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Helvik AS, Bergh S, Kabukcuoğlu K, Šaltytė Benth J, Lichtwarck B, Husebø B, Tevik K. Prevalence and persistent prescription of analgesic drugs in persons admitted with dementia to a nursing home - A longitudinal study. PLoS One 2022; 17:e0279909. [PMID: 36584218 PMCID: PMC9803316 DOI: 10.1371/journal.pone.0279909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/18/2022] [Indexed: 01/01/2023] Open
Abstract
The overall aim was to explore the prevalence and persistent regular prescription of opioids and paracetamol among nursing home (NH) residents with dementia at admission and over time. A total of 996 residents with dementia, mean (SD) age 84.5 (7.6) years and (36.1% men), were included at admission (A1). Yearly assessments were performed for two years (A2 and A3) or until death. Pain was assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale. Information regarding prescription of analgesics, general physical health, personal activities of daily living, severity of dementia, neuropsychiatric symptoms, and prescription of psychotropic drugs was collected. A generalized linear mixed model was used to explore whether pain severity was associated with persistent and persistent prescription of opioids and/or paracetamol across timepoints. At A1, 495 of 996 (49.7%) NH residents were prescribed analgesics and prevalence increased at the follow-ups (A2: n = 630, 65.1%; A3: n = 382, 71.2%). Paracetamol was the most frequently prescribed analgesic at all assessments (A1: 45.5%; A2: 59.5%; A3: 67.1%). Opioid prescriptions were quite prevalent (A1: 18.1%; A2: 25.1%; A3: 28.3%), with odds approximately 13 times (OR = 13.3, 95% CI 6.8-26.0) and 9 times (OR = 8.6, 95% CI 3.7-20.3) higher for prescription at follow-up A2 and A3, respectively, relative to prescription at A1. In adjusted analyses, higher pain intensity and poor physical health were associated with prescription and persistent prescription of opioids and paracetamol. In conclusion, prevalence and persistent prescription of analgesics were high in NH residents with dementia. The odds for the prescription of opioids at follow-up were high if prescribed at baseline. Interdisciplinary collaboration, routine assessment of pain at admission and regularly thereafter, and systematic drug reviews are essential to adequately assess and treat pain in NH residents with dementia.
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Affiliation(s)
- Anne-Sofie Helvik
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian National Centre for Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- * E-mail:
| | - Sverre Bergh
- Norwegian National Centre for Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- Research Centre for Age-related Functional Decline and Disease, Innlandet Hospital Trust, Ottestad, Norway
| | - Kamile Kabukcuoğlu
- Faculty of Nursing, Akdeniz University, Campus Antalya, Antalya, Türkiye
| | - Jūratė Šaltytė Benth
- Research Centre for Age-related Functional Decline and Disease, Innlandet Hospital Trust, Ottestad, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Lichtwarck
- Research Centre for Age-related Functional Decline and Disease, Innlandet Hospital Trust, Ottestad, Norway
| | - Bettina Husebø
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
- Municipality of Bergen, Bergen, Norway
| | - Kjerstin Tevik
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian National Centre for Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
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2
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Helvik AS, Bergh S, Šaltytė Benth J, Selbaek G, Husebo BS, Tevik K. Pain in nursing home residents with dementia and its association to quality of life. Aging Ment Health 2022; 26:1787-1797. [PMID: 34251936 DOI: 10.1080/13607863.2021.1947968] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES We aimed to describe pain, use of analgesics and quality of life (QoL) in people with dementia admitted to a Norwegian nursing home (NH), and to explore if and how pain was associated with their QoL when adjusting for sociodemographic characteristics, other health conditions and use of analgesics. METHOD A total of 953 Norwegian NH residents with dementia (mean age 84.0, SD 7.5 years, 35.8% men) were included at admission to the NH. Pain and QoL were assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale and the Quality of Life in Late-Stage Dementia (QUALID) scale, respectively. Severity of dementia, personal level of activities of daily living, general medical health, neuropsychiatric symptoms, and the use of psychotropic drugs and analgesics were assessed. RESULTS In total, 36% of the participants had clinically relevant pain intensity (MOBID-2 ≥ 3) and 52% received analgesics. Paracetamol was most frequently prescribed (45%). In an adjusted linear mixed model, more severe pain was associated with higher QUALID total scores, indicating poorer QoL (regression coefficient 0.52, 95% CI 0.36-0.69). CONCLUSION Pain prevalence at NH admission was high in residents with dementia; half used analgesics, particularly paracetamol. More severe pain was associated with poorer QoL when adjusting for sociodemographic characteristics, other health conditions, and use of analgesics. The routine assessment of pain at NH admission can uncover undiagnosed and untreated pain and allow for adequate non-pharmacological and pharmacological pain management and likely increased QoL.
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Affiliation(s)
- Anne-Sofie Helvik
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Vestfold Hospital Trust, Norwegian National Advisory Unit on Ageing and Health, Tønsberg, Norway
| | - Sverre Bergh
- Vestfold Hospital Trust, Norwegian National Advisory Unit on Ageing and Health, Tønsberg, Norway.,The Research Centre for Age Related Functional Decline and Diseases, Innlandet Hospital Trust, Ottestad, Norway
| | - Jūratė Šaltytė Benth
- The Research Centre for Age Related Functional Decline and Diseases, Innlandet Hospital Trust, Ottestad, Norway.,Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.,Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Geir Selbaek
- Vestfold Hospital Trust, Norwegian National Advisory Unit on Ageing and Health, Tønsberg, Norway.,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Norway.,Municipality of Bergen, Bergen, Norway
| | - Kjerstin Tevik
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Vestfold Hospital Trust, Norwegian National Advisory Unit on Ageing and Health, Tønsberg, Norway
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Rekatsina M, Paladini A, Viswanath O, Urits I, Myrcik D, Pergolizzi J, Breve F, Varrassi G. Opioids in the Elderly Patients with Cognitive Impairment: A Narrative Review. Pain Ther 2022; 11:381-394. [PMID: 35380373 PMCID: PMC9098742 DOI: 10.1007/s40122-022-00376-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/10/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Assessment and management of pain in elderly people with cognitive impairment is particularly challenging. Physiological changes due to aging as well as comorbidities and polypharmacy are responsible for a complex clinical approach. Concomitantly, in cognitive impairment, including advanced dementia, changes in the central nervous system along with changes in the peripheral nervous system due to aging have a significant impact on pain perception. Sometimes clinicians decide to prescribe opioids to relieve pain, also without a clear indication. This review aims to investigate the effect of opioids in elderly patients with cognitive impairment. Methods A literature search of PubMed/Medline, Scopus, and Cochrane databases was conducted using keyword searches to generate lists of articles that were screened for relevance by title and abstract to give a final list of articles for full-text review. Further articles were identified by scanning the reference lists of the full-text articles. Discussion This review discusses the complex physiological and pharmacological changes in the elderly as well as the neurological changes that affect pain perception in this population. Additionally, it focuses on cognitive impairment and pain in Alzheimer’s disease and other dementias, the pain assessment in the elderly with cognitive impairment as well as the safety of opioid use in the elderly. Information regarding opioid prescription in nursing homes and recorded indications for opioid use, type and dosing of opioids, and compliance of treatment in advanced dementia are also provided. Conclusions Opioid prescription in the elderly population with cognitive impairment is particularly complex. All healthcare professionals involved in the care of such patients need to be aware of the challenges and strive to ensure analgesic use is guided by appropriate and accurate pain assessment.
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Affiliation(s)
- M Rekatsina
- Mid and South, Essex University Hospitals Group, Orsett Hospital, Grays, RM16 3EU, Essex, UK
| | - A Paladini
- Department MESVA, University of L'Aquila, 67100, L'Aquila, Italy
| | - O Viswanath
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - I Urits
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
- Southcoast Physician Group Pain Medicine, Southcoast Health, Wareham, MA, USA
| | - D Myrcik
- Department of Internal Medicine, Silesian University of Medicine, 42-600, Byton, Poland
| | | | - F Breve
- NEMA Research Group, Naples, FL, USA
| | - G Varrassi
- Paolo Procacci Foundation, 00193, Rome, Italy.
- NEMA Research Group (European Chapter), Naples, FL, USA.
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Mayoral V. An overview of the use and misuse/abuse of opioid analgesics in different world regions and future perspectives. Pain Manag 2022; 12:535-555. [PMID: 35118876 DOI: 10.2217/pmt-2021-0094] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Opioids are an important therapeutic option for severe resistant chronic pain but, in the absence of proper oversight, their use has risks. The level of prescription opioid misuse/abuse differs among countries, due to differences in healthcare systems and pain management approaches. However, evaluating the true dimension of prescription opioid misuse/abuse is complicated by statistical reporting which often does not differentiate between prescription and illicit opioid use, or between prescription opioid use by patients and nonpatients, highlighting a need for greater uniformity. Parallel efforts to educate patients and the general public about opioid risks, facilitate appropriate analgesic prescribing and identify alternative formulations or options to use instead of or with opioids, may contribute to optimizing prescription opioid use for pain management.
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Affiliation(s)
- Victor Mayoral
- Pain Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Dowd LA, Cross AJ, Veal F, Ooi CE, Bell JS. A Systematic Review of Interventions to Improve Analgesic Use and Appropriateness in Long-Term Care Facilities. J Am Med Dir Assoc 2021; 23:33-43.e3. [PMID: 34710365 DOI: 10.1016/j.jamda.2021.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/14/2021] [Accepted: 09/21/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To systematically review the effectiveness of interventions to improve analgesic use and appropriateness in long-term care facilities (LTCFs). DESIGN Systematic review. SETTING AND PARTICIPANTS MEDLINE, Embase, PsycINFO, and CINAHL Plus were searched from inception to June 2021. Randomized controlled trials (RCTs), controlled and uncontrolled prospective interventions that included analgesic optimization, and reported postintervention change in analgesic use or appropriateness in LTCFs were included. METHODS Screening, data extraction, and quality assessment were performed independently by 2 review authors. RESULTS Eight cluster RCTs, 2 controlled, and 6 uncontrolled studies comprising 9056 residents across 9 countries were included. The 16 interventions included education (n = 13), decision support (n = 7), system modifications (n = 6), and/or medication review (n = 3). Six interventions changed analgesic use or appropriateness, all of which included prescribers, 5 involved multidisciplinary collaboration, and 5 included a component of education. Education alone changed analgesic use and appropriateness in 1 study. Decision support was effective when combined with education in 3 interventions. Overall, 13 studies reported analgesic optimization as part of pain management interventions and 3 studies focused on medication optimization. Two pain management interventions reduced the percentage of residents reporting pain not receiving analgesics by 50% to 60% (P = .03 and P < .001, respectively), and 1 improved analgesic appropriateness (P = .03). One reduced nonsteroidal anti-inflammatory drugs (NSAIDs) (P < .001) and another resulted in 3-fold higher odds of opioid prescription in advanced dementia [95% confidence interval (CI) 1.1-8.7]. One medication optimization intervention reduced NSAID prescription (P = .036), and another reduced as-needed opioid (95% CI 8.6-13.8) and NSAID prescription (95% CI 1.6-4.2). CONCLUSIONS AND IMPLICATIONS Interventions involving prescribers and enhanced roles for pharmacists and nurses, with a component of education, are most effective at changing analgesic use or appropriateness. Interventions combining education and decision support are also promising. Medication review interventions can change analgesic prescription, although there is currently minimal evidence in relation to possible corresponding improvements in resident-related outcomes.
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Affiliation(s)
- Laura A Dowd
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia.
| | - Amanda J Cross
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Felicity Veal
- Unit for Medication Outcomes Research & Education (UMORE), School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Choon Ean Ooi
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia; National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, South Australia
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Gustafsson M, Lövheim H, Sjölander M. Pharmacological Pain Treatment in 2012 and 2017 Among Older People with Major Neurocognitive Disorder. Drugs Aging 2021; 38:1017-1023. [PMID: 34664213 PMCID: PMC8593018 DOI: 10.1007/s40266-021-00897-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 11/29/2022]
Abstract
Background and Objective Pain is highly prevalent among older people, and treatment is complicated because of comorbidities and polypharmacy. Among people with major neurocognitive disorder additional difficulties might arise. The aim of this study was to describe analgesic drug use in 2012 and 2017 and associated factors among older people with major neurocognitive disorder. Methods In this register-based study, the Swedish Dementia Registry and the Swedish Prescribed Drug Register were combined in order to obtain data regarding analgesic drug use among older people with major neurocognitive disorder. One or more filled prescriptions during the timeframe of 6 months (1 July–31 December 2012 and 1 July–31 December 2017) defined drug use during the respective period. A comparison between 2012 and 2017 was made, including a total of 56,101 people (20,889 and 35,212 respectively) with a mean age of 81.9 and 82.7 years, respectively. Results The overall use of analgesic drugs increased significantly from 41.6% of individuals to 46.0% between the years 2012 and 2017. Users of opioid analgesics (15.2% vs 17.3%) and paracetamol (37.0% vs 42.3%) increased, while the users of non-steroidal anti-inflammatory drugs (4.9% vs 2.7%) declined between the two data collections. Multiple logistic regression analyses were performed for different drugs and drug classes, and it was found that the use of opioids and paracetamol was associated with older age and a longer time since diagnosis. In contrast, non-steroidal anti-inflammatory drugs were associated with younger age and a shorter time since diagnosis. Conclusions The results indicate that on a population level, pharmacological drug treatment has changed in line with guidelines between 2012 and 2017, with an increase in paracetamol and strong opioids and a decrease in non-steroidal anti-inflammatory drugs and tramadol. The relatively high prevalence of opioids warrants concern given the significant risk of adverse effects among older people with major neurocognitive disorder. Supplementary Information The online version contains supplementary material available at 10.1007/s40266-021-00897-9.
