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Ingelson B, Dahlke S, O'Rourke H, Hunter KF. Nurses' knowledge and beliefs on pain management practices with hospitalised persons living with dementia: A qualitative descriptive study. J Clin Nurs 2024; 33:3224-3235. [PMID: 38590077 DOI: 10.1111/jocn.17164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/18/2024] [Accepted: 03/29/2024] [Indexed: 04/10/2024]
Abstract
AIM To understand nurses' knowledge, beliefs and experiences affect pain management practices in hospitalised persons living with dementia (PLWD). DESIGN Naturalistic inquiry using qualitative descriptive design. METHODS Semi-structured interviews were conducted with 12 registered nurses who worked in one acute care hospital in Southern California from October to November 2022. Data were analysed using content analysis to identify themes. RESULTS Two themes were developed: improvising pain assessment, which included how pain was documented, and administration hesitancy referring to nurse's concerns about PLWD's confusion. Nurses described the challenges of assessing pain in hospitalised PLWD particularly if they were non-verbal and/or demonstrating responsive behaviours. Nurse's years of experience, dementia stigma, and their unconscious biases affected nurses' pain management practices. CONCLUSIONS The study findings highlight the complex challenges of pain management in hospitalised PLWD that are exacerbated by nurses' knowledge deficits, negative stereotypical beliefs, dementia stigma and unconscious biases towards older people that contributes to undermanaged pain in hospitalised PLWD. IMPLICATIONS A comprehensive strategy using an implementation framework is needed to address nurse's knowledge gaps, unconscious bias, dementia stigma and techniques that enhance communication skills is suggested. Building a foundation in these areas would improve pain management in hospitalised PLWD. IMPACT Improving pain management in hospitalised PLWD would improve the quality of life, decrease hospital length of stay, prevent readmissions, and improve nurse satisfaction. REPORTING METHOD The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ). PATIENT CONTRIBUTIONS Improving pain management in hospitalised PLWD would prevent long term confusion, episodes of delirium and improve quality of life as they recover from their acute illness for which they required hospital care.
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Affiliation(s)
- Beverly Ingelson
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Sherry Dahlke
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Hannah O'Rourke
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Kathleen F Hunter
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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White N, Bazo-Alvarez JC, Koopmans M, West E, Sampson EL. Understanding the association between pain and delirium in older hospital inpatients: systematic review and meta-analysis. Age Ageing 2024; 53:afae073. [PMID: 38610062 PMCID: PMC11014791 DOI: 10.1093/ageing/afae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/01/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVE Delirium and pain are common in older adults admitted to hospital. The relationship between these is unclear, but clinically important. We aimed to systematically review the association between pain (at rest, movement, pain severity) and delirium in this population. METHODS PubMed, EMBASE, CINAHL, PsycINFO, Cochrane and Web of Science were searched (January 1982-November 2022) for Medical Subject Heading terms and synonyms ('Pain', 'Analgesic', 'Delirium'). Study eligibility: (1) validated pain measure as exposure, (2) validated delirium tool as an outcome; participant eligibility: (1) medical or surgical (planned/unplanned) inpatients, (2) admission length ≥ 48 h and (3) median cohort age over 65 years. Study quality was assessed with the Newcastle Ottawa Scale. We collected/calculated odds ratios (ORs) for categorical data and standard mean differences (SMDs) for continuous data and conducted multi-level random-intercepts meta-regression models. This review was prospectively registered with PROSPERO [18/5/2020] (CRD42020181346). RESULTS Thirty studies were selected: 14 reported categorical data; 16 reported continuous data. Delirium prevalence ranged from 2.2 to 55%. In the multi-level analysis, pain at rest (OR 2.14; 95% confidence interval [CI] 1.39-3.30), movement (OR 1.30; 95% CI 0.66-2.56), pain categorised as 'severe' (OR 3.42; 95% CI 2.09-5.59) and increased pain severity when measured continuously (SMD 0.33; 95% CI 0.08-0.59) were associated with an increased delirium risk. There was substantial heterogeneity in both categorical (I2 = 0%-77%) and continuous analyses (I2 = 85%). CONCLUSION An increase in pain was associated with a higher risk of developing delirium. Adequate pain management with appropriate analgesia may reduce incidence and severity of delirium.
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Affiliation(s)
- Nicola White
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Juan Carlos Bazo-Alvarez
- Research Department of Primary Care and Population Health, University College London, London, UK
- Escuela de Medicina, Universidad Cesar Vallejo, Trujillo, Peru
| | - Michel Koopmans
- Respiratory Medicine Department, Erasmus Medical Centre in Rotterdam, Rotterdam, The Netherlands
| | - Emily West
- e-Referrals Service, NHS England, Redditch, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
- Department of Psychological Medicine, Royal London hospital, East London Foundation Trust, London, UK
- Centre for Psychiatry and Mental Health, Queen Mary University London, London, UK
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Miller EL, Okour A. Pain Management Among the Cognitively Impaired. Pain Manag Nurs 2024; 25:101-103. [PMID: 38616057 DOI: 10.1016/j.pmn.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
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Chang A, Espinosa J, Lucerna A. Emergency Department Management of Common End-of-Life and Palliative Care Symptoms: Three Cases. Cureus 2024; 16:e53538. [PMID: 38445127 PMCID: PMC10912970 DOI: 10.7759/cureus.53538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 03/07/2024] Open
Abstract
The emergency department (ED) is at times the only place where patients can turn for symptom relief. Patients of all ages may turn to the ED for help with the management of end-of-life (EOL) and palliative care (PC) symptoms. Emergency medicine (EM) is a specialty that manages disease-directed treatment for a variety of acute conditions. In contrast, EOL and PC are focused on improving quality of life. Patients with serious illness, even hospice patients, present to the ED in increasing numbers for symptom management. It has become essential for emergency physicians to care for patients who are not seeking life-sustaining measures but instead need quality-of-life interventions. The development of a clear, concise review of the most common acute symptoms can provide a framework for EM physicians to adequately address the needs of patients at the EOL. Here, we discuss three cases that highlight the management of five of the most common EOL and PC presentations to the ED.
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Affiliation(s)
- Alice Chang
- Emergency Medicine, Jefferson Health New Jersey, Stratford, USA
| | - James Espinosa
- Emergency Medicine, Jefferson Health New Jersey, Stratford, USA
| | - Alan Lucerna
- Emergency Medicine, Jefferson Health New Jersey, Stratford, USA
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Fichtner A, Schrofner-Brunner B, Magath T, Mutze P, Koch T. Regional Anesthesia for Acute Pain Treatment in Pre-Hospital and In-Hospital Emergency Medicine. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:815-822. [PMID: 37850298 PMCID: PMC10853923 DOI: 10.3238/arztebl.m2023.0221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND More than half of all emergency department patients seek help for acute pain, which is usually of musculoskeletal origin. Acute pain is often inadequately treated even today, particularly in children and in older patients. In this study, we assess the potential role of regional anesthetic methods in improving the treatment of pain in the preclinical and clinical emergency setting. METHODS Pain-related reasons for admission were identified and quantified from emergency admission data. A structured literature search was carried out for clinical studies on the treatment of pain in the emergency setting, and a before-and-after comparison of the pain relief achieved with established vs. newer regional anesthetic methods was performed. RESULTS 43% of emergency patients presented with acute musculoskeletal pain. The literature search yielded 3732 hits for screening; data on entity-specific pain therapy spectra were extracted from 153 studies and presented for the main pain regions. The degree of pain relief obtained through regional anesthetic procedures, on a nominal rating scale from 0 to 10, was 4 to 7 points for acute back and chest wall pain, >6 for shoulder pain, 5 to 7 for hand and forearm injuries, and >4 for hip fractures. These results were as good as, or better than, those obtained by analgesia/sedation with strong opioids. CONCLUSION Modern regional anesthetic techniques can improve acute pain management in the emergency department and, to some extent, in the pre-hospital setting as well. Pain relief with these techniques is quantifiably better than with strong opioids in some clinical situations; moreover, there is evidence of further advantages including process optimization and fewer complications. Data for comparative study remain scarce because of a lack of standardization.
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Affiliation(s)
| | | | - Tina Magath
- Deparment of Orthopedics and Trauma Surgery, Kreiskrankenhaus Freiberg
| | - Peik Mutze
- Deparment of Orthopedics and Trauma Surgery, Kreiskrankenhaus Freiberg
| | - Thea Koch
- Department of Anesthesiology and Critical Care Medicine of the University Hospital Carl Gustav Carus, TU-Dresden
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Park DY, Jamil Y, Hu JR, Lowenstern A, Frampton J, Abdullah A, Damluji AA, Ahmad Y, Soufer R, Nanna MG. Delirium in older adults after percutaneous coronary intervention: Prevalence, risks, and clinical phenotypes. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 57:60-67. [PMID: 37414611 PMCID: PMC10730763 DOI: 10.1016/j.carrev.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/02/2023] [Accepted: 06/13/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION In-hospital delirium is more common among older adults and is associated with increased mortality and adverse health-related outcomes. We aim to establish the contemporary prevalence of delirium among older adults undergoing percutaneous coronary intervention (PCI) and the impact of delirium on in-hospital complications. METHODS We identified older adults aged ≥75 years in the National Inpatient Sample who underwent inpatient PCI for any reason from 2016 to 2020 and stratified them into those with and without delirium. The primary outcome was in-hospital mortality, and secondary outcomes encompassed post-procedural complications. RESULTS Delirium occurred in 14,130 (2.6 %) hospitalizations in which PCI was performed. Patients who developed delirium were older and had more comorbidities. Patients with in-hospital delirium had higher odds of in-hospital mortality (adjusted odds ratio [aOR] 1.27, p = 0.002) and non-home discharge (aOR 3.17, p < 0.001). Delirium was also associated with higher odds of intracranial hemorrhage (aOR 2.49, p < 0.001), gastrointestinal hemorrhage (aOR 1.25, p = 0.030), need for blood transfusion (aOR 1.52, p < 0.001), acute kidney injury (aOR 1.62, p < 0.001), and fall in hospital (aOR 1.97, p < 0.001). CONCLUSION Delirium among older adults undergoing PCI is relatively common and associated with higher odds of in-hospital mortality and adverse events. This highlights the importance of vigilant delirium prevention and early recognition in the peri-procedural setting, especially for older adults.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, IL, USA
| | - Yasser Jamil
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Angela Lowenstern
- Section of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer Frampton
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ahmed Abdullah
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Abdulla A Damluji
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Inova Center of Outcomes Research, Falls Church, VA, USA
| | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Robert Soufer
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA; Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA; Department of Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.
