suggested.
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Affiliation(s)
- Cecilia Håkanson
- Palliative Research Centre, Ersta University College and Ersta Hospital, Stockholm, Sweden ; Department of Neurobiology, Care science and Society, Karolinska Institutet, Stockholm, Sweden
| | - Berit Seiger Cronfalk
- Palliative Research Centre, Ersta University College and Ersta Hospital, Stockholm, Sweden ; Department of Oncology/Pathology, Karolinska Institutet, Stockholm, Sweden ; Stord Haugesund University College, Norway
| | - Eva Henriksen
- Department of Neurobiology, Care science and Society, Karolinska Institutet, Stockholm, Sweden ; FOU-nu, Stockholm County Council, Stockholm, Sweden
| | - Astrid Norberg
- Palliative Research Centre, Ersta University College and Ersta Hospital, Stockholm, Sweden ; Department of Nursing, Umeå University, Umeå, Sweden
| | - Britt-Marie Ternestedt
- Palliative Research Centre, Ersta University College and Ersta Hospital, Stockholm, Sweden ; Department of Neurobiology, Care science and Society, Karolinska Institutet, Stockholm, Sweden ; Stockholms Sjukhem foundation, Research, Development and Education Unit, Stockholm, Sweden
| | - Jonas Sandberg
- Palliative Research Centre, Ersta University College and Ersta Hospital, Stockholm, Sweden ; Department of Nursing, School of Health Sciences, Jönköping University, Jönköping, Sweden
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Givens JL, Mitchell SL, Kuo S, Gozalo P, Mor V, Teno J. Skilled nursing facility admissions of nursing home residents with advanced dementia. J Am Geriatr Soc 2013; 61:1645-50. [PMID: 24117283 PMCID: PMC3801431 DOI: 10.1111/jgs.12476] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To describe the extent to which hospitalized nursing home (NH) residents with advanced dementia were admitted to a skilled nursing facility (SNF) after a qualifying hospitalization and to identify resident and nursing home characteristics associated with a greater likelihood of SNF admissions. DESIGN Cohort study using data from the Minimum Data Set, Medicare claims, and the On-line Survey Certification of Automated Records. SETTING United States, 2000-2006. PARTICIPANTS Nursing home residents with advanced dementia aged 65 and older with a 3-day hospitalization (N = 4,177). MEASUREMENTS The likelihood of SNF admission after hospitalization was calculated. Resident and nursing home factors associated with SNF admission were identified using hierarchical multivariable logistic regression. RESULTS Sixty-one percent of residents with advanced dementia were admitted to a SNF after their hospitalization. Percutaneous endoscopic gastrostomy (PEG) tube placement during hospitalization was strongly associated with SNF admission (adjusted odds ratio (AOR) = 2.31, 95% confidence interval (CI) = 1.85-2.88), as was better functional status (AOR = 1.21, 95% CI = 1.05-1.38). The presence of diabetes mellitus was associated with lower likelihood of SNF admission (AOR = 0.85, 95% CI = 0.73-0.99). Facility features significantly associated with SNF admission included more than 100 beds (AOR = 1.25, 95% CI = 1.07-1.46), being part of a chain (AOR = 1.31, 95% CI = 1.14-1.50), urban location (AOR = 1.21, 95% CI = 1.03-1.41), and for-profit status (AOR = 1.28, 95% CI = 1.09-1.51). CONCLUSION The majority of nursing home residents with advanced dementia are admitted to SNFs after a qualifying hospitalization. SNF admission is strongly associated with PEG tube insertion during hospitalization and with nursing home factors. Efforts to optimize appropriate use of SNF services in individuals with advanced dementia should focus on these factors.