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Affiliation(s)
- Maria Gustafsson
- Department of Integrative Medical Biology, Umeå University, Umeå, Sweden.
| | - Hugo Lövheim
- Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
| | - Maria Sjölander
- Department of Integrative Medical Biology, Umeå University, Umeå, Sweden
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7
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Neelamegam M, Zgibor J, Chen H, O’rourke K, Bakour C, Rajaram L, Anstey KJ. The effect of opioids on the cognitive function of older adults: results from the Personality and Total Health through life study. Age Ageing 2021; 50:1699-1708. [PMID: 33755047 PMCID: PMC8437064 DOI: 10.1093/ageing/afab048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND chronic pain, a common complaint among older adults, affects physical and mental well-being. While opioid use for pain management has increased over the years, pain management in older adults remains challenging, due to potential severe adverse effects of opioids in this population. OBJECTIVE we examined the association between opioid use, and changes in cognitive function of older adults. DESIGN prospective study. SETTING community dwelling older adults. SUBJECTS study population consisted of 2,222 individuals aged 65-69 years at baseline from the Personality and Total Health Through Life Study in Australia. METHODS medication data were obtained from the Pharmaceutical Benefits Scheme. Cognitive measures were obtained from neuropsychological battery assessment. Opioid exposure was quantified as Total Morphine Equivalent Dose (MED). The association between change in cognitive function between Wave 2 and Wave 3, and cumulative opioid use was assessed through generalized linear models. RESULTS cumulative opioid exposure exceeding total MED of 2,940 was significantly associated with poorer performance in the Mini Mental State Examination (MMSE). Compared with those not on opioids, individuals exposed to opioids resulting in cumulative total MED of greater than 2,940 had significantly lower scores in the MMSE (Model 1: β = -0.34, Model 2: β = -0.35 and Model 3: β = -0.39, P < 0.01). Performance in other cognitive assessments was not associated with opioid use. CONCLUSION prolonged opioid use in older adults can affect cognitive function, further encouraging the need for alternative pain management strategies in this population. Pain management options should not adversely affect healthy ageing trajectories and cognitive health.
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Affiliation(s)
- Malinee Neelamegam
- Yale School of Public Health, Yale University, New Haven, CT, USA
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Janice Zgibor
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Henian Chen
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Kathleen O’rourke
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Chighaf Bakour
- College of Public Health, University of South Florida, Tampa, FL, USA
| | | | - Kaarin J Anstey
- Centre for Research on Ageing, Health and Wellbeing, Australian National University, Canberra, Australia
- School of Psychology, University of New South Wales, Sydney, Australia
- Neuroscience Research Australia, Sydney, Australia
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La Frenais F, Vickerstaff V, Cooper C, Livingston G, Stone P, Sampson EL. Factors influencing prescription and administration of analgesic medication: A longitudinal study of people with dementia living in care homes. Int J Geriatr Psychiatry 2021; 36:1354-1361. [PMID: 33719098 DOI: 10.1002/gps.5526] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/25/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To (1) describe the prescription and administration of regular and 'as required' (pro re nata [PRN]) analgesics in English care homes, (2) investigate individual and care home factors associated with analgesic use. METHODS We collected data (2014-2016) at 0-, 4-, and 12-months nested in a longitudinal cohort study of 86 English care homes about residents with diagnosed or probable dementia. We describe analgesics prescribed as regular or PRN medication, by class, and PRN administration. We explored individual differences (sociodemographic; dementia severity [Clinical Dementia Rating]), and care home differences (type; ownership; number of beds; dementia-registered/specialist; Care Quality Commission rating) in prescription and administration using multilevel regression models. RESULTS Data were available for 1483 residents. At baseline, 967 residents (67.9%) were prescribed analgesics: 426 residents (28.7%) prescribed regular analgesics and 670 (45.2%) prescribed PRN. Paracetamol was the most prescribed analgesic (56.7%), with PRN prescriptions more common than regular (39.7% vs. 16.6%). Across all study visits, 344 residents (mean = 41.9%) with a PRN prescription did not receive any analgesic in the 2 weeks prior to data collection. Male residents and those with severe dementia received fewer analgesics. Care homes differences in PRN administration were not explained by the modelled variables. CONCLUSIONS Pain management in English care homes largely relies on PRN paracetamol that is frequently prescribed but infrequently administered. Care homes differ in how often they administer PRN analgesics. Some care home residents particularly those with more severe dementia are likely to have untreated pain.
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Affiliation(s)
- Francesca La Frenais
- Division of Psychiatry, University College London, London, UK
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Claudia Cooper
- Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, St. Pancras Hospital, London, UK
| | - Gill Livingston
- Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, St. Pancras Hospital, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, University College London, London, UK
- Marie Curie Palliative Care Research Department, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, London, UK
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Habiger TF, Achterberg WP, Flo-Groeneboom E, Mannseth J, Husebo BS. Managing Pain and Psychosis Symptoms in Nursing Home Patients: Results from a Cluster-Randomized Controlled Trial (COSMOS). J Am Med Dir Assoc 2021; 22:1692-1698. [PMID: 34087225 DOI: 10.1016/j.jamda.2021.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/22/2021] [Accepted: 05/02/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVES In nursing homes (NHs), 30% to 60% of patients experience daily pain and >80% have dementia. This can lead to neuropsychiatric symptoms, including psychosis symptoms such as delusion. We investigated if there was a relationship between pain and psychosis symptoms over time. We also aimed to investigate the effect of a multicomponent intervention (COSMOS) on pain, psychosis symptoms, and analgesic prescription. DESIGN COSMOS is a cluster-randomized, single blinded, controlled trial. Each NH unit was defined as a cluster and randomized to either the COSMOS intervention or care as usual. The COSMOS intervention is a multicomponent intervention, consisting of staff training in communication, pain treatment, medication review, organization of activities, and safety. The intervention lasted for 4 months with a follow-up at month 9. SETTING AND PARTICIPANTS Sixty-seven units from 33 Norwegian NHs in 8 municipalities. The study included 723 patients aged ≥65 years, residing at the NH ≥2 weeks before inclusion. Patients with a life expectancy <6 months were excluded. MEASURES Pain was measured using the Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale. Psychosis symptoms were measured using the Neuropsychiatric Inventory-NH version. Measurements were performed at baseline, and months 4 and 9. RESULTS Multilevel Mixed-Effect statistical analysis found that psychosis symptoms as a group (odds ratio [OR] 2.03, P = .009), and delusion (OR 2.12, P = .007) were associated with pain over time. No significant intervention effect on psychosis symptoms was observed. Compared with the control group, people with dementia in the intervention group experienced less musculoskeletal pain (β: -0.47, P = .047). Analgesic prescription was not affected by the intervention. CONCLUSION AND IMPLICATIONS Pain is associated with psychosis symptoms, and pain assessment should be done when making treatment decisions on psychosis symptoms in NH patients. The COSMOS intervention improved musculoskeletal pain in people with dementia, but not psychosis symptoms, and there is need for further studies on treatment of psychosis symptoms in NH patients.
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Affiliation(s)
- Torstein F Habiger
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.
| | - Wilco P Achterberg
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway; Department of Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, Leiden University Medical Centre, Netherlands
| | - Elisabeth Flo-Groeneboom
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway; Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Janne Mannseth
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway; Municipality of Bergen, Bergen, Norway
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10
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Wagatsuma S, Yamaguchi T, Berge LI, Husebo B, Habiger TF, Nouchi R, Angeles RC. How, Why and Where it Hurts—Breaking Down Pain Syndrome Among Nursing Home Patients With Dementia: A Cross-Sectional Analysis of the COSMOS Trial. Pain Manag Nurs 2021; 22:319-326. [DOI: 10.1016/j.pmn.2020.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/17/2020] [Accepted: 11/30/2020] [Indexed: 12/01/2022]
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11
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Jensen-Dahm C, Christensen AN, Gasse C, Waldemar G. The Use of Opioids and Antipsychotics in Elderly with Dementia - Have Opioids Replaced Antipsychotics in Treating Behavioral Symptoms in Dementia? J Alzheimers Dis 2021; 73:259-267. [PMID: 31771062 PMCID: PMC7029326 DOI: 10.3233/jad-190787] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background: Opioids are used with increasing frequency. Elderly with dementia are prescribed opioids more frequent than elderly without. One possible explanation is that opioids may be used not only to treat pain but also behavioral symptoms. Objective: To test the hypothesis that strong opioid use, especially transdermal formulations, had increased, especially in elderly with dementia, in parallel with a decrease in antipsychotic use. Methods: Population-based cross-sectional study conducted using nationwide Danish registers with data on Denmark’s entire elderly population age ≥65 (2000: n = 802,106; 2015: n = 1,056,476). The registers were used to identify elderly with and without dementia and filled prescriptions for opioids and antipsychotics. Annual prevalence of opioid and antipsychotic use from 2000–2015 was calculated. Results: Prevalence of opioid use increased by 35% (24.2 to 32.5%) among elderly with dementia and by 13% among elderly without (14.9 to 16.8%) from 2000–2015. The disproportionate increase in opioid use among elderly with dementia was mainly driven by an increase in strong opioids (dementia: 11.7 to 23.1%; without dementia: 5.9 to 7.4%). Use of antipsychotics decreased during the same period (dementia: 31.3 to 19.3%; no dementia: 4.5 to 2.7%). Conclusion: From 2000–2015, use of opioids among the elderly increased with a disproportionately higher increase among elderly with dementia. The parallel decrease in the use of antipsychotics may suggest that opioids to some extent have replaced antipsychotics in managing behavioral symptoms, despite safety concerns and lack of evidence for effect of opioids. Future research should focus on potential risks associated with increased opioid use.
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Affiliation(s)
- Christina Jensen-Dahm
- Department of Neurology, Danish Dementia Research Centre (DDRC), Rigshospitalet - University of Copenhagen, Copenhagen, Denmark
| | - Ane Nørgaard Christensen
- Department of Neurology, Danish Dementia Research Centre (DDRC), Rigshospitalet - University of Copenhagen, Copenhagen, Denmark
| | - Christiane Gasse
- Depression and Anxiety/Psychosis Research Unit, Aarhus University Hospital Psychiatry, Aarhus N, Denmark.,National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
| | - Gunhild Waldemar
- Department of Neurology, Danish Dementia Research Centre (DDRC), Rigshospitalet - University of Copenhagen, Copenhagen, Denmark
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12
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Affiliation(s)
- Wilco Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, Niederlande.
| | | | - Bettina Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, Faculty of Medicine, University of Bergen, Bergen, Norwegen
| | - Ane Erdal
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, Faculty of Medicine, University of Bergen, Bergen, Norwegen
| | - Keela Herr
- University of Iowa College of Nursing, Iowa City, IA, USA
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13
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Achterberg WP, Erdal A, Husebo BS, Kunz M, Lautenbacher S. Are Chronic Pain Patients with Dementia Being Undermedicated? J Pain Res 2021; 14:431-439. [PMID: 33623425 PMCID: PMC7894836 DOI: 10.2147/jpr.s239321] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/25/2021] [Indexed: 01/08/2023] Open
Abstract
In dementia, neuropathological changes alter the perception and expression of pain. For clinicians and family members, this knowledge gap leads to difficulties in recognizing and assessing chronic pain, which may consequently result in persons with dementia receiving lower levels of pain medication compared to those without cognitive impairment. Although this situation seems to have improved in recent years, considerable geographical variation persists. Over the last decade, opioid use has received global attention as a result of overuse and the risk of addiction, while the literature on older persons with dementia actually suggests undertreatment. This review stresses the importance of reliable assessment and the regular evaluation and monitoring of symptoms in persons with dementia. Based on current evidence, we concluded that chronic pain is still undertreated in dementia.