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Qian J, Shen X, Gao X, Sun Q. Grip Strength is a Predictor for Subsyndromal Delirium Among Older Adults Following Joint Replacement. Clin Interv Aging 2023; 18:1675-1685. [PMID: 37810954 PMCID: PMC10559797 DOI: 10.2147/cia.s423727] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/22/2023] [Indexed: 10/10/2023] Open
Abstract
Background Delirium is common in older patients during the postoperative period, increasing the number of adverse events, and grip strength is associated with delirium. Subsyndromal delirium (SSD) is a prostate of clinical delirium; nevertheless, the relationship between grip strength and SSD has not been elucidated. This study aimed to examine the association between grip strength and SSD in the elderly after arthroplasty. Methods A total of 181 patients were recruited from two Chinese hospitals. SSD and delirium were evaluated before the surgery and the first week after surgery using the confusion assessment method. The Mini-mental State Examination was used to assess patients' cognitive function, and their grip strength was evaluated with an electronic hand dynamometer before surgery. Logistic regression and ROC curve analysis were conducted to determine the odds ratio and predictive value of grip strength for SSD. Results The incidence of SSD and postoperative delirium (POD) was 41.44% and 14.36% for the elderly following arthroplasty respectively, and approximately 1/3 of SSD progressed into POD. Older age, declined cognitive function, fall history, and lower grip strength were risk factors for SSD (P<0.05). The area under the ROC curve of grip strength was 0.863 and 0.900 for males and females respectively, and the cut-off point of it was determined to be 22.050 kg for men and 18.050 kg for women. Conclusion SSD and POD are common among older people. Decreased grip strength, advanced age, lower cognitive function, and fall history were independent risk factors for SSD, and grip strength was a significant predictor for SSD in aged patients after the arthroplasty.
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Affiliation(s)
- Jiawei Qian
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- School of Nursing, Zhejiang Chinese Medical University, Hangzhou, People’s Republic of China
| | - Xiulan Shen
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Xin Gao
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Qiuhua Sun
- School of Nursing, Zhejiang Chinese Medical University, Hangzhou, People’s Republic of China
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Merrick M, Grange R, Rudd S, Shipway D. Evaluation and Treatment of Acute Trauma Pain in Older Adults. Drugs Aging 2023; 40:869-880. [PMID: 37563445 DOI: 10.1007/s40266-023-01052-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/12/2023]
Abstract
In the context of an ageing population, the demographic sands of trauma are shifting. Increasingly, trauma units are serving older adults who have sustained injuries in low-energy falls from a standing height. Older age is commonly associated with changes in physiology, as well as an increased prevalence of frailty and multimorbidity, including cardiac, renal and liver disease. These factors can complicate the safe and effective administration of analgesia in the older trauma patient. Trauma services therefore need to adapt to meet this demographic shift and ensure that trauma clinicians are sufficiently skilled in treating pain in complex older people. This article is dedicated to the management of acute trauma pain in older adults. It aims to highlight the notable clinical challenges of managing older trauma patients compared with their younger counterparts. It offers an overview of the evidence and practical opinion on the merits and drawbacks of commonly used analgesics, as well as more novel and emerging analgesic adjuncts. A search of Medline (Ovid, from inception to 7 November 2022) was conducted by a medical librarian to identify relevant articles using keyword and subject heading terms for trauma, pain, older adults and analgesics. Results were limited to articles published in the last 10 years and English language. Relevant articles' references were hand-screened to identify other relevant articles. There is paucity of dedicated high-quality evidence to guide management of trauma-related pain in older adults. Ageing-related changes in physiology, the accumulation of multimorbidity, frailty and the risk of inducing delirium secondary to analgesic medication present a suite of challenges in the older trauma patient. An important nuance of treating pain in older trauma patients is the challenge of balancing iatrogenic adverse effects of analgesia against the harms of undertreated pain, the complications and consequences of which include immobility, pneumonia, sarcopenia, pressure ulcers, long-term functional decline, increased long-term care needs and mortality. In this article, the role of non-opioid agents including short-course non-steroidal anti-inflammatory drugs (NSAIDs) is discussed. Opioid selection and dosing are reviewed for older adults suffering from acute trauma pain in the context of kidney and liver disease. The evidence base and limitations of other adjuncts such as topical and intravenous lidocaine, ketamine and regional anaesthesia in acute geriatric trauma are discussed.
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Affiliation(s)
- Minnie Merrick
- Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK
| | - Robert Grange
- Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK
| | - Sarah Rudd
- Library and Knowledge Service, North Bristol NHS Trust, Bristol, UK
| | - David Shipway
- Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK.
- University of Bristol, Bristol, UK.
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Jambulingam R, Campion A, Howard J, Tokala DP. Do Patients With Neck of Femur Fractures (NOFF) Experience Long Pre-Hospital Delays in the United Kingdom? Cureus 2023; 15:e45729. [PMID: 37868490 PMCID: PMC10590251 DOI: 10.7759/cureus.45729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
Background and objective It is well documented that prolonged preoperative delay is associated with increased morbidity and mortality among patients presenting with neck of femur fractures (NOFF). The target time from arrival to the emergency department (ED) to be transported to the theatre for these patients in England is 36 hours. However, the time before the patient arrives at the hospital is not often considered. In light of this, we aimed to assess the duration of the waiting period for NOFF patients before they are brought to the ED. Methods Data were collected retrospectively using IT and theatre systems at a single trust. A total of 223 consecutive NOFF patients undergoing operations in the six-month period between February and August 2020 were reviewed. Results The mean time for ambulance response was one hour and 50 minutes, whereas the time spent in the ambulance was one hour and 47 minutes and the total pre-hospital time was three hours and 37 minutes (range: 59 minutes to 14 hours and 41 minutes). The mean time from ED arrival to the theatre was 33 hours and one minute. The mean total preoperative time was 36 hours and 38 minutes. Conclusion The mean pre-hospital time of three hours and 37 minutes represents approximately 10% of the 36-hour national target. Pre-hospital time is often overlooked when considering the order of the list for the theatre. It may be possible to reduce morbidity and mortality by prioritising patients with a longer pre-hospital time, especially given our finding that some patients may wait up to 14 hours. We recommend that pre-hospital time be considered for all patients with NOFF.
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Affiliation(s)
| | - Alice Campion
- Trauma and Orthopaedics, Royal Gwent Hospital, Newport, GBR
| | - Joshua Howard
- Trauma and Orthopaedics, Royal Gwent Hospital, Newport, GBR
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Rommerskirch-Manietta M, Manietta C, Purwins D, Braunwarth JI, Quasdorf T, Roes M. Mapping implementation strategies of evidence-based interventions for three preselected phenomena in people with dementia-a scoping review. Implement Sci Commun 2023; 4:104. [PMID: 37641142 PMCID: PMC10463361 DOI: 10.1186/s43058-023-00486-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/09/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Caring for people with dementia is complex, and there are various evidence-based interventions. However, a gap exists between the available interventions and how to implement them. The objectives of our review are to identify implementation strategies, implementation outcomes, and influencing factors for the implementation of evidence-based interventions that focus on three preselected phenomena in people with dementia: (A) behavior that challenges supporting a person with dementia in long-term care, (B) delirium in acute care, and (C) postacute care needs. METHODS We conducted a scoping review according to the description of the Joanna Briggs Institute. We searched MEDLINE, CINAHL, and PsycINFO. For the data analysis, we conducted deductive content analysis. For this analysis, we used the Expert Recommendations for Implementation Change (ERIC), implementation outcomes according to Proctor and colleagues, and the Consolidated Framework for Implementation Research (CFIR). RESULTS We identified 362 (A), 544 (B), and 714 records (C) on the three phenomena and included 7 (A), 3 (B), and 3 (C) studies. Among the studies, nine reported on the implementation strategies they used. Clusters with the most reported strategies were adapt and tailor to context and train and educate stakeholders. We identified one study that tested the effectiveness of the applied implementation strategy, while ten studies reported implementation outcomes (mostly fidelity). Regarding factors that influence implementation, all identified studies reported between 1 and 19 factors. The most reported factors were available resources and the adaptability of the intervention. To address dementia-specific influencing factors, we enhanced the CFIR construct of patient needs and resources to include family needs and resources. CONCLUSIONS We found a high degree of homogeneity across the different dementia phenomena, the evidence-based interventions, and the care settings in terms of the implementation strategies used, implementation outcomes measured, and influencing factors identified. However, it remains unclear to what extent implementation strategies themselves are evidence-based and which intervention strategy can be used by practitioners when either the implementation outcomes are not adjusted to the implementation strategy and/or the effects of implementation strategies are mostly unknown. Future research needs to focus on investigating the effectiveness of implementation strategies for evidence-based interventions for dementia care. TRIAL REGISTRATION The review protocol was prospectively published (Manietta et al., BMJ Open 11:e051611, 2021).
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Affiliation(s)
- Mike Rommerskirch-Manietta
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Site Witten, Witten, Germany.
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany.
| | - Christina Manietta
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Site Witten, Witten, Germany
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Daniel Purwins
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Site Witten, Witten, Germany
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Jana Isabelle Braunwarth
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Site Witten, Witten, Germany
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Tina Quasdorf
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Site Witten, Witten, Germany
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
- School of Health Science, Institute of Nursing, ZHAW Zürich University of Applied Science, Winterthur, Switzerland
| | - Martina Roes
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Site Witten, Witten, Germany
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
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Tegenborg S, Fransson P, Martinsson L. The Abbey Pain Scale: not sufficiently valid or reliable for assessing pain in patients with advanced cancer. Acta Oncol 2023; 62:953-960. [PMID: 37382384 DOI: 10.1080/0284186x.2023.2228992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/19/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Patients with advanced cancer can be unable to verbalize their pain. The Abbey Pain Scale (APS), an observational tool, is used to assess pain in this setting, but has never been psychometrically tested for people with cancer. The aim of this study was to assess the validity, reliability, and the responsiveness of the APS to opioids for patients with advanced cancer in a palliative oncology care setting. MATERIAL AND METHODS Patients with advanced cancer and poor performance status, drowsiness, unconsciousness, or delirium, were assessed for pain using a Swedish translation of the APS (APS-SE) and, if possible, the Numeric Rating Scale (NRS). The assessments using APS were conducted simultaneously, but independently, by the same raters on two separate occasions, approximately one hour apart. Criterion validity was assessed by comparing the APS and NRS values using Cohen's kappa (κ). Inter-rater reliability was determined using the intraclass correlation coefficient (ICC), internal consistency using Cronbach's α, and responsiveness to opioids using the Wilcoxon signed-rank test. RESULTS Seventy-two patients were included, of whom n = 45 could rate their pain using the NRS. The APS did not detect any of the n = 22 cases of moderate or severe pain self-reported using the NRS. The APS at first assessment had a κ of 0.08 (CI: -0.06 to 0.22) for criterion validity, an ICC of 0.64 (CI: 0.43-0.78) for inter-rater reliability, and a Cronbach's α of 0.01 for internal consistency. The responsiveness to opioids was z = -2.53 (p = 0.01). CONCLUSION The APS was responsive to opioids but displayed insufficient validity and reliability and did not detect moderate or severe pain as indicated by the NRS. The study showed a very limited clinical use of the APS in patients with advanced cancer.
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Affiliation(s)
- Sussi Tegenborg
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Per Fransson
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Lisa Martinsson
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
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Resnick B, Boltz M, Galik E, Kuzmik A, Drazich BF, McPherson R, Wells CL, Renn C, Dorsey SG, Ellis J. Factors Associated With Function-Focused Care Among Hospitalized Older Adults Living With Dementia. Crit Care Nurs Q 2023; 46:299-309. [PMID: 37226921 PMCID: PMC10508903 DOI: 10.1097/cnq.0000000000000466] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
This article reports a study that was designed to describe the incidence of pain among older hospitalized patients with dementia and to evaluate the factors that influence pain among these individuals. It was hypothesized that function, behavioral and psychological symptoms of dementia, delirium, pain treatment, and patient exposure to care interventions would be associated with pain. Patients who performed more functional activities had less delirium. They also experienced higher quality-of-care interactions and were less likely to have pain. The findings from this study support the relationship between function, delirium, and quality-of-care interactions and pain. It suggests that it may be useful to encourage patients with dementia to engage in functional and physical activity to prevent or manage pain. This study serves as a reminder to avoid neutral or negative care interactions among patients with dementia as a strategy to mediate delirium and pain.
