Research priorities in geriatric palliative care: nonpain symptoms

Distressing symptoms after major surgery among community-living older persons

BACKGROUND

Relatively little is known about how distressing symptoms change among older persons in the setting of major surgery. Our objective was to evaluate changes in distressing symptoms after major surgery and determine whether these changes differ according to the timing of surgery (nonelective vs. elective), sex, multimorbidity, and socioeconomic disadvantage.

METHODS

From a prospective longitudinal study of 754 nondisabled community-living persons, 70 years of age or older, 368 admissions for major surgery were identified from 274 participants who were discharged from the hospital from March 1998 to December 2017. The occurrence of 15 distressing symptoms was ascertained in the month before and 6 months after major surgery. Multimorbidity was defined as more than two chronic conditions. Socioeconomic disadvantage was assessed at the individual level, based on Medicaid eligibility, and neighborhood level, based on an area deprivation index (ADI) score above the 80th state percentile.

RESULTS

In the month before major surgery, the occurrence and mean number of distressing symptoms were 19.6% and 0.75, respectively. In multivariable analyses, the rate ratios, denoting proportional increases in the 6 months after major surgery relative to presurgery values, were 2.56 (95% confidence interval [CI], 1.91-3.44) and 2.90 (95% CI, 2.01-4.18) for the occurrence and number of distressing symptoms, respectively. The corresponding values were 3.54 (95% CI, 2.06-6.08) and 4.51 for nonelective surgery (95% CI, 2.32-8.76) and 2.12 (95% CI, 1.53-2.92) and 2.20 (95% CI, 1.48-3.29) for elective surgery; p-values for interaction were 0.030 and 0.009. None of the other subgroup differences were statistically significant, although men had a greater proportional increase in the occurrence and number of distressing symptoms than women.

CONCLUSIONS

Among community-living older persons, the burden of distressing symptoms increases substantially after major surgery, especially in those having nonelective procedures. Reducing symptom burden has the potential to improve quality of life and enhance functional outcomes after major surgery.

Symptom management strategies used by older community-dwelling people with multimorbidity and a high symptom burden - a qualitative study

BACKGROUND

Older community-dwelling people with multimorbidity are often not only vulnerable, but also suffer from several conditions that could produce a multiplicity of symptoms. This results in a high symptom burden and a reduced health-related quality of life. Even though these individuals often have frequent contact with healthcare providers they are expected to manage both appropriate disease control and symptoms by themselves or with the support of caregivers. The aim of this study was therefore to describe the symptom management strategies used by older community-dwelling people with multimorbidity and a high symptom burden.

METHOD

A qualitative descriptive design using face-to-face interviews with 20 community-dwelling older people with multimorbidity, a high healthcare consumption and a high symptom burden. People ≥75 years, who had been hospitalized ≥3 times during the previous year, ≥ 3 diagnoses in their medical records and lived at home were included. The participants were between 79 and 89 years old. Data were analysed using content analyses.

RESULT

Two main strategy categories were found: active symptom management and passive symptom management. The active strategies include the subcategories; to plan, to distract, to get assistance and to use facilitating techniques. An active strategy meant that participants took matters in their own hands, they could often describe the source of the symptoms and they felt that they had the power to do something to ease their symptoms. A passive symptom management strategy includes the subcategories to give in and to endure. These subcategories often reflected an inability to describe the source of the symptoms as well as the experience of having no alternative other than passively waiting it out.

CONCLUSIONS

These findings show that older people with multimorbidity and a high symptom burden employ various symptom management strategies on daily basis. They had adopted appropriate strategies based on their own experience and knowledge. Healthcare professionals might facilitate daily life for older people with multimorbidity by providing guidance on active management strategies with focus on patient's own experience and preferences.

Symptom prevalence and management in older adult patients in Lebanon

OBJECTIVE

The purpose of this study is to explore symptoms and the effectiveness of their management in older adult palliative care candidates in Lebanon. The aims of this study were to: (1) determine symptom prevalence in Lebanese older adults who qualify for palliative care; (2) identify the severity and distress of symptoms; (3) identify the prevalence of symptom management and its efficacy; and (4) explore the relationship between overall symptom burden and its correlates.

METHOD

This study uses an observational cross-sectional design using convenience sampling (N = 203) to recruit older adults qualifying for palliative care from three major medical centers in Lebanon.

RESULT

The mean age of the sample was 78.61 years. The most prevalent symptoms were lack of energy (93.5%), worrying (83.2%), and pain (71.4%). Psychological symptoms had the highest mean scores, preceded only by the physical symptoms and lack of energy. The most treated symptoms were physical with pain having the highest treatment prevalence (91%). Although psychological symptoms were the most burdensome, they were poorly treated. Multiple regression analysis showed that symptom scores had significant positive associations with financial status, social functioning, and comorbidities; there was a negative association with age.