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Affiliation(s)
- Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, RC Leiden, 2300, the Netherlands
| | - Ane Erdal
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, 5020, Norway
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, 5020, Norway
| | - Miriam Kunz
- Department of Medical Psychology, University of Augsburg, Augsburg, 86156, Germany
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14
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Husebo BS, Kerns RD, Han L, Skanderson M, Gnjidic D, Allore HG. Pain, Complex Chronic Conditions and Potential Inappropriate Medication in People with Dementia. Lessons Learnt for Pain Treatment Plans Utilizing Data from the Veteran Health Administration. Brain Sci 2021; 11:86. [PMID: 33440668 PMCID: PMC7827274 DOI: 10.3390/brainsci11010086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 12/21/2022] Open
Abstract
Alzheimer's disease and related dementias (ADRD), pain and chronic complex conditions (CCC) often co-occur leading to polypharmacy and with potential inappropriate medications (PIMs) use, are important risk factors for adverse drug reactions and hospitalizations in older adults. Many US veterans are at high risk for persistent pain due to age, injury or medical illness. Concerns about inadequate treatment of pain-accompanied by evidence about the analgesic efficacy of opioids-has led to an increase in the use of opioid medications to treat chronic pain in the Veterans Health Administration (VHA) and other healthcare systems. This study aims to investigate the relationship between receipt of pain medications and centrally (CNS) acting PIMs among veterans diagnosed with dementia, pain intensity, and CCC 90-days prior to hospitalization. The final analytic sample included 96,224 (81.7%) eligible older veterans from outpatient visits between October 2012-30 September 2013. We hypothesized that veterans with ADRD, and severe pain intensity may receive inappropriate pain management and CNS-acting PIMs. Seventy percent of the veterans, and especially people with ADRD, reported severe pain intensity. One in three veterans with ADRD and severe pain intensity have an increased likelihood for CNS-acting PIMs, and/or opioids. Regular assessment and re-assessment of pain among older persons with CCC, patient-centered tapering or discontinuation of opioids, alternatives to CNS-acting PIMs, and use of non-pharmacological approaches should be considered.
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Affiliation(s)
- Bettina S. Husebo
- Centre for Elderly and Nursing Home Medicine, Department of Global Public Health and Primary Care, University of Bergen, 5020 Bergen, Norway
- Municipality of Bergen, 5020 Bergen, Norway
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT 06511, USA;
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA;
| | - Ling Han
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT 06511, USA; (L.H.); (H.G.A.)
| | - Melissa Skanderson
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA;
| | - Danijela Gnjidic
- Charles Perkins Centre, Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Sydney 2006 NSW, Australia;
| | - Heather G. Allore
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT 06511, USA; (L.H.); (H.G.A.)
- Department of Biostatistics, School of Public Health, Yale University, New Haven, CT 06511, USA
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15
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van Dam PH, Achterberg WP, Husebo BS, Caljouw MAA. Does paracetamol improve quality of life, discomfort, pain and neuropsychiatric symptoms in persons with advanced dementia living in long-term care facilities? A randomised double-blind placebo-controlled crossover (Q-PID) trial. BMC Med 2020; 18:407. [PMID: 33342434 PMCID: PMC7751102 DOI: 10.1186/s12916-020-01858-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/19/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The objectives of this study are to determine the effects of regularly scheduled administration of paracetamol (acetaminophen) on quality of life (QoL), discomfort, pain and neuropsychiatric symptoms of persons with dementia living in long-term care facilities (LTCFs). METHODS A multicentre randomised double-blind placebo-controlled crossover trial for 13 weeks (January 2018 to June 2019) in 17 LTCFs across the west of the Netherlands. Inclusion criteria were age ≥ 65 years, (advanced) dementia and a moderate to low QoL, independent of the presence of pain (QUALIDEM ≤ 70). Exclusion criteria were the use of regular pain treatment, allergies to the study medication, severe liver disease, use of > 4 units of alcohol/day, weight < 50 kg and/or concomitant use of flucloxacillin. Participants received study medication (paracetamol/placebo) in two periods of 6 weeks each (1 week in between as a wash-out period). Randomisation decided in which order participants received paracetamol and placebo. Primary outcomes included QoL (QUALIDEM) and discomfort (DS-DAT), secondary outcomes included pain (MOBID-2) and neuropsychiatric symptoms (NPI-NH). RESULTS Ninety-five LTCF residents (mean age 83.9 years [SD 7.6], 57.9% females) were included. Repeated linear mixed models showed no difference in mean differences of QUALIDEM (paracetamol +1.3 [95% CI -1.0-3.5], placebo +1.5 [95% CI -0.7-3.8]), DS-DAT (paracetamol -0.1 [95% CI -1.4-1.2], placebo 0.6 [95 CI -0.7-1.8]), MOBID-2 (paracetamol 0.0 [95% CI -0.5-0.5], placebo -0.2 [95% CI -0.7-0.3]) and NPI-NH (paracetamol +1.5 [95% CI -2.3-5.4], placebo -2.1 [95% CI -6.0-1.7]) in favour of either paracetamol or placebo. CONCLUSIONS Compared to placebo, paracetamol showed no positive effect on QoL, discomfort, pain and neuropsychiatric symptoms in persons with advanced dementia with low QoL. It is important to find out more specifically which individual persons with advanced dementia could benefit from pain treatment with paracetamol, and for clinicians to acknowledge that a good assessment, monitoring and multidomain approach is vital for improving QoL in this vulnerable group. TRIAL REGISTRATION Netherlands Trial Register NTR6766 . Trial registration date: 20 October 2017.
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Affiliation(s)
- Paulien H van Dam
- Department of Public Health and Primary Care, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.,Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.,, Municipality of Bergen, Norway
| | - Monique A A Caljouw
- Department of Public Health and Primary Care, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
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16
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Jensen-Dahm C, Zakarias JK, Gasse C, Waldemar G. Geographical Variation in Opioid Use in Elderly Patients with Dementia: A Nationwide Study. J Alzheimers Dis 2020; 70:1209-1216. [PMID: 31322575 PMCID: PMC6839457 DOI: 10.3233/jad-190413] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: We recently reported frequent use of opioids among elderly with dementia. Discrepancies in clinical practice may in part explain the higher use of opioids in elderly with dementia, which geographical variation may be able to clarify. Objective: To investigate geographical variation in opioid use in elderly with dementia compared to elderly without dementia. Methods: Register-based cross-sectional study in the entire elderly (≥65 years) population of Denmark in 2015. Data included place of residence, prescriptions, and discharge diagnoses from hospital contacts. Prevalence of opioid use among elderly with (n = 36,014) and without dementia (n = 1,011,787) was compared nationwide across the five Danish regions using logistic regression analysis and for the 98 municipalities using age and sex standardization. Results: 32.5% of elderly with dementia and 16.9% without were treated with an opioid in 2015. For home-living elderly with dementia, there was a 4-fold difference in opioid use (9.4 to 36.8%) between municipalities compared to a 1.6-fold (12.7 to 20.2%) difference for elderly without. In nursing home residents there was a 2-fold difference (dementia: 26.5 to 55.2%; no dementia: 31.8 to 60.4%). Differences between the five regions were minor. Conclusion: Opioid use in elderly with dementia was frequent and almost twice as high compared to elderly without dementia, which may challenge patient safety. The pronounced geographical variations at municipality level, particularly among elderly with dementia, indicate differences in the approach to treatment of chronic pain in primary care. Our study suggests that more guidance on treatment of pain in elderly with dementia is needed.
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Affiliation(s)
- Christina Jensen-Dahm
- Danish Dementia Research Centre, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Johanne Købstrup Zakarias
- Danish Dementia Research Centre, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christiane Gasse
- Depression and Anxiety/Psychosis Research Unit, Aarhus University Hospital Psychiatry, Aarhus N, Denmark.,National Centre for Register Based Research, Aarhus University, Aarhus, Denmark
| | - Gunhild Waldemar
- Danish Dementia Research Centre, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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17
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Abstract
Aim: The review aimed to identify factors influencing opioid prescribing as regular pain-management medication for older people. Background: Chronic pain occurs in 45%–85% of older people, but appears to be under-recognised and under-treated. However, strong opiate prescribing is more prevalent in older people, increasing at the fastest rate in this age group. Methods: This review included all study types, published 1990–2017, which focused on opioid prescribing for pain management among older adults. Arksey and O’Malley’s framework was used to scope the literature. PubMed, EBSCO Host, the UK Drug Database, and Google Scholar were searched. Data extraction, carried out by two researchers, included factors explaining opioid prescribing patterns and prescribing trends. Findings: A total of 613 papers were identified and 53 were included in the final review consisting of 35 research papers, 10 opinion pieces and 8 grey literature sources. Factors associated with prescribing patterns were categorised according to whether they were patient-related, prescriber-driven, or system-driven. Patient factors included age, gender, race, and cognition; prescriber factors included attitudes towards opioids and judgements about ‘normal’ pain; and policy/system factors related to the changing policy landscape over the last three decades, particularly in the USA. Conclusions: A large number of context-dependent factors appeared to influence opioid prescribing for chronic pain management in older adults, but the findings were inconsistent. There is a gap in the literature relating to the UK healthcare system; the prescriber and the patient perspective; and within the context of multi-morbidity and treatment burden.
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Fog AF, Mdala I, Engedal K, Straand J. Variation between nursing homes in drug use and in drug-related problems. BMC Geriatr 2020; 20:336. [PMID: 32907532 PMCID: PMC7488067 DOI: 10.1186/s12877-020-01745-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 08/30/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Residents at nursing homes (NHs) are at particular risk for drug related harm. Regular medication reviews using explicit criteria for pharmacological inappropriateness and classification of drug related problems (DRPs) have recently been introduced as measures to improve the quality of medication use and for making the treatment more uniform across different institutions. Knowledge about variation in DRPs between NHs is scarce. To explore if increased attention towards more appropriate drug treatment in NHs have led to more uniform treatment, we have analyzed variations between different nursing homes' drug use and DRPs. METHODS Cross-sectional medication review study including 2465 long-term care residents at 41 NHs in Oslo, Norway. Regular drug use was retrieved from the patients' medical records. DRPs were identified by using STOPP/START and NORGEP criteria and a drug-drug interactions database. NHs were grouped in quartiles based on average levels of drug use. The upper and lower quartiles were compared using independent samples t-test and associations between drug use and DRPs were tested by logistic regression. RESULTS Patients' mean age was 85.9 years, 74.2% were women. Mean numbers of regular drugs per patient was 6.8 and varied between NHs from 4.8 to 9.3. The proportion of patients within each NH using psychotropic and analgesic drugs varied largely: antipsychotics from three to 50%, benzodiazepines from 24 to 99%, antidepressants from nine to 75%, anti-dementia drugs from no use to 42%, opioids from no use to 65% and paracetamol from 16 to 74%. Mean DRPs per patient was 2.0 and varied between NHs from 0.5 to 3.4. The quartiles of NHs with highest and lowest mean drugs per patient (7.7 vs. 5.7, p < 0.001) had comparable mean number of DRPs per patient (2.2 vs. 1.8, p = 0.2). Using more drugs and the use of opioids, antipsychotics, benzodiazepines and antidepressants were associated with more DRPs. CONCLUSIONS The use of psychotropic and analgesic drugs was high and varied substantially between different NHs. Even if the use of more drugs, opioids and psychotropic drugs was associated with DRPs, no difference was found in DRPs between the NHs with highest vs. lowest drug use.