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Affiliation(s)
- Barbara Resnick
- School of Nursing (Drs Resnick, Galik, Drazich, Wells, Renn, and Dorsey, and Ms Ellis) and School of Medicine (Dr McPherson), University of Maryland, Baltimore; and Penn State University, University Park, Pennsylvania (Drs Boltz and Kuzmik)
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Resnick B, Boltz M, Galik E, Ellis J, Kuzmik A, Drazich B, McPherson R, Kim E. A Descriptive Study of Treatment of Pain in Acute Care for Patients Living With Dementia. Pain Manag Nurs 2023; 24:248-253. [PMID: 36737349 PMCID: PMC10213108 DOI: 10.1016/j.pmn.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 12/09/2022] [Accepted: 12/30/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND During the hospital stay pain is very common among patients living with dementia. METHODS Descriptive data was obtained from chart review and included age, gender, race, comorbidities and admitting diagnosis. AIMS The purpose of this study was to describe pain among patients living with dementia, the use of pharmacologic and nonpharmacologic treatment, and to compare treatments among those with and without pain. DESIGN This was a descriptive study using baseline data from the first 233 participants from the study "Testing the Implementation of Function Focused Care for Acute Care Using the Evidence Integration Triangle (FFC-AC-EIT)". PARTICIPANTS/SUBJECTS The mean age of participants was 83 (SD=5) and the majority was female (65%) and White (67%) with evidence of dementia (based on a mean Saint Louis University Mental Status Test = 7.23, SD=5.85). RESULTS Overall 98 (42%) participants had pain and 135 (58%) no pain. Only 14 (6%) participants received no nonpharmacologic or pharmacologic interventions for pain and five of these individuals had pain. The most frequently used pharmacologic intervention among all participants was acetaminophen (n = 121, 52%), then tramadol (n = 19, 8%). Comfort measures and general nonpharmacologic approaches were the most frequently used non-pharmacologic approaches, then physical activity and therapeutic communication. From admission to discharge, there was a trend towards a decrease in pain. There was more use of opioids, physical activity, and therapeutic communication in the no pain group versus the pain group. CONCLUSIONS The majority of hospitalized medical patients living with dementia were treated for pain, but an ongoing focus is needed to assure optimal pain management for all patients.
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Affiliation(s)
- Barbara Resnick
- University of Maryland School of Nursing, Baltimore, Maryland.
| | - Marie Boltz
- Penn State University, University Park, Pennsylvania
| | - Elizabeth Galik
- University of Maryland School of Nursing, Baltimore, Maryland
| | - Jeanette Ellis
- University of Maryland School of Nursing, Baltimore, Maryland
| | - Ashley Kuzmik
- Penn State University, University Park, Pennsylvania
| | | | | | - Emma Kim
- University of Maryland School of Nursing, Baltimore, Maryland
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Kovaleva MA, Kleinpell R, Dietrich MS, Jones AC, Boon JT, Duggan MC, Dennis BM, Lauderdale J, Maxwell CA. Caregivers’ experience with Tele-Savvy Caregiver Program post-hospitalization. Geriatr Nurs 2023; 51:156-166. [PMID: 36990041 DOI: 10.1016/j.gerinurse.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 03/30/2023]
Abstract
Despite the frequent hospitalizations and readmissions of persons living with dementia (PLWD), no telehealth transitional care interventions focus on PLWDs' unpaid caregivers. Tele-Savvy Caregiver Program is a 43-day evidence-based online psychoeducational intervention for PLWDs' caregivers. The aim of this formative evaluation was to explore caregivers' acceptability of and experience with their participation in Tele-Savvy after their PLWDs' hospital discharge. Additionally, we gathered caregivers' feedback on the recommended features of a transitional care intervention, suitable for caregivers' schedule and needs post-discharge. Fifteen caregivers completed the interviews. Data were analyzed via conventional content analysis. Four categories were identified: (1) Tele-Savvy improved participants' understanding of dementia and caregiving; (2) hospitalization started a "new level of normal"; (3) PLWDs' health concerns; and (4) transitional care intervention development. Participation in Tele-Savvy was acceptable for most caregivers. Participants' feedback provides content and structural guidance for the development of a new transitional care intervention for PLWDs' caregivers.
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Affiliation(s)
- Mariya A Kovaleva
- College of Nursing - Omaha Division, University of Nebraska Medical Center, 985330 Nebraska Medical Center, Omaha, NE 68198-5330, USA.
| | - Ruth Kleinpell
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA
| | - Mary S Dietrich
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA; Department of Biostatistics, Vanderbilt University School of Medicine, 1161 21st Ave S, #D3300, Nashville, TN 37232, USA
| | - Abigail C Jones
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA; Yale University School of Nursing, 400 West Campus Drive, Orange, CT 06477, USA
| | - Jeffrey T Boon
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA; Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Maria C Duggan
- Division of Geriatric Medicine, Vanderbilt University School of Medicine, 1161 21st Ave S, #D3300, Nashville, TN 37232, USA; Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Tennessee Valley Healthcare System, 1310 24th Ave South, Nashville, TN 37212-2637, USA
| | - Bradley M Dennis
- Division of Acute Care Surgery, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Jana Lauderdale
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA
| | - Cathy A Maxwell
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA
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Alhalaiqa F, Masa’Deh R, Al Omari O, Shawashreh A, Khalifeh AH, Gray R. The Impact of an Educational Programme on Jordanian Intensive Care Nurses' Knowledge, Attitudes, and Practice Regarding Delirium and their Levels of Self-Efficacy: A Quasi-Experimental Design. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2023; 28:312-319. [PMID: 37575493 PMCID: PMC10412801 DOI: 10.4103/ijnmr.ijnmr_437_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/06/2021] [Accepted: 09/21/2022] [Indexed: 08/15/2023]
Abstract
Background Delirium is a common problem among patients in Intensive Care Units (ICUs); however, it remains underdiagnosed. We aimed to determine the impact of a nursing education program on Jordanian nurses' knowledge, practice, attitudes, self-efficacy, and ability to detect delirium among ICU patients. Materials and Methods We conducted a nonequivalent, quasi-experimental design from January 2019 to January 2020. A total of 175 nurses who work in an ICU were included at the baseline and divided into two groups: (1) intervention (86 nurses), who received education for 6 hours each day across two different days and (2) a control group (89 nurses), who maintained their usual routine of care. Data were collected by means of a booklet of questionnaires about the nurses' knowledge and practice, attitudes, and self-efficacy. Results Data from 160 nurses were included in the analysis. The education program intervention (n = 81) significantly increased nurses' knowledge and practice, positive attitudes, and self-efficacy compared with the control group (n = 79, p < 0.001). In addition, nurses who received the educational intervention were able to detect more cases of delirium (28%, from a total of 51 patients) than the controls, who detected three (6.50%) out of a total of 31 patients (p = 0.003). Conclusions The ICU nurses who received the delirium-focused educational program increased their knowledge and practice, positive attitudes, and their self-efficacy; in addition, their ability to detect delirium was increased. The implementation of such a program is recommended for the health policymakers and stakeholders.
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Affiliation(s)
- Fadwa Alhalaiqa
- Professor Psychiatric Mental Health Nursing, Faculty of Nursing, Dean of Allied Medical Sciences, Oman
| | - Rami Masa’Deh
- School of Nursing, Applied Science Private University, Jordan, Philadelphia University, Jordan
| | - Omar Al Omari
- Professor, Fundamentals and Administration, Faculty of Nursing, Sultan Qaboos University, Oman
| | - Atef Shawashreh
- Training and Consultation Unit, Institute of Family Health, Noor Al-Hussein Foundation, Amman, Jordan
| | | | - Richard Gray
- Professor of Clinical Nursing Practice and Director, The La Trobe Alfred Clinical School, The Alfred Centre, 99 Commercial Rd, Melbourne VIC 3004, Australia
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Pu L, Chen H, Jones C, Moyle W. Family Involvement in Pain Management for People Living With Dementia: An Integrative Review. JOURNAL OF FAMILY NURSING 2023; 29:43-58. [PMID: 35898190 DOI: 10.1177/10748407221114502] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This review aimed to synthesize current evidence on family involvement in pain management for people living with dementia from the perceptions of family carers and health care professionals. An integrative review was conducted using CINAHL, Embase, PubMed, PsycINFO and Cochrane Library electronic databases. The Mixed Methods Appraisal Tool was used to appraise the articles, followed by thematic analysis. Twelve studies were included and four themes were identified: (1) The roles and responsibilities of family carers; (2) Enablers and barriers for pain identification; (3) Strategies and concerns for pain management; and (4) Lack of staff education and communication with health care providers. Family carers play an important role in pain assessment and management for people living with dementia, but they cannot be actively involved in this process due to a lack of communication with health care providers. An integrated approach that includes education and communication with family carers and health care providers is needed.
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Affiliation(s)
- Lihui Pu
- Griffith University, Nathan Queensland, Australia
| | | | - Cindy Jones
- Bond University, Robina Queensland, Australia
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Ormseth CH, LaHue SC, Oldham MA, Josephson SA, Whitaker E, Douglas VC. Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review. JAMA Netw Open 2023; 6:e2249950. [PMID: 36607634 PMCID: PMC9856673 DOI: 10.1001/jamanetworkopen.2022.49950] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups. OBJECTIVE To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting. EVIDENCE REVIEW A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium. FINDINGS A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity. CONCLUSIONS AND RELEVANCE In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.
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Affiliation(s)
- Cora H. Ormseth
- Department of Emergency Medicine, University of California, San Francisco
| | - Sara C. LaHue
- Department of Neurology, University of California, San Francisco
| | - Mark A. Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | | | - Evans Whitaker
- University of California, San Francisco, School of Medicine
| | - Vanja C. Douglas
- Department of Neurology, University of California, San Francisco
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Lenardt MH, Rodrigues JAM, Cechinel C, Kuznier TP, Kraus R, Guedez JBB. Fatores de risco associados ao delirium em idosos hospitalizados para tratamento clínico. REME: REVISTA MINEIRA DE ENFERMAGEM 2022. [DOI: 10.35699/2316-9389.2022.38832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Objetivo: identificar fatores de risco associados ao desenvolvimento de delirium em pessoas idosas hospitalizadas para tratamento clínico. Método: revisão integrativa da literatura. Busca realizada em fevereiro de 2022 através da aplicação de estratégia de busca em portais e bases de dados eletrônicas, como a Biblioteca Virtual em Saúde, o PubMed/MEDLINE e o Web of Science. Resultados: a busca resultou em 965 artigos. Após retirada de duplicatas, 583 tiveram títulos e resumos lidos. Respeitados critérios de elegibilidade, chegou-se a 127 estudos para leitura completa, dos quais 110 foram excluídos e 17 analisados, totalizando amostra de 6.170 pacientes. Foram incluídos estudos com pacientes ≥ 60 anos de idade, tratamento clínico, avaliação de fatores de risco para delirium; e excluídos estudos que utilizaram instrumentos não validados, relatos de casos, teses, monografias, artigos de revisão ou que não responderam à questão de pesquisa. Os fatores de risco mais encontrados foram a presença de déficit cognitivo e demência. Outros fatores também encontrados foram: idade avançada, presença de febre/infecção, desidratação, déficit funcional, uso de psicotrópicos antes do internamento, severidade das doenças de base, polifarmácia, déficit visual, dor ao repouso, presença de diabetes mellitus, fragilidade e tempo de internamento na emergência. Conclusões: os estudos apontam diversos fatores de risco associados ao delirium e destacam a relevância do reconhecimento do delirium pela equipe assistencial. Ação rápida e eficaz na prevenção do delirium em idosos depende da sua identificação. A equipe de saúde deve estar atenta durante o cuidado de populações vulneráveis para que o rastreio de sinais, muitas vezes flutuantes, seja facilitado.
