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Cai S, Yan D, Wang S, Temkin-Greener H. Quality of Nursing Homes Among ADRD Residents Newly Admitted From the Community: Does Race Matter? J Am Med Dir Assoc 2023; 24:712-717. [PMID: 36870366 PMCID: PMC10182813 DOI: 10.1016/j.jamda.2023.01.017] [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: 12/09/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVE To examine racial differences in admissions to high-quality nursing homes (NHs) among residents with Alzheimer disease and related dementias (ADRD), and whether such racial differences can be influenced by dementia-related state Medicaid add-on policies. DESIGN Retrospective cross-sectional study. SETTING AND PARTICIPANTS The study included 786,096 Medicare beneficiaries with ADRD newly admitted from the community to NHs between January 1, 2011 and December 31, 2017. METHODS 2010-2017 Minimum Data Set 3.0, Medicare Beneficiary Summary File, Medicare Provider Analysis and Review, and Nursing Home Compare data were linked. For each individual, we constructed a "choice" set of NHs based on the distance between the NH and an individual residential zip code. McFadden's choice models were estimated to examine the relationship between admission into a high-quality (4- or 5-star) NH and individual characteristics, specifically race, and state Medicaid dementia-related add-on policies. RESULTS Among the identified residents, 89% were White, and 11% were Black. Overall, 50% of White and 35% of Black individuals were admitted to high-quality NHs. Black individuals were more likely to be Medicare-Medicaid dually eligible. Results from McFadden's model suggested that Black individuals were less likely to be admitted to a high-quality NH than White individuals (OR = 0.615, P < .01), and such differences were partially explained by some individual characteristics. Furthermore, we found that the racial difference was reduced in states with dementia-related add-on policies, compared with states without these policies (OR = 1.16, P < .01). CONCLUSIONS AND IMPLICATIONS Black individuals with ADRD were less likely to be admitted to high-quality NHs than White individuals. Such difference was partially related to individuals' health conditions, social-economic status, and state Medicaid add-on policies. Policies to reduce barriers to high-quality NHs among Black individuals are necessary to mitigate health inequity in this vulnerable population.
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Affiliation(s)
- Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Di Yan
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Sijiu Wang
- Department of Public Health Sciences, Biological Sciences Division, University of Chicago, Chicago, IL, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Osakwe ZT, Obioha CU, Muller K, Saint Fleur-Calixte R. A Description of Persons With Alzheimer Disease and Related Dementias Receiving Home Health Care: A National Analysis. J Hosp Palliat Nurs 2022; 24:00129191-990000000-00045. [PMID: 36178738 DOI: 10.1097/njh.0000000000000904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The end-of-life period of individuals with Alzheimer disease and related dementias receiving home health care (HHC) is understudied. We sought to describe characteristics of HHC patients with Alzheimer disease and related dementias at risk of death within a year, based on clinician assessment. We conducted a secondary data analysis of a 5% random sample of the Outcome and Assessment Information Set data set for the year 2017. We used Outcome and Assessment Information Set-C item M1034 to identify HHC patients with overall status of progressive condition leading to death within a year. Multivariable logistic regression model was used to examine the association between sociodemographic, functional, clinical, and caregiving factors and likelihood of decline leading to death within a year, as identified by HHC clinicians. Clinician perception of decline leading to death within a year was higher for Whites (vs Blacks or Hispanics) (odds ratio [OR], 0.74 [95% confidence interval (CI), 0.69-0.80], and OR, 0.63 [95% CI, 0.57-0.69], respectively). Factors associated with increased odds of decline leading to death within a year included daily pain (OR, 1.11 [95% CI, 1.06-1.17]), anxiety daily or more often (OR, 1.58 [95% CI, 1.49-1.67]), shortness of breath (OR, 1.45 [95% CI, 1.34-1.57]), use of oxygen (OR, 1.60 [95% CI, 1.52-1.69]), disruptive behavior (OR, 1.26 [95% CI, 1.20-1.31]), and feeding difficulty (OR, 2.25 [95% CI, 2.09-2.43]). High symptom burden exists among HHC patients with Alzheimer disease and related dementias identified to have a status of decline leading to death within a year.