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Affiliation(s)
- Amura Francesca Fog
- Nursing Home Agency, Oslo Municipality, Norway
- General Practice Research Unit, Department of General Practice, Institute of Health and Society, University of Oslo, Postbox 1130 Blinderen, N-0318 Oslo, Norway
| | - Ibrahimu Mdala
- General Practice Research Unit, Department of General Practice, Institute of Health and Society, University of Oslo, Postbox 1130 Blinderen, N-0318 Oslo, Norway
| | - Knut Engedal
- Norwegian National Advisory Unit for Aging and Health, Vestfold County Hospital HF, Toensberg and Oslo University Hospital, Oslo, Norway
| | - Jørund Straand
- General Practice Research Unit, Department of General Practice, Institute of Health and Society, University of Oslo, Postbox 1130 Blinderen, N-0318 Oslo, Norway
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19
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Siddiqui TG, Cheng S, Gossop M, Kristoffersen ES, Grambaite R, Lundqvist C. Association between prescribed central nervous system depressant drugs, comorbidity and cognition among hospitalised older patients: a cross-sectional study. BMJ Open 2020; 10:e038432. [PMID: 32718926 PMCID: PMC7389767 DOI: 10.1136/bmjopen-2020-038432] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Central nervous system depressants (CNSDs) such as opioids, benzodiazepine and Z-hypnotics are commonly used. However, CNSDs may influence cognitive function, especially in older hospitalised patients with comorbidities. The aim was to examine the association between CNSD use and cognitive function in older patients. We assessed global and domain specific cognitive function, among hospitalised older patients, including covariates for comorbidity, anxiety and depression. DESIGN Cross-sectional hospital-based study. SETTINGS Data was collected consecutively from inpatients at somatic wards of a general university hospital. PARTICIPANTS Older patients between 65 and 90 years with/without CNSD use for ≥4 weeks. OUTCOME MEASURES The main outcome was cognitive function assessed by Cognistat. Secondary outcomes were routine clinical tests in the wards (mini-mental state examination (MMSE), trail making test (TMT) A and B, and clock drawing tests). Analyses were bivariate and multiple linear regression, adjusted for age, gender, and education. Covariates were comorbidity, depression and anxiety scores. RESULTS The main result indicated that CNSD users (n=100) had (β=-3.4, 95% CI 6.27 to -0.58, p=0.017) lower Cognistat score than non-users (n=146), adjusted for age, gender, education, anxiety and depression, but not significant when including covariate for comorbidity (β= -2.50 - 5.45; -0.46, p=0.097). Comorbidity was associated with cognitive function (β=-0.77, 95% CI -1.22 to -0.14, p=0.014). Cognistat subdimensions associated with CNSD use were language (p=0.017) and calculation (p=0.003). In clock drawing test, users had lower scores than non-users (β=-0.80, 95% CI 1.24 to -0.36, p=0.004), but no significant difference was found with MMSE and TMT A or B. Z-hypnotics were associated with reduced cognitive function. CONCLUSION Among older hospitalised patients, global cognition and specific cognitive functions were associated with long-term use of CNSD medication as well as with somatic comorbidity. TRIAL REGISTRATION NUMBER NCT03162081, 22 May 2017.
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Affiliation(s)
- Tahreem Ghazal Siddiqui
- Health Services Research Unit (HØKH), Akershus University Hospital, Lorenskog, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Socheat Cheng
- Health Services Research Unit (HØKH), Akershus University Hospital, Lorenskog, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Michael Gossop
- Centre for Addiction Research, King's College London, London, UK
| | - Espen Saxhaug Kristoffersen
- Health Services Research Unit (HØKH), Akershus University Hospital, Lorenskog, Norway
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Ramune Grambaite
- Health Services Research Unit (HØKH), Akershus University Hospital, Lorenskog, Norway
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Christofer Lundqvist
- Health Services Research Unit (HØKH), Akershus University Hospital, Lorenskog, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Neurology, Akershus University Hospital, Lorenskog, Norway
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20
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Lintula E, Tiihonen M, Taipale H, Tolppanen AM, Tanskanen A, Tiihonen J, Hartikainen S, Hamina A. Opioid Use After Hospital Care due to Hip Fracture Among Community-Dwelling Persons With and Without Alzheimer's Disease. Drugs Aging 2020; 37:193-203. [PMID: 31879863 PMCID: PMC7044157 DOI: 10.1007/s40266-019-00734-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Hip fractures are common among persons with Alzheimer's disease (AD), but problems in pain assessment may lead to insufficient analgesia after hospitalization. OBJECTIVE We investigated the prevalence of opioid use in the 6 months after discharge from hospital care due to hip fracture among community-dwellers with and without AD. SETTING AND METHOD The Medication use and Alzheimer's disease (MEDALZ) cohort was used for this study, consisting of all community-dwelling persons newly diagnosed with AD during 2005-2011 in Finland and their comparison persons without AD matched on age, sex, and region of residence at the time of AD diagnosis. Data were collected from nationwide healthcare registers. MAIN OUTCOME MEASURES We investigated opioid use versus non-use in persons with and without AD in the 6 months after discharge from hospital care due to hip fracture. RESULTS Altogether 2342 persons with AD and 1615 persons without AD, discharged to community settings within ≤ 120 days after a hip fracture, were included. A higher percentage of persons with AD used opioids compared to those without AD, 39.5% [95% confidence interval (CI) 37.5-41.5] versus 31.2% (95% CI 28.9-33.5). Persons with AD used more frequently strong opioids during the first 3 months and buprenorphine during the 6-month period, and used weak opioids less frequently after the first month after discharge compared to those without AD. CONCLUSIONS Frequent opioid use after hospital care due to hip fracture may indicate increased attention to pain among persons with AD. Nevertheless, the benefits and harms of opioid use should be evaluated regularly in community-dwelling older persons.
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Affiliation(s)
- Eveliina Lintula
- School of Pharmacy, University of Eastern Finland, P.O.B 1627, 70211, Kuopio, Finland
| | - Miia Tiihonen
- School of Pharmacy, University of Eastern Finland, P.O.B 1627, 70211, Kuopio, Finland.
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O.B 1627, 70211, Kuopio, Finland.
| | - Heidi Taipale
- School of Pharmacy, University of Eastern Finland, P.O.B 1627, 70211, Kuopio, Finland
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O.B 1627, 70211, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77, Stockholm, Sweden
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, 70240, Kuopio, Finland
| | - Anna-Maija Tolppanen
- School of Pharmacy, University of Eastern Finland, P.O.B 1627, 70211, Kuopio, Finland
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O.B 1627, 70211, Kuopio, Finland
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77, Stockholm, Sweden
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, 70240, Kuopio, Finland
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77, Stockholm, Sweden
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, 70240, Kuopio, Finland
| | - Sirpa Hartikainen
- School of Pharmacy, University of Eastern Finland, P.O.B 1627, 70211, Kuopio, Finland
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O.B 1627, 70211, Kuopio, Finland
| | - Aleksi Hamina
- School of Pharmacy, University of Eastern Finland, P.O.B 1627, 70211, Kuopio, Finland
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O.B 1627, 70211, Kuopio, Finland
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21
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Resnick B, Boltz M, Galik E, Holmes S, Fix S, Zhu S. Gender Differences in Function, Physical Activity, Falls, Medication Use, and Life Satisfaction Among Residents in Assisted Living Settings. Res Gerontol Nurs 2020; 13:31-40. [PMID: 31584687 PMCID: PMC6980912 DOI: 10.3928/19404921-20190930-02] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/06/2019] [Indexed: 11/20/2022]
Abstract
The purpose of the current study was to test for gender differences among residents living in assisted living settings. This was a secondary data analysis using data from the first 64 facilities participating in the ongoing Function Focused Care for Assisted Living study using the Evidence Integration Triangle (FFC-AL-EIT). A total of 593 residents were recruited. Differences by gender with regard to function, physical activity, falls, total number of medications, and satisfaction with assisted living were tested using multivariate analysis of variance. There were 166 (28%) men and 427 (72%) women with a mean age of 88 (SD = 7.5 years). Participants had five (SD = 2) comorbidities and took on average 6.88 medications (SD = 3.47). Participants had moderate functional impairment with a mean of 64.13 (SD = 19.09) on the Barthel Index and engaged in 43.8 (SD = 76.12) minutes daily of moderate level physical activity. Women reported higher satisfaction with activities (4.32 [SD = 1.14]) than men (3.85 [SD = 1.51]), and women received more medications than men (7.09 [SD = 3.51] vs. 6.34 [SD = 3.31]). Current study findings suggest that deprescribing may be particularly important for women versus men and focusing on expanding activity options to include those preferred by men should be considered in assisted living settings. [Research in Gerontological Nursing, 13(1), 31-40.].
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Abstract
The ageing revolution is changing the composition of our society with more people becoming very old with higher risks for developing both pain and dementia. Pain is normally signaled by verbal communication, which becomes more and more deteriorated in people with dementia. Thus, these individuals unnecessarily suffer from manageable but unrecognized pain. Pain assessment in patients with dementia is a challenging endeavor, with scientific advancements quickly developing. Pain assessment tools and protocols (mainly observational scales) have been incorporated into national and international guidelines of pain assessment in aged individuals. To effectively assess pain, interdisciplinary collaboration (nurses, physicians, psychologists, computer scientists, and engineers) is essential. Pain management in this vulnerable population is also preferably done in an interdisciplinary setting. Nonpharmacological management programs have been predominantly tested in younger populations without dementia. However, many of them are relatively safe, have proven their efficacy, and therefore deserve a first place in pain management programs. Paracetamol is a relatively safe and effective first-choice analgesic. There are many safety issues regarding nonsteroidal anti-inflammatory drugs, opioids, and adjuvant analgesics in dementia patients. It is therefore recommended to monitor both pain and potential side effects regularly. More research is necessary to provide better guidance for pain management in dementia.
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23
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Pergolizzi JV, Raffa RB, Paladini A, Varrasi G, LeQuang JA. Treating pain in patients with dementia and the possible concomitant relief of symptoms of agitation. Pain Manag 2019; 9:569-582. [DOI: 10.2217/pmt-2019-0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Dementia is an irreversible, progressive form of cognitive dysfunction that can affect memory, learning ability, thinking, orientation, comprehension, calculation, linguistic skills and executive function but which does not impair consciousness. Pain prevalence is high among the elderly who are also at elevated risk for dementia. Pain control for dementia patients is important but can be challenging for clinicians as cognitive deficits can make it difficult to identify, localize and assess pain. Cerebral changes associated with dementia may change how people process and experience pain in ways that are not entirely elucidated. Agitation is a frequent symptom of dementia and may be associated with untreated pain as agitation and aggression symptoms decrease when pain is effectively addressed.
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Affiliation(s)
| | - Robert B Raffa
- University of Arizona, Department of Pharmacy, Tucson, AZ 85721, USA
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Griffioen C, Husebo BS, Flo E, Caljouw MAA, Achterberg WP. Opioid Prescription Use in Nursing Home Residents with Advanced Dementia. PAIN MEDICINE 2019; 20:50-57. [PMID: 29136228 DOI: 10.1093/pm/pnx268] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 10/04/2017] [Indexed: 11/14/2022]
Abstract
Background Although proper pain treatment may require opioids, discussion continues about possible undertreatment or overtreatment in persons with advanced dementia. Objective To investigate the prevalence of pain, frequency of opioid prescription use, and factors associated with strong opioid prescription use in nursing homes. Design Cross-sectional study. Setting and Subjects Eighteen Norwegian nursing homes; 327 persons with advanced dementia and behavioral disturbances participated. Methods Potential factors associated with strong opioid prescription use were assessed: demographics (age, gender), medical conditions (comorbidity, number of medications), pain (Mobilization-Observation-Behaviour-Intensity-Dementia-2 Pain Scale ≥ 3, pain-related diagnoses, analgesic prescription use), functioning (activities of daily living, Mini-Mental State Examination) and behavior (Neuropsychiatric Inventory-Nursing Home version, Cohen-Mansfield Agitation Inventory). Factors with P < 0.10, age, and gender were included in multivariate regression analysis. Results The prevalence of moderate to severe pain was 62.1%. Of all participants, 19.3% (N = 63) were prescribed opioids, and of these, 79.4% (N = 50) were still in pain; 66.7% of the opioid prescriptions were less than or equal to the lowest dosage of fentanyl patches (12 mcg/h) or buprenorphine (5 or 10 mcg/h). Pain (odds ratio [OR] = 1.26, 95% confidence interval [CI] = 1.12-1.42), total number of pain-related diagnoses (OR = 1.47, 95% CI = 1.14-1.90), and depression and anxiety (OR = 1.05, 95% CI = 1.01-1.11) were positively associated with an opioid prescription. Stroke was negatively associated (OR = 0.43, 95% CI = 0.19-0.99). Conclusions Strong opioid prescription use was mainly associated with pain. However, in this population, despite the relatively prevalent use of strong prescription opioids, pain was still prevalent. This emphasizes the challenge of proper pain treatment and need for regular evaluation of pain and pain management.