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19
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Tsai YI, Browne G, Inder KJ. Nurses' perspectives of pain assessment and management in dementia care in hospital. Australas J Ageing 2022. [DOI: 10.1111/ajag.13146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 09/21/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Yvette I‐Pei Tsai
- School of Nursing and Midwifery, College of Health, Medicine and Wellbeing University of Newcastle Newcastle New South Wales Australia
| | - Graeme Browne
- School of Nursing and Midwifery, College of Health, Medicine and Wellbeing University of Newcastle Newcastle New South Wales Australia
| | - Kerry Jill Inder
- School of Nursing and Midwifery, College of Health, Medicine and Wellbeing University of Newcastle Newcastle New South Wales Australia
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20
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Harkin D, Coates V, Brown D. Exploring ways to enhance pain management for older people with dementia in acute care settings using a Participatory Action Research approach. Int J Older People Nurs 2022; 17:e12487. [PMID: 35761509 PMCID: PMC9787744 DOI: 10.1111/opn.12487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Dementia is a progressive condition that leads to reduced cognition, deteriorating communication and is a risk factor for other acute and chronic health problems. The rise in the prevalence of dementia means untreated pain is becoming increasingly common with healthcare staff being challenged to provide optimal pain management. This negatively impacts the person living with dementia and their carers. There is minimal evidence that explores the pain management experience of patients as they move through acute care settings. OBJECTIVE To understand the complexities of managing the pain of older people with dementia as they progress through acute care settings, with the view of assisting staff to improve practice. METHOD A Participatory Action Research approach, guided by the Promoting Action Research in Health Services framework, was used. Three Action Cycles were completed comprising of an exploratory audit and two case studies (Action Cycle One), three focus groups with a total of 14 participants (Action Cycle Two) and the development and implementation of immediate and long-term actions (Action Cycle Three). RESULTS Thematic analysis identified four themes that affected pain management practices. These were not knowing the patient; balancing competing priorities; knowledge and understanding of pain and dementia and not assimilating available information. CONCLUSION Pain management practices for patient living with dementia, across acute care settings, was influenced by shared ways of thinking and working. Not knowing the patient, fragmentation of information and having insufficient knowledge of the subtleties of dementia led participants to deliver task-focused, target and policy-driven care that was not person-centred in its approach. Facilitated reflection enabled acute care teams to actively participate in identifying problems and finding solutions to enhance practice.
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Affiliation(s)
| | - Vivien Coates
- Florence Nightingale Foundation Professor of Clinical Nursing Practice ResearchUlster University & Western Health & Social Care TrustLondonderryUK
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21
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Tegenborg S, Fransson P, Martinsson L. Translation, cultural adaptation and recommendations for clinical implementation of the Abbey Pain Scale to a Swedish dementia care context. Nurs Open 2022; 10:1367-1374. [PMID: 36217250 PMCID: PMC9912384 DOI: 10.1002/nop2.1386] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 09/03/2022] [Accepted: 09/14/2022] [Indexed: 02/11/2023] Open
Abstract
AIM To translate and culturally adapt the APS for people with end-stage dementia in various care settings in Sweden and to investigate factors important for clinical implementation. DESIGN Qualitative study design with interviews with care staff. METHODS After an initial discussion of concepts, the Abbey Pain Scale was translated into Swedish and back into English to check for accuracy. The resulting Swedish version was then revised and culturally adapted through a series of interviews with nursing assistants, nurses and physicians (n = 11) to develop the final Swedish version. RESULTS A Swedish version of the Abbey Pain Scale was developed. The instrument was considered straightforward and easy to use, but needed adjustments to make it more comprehensible to staff with less education in health care or with other first languages than Swedish. It was found important to carefully introduce new staff members to the instrument, to ensure they understand all the words and items.
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22
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Fu X, Wang L, Wang G, Liu X, Wang X, Ma S, Miao F. Delirium in elderly patients with COPD combined with respiratory failure undergoing mechanical ventilation: a prospective cohort study. BMC Pulm Med 2022; 22:266. [PMID: 35810306 PMCID: PMC9271245 DOI: 10.1186/s12890-022-02052-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 05/31/2022] [Indexed: 11/25/2022] Open
Abstract
Background COPD combined with respiratory failure is very common in intensive care unit (ICU). We aimed to evaluate the current status and influencing factors of delirium in elderly COPD patients with undergoing mechanical ventilation. Methods Patients with COPD combined with respiratory failure and mechanically ventilated who were admitted to the ICU of our hospital were selected. The characteristics of included patients were assessed. Pearson correlation analysis was performed to evaluate the characteristics of patients and delirium. Logistic regression analysis was conducted to identify the risk factors of delirium in elderly patients with COPD combined with respiratory failure undergoing mechanical ventilation. Results A total of 237 COPD combined with respiratory failure patients were included, the incidence of delirium was 21.94%. Pearson correlation analysis indicated that age (r = 0.784), BMI (r = 0.709), hypertension (r = 0.696), APACHE II score (r = 0.801), CPOT (r = 0.513), sedation(r = 0.626) and PaO2 (r = 0.611) were all correlated with the occurrence of delirium (all p < 0.05). Logistic regression analysis indicated that age ≥ 75y (OR 3.112, 95% CI 2.144–4.602), BMI ≤ 19 kg/m2 (OR 2.742, 95% CI 1.801–3.355), hypertension(OR 1.909, 95% CI 1.415–2.421), APACHE II score ≥ 15 (OR 2.087, 95% CI 1.724–2.615), CPOT ≥ 5 (OR 1.778, 95% CI 1.206–2.641), sedation(OR 3.147, 95% CI 2.714–3.758), PaO2 ≤ 75 mmHg(OR 2.196, 95%CI 1.875–3.088) were the risk factors of delirium in elderly patients with COPD combined with respiratory failure undergoing mechanical ventilation (all p < 0.05). Conclusions Delirium is common in patients with COPD and respiratory failure undergoing mechanical ventilation, and there are many related influencing factors. Medical staff should pay more attention to patients with risk factors and take intervention measures as soon as possible to reduce the incidence of delirium.
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Affiliation(s)
- Xuecai Fu
- Geriatrics Department, Aerospace Center Hospital, No 15 Yuquan Road, Haidian District, Beijing, China
| | - Lina Wang
- Geriatrics Department, Aerospace Center Hospital, No 15 Yuquan Road, Haidian District, Beijing, China
| | - Guihua Wang
- Geriatrics Department, Aerospace Center Hospital, No 15 Yuquan Road, Haidian District, Beijing, China
| | - Xuefang Liu
- Geriatrics Department, Aerospace Center Hospital, No 15 Yuquan Road, Haidian District, Beijing, China
| | - Xin Wang
- Geriatrics Department, Aerospace Center Hospital, No 15 Yuquan Road, Haidian District, Beijing, China
| | - Shuiting Ma
- Geriatrics Department, Aerospace Center Hospital, No 15 Yuquan Road, Haidian District, Beijing, China
| | - Fengru Miao
- Geriatrics Department, Aerospace Center Hospital, No 15 Yuquan Road, Haidian District, Beijing, China.
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23
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Shaw CA, Ward C, Gordon J, Williams KN, Herr K. Elderspeak communication and pain severity as modifiable factors to rejection of care in hospital dementia care. J Am Geriatr Soc 2022; 70:2258-2268. [PMID: 35642656 PMCID: PMC9378618 DOI: 10.1111/jgs.17910] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/10/2022] [Accepted: 03/25/2022] [Indexed: 11/28/2022]
Abstract
Background Rejection of care (RoC) occurs when persons living with dementia (PLWD) withstand or oppose the efforts of their caregiver. Improvements in hospital dementia care are needed, and one way to address this need is by identifying factors that lead to RoC, particularly those that are modifiable. Elderspeak communication is an established antecedent to RoC among PLWD in nursing homes. The purpose of this study was to extend these results to acute care settings by determining the impact of elderspeak communication by nursing staff on RoC by hospitalized PLWD. Methods Care encounters between nursing staff and PLWD were audio‐recorded, transcribed verbatim, and coded for semantic, pragmatic, and prosodic features of elderspeak. RoC behaviors was scored in real‐time using the Resistiveness to Care Scale. A Bayesian repeated‐measures hurdle model was used to evaluate the association between elderspeak and both the presence and severity of RoC. Results Eighty‐eight care encounters between 16 PLWD and 53 nursing staff were audio‐recorded for elderspeak and scored for RoC. Nearly all (96.6%) of the encounters included some form of elderspeak. Almost half of the care encounters (48.9%) included RoC behaviors. A 10% decrease in elderspeak was associated with a 77% decrease in odds of RoC (OR = 0.23, 95% CI = 0.03, 0.68) and a 16% decrease (eβ= 0.84, CI = 0.73, 0.96) in the severity of RoC. A one‐unit decrease in pain severity was associated with 73% reduced odds of RoC (OR = 0.27, CI = 0.12, 0.45) and a 28% decrease (eβ= 0.72, CI = 0.64, 0.80) in the severity of RoC. Conclusions Both elderspeak by nursing staff and RoC by PLWD are present and pervasive in acute care. Pain and elderspeak are two modifiable factors of RoC in hospitalized PLWD. Person‐centered interventions are needed that address communication practices and pain management for hospitalized PLWD.
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Affiliation(s)
- Clarissa A Shaw
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
| | - Caitlin Ward
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa, USA.,Department of Mathematics and Statistics, Faculty of Science, University of Calgary, Calgary, Alberta, Canada
| | - Jean Gordon
- Department of Communication Sciences and Disorders, University of Iowa, Iowa City, Iowa, USA
| | - Kristine N Williams
- School of Nursing, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Keela Herr
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
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Yoshimura M, Shiramoto H, Koga M, Yoshimatsu A, Morimoto Y. Comparing the effects of peripheral nerve block and general anesthesia with general anesthesia alone on postoperative delirium and complications in elderly patients: a retrospective cohort study using a nationwide database. Reg Anesth Pain Med 2022; 47:rapm-2022-103566. [PMID: 35636781 DOI: 10.1136/rapm-2022-103566] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/05/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The difference between the effects of peripheral nerve block (PNB) with general anesthesia (GA) and GA alone on the patients' postoperative clinical outcomes remains unknown. We assessed whether there is a difference in postoperative delirium and composite morbidity between patients receiving GA with PNB and GA alone using a national clinical database in Japan. METHODS We compared the outcomes of patients receiving GA with PNB and GA alone from April 2016 to October 2019. The primary outcome was postoperative delirium, defined as a status requiring newly prescribed antipsychotic drugs or that given the code of a reimbursable disease after the surgery date. The secondary outcome was morbidity incidence as the occurrence of at least one of any of the following life-threatening complications. We conducted propensity score-matched analyses using covariates for patients who underwent any surgical procedure. We used instrumental variables and restricted the definition of postoperative delirium and subgroup for sensitivity analyses. RESULTS Of 653,759 patients, 90,358 received GA-PNB and 563,401 received only GA. After 1:4 propensity score matching, 89,754 patients were included in the GA-PNB and 359,015 in the GA. The adjusted ORs for postoperative delirium and composite morbidity were 0.96 (95% CIs 0.94 to 0.99; p<0.01), 0.80 (95% CIs 0.76 to 0.83; p<0.001), respectively, for the GA-PNB concerning the GA. For sensitivity analyses, findings were also consistent with instrumental variables and subgroup analyses. DISCUSSION This retrospective, nationwide cohort study demonstrated that GA-PNB was associated with a small reduction in the likelihood of postoperative delirium and a moderate reduction in the likelihood of composite morbidity.