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3
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Marsilli P, Funtowicz G, Epstein L, Giunta D, Peroni L, Vergara A. [Mortality in patients with dementia admitted in critical care units]. Rev Esp Geriatr Gerontol 2022; 57:150-155. [PMID: 35597699 DOI: 10.1016/j.regg.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 03/15/2022] [Accepted: 03/21/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the mortality and comorbidities associated of patients with dementia admitted to the Intensive Care Unit (ICU) on the hospitalization and at one year of follow-up. MATERIALS AND METHODS A retrospective observational cohort study was carried out between 2012 and 2017 at the Hospital Italiano de San Justo, of patients who were admitted to the ICU, these were observed up to hospitalary death, out hospital death one year of hospitalization, the disenrollment from the institution's health plan or the end of the follow-up. RESULTS A total of 163 patients were included for analysis. We recorded those 79 patients (48.47%) died one year after the hospitalization, of them 25 (15.34%) in ICU and 8 (4.91%) in general room. The most frequent causes of death were respiratory. The factors most associated with mortality were: orotracheal intubation (HR=2.01; 95% CI: 1.11-3.65; P=.02), history of leukemia (HR=8.55; 95% CI: 1.82-40.05; P≤.05), elevated Charlson (HR=1.16, 95% CI: 1.04-1.41; P=.05), and elevated APACHE II at admission (HR=1.07; 95% CI: 1.03-1.11; P≤.05). CONCLUSIONS The present study expresses the prognosis of patients with a diagnosis of dementia admitted to the ICU and that depends not only on their baseline neurological status but also on the severity at admission and comorbidities.
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Affiliation(s)
- Pablo Marsilli
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | | | - Lucas Epstein
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Diego Giunta
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Leticia Peroni
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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4
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Nursing Leadership and Palliative Care in Long-Term Care for Residents with Advanced Dementia. Nurs Clin North Am 2022; 57:259-271. [DOI: 10.1016/j.cnur.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Lopes BNA, Garcez FB, Suemoto CK, Morillo LS. Accuracy of two prognostic indexes to predict mortality in older adults with advanced dementia. Dement Neuropsychol 2022; 16:52-60. [PMID: 35719252 PMCID: PMC9170258 DOI: 10.1590/1980-5764-dn-2021-0028] [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: 03/07/2021] [Revised: 08/05/2021] [Accepted: 09/16/2021] [Indexed: 11/25/2022] Open
Abstract
Dementia is a cause of disability among older adults. Accessing advanced dementia prognosis is a challenge.
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Affiliation(s)
| | - Flavia Barreto Garcez
- Universidade de São Paulo, Faculdade de Medicina, Divisão de Geriatria, São Paulo SP, Brazil
| | - Claudia Kimie Suemoto
- Universidade de São Paulo, Faculdade de Medicina, Divisão de Geriatria, São Paulo SP, Brazil
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Abstract
Background: Among patients seen by palliative care, dysphagia is prevalent and can lead to disturbing symptoms and challenges in medical decisions for patients and families. Case: Our patient, AP, an 88-year-old woman with a history of thyroid cancer and esophageal dysmotility, was nearing end of life. She wanted nothing more than to eat her chocolate cake in peace. This shocked her family and also presented multiple ethical and logistical issues for the medical team caring for her during an acute admission for hypoxia. Discussion: This case presents an opportunity to: review strategies for evaluating and diagnosing dysphagia; appraise evidenced based approach to the palliative management of dysphagia; and promote the education of families and staff regarding palliative options for care. Conclusion: Palliative care professionals can be instrumental in educating patients, families, other clinicians, including swallowing therapists, on how to enhance comfort and quality of life among patients with dysphagia.
