Pain Treatments for Nursing Home Residents with Advanced Dementia and Substantial Impaired Communication: A Cross-Sectional Analysis at Baseline of a Cluster Randomized Controlled Trial

End-of-life care for people with advanced dementia and pain: a qualitative study in Swedish nursing homes

Background

Of the Swedish people with advanced dementia, the majority die in nursing homes. Unresolved pain can occur in people with a terminal illness such as dementia. However, pain management in people with advanced dementia is often suboptimal and inadequate, with fewer palliative care interventions than offered to cancer patients. Although they are largely responsible for the care of these people, few studies have addressed the experiences of registered nurses in this respect. Therefore, the aim of this study was to describe the experiences of nurses in caring for people with advanced dementia and pain at the end of life.

Methods

The study had a descriptive explorative design. Individual qualitative, semi-structured interviews were carried out with 13 nurses from 12 nursing homes in Sweden. The results were analysed using thematic content analysis.

Results

The nurses described communicative, relational and organisational challenges. One major issue involved difficulties communicating with the person with advanced dementia, resulting in uncertain pain assessment. Other difficulties involved the differentiation of pain from anxiety, the balance of benefits and risks with morphine administration, and the creation of good relationships with healthcare personnel and the persons’ relatives. Relatives can greatly affect the assessment and management of pain, both because of their ability to interpret pain behaviour and by questioning the care given. Good pain management was facilitated by good communication and relationships with healthcare staff and relatives, extensive professional nursing experience, and already knowing the person with advanced dementia.

Conclusions

This study highlights the need for nursing homes to employ specialist nurses who have been trained in the appropriate knowledge and skills to deal with the challenges of end-of-life care for people with advanced dementia and pain. Additionally, there should be resources and strategies available for providing information to family members and for involving them in the decision-making process, as they are often unfamiliar with the multitude of considerations involved in decisions such as whether to administer morphine or not.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00566-7.

Polypharmacy in Assisted Living and Impact on Clinical Outcomes

OBJECTIVE

The purpose of this study was to describe medication use and polypharmacy in assisted living settings. We hypothesized that: 1) age, gender, race, setting, multi-morbidity, and cognitive status would influence polypharmacy; and 2) polypharmacy would be associated with falls, emergency room visits, and hospitalizations.

DESIGN

This was a descriptive study using data from a larger study testing the Dissemination and Implementation of Function Focused Care for Assisted Living (FFC-AL-EIT).

SETTING

Participants were recruited from 26 assisted living settings.

PARTICIPANTS

A total of 242 individuals for cohort 1 consented and completed baseline data collection.

INTERVENTIONS

Data were obtained from participant medical records, observations, and input from staff.

MAIN OUTCOME MEASURE(S)

Age, gender, race, ethnicity, comorbidities, cognitive status, medications, falls, emergency room visits, hospitalizations, function based on the Barthel Index and physical activity using the MotionWatch 8.

RESULTS

Participants had a mean age of 86.86 (standard deviation [SD] = 7.0), the majority were women (n = 179, 74%) and white (n = 233, 96%), with five (SD = 2) diagnoses. The mean number of drugs was seven (SD = 3.56), and 51% were exposed to polypharmacy. The mean Barthel Index score was 63.06 (SD = 20.20), and they engaged in 111,353 (SD = 87,262) counts of activity daily. Fifty-eight residents fell at least once (24%), 22 were sent to the hospital (9%), and 32 (13%) to the emergency room. Neither hypothesis was supported.

CONCLUSION

Continued research is needed to explore the factors that influence polypharmacy. Identification of these factors will help guide deprescribing so that medication management does not harm older adults physically or cause unnecessary financial burden.