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Affiliation(s)
- Manabu Yoshimura
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Japan
| | - Hiroko Shiramoto
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Japan
| | - Mami Koga
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Japan
| | - Aya Yoshimatsu
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Japan
| | - Yasuhiro Morimoto
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Japan
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25
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Tsai YIP, Browne G, Inder KJ. Documented nursing practices of pain assessment and management when communicating about pain in dementia care. J Adv Nurs 2022; 78:3174-3186. [PMID: 35436007 PMCID: PMC9545301 DOI: 10.1111/jan.15251] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/16/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Abstract
AIM To evaluate nurses' documented practice when communicating about pain for people with dementia in hospital. DESIGN Retrospective medical record review. METHOD Medical records were retrieved from four inpatient units in a district and a tertiary teaching hospital of people aged 65 years and over with documented dementia. Data were extracted on nurses' documented pain assessment and management. Pain frequency and association between patient self-report, pain scores, cognition levels and analgesics used during hospitalization were analysed using descriptive and inferential statistics. Multivariate regression examined patient characteristics, pain characteristics and length of hospital stay. RESULTS One-hundred patient records met the inclusion criteria between 1 January and 31 August 2017. Sixty-six percent of patients with dementia had pain documented at least once during hospitalization with 58% reported as moderate to severe pain intensity. Patients' pain severity during admission was associated with their length of hospital stay. Ninety-three percent of nurses used a self-reporting pain tool and 7% used an observational pain tool. Pain scores were not associated with patients' cognition level, nurses' pain reports or analgesic management. CONCLUSION Pain frequently occurs in people with dementia during hospitalization. Fragmented pain reporting influences the translation of pain messages. Disproportionate pain tool application and non-association between pain scores and analgesic management suggest a potential knowledge gap among nurses about the practical use of pain tools and practice gap between pain assessment and management in dementia care. IMPACT Pain was regularly assessed by nurses and implemented as a fifth vital sign for people with dementia in hospitals. However, the high frequency of pain affects care outcomes. Areas for improvement include nursing practice of pain assessment and management in dementia care in hospitals. Further understanding of the usefulness of pain tools and the efficacy of pain scores when communicating about pain in dementia care in hospitals is required.
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Affiliation(s)
- Yvette I-Pei Tsai
- School of Nursing & Midwifery, University of Newcastle, Newcastle, Australia
| | - Graeme Browne
- School of Nursing & Midwifery, University of Newcastle, Newcastle, Australia
| | - Kerry Jill Inder
- School of Nursing & Midwifery, University of Newcastle, Newcastle, Australia
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Lee S, Okoro UE, Swanson MB, Mohr N, Faine B, Carnahan R. Opioid and benzodiazepine use in the emergency department and the recognition of delirium within the first 24 hours of hospitalization. J Psychosom Res 2022; 153:110704. [PMID: 34959040 PMCID: PMC9348903 DOI: 10.1016/j.jpsychores.2021.110704] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/12/2021] [Accepted: 12/12/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Delirium is a common and serious brain dysfunction. The objective of our study was to test the hypothesis that opioids and benzodiazepines exposure in the emergency department (ED) is associated with delirium. METHODS This was a retrospective cohort study, including patients aged 65 years and older who were hospitalized from ED at an academic medical center from 2014 to 2017. Medication administration records were used to identify opioids and benzodiazepines given during the ED stay. Nurses used the Delirium Observation Screening Scale (DOSS) twice daily to assess delirium during hospitalization. The outcome was a positive DOSS within 1 day of ED encounter. We used logistic regression to predict the outcome of positive delirium screening by opioids and benzodiazepines. RESULTS A total of 7927 ED encounters that resulted in hospitalization were included in the analysis. We identified 2008 visits (25.3%) with a positive delirium screen. A total of 3304 (41.7%) received opioids, and 1801 (22.7%) received benzodiazepines. In this cohort, opioids were not associated with an increased odds of delirium (OR 1.00, 95% CI 0.87-1.15). Benzodiazepines were associated with increased odds of delirium (OR 1.37, 95% CI 1.13-1.65), as were benzodiazepines combined with opioids (OR 1.61, 95% CI 1.33-1.97). CONCLUSION In this study, the use of benzodiazepines was associated with a risk of delirium. The use of opioids did not increase the risk of delirium. Our findings imply that judicious pain management with opioids in the ED might not increase the risk of delirium.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, USA.
| | - Uche Eseoghene Okoro
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, USA
| | - Morgan Bobb Swanson
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, USA
| | - Nicholas Mohr
- Department of Emergency Medicine, Anesthesia, and Epidemiology, The University of Iowa Carver College of Medicine, USA
| | - Brett Faine
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, USA
| | - Ryan Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, USA
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Liu YM, Huang H, Gao J, Zhou J, Chu HC. Hemoglobin Concentration and Post-Operative Delirium in Elderly Patients Undergoing Femoral Neck Fracture Surgery. Front Med (Lausanne) 2022; 8:780196. [PMID: 35071265 PMCID: PMC8766508 DOI: 10.3389/fmed.2021.780196] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/03/2021] [Indexed: 02/05/2023] Open
Abstract
This study aimed to determine the relationship between hemoglobin (Hb) concentration and post-operative delirium (POD) in elderly patients undergoing femoral neck fracture (FNF) surgery and to investigate whether the change in Hb concentration is associated with POD and the risk factors for POD. A total of 889 patients admitted with FNF between January 2016 and December 2020 were enrolled in this single-center, retrospective, case–control study. Hb concentrations were determined at admission and post-operative day 1 and the change in Hb concentration was defined as the absolute value of difference in pre-operative and post-operative Hb concentration. POD was assessed using the Confusion Assessment Method for the Intensive Care Unit (ICU) or the Confusion Assessment Method once a daily after surgery. The logistic regression analysis was performed for statistical analysis. In total, 172 (19.3%) patients developed POD and 151 (87.8%) patients developed POD within post-operative 3 days. Low pre-operative Hb concentration [p = 0.026, odds ratio (OR) = 0.978] and significant change in Hb concentration (p = 0.006, OR = 1.033) were significantly associated with POD. After excluding change in Hb concentration or pre-operative Hb concentration, neither of them was significantly associated with POD (p > 0.05). The interaction analysis of change in Hb concentration and pre-operative Hb concentration in the logistic regression model was negative. There was no significant relationship between post-operative Hb concentration and POD. Age (p < 0.001, OR = 1.072), stroke history (p = 0.003, OR = 2.489), post-operative ICU transfer (p = 0.007, OR = 1.981), and visual analog scale score within post-operative 2 days (p1 = 0.016 and p2 = 0.006) were independently associated with POD in the logistic regression analysis. Patients with low pre-operative Hb concentrations and high changes in Hb concentration seem to have an increased risk of POD and should receive more attention. Old age, stroke history, post-operative ICU transfer, and pain within post-operative 2 days were significantly associated with POD.
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Affiliation(s)
- Yu-Mei Liu
- School of Clinical Medicine, Qingdao University, Qingdao, China
| | - Hui Huang
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, School of Clinical Medicine, Qingdao University, Qingdao, China
| | - Jie Gao
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, School of Clinical Medicine, Qingdao University, Qingdao, China
| | - Jian Zhou
- West China School of Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Hai-Chen Chu
- School of Clinical Medicine, Qingdao University, Qingdao, China
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Poggiali E, De Iaco F. The pain in the Emergency Department: Choosing and treating wisely before and during the COVID-19 era. EMERGENCY CARE JOURNAL 2021. [DOI: 10.4081/ecj.2021.9903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pain is a frequent reason for referral to the Emergency Department (ED). Adequate management of pain is a moral and ethical imperative. If not correctly treated, acute pain can cause physical and psychological complications, and become chronic with severe consequences such as anxiety, depression, and social isolation. As consequence, emergency clinicians should treat pain as soon as possible, avoiding delays even in case of acute abdominal pain. Pain management is particularly complex in the elderly and emergency clinicians should always consider AGS Beers criteria ® to avoid inappropriate medications, severe side-effects, and drug-drug interactions. Pain is also a common cause of delirium in older patients. The SARS CoV-2 infection not only can cause acute pain, but also exacerbate chronic pain, particularly in the elderly, who are at high risk to be infected. Looking at all this evidence, emergency clinicians should treat pain with different strategies according to their experience and cultural background, making the right choice for each patient. This work is a critical review of the pain management in the ED, with a particular attention on the effects of COVID-19 in the EDs. We conducted a systematic search of the following databases: PubMed, Google Scholar, Science Direct, Medline from 2000 to 2020, using the keywords of “pain”, “emergency”, “COVID19”, “elderly”, “palliative care”, “ketamine”, “dexmedetomidine”, and “post-traumatic stress disorder”. The aim of this review is to help emergency clinicians to correctly manage pain in the ED with a new point of view regarding the pain management in COVID-19 patients.
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DeMaagd GA, DeMaagd DR, Philip A. Delirium and Its Pharmacological Causes in Older People, Part Three. Sr Care Pharm 2021; 36:619-631. [PMID: 34861903 DOI: 10.4140/tcp.n.2021.619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. Part one of this three part series reviewed the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people. Parts two and three continued to review the pharmacological classes of medications that cause or contribute to delirium in older people.
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Affiliation(s)
| | | | - Ashok Philip
- Union University College of Pharmacy, Jackson, Tennessee
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The role of experiential knowledge in hospital nurses’ management of pain-related agitation in people with dementia: an expert performance simulation study. Int J Nurs Stud 2021; 127:104160. [DOI: 10.1016/j.ijnurstu.2021.104160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 12/08/2021] [Accepted: 12/10/2021] [Indexed: 11/19/2022]
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Han QYC, Rodrigues NG, Klainin-Yobas P, Haugan G, Wu X. Prevalence, Risk Factors, and Impact of Delirium on Hospitalized Older Adults With Dementia: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc 2021; 23:23-32.e27. [PMID: 34648761 DOI: 10.1016/j.jamda.2021.09.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/03/2021] [Accepted: 09/04/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES High prevalence of delirium superimposed on dementia (DSD) was previously reported, with associated negative impact on hospitalized older adults. However, data were conflicting, and no meta-analysis has been conducted. Although dementia is the leading risk factor for delirium, risk factors for DSD have not been adequately studied. This systematic review and meta-analysis aims to elucidate the prevalence, risk factors, and impact of DSD in hospitalized older adults. Comparisons were made between older adults with DSD and persons with dementia alone (PWDs). DESIGN Systematic review and meta-analysis. SETTING AND PARTICIPANTS Observational studies reporting prevalence, risk factors, or impact of DSD in hospitalized older adults. METHODS Database search was conducted till December 2020 in PubMed, Embase, CENTRAL, PsycINFO, CINAHL, Scopus, Web of Science, ProQuest, and OpenGrey for relevant primary and secondary studies. A piloted data collection form was used for data extraction, and methodological quality was assessed using Joanna Briggs Institute critical appraisal checklists. Meta-analyses, with risk ratio and mean differences as effect measures, were performed using random effects model with Review Manager software. Cochran's Q and I2 statistics were used to assess heterogeneity, which was investigated using subgroup analyses. RESULTS A total of 81 studies were eligible. The pooled prevalence of DSD was 48.9%, with the highest prevalence found in the Americas and orthopedic wards. Risk factors, including nonmodifiable hospital-, illness-, and medication-related factors, were found to precipitate DSD. Patients with DSD had longer length of hospitalization, disclosed worse cognitive and functional outcomes, and a higher risk of institutionalization and mortality than patients with dementia. CONCLUSIONS AND IMPLICATIONS These findings suggested high prevalence and detrimental impact of DSD in hospitalized older adults, highlighting a need for early identification, prevention, and treatments. Further research on risk factors of DSD should be conducted as data were sparse and conflicting. Future high-quality studies regarding DSD are warranted to improve knowledge of this common but under-recognized phenomenon.