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Affiliation(s)
- Charlotte Griffioen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.,Novicare, Elderly Care, Best, the Netherlands
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Elisabeth Flo
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Monique A A Caljouw
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Tanghe M, Van Den Noortgate N, Pivodic L, Deliens L, Onwuteaka-Philipsen B, Szczerbinska K, Finne-Soveri H, Collingridge-Moore D, Gambassi G, Van den Block L, Piers R. Opioid, antipsychotic and hypnotic use in end of life in long-term care facilities in six European countries: results of PACE. Eur J Public Health 2019; 29:74-79. [PMID: 30285189 PMCID: PMC6345144 DOI: 10.1093/eurpub/cky196] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Opioids, antipsychotics and hypnotics are recommended for comfort care in dying. We studied their prescription during the last 3 days in residents deceased in the long-term care facility (LTCF). Methods In a retrospective, cross-sectional survey in Belgium, England, Finland, Italy, the Netherlands and Poland, LTCFs, selected by proportional stratified random sampling, reported all deaths over the previous 3 months. The nurse most involved in the residents’ care reviewed the chart for opioid, antipsychotic and hypnotic prescription, cause of death and comorbidities. Multivariable logistic regression was performed to adjust for resident characteristics. Results Response rate was 81.6%. We included 1079 deceased residents in 322 LCTFs. Opioid prescription ranged from 18.5% (95% CI: 13.0–25.8) of residents in Poland to 77.9% (95% CI: 69.5–84.5) in the Netherlands, antipsychotic prescription from 4.8% (95% CI: 2.4–9.1) in Finland to 22.4% (95% CI: 14.7–32.4) in Italy, hypnotic prescription from 7.8% (95% CI: 4.6–12.8) in Finland to 47.9% (95% CI: 38.5–57.3) in the Netherlands. Differences in opioid, antipsychotic and hypnotic prescription between countries remained significant (P < 0.001) when controlling for age, gender, length of stay, cognitive status, cause of death in multilevel, multivariable analyses. Dying from cancer showed higher odds for receiving opioids (OR 3.51; P < 0.001) and hypnotics (OR 2.10; P = 0.010). Conclusions Opioid, antipsychotic and hypnotic prescription in the dying phase differed significantly between six European countries. Further research should determine the appropriateness of their prescription and refine guidelines especially for LTCF residents dying of non-cancer diseases.
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Affiliation(s)
- Marc Tanghe
- End-of-Life Care Research Group, Ghent University, Ghent, Belgium
| | | | - Lara Pivodic
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | | | | | - Giovanni Gambassi
- Fondazione Policlinico Universitario A. Gemelli, IRCCS and Università Cattolica del Sacro Cuore, Roma, Italy
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Ruth Piers
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium
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Iaboni A, Campitelli MA, Bronskill SE, Diong C, Kumar M, Maclagan LC, Gomes T, Tadrous M, Maxwell CJ. Time trends in opioid prescribing among Ontario long-term care residents: a repeated cross-sectional study. CMAJ Open 2019; 7:E582-E589. [PMID: 31551235 PMCID: PMC6759016 DOI: 10.9778/cmajo.20190052] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Opioids are an important pain therapy, but their use may be associated with adverse events in frail and cognitively impaired long-term care residents. The objective of this study was to investigate trends in opioid prescribing among Ontario long-term care residents over time, given the paucity of data for this setting. METHODS We used linked clinical and health administrative databases to conduct a population-based, repeated cross-sectional study of opioid use among Ontario long-term care residents between Apr. 1, 2009, and Mar. 31, 2017. We identified prevalent opioid use by drug type, dosage and coprescription with benzodiazepines, and within certain vulnerable subgroups. We used log-binomial regression to quantify the percent change between 2009/10 and 2016/17. RESULTS Among an average of 76 147 long-term care residents per year, the prevalence of opioid use increased from 15.8% in 2009/10 to 19.6% in 2016/17 (p < 0.001). Over the study period, the use of hydromorphone increased by 233.2%, whereas the use of all other opioid agents decreased. The use of high-dose opioids (> 90 mg of morphine equivalents) and the coprescription of opioids with benzodiazepines decreased significantly, by 17.7% (p < 0.001) and 23.8% (p < 0.001), respectively. Increases in opioid prevalence were more notable among frail residents (37.6% v. 18.8% among nonfrail residents, p < 0.001) and those with dementia (38.6% v. 21.6% among those without dementia, p < 0.001). INTERPRETATION Within Ontario long-term care, trends suggest a shift toward increased use of hydromorphone but reduced prevalence of use of other opioid agents and potentially inappropriate opioid prescribing. Further investigation is needed on the impact of these trends on resident outcomes.
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Affiliation(s)
- Andrea Iaboni
- Toronto Rehabilitation Institute (Iaboni), University Health Network; Department of Psychiatry (Iaboni), University of Toronto; ICES (Campitelli, Bronskill, Diong, Kumar, Maclagan, Gomes, Tadrous, Maxwell); Institute of Health Policy, Management and Evaluation (Bronskill, Gomes), University of Toronto; Sunnybrook Research Institute (Bronskill), Sunnybrook Health Sciences Centre; Women's College Research Institute (Bronskill, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes, Tadrous), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes, Tadrous), University of Toronto, Toronto, Ont.; Schools of Pharmacy and of Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont
| | - Michael A Campitelli
- Toronto Rehabilitation Institute (Iaboni), University Health Network; Department of Psychiatry (Iaboni), University of Toronto; ICES (Campitelli, Bronskill, Diong, Kumar, Maclagan, Gomes, Tadrous, Maxwell); Institute of Health Policy, Management and Evaluation (Bronskill, Gomes), University of Toronto; Sunnybrook Research Institute (Bronskill), Sunnybrook Health Sciences Centre; Women's College Research Institute (Bronskill, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes, Tadrous), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes, Tadrous), University of Toronto, Toronto, Ont.; Schools of Pharmacy and of Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont
| | - Susan E Bronskill
- Toronto Rehabilitation Institute (Iaboni), University Health Network; Department of Psychiatry (Iaboni), University of Toronto; ICES (Campitelli, Bronskill, Diong, Kumar, Maclagan, Gomes, Tadrous, Maxwell); Institute of Health Policy, Management and Evaluation (Bronskill, Gomes), University of Toronto; Sunnybrook Research Institute (Bronskill), Sunnybrook Health Sciences Centre; Women's College Research Institute (Bronskill, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes, Tadrous), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes, Tadrous), University of Toronto, Toronto, Ont.; Schools of Pharmacy and of Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont
| | - Christina Diong
- Toronto Rehabilitation Institute (Iaboni), University Health Network; Department of Psychiatry (Iaboni), University of Toronto; ICES (Campitelli, Bronskill, Diong, Kumar, Maclagan, Gomes, Tadrous, Maxwell); Institute of Health Policy, Management and Evaluation (Bronskill, Gomes), University of Toronto; Sunnybrook Research Institute (Bronskill), Sunnybrook Health Sciences Centre; Women's College Research Institute (Bronskill, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes, Tadrous), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes, Tadrous), University of Toronto, Toronto, Ont.; Schools of Pharmacy and of Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont
| | - Matthew Kumar
- Toronto Rehabilitation Institute (Iaboni), University Health Network; Department of Psychiatry (Iaboni), University of Toronto; ICES (Campitelli, Bronskill, Diong, Kumar, Maclagan, Gomes, Tadrous, Maxwell); Institute of Health Policy, Management and Evaluation (Bronskill, Gomes), University of Toronto; Sunnybrook Research Institute (Bronskill), Sunnybrook Health Sciences Centre; Women's College Research Institute (Bronskill, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes, Tadrous), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes, Tadrous), University of Toronto, Toronto, Ont.; Schools of Pharmacy and of Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont
| | - Laura C Maclagan
- Toronto Rehabilitation Institute (Iaboni), University Health Network; Department of Psychiatry (Iaboni), University of Toronto; ICES (Campitelli, Bronskill, Diong, Kumar, Maclagan, Gomes, Tadrous, Maxwell); Institute of Health Policy, Management and Evaluation (Bronskill, Gomes), University of Toronto; Sunnybrook Research Institute (Bronskill), Sunnybrook Health Sciences Centre; Women's College Research Institute (Bronskill, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes, Tadrous), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes, Tadrous), University of Toronto, Toronto, Ont.; Schools of Pharmacy and of Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont
| | - Tara Gomes
- Toronto Rehabilitation Institute (Iaboni), University Health Network; Department of Psychiatry (Iaboni), University of Toronto; ICES (Campitelli, Bronskill, Diong, Kumar, Maclagan, Gomes, Tadrous, Maxwell); Institute of Health Policy, Management and Evaluation (Bronskill, Gomes), University of Toronto; Sunnybrook Research Institute (Bronskill), Sunnybrook Health Sciences Centre; Women's College Research Institute (Bronskill, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes, Tadrous), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes, Tadrous), University of Toronto, Toronto, Ont.; Schools of Pharmacy and of Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont
| | - Mina Tadrous
- Toronto Rehabilitation Institute (Iaboni), University Health Network; Department of Psychiatry (Iaboni), University of Toronto; ICES (Campitelli, Bronskill, Diong, Kumar, Maclagan, Gomes, Tadrous, Maxwell); Institute of Health Policy, Management and Evaluation (Bronskill, Gomes), University of Toronto; Sunnybrook Research Institute (Bronskill), Sunnybrook Health Sciences Centre; Women's College Research Institute (Bronskill, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes, Tadrous), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes, Tadrous), University of Toronto, Toronto, Ont.; Schools of Pharmacy and of Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont
| | - Colleen J Maxwell
- Toronto Rehabilitation Institute (Iaboni), University Health Network; Department of Psychiatry (Iaboni), University of Toronto; ICES (Campitelli, Bronskill, Diong, Kumar, Maclagan, Gomes, Tadrous, Maxwell); Institute of Health Policy, Management and Evaluation (Bronskill, Gomes), University of Toronto; Sunnybrook Research Institute (Bronskill), Sunnybrook Health Sciences Centre; Women's College Research Institute (Bronskill, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes, Tadrous), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes, Tadrous), University of Toronto, Toronto, Ont.; Schools of Pharmacy and of Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont.
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Erdal A, Ballard C, Vahia IV, Husebo BS. Analgesic treatments in people with dementia - how safe are they? A systematic review. Expert Opin Drug Saf 2019; 18:511-522. [PMID: 31038371 DOI: 10.1080/14740338.2019.1614166] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/29/2019] [Indexed: 01/01/2023]
Abstract
INTRODUCTION People with dementia may be unable to verbally express pain and suffer from untreated pain. Use of analgesics in people with dementia has increased during the last decade, in particular opioid analgesics with high potential for adverse effects. AREAS COVERED This article presents a systematic review of the current evidence for safety and tolerability of analgesic drugs from randomized controlled trials in people with dementia. Relevant trials were identified by a literature search in the EMBASE, MEDLINE, and Cochrane databases from inception to November 2018. The search included the main terms 'dementia' and 'analgesic' or their subterms, and was filtered to limit results to clinical trials. EXPERT OPINION Although pain treatment is increasingly recognized as an important clinical issue in people with advanced dementia, there is currently a lack of evidence to support safety evaluations of commonly used analgesics in this group. To inform treatment decisions and enable care providers to appropriately monitor patients at risk of adverse effects, it is necessary to conduct well-designed clinical trials to investigate the relative efficacy and safety of analgesics in people with dementia, with particular emphasis on harmful effects of long-term opioid use as well as short-term use of nonsteroidal anti-inflammatory drugs.
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Affiliation(s)
- Ane Erdal
- a Department of Global Public Health and Primary Care , Centre for Elderly and Nursing Home Medicine, University of Bergen , Bergen , Norway
| | | | - Ipsit Vihang Vahia
- c McLean Institute for Technology in Psychiatry and Geriatric Psychiatry Outpatient Services , McLean Hospital , Belmont , MA , USA
- d Department of Psychiatry , Harvard Medical School , Boston , MA , USA
| | - Bettina Sandgathe Husebo
- a Department of Global Public Health and Primary Care , Centre for Elderly and Nursing Home Medicine, University of Bergen , Bergen , Norway
- e Department of Health and Care , Municipality of Bergen , Bergen , Norway
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28
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Bullock L, Bedson J, Jordan JL, Bartlam B, Chew-Graham CA, Campbell P. Pain assessment and pain treatment for community-dwelling people with dementia: A systematic review and narrative synthesis. Int J Geriatr Psychiatry 2019; 34:807-821. [PMID: 30724409 DOI: 10.1002/gps.5078] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 01/26/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To describe the current literature on pain assessment and pain treatment for community-dwelling people with dementia. METHOD A comprehensive systematic search of the literature with narrative synthesis was conducted. Eight major bibliographic databases were searched in October 2018. Titles, abstracts, and full-text articles were sequentially screened. Standardised data extraction and quality appraisal exercises were conducted. RESULTS Thirty-two studies were included in the review, 11 reporting findings on pain assessment tools or methods and 27 reporting findings on treatments for pain. In regard to pain assessment, a large proportion of people with moderate to severe dementia were unable to complete a self-report pain instrument. Pain was more commonly reported by informal caregivers than the person with dementia themselves. Limited evidence was available for pain-focused behavioural observation assessment. In regard to pain treatment, paracetamol use was more common in community-dwelling people with dementia compared with people without dementia. However, non-steroidal anti-inflammatory drugs (NSAIDs) were used less. For stronger analgesics, community-dwelling people with dementia were more likely to receive strong opioids (eg, fentanyl) than people without dementia. CONCLUSION This review identifies a dearth of high-quality studies exploring pain assessment and/or treatment for community-dwelling people with dementia, not least into non-pharmacological interventions. The consequences of this lack of evidence, given the current and projected prevalence of the disease, are very serious and require urgent redress. In the meantime, clinicians should adopt a patient- and caregiver-centred, multi-dimensional, longitudinal approach to pain assessment and pain treatment for this population.