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Affiliation(s)
- Amanda Warren
- Department of Communication Sciences and Disorders, Emerson College, Boston, Massachusetts, USA
| | - Mary K Buss
- Department of Ambulatory Palliative Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Shepard V, Chou LN, Kuo YF, Raji M. Characteristics Associated with Feeding Tube Placement: Retrospective Cohort Study of Texas Nursing Home Residents with Advanced Dementia. J Am Med Dir Assoc 2021; 22:1471-1476.e4. [PMID: 33238144 PMCID: PMC10928907 DOI: 10.1016/j.jamda.2020.10.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To investigate resident-level, provider-type, nursing home (NH), and regional factors associated with feeding tube (FT) placement in advanced dementia. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS NH residents in Texas with dementia diagnosis and severe cognitive impairment (N = 20,582). METHODS This study used 2011-2016 Texas Medicare data to identify NH residents with a stay of at least 120 days who had a diagnosis of dementia on Long Term Care Minimum Data Set (MDS) evaluation and severe cognitive impairment on clinical score. Multivariable repeated measures analyses were conducted to identify associations between FT placement and resident-level, provider-type, NH, and regional factors. RESULTS The prevalence of FT placement in advanced dementia in Texas between 2011 and 2016 ranged from 12.5% to 16.1% with a nonlinear trend. At the resident level, the prevalence of FT decreased with age [age > 85 years, prevalence ratio (PR) 0.60, 95% confidence interval (CI) 0.52-0.69] and increased among residents who are black (2.74, 95% CI 2.48-3.03) or Hispanic (PR 1.91, 95% CI 1.71-2.13). Residents cared for by a nurse practitioner or physician assistant were less likely to have an FT (PR 0.90, 95% CI 0.85-0.96). No facility characteristics were associated with prevalence of FT placement in advanced dementia. There were regional differences in FT placement with the highest use areas on the Texas-Mexico border and in South and East Texas (Harlingen border area, PR 4.26, 95% CI 3.69-4.86; San Antonio border area, PR 3.93, 95% CI 3.04-4.93; Houston, PR 2.17, 95% CI 1.87-2.50), and in metro areas (PR 1.36, 95% CI 1.22-1.50). CONCLUSIONS AND IMPLICATIONS Regional, race, and ethnic variations in prevalence of FT use among NH residents suggest opportunities for clinicians and policy makers to improve the quality of end-of-life care by especially considering other palliative care measures for minorities living in border towns.
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Affiliation(s)
- Victoria Shepard
- Department of Population Health, University of Texas Dell Medical School, Austin, TX, USA
| | - Lin-Na Chou
- University of Texas Medical Branch, Office of Biostatistics, Galveston, TX, USA
| | - Yong-Fang Kuo
- University of Texas Medical Branch, Office of Biostatistics, Galveston, TX, USA; Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA; University of Texas Medical Branch Division of Geriatrics and Palliative Care; Galveston, Texas, USA
| | - Mukaila Raji
- University of Texas Medical Branch Division of Geriatrics and Palliative Care; Galveston, Texas, USA.
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Hanson LC, Bennett AV, Jonsson M, Kelley A, Ritchie C, Saliba D, Teno J, Zimmerman S. Selecting Outcomes to Ensure Pragmatic Trials Are Relevant to People Living with Dementia. J Am Geriatr Soc 2021; 68 Suppl 2:S55-S61. [PMID: 32589279 DOI: 10.1111/jgs.16619] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/04/2020] [Accepted: 04/10/2020] [Indexed: 11/29/2022]
Abstract
Outcome measures for embedded pragmatic clinical trials (ePCTs) should reflect the lived experience of people living with dementia (PLWD) and their caregivers, yet patient- and caregiver-reported outcomes (PCROs) are rarely available in large clinical and administrative data sources. Although pragmatic methods may lead to use of existing administrative data rather than new data collected directly from PLWD, interventions are truly impactful only when they change outcomes prioritized by PLWD and their caregivers. The Patient- and Caregiver-Reported Outcomes Core (PCRO Core) of the IMbedded Pragmatic Alzheimer's Disease (AD) and AD-Related Dementias Clinical Trials (IMPACT) Collaboratory aims to promote optimal use of outcomes relevant to PLWD and their caregivers in pragmatic trials. The PCRO Core will address key scientific challenges limiting outcome measurement, such as gaps in existing measures, methodologic constraints, and burdensome data capture. PCRO Core investigators will create a searchable library of AD/AD-related dementias (ADRD) clinical outcome measures, including measures in existing data sources with potential for AD/ADRD ePCTs, and will support best practices in measure development, including pragmatic adaptation of PCROs. Working together with other Cores and Teams within the IMPACT Collaboratory, the PCRO Core will support investigators to select from existing outcome measures, and to innovate in methods for measurement and data capture. In the future, the work of the IMPACT Collaboratory may galvanize broader embedded use of outcomes that matter to PLWD and their care partners in large health systems. J Am Geriatr Soc 68:S55-S61, 2020.