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Affiliation(s)
- Qin Yun Claudia Han
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Natalie Grace Rodrigues
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Piyanee Klainin-Yobas
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gørill Haugan
- Department of Public Health and Nursing, Centre for Health Promoting Research, Norwegian University of Science and Technology, Trondheim, Trøndelag, Norway
| | - XiVivien Wu
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Peisah C, Sampson EL, Rabheru K, Wand A, Lapid M. The Human Rights of Older People With Mental Health Conditions and Psychosocial Disability to a Good Death and Dying Well. Am J Geriatr Psychiatry 2021; 29:1041-1046. [PMID: 34175232 DOI: 10.1016/j.jagp.2021.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 12/17/2022]
Abstract
The human right to a good death and dying well is as important as the right to life. At stake at the end of life are human rights to dignity, autonomy, self-determination and respect for will and preferences, equitable access to quality health care that is needs-based, and respect for family and relationships. Older people with dementia, those with serious mental illness, and those with intellectual disability are vulnerable to "bad deaths" due to violations of these rights. In this paper we explore why this is so and examine existing and potential solutions. A human rights-approach to end-of-life care and policy for older persons with mental health conditions and psychosocial disability is one that is needs-based, encompassing physical and mental health, palliative care, social, and spiritual support services provided in the context of inclusive living. Most importantly, end of life care must be self-determined, and not "one size fits all." An important remedy to existing violations is to strengthen human rights frameworks to cater specifically to older persons' needs with a UN convention on the rights of older persons. Finally, as health professionals we have important contributions to make at the coalface by accepting our responsibilities in the area of death and dying. With the concept of the palliative psychiatrist gaining traction and recognition that death is our business, we add that human rights is also our business.
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Affiliation(s)
- Carmelle Peisah
- School of Psychiatry, Faculty Medicine & Ageing Futures Institute, University of New South Wales, Capacity Australia (CP), Sydney, Australia.
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London (ELS), London, United Kingdom
| | | | - Anne Wand
- Specialty of Psychiatry, Faculty Medicine and Health, University of Sydney (AW), Sydney, Australia; Discipline of Psychiatry, Faculty of Medicine, University of New South Wales (AW), New South Wales, Australia
| | - Maria Lapid
- Department of Psychiatry and Psychology, Mayo Clinic (ML), Rochester, MN
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Postoperative Delirium. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00445-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Jiao B, Liu J, Chen C. Comment on: The association of bispectral index values and metrics of cerebral perfusion during cardiopulmonary bypass. J Clin Anesth 2021; 75:110441. [PMID: 34314908 DOI: 10.1016/j.jclinane.2021.110441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/26/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Bo Jiao
- Department of Anesthesiology, West China Hospital, Sichuan University, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, China
| | - Chan Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, China.
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Johansson YA, Gillsjö C, Kenne Sarenmalm E. Symptoms and Well-Being in Older Hospitalized Patients with Cognitive Impairment, As Self-Reported and Reported in Patient Records: A Quantitative Exploratory Subgroup Analysis. Dement Geriatr Cogn Dis Extra 2021; 11:71-77. [PMID: 34178010 PMCID: PMC8215956 DOI: 10.1159/000515822] [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: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Given the aging population and the high prevalence of cognitive impairment in older hospitalized patients, it is essential to provide good fundamental care to these vulnerable patients, who easily might be affected by poor outcomes as delirium. Risk factors for delirium are, for example, cognitive impairment, old age, pain, and sleep deprivation. Different symptoms are often unidentified in hospitals, and associated with poor well-being, but this is rarely studied in older patients with cognitive impairment. The study aim was to examine symptoms and sense of well-being in older hospitalized patients with cognitive impairment, as self-reported and reported in patient records. Methods Exploratory quantitative subgroup (n = 25) analysis of a point-prevalence study (n = 210). Inclusion criteria were age ≥65, and cognitive impairment. Data were collected through structured interviews, validated instruments, and patient records. Associations between well-being and symptoms, and concordance between the occurrence of self-reported symptoms and symptoms reported in patient records were analyzed. Results The patients reported severe and distressing symptoms that were sparsely reported (14%) in their records. As well were cognitive impairment, and the patients' own descriptions of their well-being. Some symptoms and the total symptom burden were associated with poor well-being. Discussion/Conclusion To our knowledge, this hypothesis-generating study is one of few studies that describe both symptoms and well-being as self-reported and reported in patient records, in vulnerable patients due to old age, cognitive impairment, and hospitalization. Despite the limited sample size, the results indicate that symptoms were more insufficient alleviated in these patients compared to patients with normal cognitive function in other studies. To our knowledge, this has not been shown previously. Additionally, patients' own experiences were sparsely reported in their records. A larger sample size and longitudinal design has the potential to determine if symptom alleviation differs between patients with and without cognitive impairment, and if a total symptom burden increases the risk of poor outcomes as delirium in vulnerable patients.
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Affiliation(s)
- Yvonne A Johansson
- Skaraborg Hospital, Skövde, Sweden.,Jönköping University, The Research School of Health and Welfare, Aging Research Network-Jönköping (ARN-J), Jönköping, Sweden
| | - Catharina Gillsjö
- University of Skövde, Skövde, Sweden.,College of Nursing, University of Rhode Island, Kingston, Rhode Island, USA
| | - Elisabeth Kenne Sarenmalm
- Skaraborg Hospital, Skövde, Sweden.,University of Skövde, Skövde, Sweden.,Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Boltz M, Resnick B, Kuzmik A, Mogle J, Jones JR, Arendacs R, BeLue R, Cacchione P, Galvin JE. Pain Incidence, Treatment, and Associated Symptoms in Hospitalized Persons with Dementia. Pain Manag Nurs 2021; 22:158-163. [PMID: 32921569 PMCID: PMC7943650 DOI: 10.1016/j.pmn.2020.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 08/08/2020] [Accepted: 08/11/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Moderate to severe pain has been frequently reported in hospitalized older adults. Pain in hospitalized persons with dementia within the context of other common symptoms, functional decline, delirium, and behavioral and psychological symptoms of dementia (BPSD), has received little attention. AIMS Describe the incidence of pain, the pharmacologic management of pain, and the association of pain with physical function, delirium, and BPSD in hospitalized persons with dementia. DESIGN Descriptive, cross-sectional study. SETTING Six medical units in three hospitals. PARTICIPANTS Baseline data from 299 hospitalized persons with dementia enrolled in the Family-centered Function-focused Care (Fam-FFC) cluster randomized trial. METHODS Descriptive analyses of pain used the Pain Assessment in Advanced Dementia (PAINAD) scale and the use of medication for pain management. Linear regression analyses tested relationships between pain and:1) physical function (Barthel Index), 2) delirium severity (Confusion Assessment Method Severity Short Form) and 3) BPSD severity (Neuropsychiatric Inventory- Questionnaire). RESULTS The majority of the sample was female (61.9%), non-Hispanic (98%), and Black (53.2%), with a mean age of 81.58 (SD=8.54).Of the 299 patients, 166 (56%) received pain medication. Of the 108 individuals who demonstrated pain, 40% (n=43) did not receive pain medication. When controlling for age, gender, cognition, and comorbidities, pain was significantly associated with function, delirium severity, and BPSD severity. CONCLUSIONS Results suggest that pain may be undertreated in hospitalized persons with dementia, and should be considered upon admission to optimize function, decrease delirium, and prevent or decrease BPSD.
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Affiliation(s)
- Marie Boltz
- College of Nursing, Pennsylvania State University, University Park, PA.
| | | | - Ashley Kuzmik
- College of Nursing, Pennsylvania State University, University Park, PA
| | | | | | - Rachel Arendacs
- College of Nursing, Pennsylvania State University, University Park, PA
| | | | - Pamela Cacchione
- College of Nursing, Pennsylvania State University, University Park, PA
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Lee S, Angel C, Han JH. Succinct Approach to Delirium in the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2021; 9:11-18. [PMID: 33758677 PMCID: PMC7971395 DOI: 10.1007/s40138-021-00226-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 11/25/2022]
Abstract
Purpose of Review This study aims to provide a concise delirium review for practicing emergency medicine providers using the Assess, Diagnose, Evaluate, Prevent, and Treat (ADEPT) framework. Recent Findings Delirium is a form of acute brain dysfunction that results in significant mortality and morbidity for older emergency department (ED) patients. Delirium is frequently missed by healthcare providers, but monitoring for this syndrome using brief delirium assessments may improve recognition. Once delirium is diagnosed, emergency medicine providers' primary goal is to perform a comprehensive history and physical examination to uncover the underlying etiology for delirium. This includes obtaining history from a collateral historian and obtaining an accurate medication history. If posssible, emergency physicians (EPs) should treat the medical etiology that precipitated the delirium. If agitated, non-pharmacologic interventions such that minimize the use of tethers are preferred. Pharmacologic agents such as antipsychotic medications should be used as a last resort. Summary Delirium is a common geriatric emergency and requires the EP to assess, diagnose, evaluate, prevent, and treat. Delirium is a key geriatric syndrome that geriatric ED providers should routinely screen for. A strong emphasis is on the widespread use of delirium screening, followed by prevention and treatment efforts.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA USA
| | - Clay Angel
- Department of Hospital Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA USA
| | - Jin H. Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN USA
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN USA
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Eagles D, Khoujah D. Rapid Fire: Acute Brain Failure in Older Emergency Department Patients. Emerg Med Clin North Am 2021; 39:287-305. [PMID: 33863460 DOI: 10.1016/j.emc.2020.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Delirium is common in older emergency department (ED) patients. Although associated with significant morbidity and mortality, it often goes unrecognized. A consistent approach to evaluation of mental status, including use of validated tools, is key to diagnosing delirium. Identification of the precipitating event requires thorough evaluation, including detailed history, medication reconciliation, physical examination, and medical work-up, for causes of delirium. Management is aimed at identifying and treating the underlying cause. Meaningful improvements in delirium care can be achieved when prevention, identification, and management of older delirious ED patients is integrated by physicians and corresponding frameworks implemented at the health system level.