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Affiliation(s)
- Jane L. Givens
- Beth Israel Deaconess Medical Center, Department of Medicine, Boston, MA
- Hebrew SeniorLife Institute for Aging Research, Boston, MA
| | - Susan L. Mitchell
- Beth Israel Deaconess Medical Center, Department of Medicine, Boston, MA
- Hebrew SeniorLife Institute for Aging Research, Boston, MA
| | - Sylvia Kuo
- Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Pedro Gozalo
- Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Vince Mor
- Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Joan Teno
- Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
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Ersek M, Carpenter JG. Geriatric palliative care in long-term care settings with a focus on nursing homes. J Palliat Med 2013; 16:1180-7. [PMID: 23984636 DOI: 10.1089/jpm.2013.9474] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Almost 1.7 million older Americans live in nursing homes, representing a large proportion of the frailest, most vulnerable elders needing long-term care. In the future, increasing numbers of older adults are expected to spend time and to die in nursing homes. Thus, understanding and addressing the palliative care needs of this population are critical. The goals of this paper are to describe briefly the current state of knowledge about palliative care needs, processes, and outcomes for nursing home residents; identify gaps in this knowledge; and propose priorities for future research in this area.
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Affiliation(s)
- Mary Ersek
- 1 Center for Health Equity Research and Promotion, Philadelphia VA Medical Center , Philadelphia, Pennsylvania
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36
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Howe E. Clinical implications of the new diagnostic guidelines for dementia. INNOVATIONS IN CLINICAL NEUROSCIENCE 2013; 10:32-8. [PMID: 23882439 PMCID: PMC3719461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
New criteria have been proposed for diagnosing Alzheimer's disease. These emphasize that this illness exists on a continuum and begins early on. This article reviews the pros and cons of these criteria. It also provides practical guidelines for psychiatrists whose patients may be affected by these new criteria. Particular attention is given to patients who, as opposed to their wanting to know whether they are likely to have AD, want to deny this possibility.
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Affiliation(s)
- Edmund Howe
- Dr. Howe is Professor, Department of Psychiatry, Director, Programs in Medical Ethics, and Senior Scientist, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Miller SC, Lima JC, Mitchell SL. Influence of hospice on nursing home residents with advanced dementia who received Medicare-skilled nursing facility care near the end of life. J Am Geriatr Soc 2012; 60:2035-41. [PMID: 23110337 DOI: 10.1111/j.1532-5415.2012.04204.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine differences in outcomes according to hospice status of skilled nursing facility (SNF) care recipients. DESIGN Retrospective cohort. SETTING Three thousand three hundred fifty-three U.S. nursing homes (NHs). PARTICIPANTS Four thousand three hundred forty-four persons with advanced dementia who died in NHs in 2006 and received SNF care within 90 days of death were studied, 1,086 of these also received hospice before death: 705 after SNF care, and 381 concurrent with SNF care. MEASUREMENTS Treatments, persistent pain and dyspnea, and hospital death. RESULTS Decedents with any hospice received fewer medications, injections, feeding tubes, intravenous fluids, and therapy services and more hypnotics than those without hospice (all P < .001). Decedents with hospice after SNF care received fewer antipsychotics and those with hospice concurrent with SNF care received more antipsychotics than those without (all P < .001). Multivariate logistic regressions showed that decedents with hospice after SNF had lower likelihood of persistent dyspnea (adjusted odds ratio (AOR) = 0.63, 95% confidence interval (CI) = 0.45-0.87) and hospital death (AOR = 0.02, 95% = CI 0.01, 0.07) than those without hospice. Decedents with hospice concurrent with SNF care had a higher likelihood of persistent pain (AOR = 1.65, 95% CI = 1.23, 2.19) and a lower likelihood of hospital death (AOR = 0.13, 95% CI = 0.07, 0.26) than those without hospice. CONCLUSION Residents dying with advanced dementia who received SNF care in the last 90 days of life had fewer aggressive treatments and lower odds of hospital death if they also received hospice care at any point during that time. Associations between hospice and persistent pain or dyspnea differed according to whether hospice care was received concurrent with or after SNF care.
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Affiliation(s)
- Susan C Miller
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island, USA.
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