SIGNIFICANCE OF RESULTS

Lack of energy and psychological symptoms were the most prevalent, with the latter having the highest mean total symptom scores. Treatment was poor for psychological symptoms and effective for physical ones. Associations were found between age, comorbidity, financial problems, social functioning, and total physical and psychological mean symptom burden scores. More attention needs to be given to psychological symptoms and their management among older adults receiving palliative care.

Nursing research priorities based on CINAHL database: A scoping review

Aim

To analyse nursing research based on the CINAHL database to identify research priorities for nursing.

Design

A scoping literature review was conducted. The CINAHL Plus (EBSCO) Full Text was searched between 2012-2018.

Methods

Out of 1522 original publications, 91 fulfilled the inclusion criteria. The Joanna Briggs Institute critical appraisal tools were applied. Data were analysed by a thematic analysis method.

Results

A strong emphasis should be put on development and evaluation of nursing theories and, in addition, randomized controlled trial studies, meta-synthesis, experimental and intervention studies are needed in nursing research. Development of competencies and skills in the nursing profession ought to be studied more extensively and research should be focused on variety fields of nursing practice.

Systematic Review of the Prevalence, Predictors, and Treatment of Insomnia in Palliative Care

Introduction:

The primary function of palliative care is to improve quality of life. The recognition and treatment of symptoms causing suffering is central to the achievement of this goal. Insomnia reduces quality of life of patients under palliative care. Knowledge about prevalence, associated factors, and treatment of insomnia in palliative care is scarce.

Methodology:

Literature review about the prevalence, predictors, and treatment options of insomnia in palliative care patients. Primary sources of investigation were identified and selected through Pubmed and Scopus databases. The research was complemented by reference search in identified articles and selected reviews. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

Results:

A total of 65 studies were included in the review. Most studies had acceptable /good quality. The prevalence of insomnia in the included studies ranged from 2.1% to 100%, with a median overall prevalence of 49.5%. Sociodemographic factors such as age; clinical characteristics such as functional status, disease stage, pain, and use of specific drugs, including opioids; psychological factors such as anxiety/depression; and spiritual factors such as feelings of well-being were identified as predictors. The treatment options identified were biological (pharmacological and nonpharmacological), psychological (visualization, relaxation), and spiritual (prayer).

Conclusions:

The systematic review showed that the prevalence of insomnia is high, with at least one in 3 patients affected in most studies. Insomnia’s risk factors and treatment in palliative care are both associated to physical, psychological, social, and spiritual factors, reflecting its true holistic nature.

International palliative care research priorities: A systematic review

BACKGROUND

There has been increasing evidence and debate on palliative care research priorities and the international research agenda. To date, however, there is a lack of synthesis of this evidence, examining commonalities, differences, and gaps. To identify and synthesize literature on international palliative care research priorities originating from Western countries mapped to a quality assessment framework.

METHODS

A systematic review of several academic and grey databases were searched from January 2008-June 2019 for studies eliciting research priorities in palliative care in English. Two researchers independently reviewed, critically appraised, and conducted data extraction and synthesis.

RESULTS

The search yielded 10,235 articles (academic databases, n = 4108; grey literature, n = 6127), of which ten were included for appraisal and review. Priority areas were identified: service models; continuity of care; training and education; inequality; communication; living well and independently; and recognising family/carer needs and the importance of families. Methodological approaches and process of reporting varied. There was little representation of patient and caregiver driven agendas. The priorities were mapped to the Donabedian framework for assessing quality reflecting structure, process and outcomes and key priority areas.

CONCLUSIONS

Limited evidence exists pertaining to research priorities across palliative care. Whilst a broad range of topics were elicited, approaches and samples varied questioning the credibility of findings. The voice of the care provider dominated, calling for more inclusive means to capture the patient and family voice. The findings of this study may serve as a template to understand the commonalities of research, identify gaps, and extend the palliative care research agenda.

The National Palliative Care Research Center: Ten Years of Promoting and Developing Research in Palliative Care

BACKGROUND

The evidence base to support high-quality clinical care and number of scientists available to develop this evidence base are inadequate.

OBJECTIVE

To describe the first 10 years of the National Palliative Care Research Center's (NPCRC) programs and their outcomes.

DESIGN

Established in 2005, NPCRC was created in direct response to the recommendations of the Institute of Medicine. Specifically, NPCRC was created to expand the palliative care evidence-based needed for both health policy and clinical practice by supporting research scientists, stimulating research and innovation, and creating a community of researchers focused on the needs of persons with serious illness and their families.