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Affiliation(s)
- Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Danya Khoujah
- Emergency Medicine, MedStar Franklin Square Medical Center, 9000 Franklin Square Dr, Baltimore, MD 21237, USA; Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA. https://twitter.com/DanyaKhoujah
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Liang S, Chau JPC, Lo SHS, Li S, Gao M. Implementation of ABCDEF care bundle in intensive care units: A cross-sectional survey. Nurs Crit Care 2021; 26:386-396. [PMID: 33522036 DOI: 10.1111/nicc.12597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Delirium affects up to 80% of patients in intensive care units (ICUs) and is associated with higher mortality, physical dependence, and health care costs. The 2018 pain, agitation, delirium, immobility, and sleep guideline recommended ABCDEF care bundle for delirium prevention and management. However, limited information is available regarding the adoption of the care bundle in ICUs in Mainland China. AIMS AND OBJECTIVES To assess the current implementation of the ABCDEF care bundle for delirium prevention as reported by ICU nurses in Mainland China. DESIGN A cross-sectional study was conducted. METHODS A cross-sectional online survey using a validated questionnaire about the practices of the ABCDEF care bundle was conducted among 334 registered nurses in 167 ICUs of 65 cities in Mainland China. RESULTS Almost 50% of the sampled ICU nurses were unaware of the ABCDEF care bundle, though 86.83% of the surveyed ICUs implemented pain assessments and 95.51% implemented sedation assessments. Nearly half (46.41%) of the surveyed ICUs performed routine spontaneous awaking trials, with 21.26% performing them daily. Spontaneous breathing trials were performed in 38.32% of the surveyed ICUs. Only 47% of the surveyed ICUs routinely monitored patients for delirium. About one-third (38.35%) of the surveyed ICUs were supported by specialist teams that implemented the mobilization programmes. Most ICUs restricted the duration of family visits per day (<0.5 hour: 61.67%; 0.5-2 hours: 23.65%; >2 hours: 3.29%) and only 28.14% of the surveyed ICUs employed dedicated staff to support the families. CONCLUSIONS Although most of the surveyed ICUs implemented pain and sedation assessments, many of them did not implement structured delirium assessments. Early mobilization programmes and family participation should be encouraged. RELEVANCE TO CLINICAL PRACTICE Promoting the uses of a reliable delirium assessment tool such as Confusion Assessment Method for Intensive Care Unit patients, building an early mobilization team, and engaging family caregivers in the care plan may contribute to improved patients' clinical outcomes.
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Affiliation(s)
- Surui Liang
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Janita Pak Chun Chau
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Suzanne Hoi Shan Lo
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Shunling Li
- The Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Mingrong Gao
- The Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Sharp B, Henderson J, Brown M, Jack-Waugh A, Macrae R. Palliative and end of life care for people with advanced dementia. Nurs Older People 2020; 33:e1191. [PMID: 33295157 DOI: 10.7748/nop.2020.e1191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2019] [Indexed: 11/09/2022]
Abstract
Despite growing understanding in recent years of the biological, psychological, social, environmental and spiritual aspects of dementia, people with advanced dementia continue to experience inequalities in accessing healthcare capable of improving their lives. The complexities of advanced dementia challenge professional competence and demand the highest level of skilled, compassionate care. This article, the last in a series on living with advanced dementia, considers the status and direction of palliative care as it applies to people with dementia and explores contemporary issues regarding advanced dementia and end of life, with a focus on guidance for practitioners and support for best practice. It identifies that open communication, clear information and a person-centred approach adopted as early as possible in the syndrome can make this period less distressing. Crucially, people at the end of life should be offered care in line with best practice in palliative and end of life approaches.
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Affiliation(s)
| | | | - Margaret Brown
- Alzheimer Scotland Centre for Policy and Practice, University of the West of Scotland, Hamilton, Scotland
| | | | - Rhoda Macrae
- University of the West of Scotland, Hamilton, Scotland
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Tsai YIP, Browne G, Inder KJ. The effectiveness of interventions to improve pain assessment and management in people living with dementia: A systematic review and meta-analyses. J Adv Nurs 2020; 77:1127-1140. [PMID: 33222273 DOI: 10.1111/jan.14660] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/14/2020] [Accepted: 11/03/2020] [Indexed: 12/24/2022]
Abstract
AIMS To synthesize and evaluate the effectiveness of interventions for nurses to improve the assessment and management of pain in people living with dementia. DESIGN Systematic review and meta-analyses of randomized controlled trials. DATA SOURCES CINAHL, Joanna Briggs Institute (JBI) EBP, Cochrane Library, PubMed, and Scopus databases were searched for all journal articles published between 2009 -2019. REVIEW METHODS Papers were included under population intervention comparator outcome (PICO) framework for: (a) people living with dementia aged 65 years and over; (b) interventions developed for nurses or other health professionals; (c) comparison group of standard care or control; and (d) outcome that measures the intervention effects on nurses and people living with dementia. Independent reviewers undertook critical appraisal, data abstraction, and synthesis. Meta-analyses were performed to determine the effectiveness of interventions. RESULTS Of 2099 titles and abstracts screened, six interventions with low-to-moderate risk of bias met inclusion criteria. Studies that implemented a routine pain assessment tool showed no effect on nurses' analgesic management. Studies that developed a comprehensive pain model involving multidisciplinary health professionals showed overall effects on pain assessment and management in dementia care. Physician involvement had an impact on analgesic management. CONCLUSION Comprehensive pain models improve nurses' pain assessment and management. A lack of balance between analgesia use and non-pharmacological pain management in dementia care is evident. Multidisciplinary health professionals' involvement is essential for effective intervention design for pain management in dementia. IMPACT Various pain assessment tools have been considered to assist identification and management of pain in people living with dementia. Nevertheless, challenges exist when caring for people living with dementia in pain. These findings support the development of a comprehensive pain model, which may be a more effective strategy than routine use of a pain tool alone for nurses to improve pain management in dementia care.
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Affiliation(s)
- Yvette I-Pei Tsai
- School of Nursing & Midwifery, University of Newcastle, Callaghan, NSW, Australia
| | - Graeme Browne
- School of Nursing & Midwifery, University of Newcastle, Callaghan, NSW, Australia
| | - Kerry Jill Inder
- School of Nursing & Midwifery, University of Newcastle, Callaghan, NSW, Australia
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42
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Efraim NT, Zikrin E, Shacham D, Katz D, Makulin E, Barski L, Zeller L, Bartal C, Freud T, Lebedinski S, Press Y. Delirium in Internal Medicine Departments in a Tertiary Hospital in Israel: Occurrence, Detection Rates, Risk Factors, and Outcomes. Front Med (Lausanne) 2020; 7:581069. [PMID: 33195329 PMCID: PMC7604336 DOI: 10.3389/fmed.2020.581069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/16/2020] [Indexed: 12/19/2022] Open
Abstract
Background: The aim of the study was to assess the occurrence rate of delirium among elderly hospitalized patients in the medicine wards of a large tertiary hospital, to identify risk factors, and to evaluate the diagnostic rate for delirium among the medical teams. Methods: A 3-month prospective study of patients 65 years of age and above in three medicine wards: in two wards patients were examined by trained study team members using the Confusion Assessment Method (CAM), while the third was a control ward where CAM was not administered. The third ward served to control for the effect of the presence of investigators in the other wards as a potential confounding factor. Based on the results of this assessment patients were defined as suffering from subsyndromal delirium, full delirium (these two groups were later combined into an “any symptoms of delirium” group), and no delirium. The rate of diagnosis by the medical team was obtained from the electronic medical records. Results: The full delirium rate was 5.1%, the rate of subsyndromal delirium was 14.6%, and the rate of any symptoms of delirium was 19.6%. Absence of a partner, pain, anemia, hyponatremia, hypocalcemia, and the use of drugs with an anticholinergic burden were factors for any symptoms of delirium as well as for subsyndromal delirium. Subsyndromal delirium and any symptoms of delirium were associated with a reduced chance of being discharged to home and a higher 3-month mortality rate. A diagnosis of delirium was found in only 19.4% of the patients with any symptoms of delirium in the medical records. Conclusions: Delirium is a common problem among elderly hospitalized patients, but it is diagnosed sub-optimally by the medical team. There is a need for further training of the medical teams and implementation of delirium assessment as part of the ward's routine.
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Affiliation(s)
- Nirit Tzur Efraim
- Department of Psychiatry, Soroka Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Evgeniya Zikrin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - David Shacham
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Dori Katz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Evgeni Makulin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Leonid Barski
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Internal Medicine F, Soroka Medical Center, Beer-Sheva, Israel
| | - Lior Zeller
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Internal Medicine C, Soroka Medical Center, Beer-Sheva, Israel
| | - Carmi Bartal
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Internal Medicine E, Soroka Medical Center, Beer-Sheva, Israel
| | - Tamar Freud
- Faculty of Health Sciences, Siaal Research Center for Family Medicine and Primary Care, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Svetlana Lebedinski
- Clinical Pharmacy Services, Pharmacy Department, Clalit Health Services, Beer-Sheva, Israel
| | - Yan Press
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Siaal Research Center for Family Medicine and Primary Care, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Unit for Community Geriatrics, Division of Health in the Community, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Center for Multidisciplinary Research in Aging, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Tyler KR, Hullick C, Newton BA, Adams CB, Arendts G. Emergency department pain management in older patients. Emerg Med Australas 2020; 32:840-846. [PMID: 32594659 DOI: 10.1111/1742-6723.13562] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Katren R Tyler
- Department of Emergency Medicine, University of California, Davis, Davis, California, USA
| | - Carolyn Hullick
- Emergency Department, Hunter New England Health, Newcastle, New South Wales, Australia
| | - Brittany A Newton
- Department of Pharmacy Services, UC Davis Health System, University of California, Davis, Davis, California, USA
| | - Christopher B Adams
- Department of Pharmacy Services, UC Davis Health System, University of California, Davis, Davis, California, USA
| | - Glenn Arendts
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Walsh B, Dahlke S, O'Rourke H, Hunter KF. Exploring acute care nurses' decision-making in psychotropic PRN use in hospitalised people with dementia. J Clin Nurs 2020; 31:2024-2035. [PMID: 32860272 DOI: 10.1111/jocn.15477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/30/2020] [Accepted: 08/19/2020] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To understand how acute care nurses make decisions about administering "as-needed" (PRN) psychotropic medications to hospitalised people with dementia (PWD). BACKGROUND Behavioural and psychological symptoms of dementia occur in approximately 75% of PWD admitted to acute care. Despite this, few studies provide insight into the use and prevalence of psychotropic use in acute care. DESIGN A qualitative descriptive design was used to explore acute care nurses' decision-making about PRN psychotropic medication administration to PWD. METHODS Semi-structured interviews were conducted with eight nurses from three acute care medical units in a large tertiary hospital in Western Canada. Conventional content analysis was used to develop three themes that reflect nurses' decision-making related to administering PRNs to hospitalised PWD. COREQ guidelines were followed. RESULTS Three themes of legitimising control, making the patient fit and future telling were developed. Legitimising control involved medicating undesirable behaviours to promote the nurses' perceptions of safety. Making the patient fit involved maintaining routine and order. Future telling involved pre-emptively medicating to prevent undesirable behaviours from escalating. Nurses provided little to no mention of assessing for physical causes contributing to behaviours. PRNs were seen as a reasonable alternative to physical restraints and were frequently used. Additionally, organisational and unit routines greatly influenced nurses' decision-making. CONCLUSIONS These findings provide an initial understanding of how nurses make decisions to administer PRN medications to hospitalised older people and may inform prescribing practices. There were novel findings about the lack of assessment prior to PRN administration, and the nurses' collective response in decision-making. More research is needed to better understand the complexities of nurses' decision-making, to assist in the development of interventions for nursing practice.