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Affiliation(s)
- Laurna Bullock
- Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - John Bedson
- Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - Joanne L Jordan
- Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - Bernadette Bartlam
- Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technical University, Singapore, Singapore
| | - Carolyn A Chew-Graham
- Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
- Midlands Partnership NHS Foundation Trust, St George's Hospital, UK
| | - Paul Campbell
- Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
- Midlands Partnership NHS Foundation Trust, St George's Hospital, UK
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29
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Roitto HM, Kautiainen H, Aalto UL, Öhman H, Laurila J, Pitkälä KH. Fourteen-Year Trends in the Use of Psychotropic Medications, Opioids, and Other Sedatives Among Institutionalized Older People in Helsinki, Finland. J Am Med Dir Assoc 2019; 20:305-311. [DOI: 10.1016/j.jamda.2018.12.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/18/2018] [Accepted: 12/20/2018] [Indexed: 10/27/2022]
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30
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Gilmartin-Thomas JFM, Bell JS, Liew D, Arnold CA, Buchbinder R, Chapman C, Cicuttini F, Dobbin M, Gibson SJ, Giummarra MJ, Gowan J, Katz B, Lubman DI, McCrone M, Pilgrim J, Synnot A, van Dyk E, Workman B, McNeil J. Chronic pain medication management of older populations: Key points from a national conference and innovative opportunities for pharmacy practice. Res Social Adm Pharm 2019; 15:207-213. [DOI: 10.1016/j.sapharm.2018.03.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 03/01/2018] [Accepted: 03/18/2018] [Indexed: 01/20/2023]
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McCabe SE, Veliz PT, Boyd CJ, Schepis TS, McCabe VV, Schulenberg JE. A prospective study of nonmedical use of prescription opioids during adolescence and subsequent substance use disorder symptoms in early midlife. Drug Alcohol Depend 2019; 194:377-385. [PMID: 30481692 PMCID: PMC6355143 DOI: 10.1016/j.drugalcdep.2018.10.027] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 10/18/2018] [Accepted: 10/26/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND This longitudinal study assesses characteristics associated with adolescents' nonmedical use of prescription opioids (NMUPO) including: frequency, co-ingestion, motives, specific opioid type; sequence of initiation of medical use of prescription opioids and NMUPO in relationship to subsequent substance use disorder (SUD) symptoms. METHODS Twenty-one independent national cohorts of U.S. high school seniors (n = 8,373) were surveyed and followed 17 years from adolescence to age 35. RESULTS The majority of adolescents who engaged in NMUPO reported occasional/frequent NMUPO, non-pain relief motives for NMUPO, simultaneous co-ingestion involving NMUPO and other drugs, opioid analgesics with high misuse potential, and multiple types of opioid analgesics. Adolescents who reported NMUPO for pain relief, NMUPO involving opioid analgesics with high misuse potential, or multiple prescription opioids had significantly greater odds of SUD symptoms at age 35, relative to those who had no history of NMUPO during adolescence. In addition, medical use of prescription opioids after initiating NMUPO (or NMUPO only) during adolescence was associated with significantly greater odds of subsequent SUD symptoms at age 35 relative to those who reported the medical use of prescription opioids only or had no medical use or NMUPO during adolescence. CONCLUSIONS This is the first U.S. national prospective study to examine the relationships between adolescents' NMUPO characteristics and later SUD symptoms in early midlife. Several characteristics (frequency, co-ingestion, motives, opioid type, and medical/NMUPO initiation history) were identified that could be used to screen and detect high-risk youth for indicated interventions to reduce prescription opioid misuse and SUDs.
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Affiliation(s)
- Sean Esteban McCabe
- Center for the Study of Drugs, Alcohol, Smoking, and Health, Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI 48109, USA; Institute for Research on Women and Gender, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Philip T. Veliz
- Center for the Study of Drugs, Alcohol, Smoking, and Health, Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI 48109, USA,Institute for Research on Women and Gender, University of Michigan, Ann Arbor, MI 48109, USA
| | - Carol J. Boyd
- Center for the Study of Drugs, Alcohol, Smoking, and Health, Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI 48109, USA,Institute for Research on Women and Gender, University of Michigan, Ann Arbor, MI 48109, USA,Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ty S. Schepis
- Department of Psychology, Texas State University, San Marcos, TX 78666, USA
| | - Vita V. McCabe
- Center for the Study of Drugs, Alcohol, Smoking, and Health, Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI 48109, USA,St. Joseph Mercy Ann Arbor, St. Joseph Mercy Health System, Ypsilanti, MI 48197, USA
| | - John E. Schulenberg
- Developmental Psychology, Department of Psychology, University of Michigan, Ann Arbor, MI 48106, USA,Institute for Social Research, University of Michigan, Ann Arbor, MI 48106, USA
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Erdal A, Flo E, Aarsland D, Ballard C, Slettebo DD, Husebo BS. Efficacy and Safety of Analgesic Treatment for Depression in People with Advanced Dementia: Randomised, Multicentre, Double-Blind, Placebo-Controlled Trial (DEP.PAIN.DEM). Drugs Aging 2018; 35:545-558. [PMID: 29725986 PMCID: PMC5999156 DOI: 10.1007/s40266-018-0546-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Chronic pain and depression often co-occur, and pain may exacerbate depression in people with dementia. Objective The objective of this study was to assess the efficacy and safety of analgesic treatment for depression in nursing home patients with advanced dementia and clinically significant depressive symptoms. Methods We conducted a multicentre, parallel-group, double-blind, placebo-controlled trial in 47 nursing homes, including 162 nursing home patients aged ≥ 60 years with dementia (Mini-Mental State Examination ≤ 20) and depression (Cornell Scale for Depression in Dementia ≥ 8). Patients were randomised to receive active analgesic treatment (paracetamol or buprenorphine transdermal system) or identical placebo for 13 weeks. The main outcome measure was the change in depression (Cornell Scale for Depression in Dementia) from baseline to 13 weeks, assessed using linear mixed models with fixed effects for time, intervention and their interaction in the models. Secondary outcomes were to assess whether any change in depression was secondary to change in pain (Mobilisation-Observation-Behaviour-Intensity-Dementia-2 Pain Scale) and adverse events. Results The mean depression change was − 0.66 (95% confidence interval − 2.27 to 0.94) in the active group (n = 80) and − 3.30 (− 4.68 to −1.92) in the placebo group (n = 82). The estimated treatment effect was 2.64 (0.55–4.72, p = 0.013), indicating that analgesic treatment had no effect on depressive symptoms from baseline to 13 weeks while placebo appeared to ameliorate depressive symptoms. There was no significant reduction in pain in the active treatment group (paracetamol and buprenorphine combined) vs. placebo; however, a subgroup analysis demonstrated a significant reduction in pain for paracetamol vs. placebo [by − 1.11 (− 2.16 to − 0.06, p = 0.037)] from week 6 to 13 without a change in depression. Buprenorphine did not have significant effects on depression [3.04 (− 0.11 to 6.19), p = 0.059] or pain [0.47 (− 0.77 to 1.71), p = 0.456] from 0 to 13 weeks. Thirty-five patients were withdrawn from the study because of adverse reactions, deterioration or death: 25 (31.3%) during active treatment [23 (52.3%) who received buprenorphine], and ten (12.2%) in the placebo group. The most frequently occurring adverse events were psychiatric (17 adverse reactions) and neurological (14 adverse reactions). Conclusion Analgesic treatment did not reduce depression while placebo appeared to improve depressive symptoms significantly by comparison, possibly owing to the adverse effects of active buprenorphine. The risk of adverse events warrants caution when prescribing buprenorphine for people with advanced dementia. Trial registration ClinicalTrials.gov NCT02267057 (registered 7 July, 2014) and Norwegian Medicines Agency EudraCT 2013-002226-23. Electronic supplementary material The online version of this article (10.1007/s40266-018-0546-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ane Erdal
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.
| | - Elisabeth Flo
- Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Dag Aarsland
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Dagrun D Slettebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.,Department of Health and Care, Municipality of Bergen, Bergen, Norway
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Aman Y, Pitcher T, Ballard C, Malcangio M. Impaired chronic pain-like behaviour and altered opioidergic system in the TASTPM mouse model of Alzheimer's disease. Eur J Pain 2018; 23:91-106. [PMID: 29987897 PMCID: PMC6492091 DOI: 10.1002/ejp.1288] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Chronic pain conditions, especially osteoarthritis (OA), are as common in individuals with Alzheimer's disease (AD) as in the general elderly population, which results in detrimental impact on patient's quality of life. However, alteration in perception of pain in AD coupled with deteriorating ability to communicate pain sensations often result in under-diagnosis and inappropriate management of pain. Therefore, a better understanding of mechanisms in chronic pain processing in AD is needed. Here, we explored the development and progression of OA pain and the effect of analgesics in a transgenic mouse model of AD. METHODS Unilateral OA pain was induced chemically, via an intra-articular injection of monosodium iodoacetate (MIA) in the left knee joint of AD-mice (TASTPM) and age- and gender-matched C57BL/6J (WT). Pharmacological and biochemical assessments were conducted in plasma and spinal cord tissue. RESULTS MIA resulted in hind paw mechanical hypersensitivity (allodynia), initiating on day 3, in TASTPM and WT controls. However, from 14 to 28 days, TASTPM displayed partial attenuation of allodynia and diminished spinal microglial response compared to WT controls. Naloxone, an opioid antagonist, re-established allodynia levels as observed in the WT group. Morphine, an opioid agonist, induced heightened analgesia in AD-mice whilst gabapentin was devoid of efficacy. TASTPM exhibited elevated plasma level of β-endorphin post-MIA which correlated with impaired allodynia. CONCLUSIONS These results indicate an alteration of the opioidergic system in TASTPM as possible mechanisms underlying impaired persistent pain sensitivity in AD. This work provides basis for re-evaluation of opioid analgesic use for management of pain in AD. SIGNIFICANCE This study shows attenuated pain-like behaviour in a transgenic mouse model of Alzheimer's disease due to alterations in the opioidergic system and central plasticity mechanisms of persistent pain.
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Affiliation(s)
- Y Aman
- Wolfson Centre for Age Related Diseases, King's College London, UK
| | - T Pitcher
- Wolfson Centre for Age Related Diseases, King's College London, UK
| | - C Ballard
- Wolfson Centre for Age Related Diseases, King's College London, UK.,Medical School, University of Exeter, UK
| | - M Malcangio
- Wolfson Centre for Age Related Diseases, King's College London, UK
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Hunnicutt JN, Hume AL, Ulbricht CM, Tjia J, Lapane KL. Long-acting opioid initiation in US nursing homes. Pharmacoepidemiol Drug Saf 2018; 28:31-38. [PMID: 29869441 DOI: 10.1002/pds.4568] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 04/17/2018] [Accepted: 05/07/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To estimate the proportion of residents newly initiating long-acting opioids in comparison to residents initiating short-acting opioids and examine variation in long-acting opioid initiation by region and resident characteristics. METHODS This cross-sectional study included 182 735 long-stay nursing home residents in 13 881 US nursing homes who were Medicare beneficiaries during 2011 to 2013 and initiated a short-acting or long-acting opioid (excluding residents <50 years old, those with cancer, or receiving hospice care). Medicare Part D prescription claims were used to identify residents as newly initiating short-acting or long-acting opioids, defined as having a prescription claim for an opioid with no prior opioid prescriptions in the preceding 60 days. We estimated the overall proportion of initiators prescribed long-acting opioids. Regional variation was examined by mapping results by state and hospital referral regions. Logistic models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS Two percent of opioid initiators were prescribed long-acting opioids. State variation in long-acting opioid initiation ranged from 0.6% to 7.5% (5th-95th percentiles: 0.6-6.4%). Resident characteristics associated with increased long-acting opioid initiation included severe physical limitations (vs none/mild limitations; aOR: 2.13, 95% CI: 1.92-2.37) and pain (staff-assessed vs no pain; aOR: 1.59 95% CI: 1.40-1.80), whereas being non-White was inversely associated (non-Hispanic black vs non-Hispanic white; aOR: 0.70, 95% CI: 0.62-0.79). CONCLUSION United States nursing home residents predominantly initiate short-acting opioids in accordance with Center for Disease Control and Prevention guidelines. Documented variation by geographic and resident characteristics suggests that improvements are possible.