MEASUREMENTS

Subsequent grant funding following NPCRC investment (web searches of NIH Research Portfolio Online Reporting Tools [RePORT], Veterans Administration and Patient Centered Outcomes Research Institute [PCORI] grant databases, grantee on-line surveys, and grantee annual reports) promotions (grantee on-line surveys and annual reports), publications (PubMed searches), and NPCRC participant satisfaction (grantee questionnaires).

RESULTS

As of July 2017, NPCRC has funded 47 junior investigators representing over 10 disciplines. These investigators have leveraged NPCRC's $7.8 million investment into 52 federal grants totaling $74.8 million dollars and 69 foundation grants totaling $16 million. Thirty-five grants ($5.8 million) have been awarded to experienced investigators, resulting in additional grant funding of $104.5 million dollars ($78.5 million federal, $26 million nonfederal). Satisfaction with NPCRC's program has been uniformly high and policy efforts have resulted in enhanced federal funding opportunities in palliative care research.

CONCLUSIONS

NPCRC's focus on people and infrastructure in conjunction with a top-down bottom-up strategy has been critical in improving the palliative care evidence base.

The Case for Dual Training in Geriatric Medicine and Palliative Care: The Time is Now

The majority of older adults die from chronic illnesses which are preceded by years of progressive decline and increasing symptom burden. Delivery of high-quality care cannot take place without sufficient numbers of health professionals with appropriate training and skills in both geriatric and palliative care medicine. Despite the surge in aging population and the majority of deaths being attributed to patients with multiple comorbidities, very few health-care providers undergo dual training in these areas. Thus, the nation is facing a health-care crisis as the number of geriatric patients with chronic disease increasingly outpaces the number of physicians with adequate skills to manage them. Joint training in palliative care and geriatric medicine could prepare physicians to better manage our aging population by addressing all their health-care needs irrespective of their stage of disease emphasizing patient-directed care.

Symptom trajectory and symptom burden in older people with multimorbidity, secondary outcome from the RCT AGe-FIT study

AIM

The aim of this study was to follow the symptom trajectory of community-dwelling older people with multimorbidity and to explore the effect on symptom burden from an ambulatory geriatric care unit, based on comprehensive geriatric assessment.

BACKGROUND

Older community-dwelling people with multimorbidity suffer from a high symptom burden with a wide range of co-occurring symptoms often resulting to decreased health-related quality of life. There is a need to move from a single-disease model and address the complexity of older people living with multimorbidity.

DESIGN

Secondary outcome data from the randomized controlled Ambulatory Geriatric Assessment Frailty Intervention Trial (AGe-FIT).

METHODS

Symptom trajectory of 31 symptoms was assessed with the Memorial Symptom Assessment Scale. Data from 247 participants were assessments at baseline, 12 and 24 months, 2011-2013. Participants in the intervention group received care from an ambulatory geriatric care unit based on comprehensive geriatric assessment in addition to usual care.

RESULTS

Symptom prevalence and symptom burden were high and stayed high over time. Pain was the symptom with the highest prevalence and burden. Over the 2-year period 68-81% of the participants reported pain. Other highly prevalent and persistent symptoms were dry mouth, lack of energy and numbness/tingling in the hands/feet, affecting 38-59% of participants. No differences were found between the intervention and control group regarding prevalence, burden or trajectory of symptoms.

CONCLUSIONS

Older community-dwelling people with multimorbidity had a persistent high burden of symptoms. Receiving advanced interdisciplinary care at an ambulatory geriatric unit did not significantly reduce the prevalence or the burden of symptoms.

Depression in Older Adults: A Palliative Medicine Perspective

This article aims to discuss the rapidly growing field of palliative medicine and its unique approach to treating depression in older adults.

Leveraging the health and retirement study to advance palliative care research

BACKGROUND

The critical need to expand and develop the palliative care evidence base was recently highlighted by the Journal of Palliative Medicine's series of articles describing the Research Priorities in Geriatric Palliative Care. The Health and Retirement Study (HRS) is uniquely positioned to address many priority areas of palliative care research. This nationally representative, ongoing, longitudinal study collects detailed survey data every 2 years, including demographics, health and functional characteristics, information on family and caregivers, and personal finances, and also conducts a proxy interview after each subject's death. The HRS can also be linked with Medicare claims data and many other data sources, e.g., U.S. Census, Dartmouth Atlas of Health Care.

SETTING

While the HRS offers innumerable research opportunities, these data are complex and limitations do exist. Therefore, we assembled an interdisciplinary group of investigators using the HRS for palliative care research to identify the key palliative care research gaps that may be amenable to study within the HRS and the strengths and weaknesses of the HRS for each of these topic areas.

CONCLUSION

In this article we present the work of this group as a potential roadmap for investigators contemplating the use of HRS data for palliative care research.