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Affiliation(s)
- Brittany Walsh
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Sherry Dahlke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Hannah O'Rourke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
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45
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Daoust R, Paquet J, Boucher V, Pelletier M, Gouin É, Émond M. Relationship Between Pain, Opioid Treatment, and Delirium in Older Emergency Department Patients. Acad Emerg Med 2020; 27:708-716. [PMID: 32441414 DOI: 10.1111/acem.14033] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/12/2020] [Accepted: 05/18/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Emergency department (ED) stay and its associated conditions (immobility, inadequate hydration and nutrition, lack of stimulation) increase the risk of delirium in older patients. Poorly controlled pain and paradoxically opioid pain treatment have also been identified as triggers for delirium. The aim of this study was to assess the relationship between pain, opioid treatment, and delirium in older ED patients. METHODS A multicenter prospective cohort study was conducted in four hospitals across the province of Québec (Canada). Patients aged ≥ 65 years old, waiting for hospital admission between March and July 2015, who were nondelirious upon ED arrival, who were independent or semi-independent in their daily living activities, and who had an ED stay of at least 8 hours were included. Delirium assessments were conducted twice a day during the patient's entire ED stay and their first 24 hours on the hospital ward using the Confusion Assessment Method. Pain intensity was evaluated using a visual analog scale (VAS = 0-100) during the initial interview, and all opioid treatments were documented. RESULTS A total of 338 patients were included; 51% were female, and mean (±SD) age was 77 (±8) years. Forty-one patients (12%) experienced delirium during their hospital stay occurring within a mean (±SD) delay of 47 (±19) hours after ED admission. Among patients with pain intensity ≥ 65 from VAS (0-100), 26% experienced delirium compared to 11% for patients with pain < 65 (p < 0.01), and no significant association was found between opioid consumption and delirium (p = 0.31). Logistic regression controlling for confounding factors showed that patients with pain intensity ≥ 65 are 3.3 (95% confidence interval = 1.4 to 7.9) times more likely to develop delirium than patients who had pain intensity of <65. CONCLUSIONS Severe pain, not opioids, is associated with the development of delirium during ED stay. Adequate pain control during the hospital stay may contribute to a decrease in delirium episodes.
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Affiliation(s)
- Raoul Daoust
- From the Centre d’Étude en Médecine d’Urgence Hôpital du Sacré‐Cœur de Montréal Montréal Québec Canada
- the Faculté de Médecine Département Médecine Familiale et Médecine d’Urgence Université de Montréal Montréal Québec Canada
| | - Jean Paquet
- the Faculté de Médecine Département Médecine Familiale et Médecine d’Urgence Université de Montréal Montréal Québec Canada
| | - Valérie Boucher
- CHU de Québec–Université Laval Québec Québec Canada
- the Centre d’Excellence du Vieillissement de Québec Québec Québec Canada
| | - Mathieu Pelletier
- the Faculté de Médecine Université Laval Québec Québec Canada
- the Centre Intégré de Santé et de Services Sociaux de Lanaudière Joliette Québec Canada
| | - Émilie Gouin
- and the Centre Hospitalier Régional de Trois‐Rivières Trois‐Rivières Québec Canada
| | - Marcel Émond
- CHU de Québec–Université Laval Québec Québec Canada
- the Centre d’Excellence du Vieillissement de Québec Québec Québec Canada
- the Faculté de Médecine Université Laval Québec Québec Canada
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Bullock L, Chew-Graham CA, Bedson J, Bartlam B, Campbell P. The challenge of pain identification, assessment, and management in people with dementia: a qualitative study. BJGP Open 2020; 4:bjgpopen20X101040. [PMID: 32457099 PMCID: PMC7330220 DOI: 10.3399/bjgpopen20x101040] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/10/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Painful conditions are common in older adults, including people with dementia. The symptoms associated with dementia (for example, diminished language capacity, memory impairment, and behavioural changes), however, may lead to the suboptimal identification, assessment, and management of pain. Research has yet to qualitatively explore pain management for community-dwelling people with dementia. AIM To explore pain identification, assessment, and management for community-dwelling people with dementia. DESIGN & SETTING A qualitative study was undertaken, set in England. METHOD Semi-structured interviews took place with people with dementia, family caregivers, GPs, and old-age psychiatrists. Data were analysed thematically. RESULTS Interviews were conducted with eight people with dementia, nine family caregivers, nine GPs, and five old-age psychiatrists. Three themes were identified that related to pain identification and assessment: gathering information to identify pain; the importance of knowing the person; and the use of pain assessment tools. A further three themes were identified that related to pain management: non-drug strategies; concerns related to analgesic medications; and responsibility of the caregiver to manage pain. CONCLUSION Identifying and assessing the pain experienced by people with dementia was challenging. Most people with dementia, family caregivers, and healthcare professionals supported non-drug strategies to manage pain. The minimal concerns associated with non-drug strategies contrasted the multifactorial concerns associated with analgesic treatment for people with dementia. Given the complexity of pain identification, assessment, and management, primary care should work together with family caregivers and community services, with case finding for pain being considered in all assessment and management plans.
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Affiliation(s)
- Laurna Bullock
- School of Primary Community and Social Care, Keele University, Keele, UK
| | - Carolyn A Chew-Graham
- School of Primary Community and Social Care, Keele University, Keele, UK
- Midlands Partnership NHS Foundation Trust, St Georges' Hospital, Stafford, UK
| | - John Bedson
- School of Primary Community and Social Care, Keele University, Keele, UK
| | - Bernadette Bartlam
- School of Primary Community and Social Care, Keele University, Keele, UK
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technical University Singapore, Singapore, UK
| | - Paul Campbell
- School of Primary Community and Social Care, Keele University, Keele, UK
- Midlands Partnership NHS Foundation Trust, St Georges' Hospital, Stafford, UK
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Brink O. Hip fracture clearance: How much optimisation is necessary? Injury 2020; 51 Suppl 2:S111-S117. [PMID: 32081388 DOI: 10.1016/j.injury.2020.02.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/09/2020] [Indexed: 02/02/2023]
Abstract
Patients with hip fractures are typically elderly individuals with several co-morbidities. Upon admission to the hospital, they often present with acute pain, electrolyte disturbances, anaemia, coagulopathy, and delirium. Long waiting times for surgery are associated with increased morbidity and mortality. The balance between the number of clinical tests and optimisation, which may (i.e., fewer complications and better survival) or may not (i.e., more complications and increased mortality due to unnecessary surgical delay) benefit the patient, has been a preoperative challenge. This summary will review existing clinical guidelines and relevant selected studies to evaluate the extent of preoperative optimisation needed prior to hip fracture surgery.
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Affiliation(s)
- Ole Brink
- Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juel-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
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48
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Lisk R, Yeong K, Enwere P, Jenkinson J, Robin J, Irvin-Sellers M, Fluck D, Osmani A, Sharmin R, Sharma P, Fry CH, Han TS. Associations of 4AT with mobility, length of stay and mortality in hospital and discharge destination among patients admitted with hip fractures. Age Ageing 2020; 49:411-417. [PMID: 31813951 DOI: 10.1093/ageing/afz161] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/07/2019] [Accepted: 11/18/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND the 4AT (Alertness, Abbreviated Mental Test-4, Attention and Acute change or fluctuating course), a tool to screen cognitive impairment and delirium, has recently been recommended by the Scottish Intercollegiate Guidelines Network. We examined its ability to predict health outcomes among patients admitted with hip fractures to a single hospital between January 2018 and June 2019. METHODS the 4AT was performed within 1 day after hip surgery. A 4AT score of 0 means unlikely delirium or severe cognitive impairment (reference group); a score of 1-3 suggests possible chronic cognitive impairment, without excluding possibility of delirium; a score ≥ 4 suggests delirium with or without chronic cognitive impairment. Logistic regression, adjusted for: age; sex; nutritional status; co-morbidities; polypharmacy; and anticholinergic burden, used the 4AT to predict mobility, length of stay (LOS), mortality and discharge destination, compared with the reference group. RESULTS from 537 (392 women, 145 men: mean = 83.7 ± standard deviation [SD] = 8.8 years) consecutive patients, 522 completed the 4AT; 132 (25%) had prolonged LOS (>2 weeks) and 36 (6.8%) died in hospital. Risk of failure to mobilise within 1 day of surgery was increased with a 4AT score ≥ 4 (OR = 2.4, 95% confidence interval [CI] = 1.3-4.3). Prolonged LOS was increased with 4AT scores of 1-3 (OR = 2.4, 95%CI = 1.4-4.1) or ≥4 (OR = 3.1, 95%CI = 1.9-6.7). In-patient mortality was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.2-8.2) but not with a 4AT score of 1-3. Change of residence on discharge was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.4-6.8). These associations persisted after excluding patients with dementia. 4AT score = 1-3 and ≥ 4 associated with increased LOS by 3 and 6 days, respectively. CONCLUSIONS for older adults with hip fracture, the 4AT independently predicts immobility, prolonged LOS, death in hospital and change in residence on discharge.
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Affiliation(s)
- Radcliffe Lisk
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Keefai Yeong
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Peter Enwere
- Dementia Service, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | | | - Jonathan Robin
- Department of Acute Medicine, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Melanie Irvin-Sellers
- Department of Respiratory Medicine, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - David Fluck
- Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Ahmad Osmani
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Rifat Sharmin
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway, University of London, Surrey TW20 0EX, UK
- Department of Clinical Neuroscience, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Christopher H Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol BS8 1TD, UK
| | - Thang S Han
- Institute of Cardiovascular Research, Royal Holloway, University of London, Surrey TW20 0EX, UK
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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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Sampson EL, West E, Fischer T. Pain and delirium: mechanisms, assessment, and management. Eur Geriatr Med 2020; 11:45-52. [PMID: 32297242 DOI: 10.1007/s41999-019-00281-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 12/10/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Pain and delirium are common problems for older people. Both conditions are prevalent in acute hospital settings. In people living in the community, delirium often precipitates presentation to the emergency department. Pain and delirium are known to interact in a complex and multidirectional way. This can make it challenging for staff to recognize and treat pain in people with delirium. METHODS This paper aims to explore the complex relationship between pain and delirium and on pain assessment in delirium, drawing together evidence from a range of settings including acute medical, cardiac and orthopaedic post-operative cohorts, as well as from aged care. RESULTS A limited number of studies suggest there is an association between pain and delirium; however, this is a complex, particularly where analgesics which may-themselves cause delirium are prescribed. Factors acting on the pathway between pain and delirium may include depression, sleep deprivation and disturbance of the cholinergic system. Delirium affects the ability to self-report pain. The fluctuating nature of delirium as well as reduced awareness and attention may challenge practitioners in recognizing, assessing and treating pain. Evidence concerning the reliability and validity of current observational and self-assessment tools in people with delirium is unclear but some show promise in this population. CONCLUSION The current evidence base regarding assessing pain in people with delirium is lacking. Tentative recommendations, drawing on current guidelines require robust testing. Guidelines for people with pain and dementia require adaptations regarding the unique characteristics of delirium. The complex interplay between dementia, pain and delirium warrants further investigation across a range of settings.
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Affiliation(s)
- Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.
- Barnet Enfield, Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK.
| | - Emily West
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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