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Affiliation(s)
- Jacob N Hunnicutt
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Anne L Hume
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Christine M Ulbricht
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jennifer Tjia
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kate L Lapane
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Nowak T, Neumann-Podczaska A, Deskur-Śmielecka E, Styszyński A, Wieczorowska-Tobis K. Pain as a challenge in nursing home residents with behavioral and psychological symptoms of dementia. Clin Interv Aging 2018; 13:1045-1051. [PMID: 29872283 PMCID: PMC5973322 DOI: 10.2147/cia.s157246] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction In patients with dementia, observational scales are recommended for use in the assessment of pain. Unfortunately, their application is rare, and as a consequence pain is frequently underdiagnosed and undertreated in these types of subjects. Thus, the aim of the study was to assess analgesic treatment in nursing home residents with cognitive impairment and to delineate the relationship between pain and behavioral and psychological symptoms of dementia. Patients and methods The research was conducted in 2 nursing home facilities in Wielkopolska, Poland. The analyzed group consisted of 96 residents (78 female) with moderate and severe cognitive impairment in whom pain was assessed with the Abbey Pain Scale (APS) and agitation with the Cohen-Mansfield Agitation Inventory (CMAI). Thereafter, medical files related to drug prescriptions were analyzed. Results Analgesics were consumed by 33 individuals (34%); 24 (25%) received regular pain treatment and 7 individuals (7%) - as when needed pain treatment. A relationship was found between the APS and CMAI (r=0.45, p<0.0001). Subjects with a higher CMAI received sedative drugs more frequently (p<0.001), and despite having a higher APS (p=0.001), this did not correlate with higher analgesia. Conclusion Our study suggests that pain can be an important underlying cause of behavioral disturbances in older subjects with dementia. In order to reduce their frequency and to avoid excessive usage of sedatives, proper pain assessment and management are essential.
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Affiliation(s)
- Tomasz Nowak
- Laboratory of Geriatrics, Department of Palliative Medicine, Poznan University of Medical Sciences, Poznań, Poland
| | | | - Ewa Deskur-Śmielecka
- Laboratory of Geriatrics, Department of Palliative Medicine, Poznan University of Medical Sciences, Poznań, Poland
| | - Arkadiusz Styszyński
- Laboratory of Geriatrics, Department of Palliative Medicine, Poznan University of Medical Sciences, Poznań, Poland
| | - Katarzyna Wieczorowska-Tobis
- Laboratory of Geriatrics, Department of Palliative Medicine, Poznan University of Medical Sciences, Poznań, Poland
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Erdal A, Flo E, Aarsland D, Selbaek G, Ballard C, Slettebo DD, Husebo BS. Tolerability of buprenorphine transdermal system in nursing home patients with advanced dementia: a randomized, placebo-controlled trial (DEP.PAIN.DEM). Clin Interv Aging 2018; 13:935-946. [PMID: 29805252 PMCID: PMC5960239 DOI: 10.2147/cia.s161052] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Purpose Buprenorphine transdermal system is increasingly prescribed in people with advanced dementia, but no clinical trial has investigated the safety and factors associated with discontinuation due to adverse events in this population. Patients and methods One hundred sixty-two people with advanced dementia and significant depression from 47 nursing homes were included and randomized to active analgesic treatment (acetaminophen/buprenorphine) or identical placebo for 13 weeks. In this secondary analysis, the main outcomes were time to and reasons for discontinuation of buprenorphine due to adverse events. Change in daytime activity as measured by actigraphy was a secondary outcome. Results Of the 44 patients who received active buprenorphine 5 µg/hour, 52.3% (n=23) discontinued treatment due to adverse events compared to 13.3% (6 of 45) in the placebo group (p<0.001). Psychiatric and neurological adverse events were the most frequently reported causes of discontinuation (69.6%, n=16). Concomitant use of antidepressants significantly increased the risk of discontinuation (HR 23.2, 95% CI: 2.95–182, p=0.003). Adjusted for age, sex, cognitive function, pain and depression at baseline, active buprenorphine was associated with 24.0 times increased risk of discontinuation (Cox model, 95% CI: 2.45–235, p=0.006). Daytime activity dropped significantly during the second day of active treatment (−21.4%, p=0.005) and decreased by 12.9% during the first week (p=0.053). Conclusion Active buprenorphine had significantly higher risk of discontinuation compared with placebo in people with advanced dementia and depression, mainly due to psychiatric and neurological adverse events. Daytime activity dropped significantly during the first week of treatment. Concomitant use of antidepressants further reduced the tolerability of buprenorphine.
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Affiliation(s)
- Ane Erdal
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
| | - Elisabeth Flo
- Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Dag Aarsland
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Geir Selbaek
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway.,National Advisory Unit on Aging and Health, Tønsberg, Norway.,Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Clive Ballard
- Exeter Medical School, University of Exeter, Exeter, UK
| | - Dagrun D Slettebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.,Municipality of Bergen, Bergen, Norway
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Blytt KM, Bjorvatn B, Husebo B, Flo E. Effects of pain treatment on sleep in nursing home patients with dementia and depression: A multicenter placebo-controlled randomized clinical trial. Int J Geriatr Psychiatry 2018; 33:663-670. [PMID: 29282768 PMCID: PMC5873424 DOI: 10.1002/gps.4839] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 11/21/2017] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To investigate the effects of pain treatment on sleep in nursing home (NH) patients with dementia and depression. METHODS A multicenter, 2-armed, double-blinded, placebo-controlled, randomized clinical trial conducted between August 2014 and September 2016. One hundred six long-term patients from 47 NHs in Norway with dementia and depression according to the Mini-Mental State Examination and the Cornell Scale for Depression in Dementia were included. Patients received stepwise pain treatment in which those who did not use analgesics were randomized to receive either paracetamol (3 g/day) or placebo tablets; those who already used pain treatment were allocated to buprenorphine transdermal system (max. 10 μg/h/7 days) or placebo transdermal patches. Sleep was assessed continuously for 14 days by actigraphy, 1 week of baseline measurement, and 1 week of ongoing treatment. The following sleep parameters were evaluated: total sleep time, sleep efficiency (SE), sleep onset latency (SOL), wake after sleep onset, early morning awakening (EMA), and number of wake bouts. RESULTS In the intervention group (paracetamol/buprenorphine), SE (70%-72%), SOL (32-24 min), and EMA (50-40 min) improved compared with the control group (SE, 70%-67%; SOL, 47-60 min; EMA, 31-35 min). Treatment effects were significant (P < .01, P < .05, and P < .05, respectively). CONCLUSION Compared with placebo, pain treatment improved sleep as measured with actigraphy. This implies that sleep, pain, and depression in NH patients should be critically evaluated and that pain treatment should be considered to be a potentially beneficial treatment.
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Affiliation(s)
- Kjersti Marie Blytt
- Department of Global Public Health and Primary CareUniversity of BergenBergenNorway,Centre for Elderly and Nursing Home MedicineUniversity of BergenBergenNorway,Norwegian Competence Centre for Sleep DisordersHaukeland University HospitalBergenNorway
| | - Bjørn Bjorvatn
- Department of Global Public Health and Primary CareUniversity of BergenBergenNorway,Norwegian Competence Centre for Sleep DisordersHaukeland University HospitalBergenNorway
| | - Bettina Husebo
- Department of Global Public Health and Primary CareUniversity of BergenBergenNorway,Centre for Elderly and Nursing Home MedicineUniversity of BergenBergenNorway,Department of Nursing Home MedicineMunicipality of BergenBergenNorway
| | - Elisabeth Flo
- Faculty of Psychology, Department of Clinical PsychologyUniversity of BergenBergenNorway
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Blytt KM, Husebo B, Flo E, Bjorvatn B. Long-Term Pain Treatment Did Not Improve Sleep in Nursing Home Patients with Comorbid Dementia and Depression: A 13-Week Randomized Placebo-Controlled Trial. Front Psychol 2018; 9:134. [PMID: 29487556 PMCID: PMC5816805 DOI: 10.3389/fpsyg.2018.00134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 01/29/2018] [Indexed: 11/24/2022] Open
Abstract
Objective: Previous research indicates that pain treatment may improve sleep among nursing home patients. We aimed to investigate the long-term effect of pain treatment on 24-h sleep patterns in patients with comorbid depression and dementia. Design: A 13-week, multicenter, parallel-group, double-blind, placebo-controlled randomized clinical trial conducted between August 2014 and September 2016. Setting: Long-term patients from 47 nursing homes in Norway. Participants: We included 106 patients with comorbid dementia and depression according to the Mini Mental Status Examination (MMSE) and the Cornell Scale for Depression in Dementia (CSDD). Intervention: Patients who were not using analgesics were randomized to receive either paracetamol (3 g/day) or placebo tablets. Those who already received pain treatment were randomized to buprenorphine transdermal system (maximum 10 μg/h/7 days) or placebo transdermal patches. Measurements: Sleep was assessed continuously for 7 days by actigraphy, at baseline and in week 13. Total sleep time (TST), sleep efficiency (SE), sleep onset latency (SOL), wake after sleep onset (WASO), early morning awakening (EMA), and number of wake bouts (NoW) were evaluated. In addition, daytime total sleep time (DTS) was estimated. Pain was assessed with Mobilization-Observation-Behavior-Intensity-Dementia-2 Pain Scale (MOBID-2). Results: The linear mixed model analyses for TST, SE, SOL, WASO, EMA, NoW and DTS showed no statistically significant differences between patients who received active pain treatment and those who received placebo. Post hoc subgroup analyses showed that there were no statistically significant differences between active treatment and placebo from baseline to week 13 in patients who were in pain (MOBID-2 ≥ 3) at baseline, or in patients who had poor sleep (defined as SE < 85%) at baseline. Patients who received active buprenorphine showed an increase in TST and SE compared to those who received active paracetamol. Conclusion: The main analyses showed that long-term pain treatment did not improve sleep as measured with actigraphy. Compared to paracetamol, TST and SE increased among patients who received buprenorphine. This could indicate that some patients had beneficial effects from the most potent pain treatment. However, based on the present findings, long-term pain treatment is not recommended as a strategy to improve sleep. Clinical Trial https://clinicaltrials.gov/ct2/show/NCT02267057.
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Affiliation(s)
- Kjersti M Blytt
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.,Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
| | - Bettina Husebo
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.,Department of Nursing Home Medicine, Bergen, Norway
| | - Elisabeth Flo
- Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Bjørn Bjorvatn
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
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La Frenais FL, Bedder R, Vickerstaff V, Stone P, Sampson EL. Temporal Trends in Analgesic Use in Long-Term Care Facilities: A Systematic Review of International Prescribing. J Am Geriatr Soc 2018; 66:376-382. [PMID: 29274247 PMCID: PMC5838548 DOI: 10.1111/jgs.15238] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To explore global changes in the prescription of analgesic drugs over time in the international long-term care (LTC) population. DESIGN Systematic review. SETTING We included original research articles in English, published and unpublished, that included number of participants, country and year(s) of data collection, and prescription of analgesics (analgesics not otherwise specified, opioids, acetaminophen; scheduled only, or scheduled plus as needed (PRN)). PARTICIPANTS LTC residents. MEASUREMENTS We searched PubMed, EMBASE, CINAHL, International Pharmaceutical Abstracts, PsycINFO, Cochrane, Web of Science, Google Scholar, using keywords for LTC facilities and analgesic medication; hand-searched references of eligible papers; correspondence. Studies were quality rated using an adapted Newcastle-Ottawa scale. Pearson correlation coefficients were generated between percentage of residents prescribed an analgesic and year of data collection. If available, we investigated changes in acetaminophen and opioid prescriptions. RESULTS Forty studies met inclusion criteria. A moderate correlation (0.59) suggested that scheduled prescription rates for analgesics have increased over time. Similar findings were reflected in scheduled prescriptions for acetaminophen and opioids. No increase was seen when analyzing scheduled plus PRN analgesics. Use of opioids (scheduled plus PRN) appears to have increased over time. CONCLUSION Worldwide, use of opioids and acetaminophen has increased in LTC residents. Research is needed to explore whether this reflects appropriate pain management for LTC residents and if PRN medication is used effectively.
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Affiliation(s)
- Francesca L. La Frenais
- Division of PsychiatryUniversity College LondonLondonUnited Kingdom
- Division of PsychiatryMarie Curie Palliative Care Research DepartmentUniversity College LondonLondonUnited Kingdom
| | - Rachel Bedder
- Division of PsychiatryUniversity College LondonLondonUnited Kingdom
- Institute of Cognitive NeuroscienceUniversity College LondonLondonUnited Kingdom
| | - Victoria Vickerstaff
- Division of PsychiatryMarie Curie Palliative Care Research DepartmentUniversity College LondonLondonUnited Kingdom
| | - Patrick Stone
- Division of PsychiatryMarie Curie Palliative Care Research DepartmentUniversity College LondonLondonUnited Kingdom
| | - Elizabeth L. Sampson
- Division of PsychiatryMarie Curie Palliative Care Research DepartmentUniversity College LondonLondonUnited Kingdom
- Barnet Enfield and Haringey Mental Health Trust Liaison TeamNorth Middlesex University HospitalLondonUnited Kingdom
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Fog AF, Kvalvaag G, Engedal K, Straand J. Drug-related problems and changes in drug utilization after medication reviews in nursing homes in Oslo, Norway. Scand J Prim Health Care 2017; 35:329-335. [PMID: 29096573 PMCID: PMC5730030 DOI: 10.1080/02813432.2017.1397246] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We describe the drug-related problems (DRPs) identified during medication reviews (MRs) and the changes in drug utilization after MRs at nursing homes in Oslo, Norway. We explored predictors for the observed changes. DESIGN Observational before-after study. SETTING Forty-one nursing homes. INTERVENTION MRs performed by multidisciplinary teams during November 2011 to February 2014. SUBJECTS In all, 2465 long-term care patients. MAIN OUTCOME MEASURES DRPs identified by explicit criteria (STOPP/START and NORGEP) and drug-drug interaction database; interventions to resolve DRPs; drug use changes after MR. RESULTS A total of 6158 DRPs were identified, an average of 2.6 DRPs/patient, 2.0 for regular and 0.6 for pro re nata (prn) drugs. Of these patients, 17.3% had no DRPs. The remaining 82.7% of the patients had on average 3.0 DRPs/patient. Use of unnecessary drugs (43.5%), excess dosing (12.5%) and lack of monitoring of the drug use (11%) were the most frequent DRPs. Opioids and psychotropic drugs were involved in 34.4% of all DRPs. The mean number of drugs decreased after the MR from 6.8 to 6.3 for regular drugs and from 3.0 to 2.6 for prn drugs. Patients with DRPs experienced a decrease of 1.1 drugs after MR (0.5 for regular and 0.6 for prn drugs). The reduction was most pronounced for the regular use of antipsychotics, antidepressants, hypnotics/sedatives, diuretics, antithrombotic agents, antacid drugs; and for prn use of anxiolytics, opioids, hypnotics/sedatives, metoclopramide and NSAIDs. CONCLUSION The medication review resulted in less drug use, especially opioids and psychotropic drugs.
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Affiliation(s)
- Amura Francesca Fog
- Nursing Home Agency, Oslo, Norway
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- CONTACT Amura Francesca Fog Department of General Practice, Institute of Health and Society, University of Oslo, Postbox 1130 Blinderen, N-0318 Oslo, Norway
| | | | - Knut Engedal
- Norwegian National Advisory Unit for Aging and Health, Vestfold County Hospital HF, Toensberg and Oslo University Hospital, Oslo, Norway
| | - Jørund Straand
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
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Jokanovic N, Jamsen KM, Tan ECK, Dooley MJ, Kirkpatrick CM, Bell JS. Prevalence and Variability in Medications Contributing to Polypharmacy in Long-Term Care Facilities. Drugs Real World Outcomes 2017; 4:235-245. [PMID: 29110295 PMCID: PMC5684050 DOI: 10.1007/s40801-017-0121-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Research into which medications contribute to polypharmacy and the variability in these medications across long-term care facilities (LTCFs) has been minimal. Objective Our objective was to investigate which medications were more prevalent among residents with polypharmacy and to determine the variability in prescribing of these medications across LTCFs. Methods This was a cross-sectional study of 27 LTCFs in regional and rural Victoria, Australia. An audit of the medication charts and medical records of 754 residents was performed in May 2015. Polypharmacy was defined as nine or more regular medications. Logistic regression was performed to determine the association between medications and resident characteristics with polypharmacy. Analyses were adjusted for age, sex and Charlson’s comorbidity index. Variability in the use of the ten most prevalent medication classes was explored using funnel plots. Characteristics of LTCFs with low (< 30%), moderate (30–49%) and high (≥ 50%) polypharmacy prevalence were compared. Results Polypharmacy was observed in 272 (36%) residents. In adjusted analyses, each of the top ten most prevalent medication classes, with the exception of antipsychotics, were associated with polypharmacy. Between 7 and 23% of LTCFs fell outside the 95% control limits for each of the ten most prevalent medications. LTCFs with ≥ 50% polypharmacy prevalence were predominately smaller. Conclusion Polypharmacy was associated with nine of the ten most prevalent medication classes. There was greater than fourfold variability in nine of the ten most prevalent medications across LTCFs. Further studies are needed to investigate the clinical appropriateness of the variability in polypharmacy.
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Affiliation(s)
- Natali Jokanovic
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University (Parkville Campus), 407 Royal Parade, Parkville, VIC, 3052, Australia.
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia.
| | - Kris M Jamsen
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University (Parkville Campus), 407 Royal Parade, Parkville, VIC, 3052, Australia
| | - Edwin C K Tan
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University (Parkville Campus), 407 Royal Parade, Parkville, VIC, 3052, Australia
- Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Michael J Dooley
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University (Parkville Campus), 407 Royal Parade, Parkville, VIC, 3052, Australia
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
| | - Carl M Kirkpatrick
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University (Parkville Campus), 407 Royal Parade, Parkville, VIC, 3052, Australia
| | - J Simon Bell
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University (Parkville Campus), 407 Royal Parade, Parkville, VIC, 3052, Australia
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Erdal A, Flo E, Selbaek G, Aarsland D, Bergh S, Slettebo DD, Husebo BS. Associations between pain and depression in nursing home patients at different stages of dementia. J Affect Disord 2017; 218:8-14. [PMID: 28456075 DOI: 10.1016/j.jad.2017.04.038] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/17/2017] [Accepted: 04/20/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pain is associated with depression in nursing home patients with dementia. It is, however, unclear whether pain increases depression. Therefore we evaluated the prospective associations between pain and depressive symptoms in nursing home patients at different stages of cognitive impairment. METHODS Two longitudinal studies were combined, including 931 patients (≥65 years) from 65 nursing homes. One study assessed patients at admission, with 6-month follow-up (2012-2014). The other study assessed residents with varying lengths of stay, with 4-month follow-up (2014-2015). Patients were assessed with the Mini-Mental State Examination, the Mobilisation-Observation-Behaviour-Intensity-Dementia-2 Pain Scale, and the Cornell Scale for Depression in Dementia. RESULTS At baseline, 343 patients (40% of 858 assessed) had moderate to severe pain, and 347 (38% of 924) had depression. Pain increased the risk of depression (OR 2.35, 95% CI 1.76-3.12). Using mixed model analyses, we found that a 1-point increase in pain was associated with a .48 increase in depression (p<.001). This association persisted in mild, moderate, and severe cognitive impairment. In those recently admitted, depressive symptoms decreased over time, and having less pain at follow-up was associated with a decrease in depressive symptoms (within-subject effect; p=.042). LIMITATIONS The two cohorts had different inclusion criteria, which may reduce generalisability. The study design does not allow conclusions on causality. CONCLUSIONS Pain and depressive symptoms are associated in patients with dementia. Because reduced pain is associated with less depressive symptoms, these patients should be assessed regularly for untreated pain. The benefit of analgesic treatment should be weighed carefully against the potential for adverse effects.
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Affiliation(s)
- Ane Erdal
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.
| | - Elisabeth Flo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway; Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Geir Selbaek
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway; National Advisory Unit on Ageing and Health, Tønsberg, Norway; Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Dag Aarsland
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Centre for Age-related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Sverre Bergh
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway; National Advisory Unit on Ageing and Health, Tønsberg, Norway
| | - Dagrun D Slettebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway; Municipality of Bergen, Bergen, Norway
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Prevalence of Pain in Nursing Home Residents: The Role of Dementia Stage and Dementia Subtypes. J Am Med Dir Assoc 2017; 18:522-527. [PMID: 28236607 DOI: 10.1016/j.jamda.2016.12.078] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 12/29/2016] [Accepted: 12/30/2016] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To study pain prevalence, pain type, and its pharmacological treatment in Dutch nursing home residents in relation to dementia subtype and dementia severity. DESIGN Data were collected as part of the PAINdemiA study, an observational cross-sectional study conducted between May 2014 and December 2015. SETTING Ten nursing homes in the Netherlands. PARTICIPANTS A total of 199 nursing home residents in various stages of dementia. MEASUREMENTS We collected data on pain (by observation: MOBID-2 Pain Scale and by self-report scales), pain type, pain medication, dementia subtype, dementia severity (GDS), and demographic features. RESULTS In the whole sample, the prevalence of pain was 43% (95% confidence interval 36%-50%) using the MOBID-2 Pain Scale. Regardless of regularly scheduled analgesics, approximately one-third of the residents with pain suffered from moderate to severe pain. Pain assessment with the MOBID-2 Pain Scale showed no difference in pain between dementia subtypes, but residents with more severe dementia experienced pain more often than those with less severe dementia (27% vs 15%). The prevalence of self-reported pain was significantly higher in residents with vascular dementia (VaD) (54%) compared with those with Alzheimer disease (18%) and other dementia subtypes (14%). Nociceptive pain was the predominant type of pain (72%) followed by mixed pain (25%). Acetaminophen was the most prescribed analgesic (80%). CONCLUSION Most of the participating nursing home residents had no pain; however, pain was observed more often in residents with severe dementia, whereas residents in the early stages of VaD self-reported pain more often that those with other dementia subtypes. As one-third of the residents with clinically relevant pain had moderate to severe pain regardless of using pain medication, more focus should be on how pain management could use more tailored approaches and be regularly adjusted to individual needs.
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La Frenais F, Stone P, Sampson EL. Analgesic prescribing in care home residents: how epidemiological studies may inform clinical practice. Pain Manag 2016; 6:561-568. [PMID: 27383004 DOI: 10.2217/pmt-2016-0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Care home residents are often frail with multiple comorbidities and cognitive impairment, most commonly caused by dementia. This population is under-represented in clinical trials, leading to a lack of valid and reliable evidence to inform clinicians' prescribing practice. This paper summarizes how epidemiological research conducted in similar populations can inform pain management by describing pain prevalence, risk factors, typical features and functional consequences. This evidence can help overcome the numerous barriers to optimal pain management in care home residents.
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Affiliation(s)
- Francesca La Frenais
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.,Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.,Barnet Enfield & Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, Sterling Way, London, N18 1QX, UK
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Affiliation(s)
- Wilco Achterberg
- Institutional Care and Elderly Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Husebo BS, Achterberg W, Flo E. Identifying and Managing Pain in People with Alzheimer's Disease and Other Types of Dementia: A Systematic Review. CNS Drugs 2016; 30:481-97. [PMID: 27240869 PMCID: PMC4920848 DOI: 10.1007/s40263-016-0342-7] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Pain in patients with Alzheimer's disease is a complex issue; these patients suffer from the common causes of acute and chronic pain, and some also have neuropathic or nociceptive pain. Whatever the mechanism of pain in these patients, their pain will require careful assessment and management, to insure the correct type and level of analgesia is given. The objective of this systematic review was the identification of studies that have investigated the efficacy of different analgesics on pain intensity or pain-related behavior during nursing home stay and at the end of life. METHODS A search using pain, pain treatment, and dementia MESH terms and keywords was conducted (October 15, 2015) in MEDLINE, EMBASE, PsychINFO, CINAHL, and Cochrane libraries. RESULTS Our search yielded 3138 unique hits, published between 1990 and October 2015. We read titles and abstracts, identified 124 papers for full-text evaluation, and included 12 papers to reflect and synthesize the following questions: (1) Which pain assessment tools for people with dementia are responsive to change in pain intensity scores? (2) Which analgesics are efficacy-tested by controlled trials including people with dementia living in nursing homes, including at the end of life? (3) Which outcome measures have been used to identify pain, pain behavior, and/or treatment efficacy in people with dementia? CONCLUSION Despite increased use of analgesics, pain is still prevalent in people with dementia. Validated pain tools are available but not implemented and not fully tested on responsiveness to treatment. Official guidelines for pain assessment and treatment addressing people with dementia living in a nursing home are lacking. The efficacy of analgesic drug use on pain or neuropsychiatric behavior related to dementia has been hardly investigated.
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Affiliation(s)
- Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.
- Section for Nursing Home Medicine, Municipality of Bergen, Bergen, Norway.
| | - Wilco Achterberg
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Elisabeth Flo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
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