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Affiliation(s)
- Laura C Hanson
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Antonia V Bennett
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Patient Reported Outcomes Core, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mattias Jonsson
- Patient Reported Outcomes Core, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amy Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Debra Saliba
- Borun Center, University of California, Los Angeles, Los Angeles, California, USA.,Los Angeles VA Geriatric Research Education and Clinical Center, Los Angeles, California, USA.,RAND, Santa Monica, California, USA
| | - Joan Teno
- Division of General Internal Medicine and Geriatrics, Oregon Health Sciences University, Portland, Oregon, USA
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Armstrong MJ, Paulson HL, Maixner SM, Fields JA, Lunde AM, Boeve BF, Manning C, Galvin JE, Taylor AS, Li Z. Protocol for an observational cohort study identifying factors predicting accurately end of life in dementia with Lewy bodies and promoting quality end-of-life experiences: the PACE-DLB study. BMJ Open 2021; 11:e047554. [PMID: 34039578 PMCID: PMC8160156 DOI: 10.1136/bmjopen-2020-047554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Dementia with Lewy bodies (DLB) is one of the most common degenerative dementias. Despite the fact that most individuals with DLB die from complications of the disease, little is known regarding what factors predict impending end of life or are associated with a quality end of life. METHODS AND ANALYSIS This is a multisite longitudinal cohort study. Participants are being recruited from five academic centres providing subspecialty DLB care and volunteers through the Lewy Body Dementia Association (not receiving specialty care). Dyads must be US residents, include individuals with a clinical diagnosis of DLB and at least moderate-to-severe dementia and include the primary caregiver, who must pass a brief cognitive screen. The first dyad was enrolled 25 February 2021; recruitment is ongoing. Dyads will attend study visits every 6 months through the end of life or 3 years. Study visits will occur in-person or virtually. Measures include demographics, DLB characteristics, caregiver considerations, quality of life and satisfaction with end-of-life experiences. For dyads where the individual with DLB dies, the caregiver will complete a final study visit 3 months after the death to assess grief, recovery and quality of the end-of-life experience. Terminal trend models will be employed to identify significant predictors of approaching end of life (death in the next 6 months). Similar models will assess caregiver factors (eg, grief, satisfaction with end-of-life experience) after the death of the individual with DLB. A qualitative descriptive analysis approach will evaluate interview transcripts regarding end-of-life experiences. ETHICS AND DISSEMINATION This study was approved by the University of Florida institutional review board (IRB202001438) and is listed on clinicaltrials.gov (NCT04829656). Data sharing follows National Institutes of Health policies. Study results will be disseminated via traditional scientific strategies (conferences, publications) and through collaborating with the Lewy Body Dementia Association, National Institute on Aging and other partnerships.
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Affiliation(s)
- Melissa J Armstrong
- Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Susan M Maixner
- Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Julie A Fields
- Psychiatry and Psychology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Angela M Lunde
- Psychiatry and Psychology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | | | - Carol Manning
- Neurology, University of Virginia, Charlottesville, Virginia, USA
| | - James E Galvin
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Zhigang Li
- Biostatistics, University of Florida College of Medicine, Gainesville, Florida, USA
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10
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Supiano KP, Andersen T, Luptak M, Beynon C, Iacob E, Levitt SE. Pre-loss group therapy for dementia family care partners at risk for complicated grief. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2021; 7:e12167. [PMID: 34027022 PMCID: PMC8116857 DOI: 10.1002/trc2.12167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 03/07/2021] [Accepted: 03/14/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Dementia family caregiving may span more than a decade and places many family care partners (CPs) at risk for poor bereavement outcomes; estimates of complicated grief in bereaved dementia family CPs range from 10% to 20%. We adapted our efficacious complicated grief group therapy intervention for bereaved dementia caregivers for soon-to-be bereaved dementia CPs at risk for complicated grief to facilitate healthy death preparedness and eventual bereavement-pre-loss group therapy (PLGT). METHODS In this Stage IB pilot intervention study, we implemented and evaluated PLGT in three psychotherapy group cohorts with family CPs at-risk for complicated grief whose person living with dementia (PLWD) had a life expectancy of 6 months or less and resided in a nursing home. PLGT is a 10-session multi-modal psychotherapy administered by social workers. RESULTS Participants in PLGT realized significant improvement in their pre-loss grief and in reported preparedness for the death of their family member, and participants evidenced lowered pre-loss grief severity and improvement, as measured by facilitators. Participants also realized significant improvement in meaning making, particularly as a sense of peace and a reduction of loneliness. DISCUSSION The process and treatment elements of the PLGT intervention affirm the value of specialized care for those dementia family CPs at risk for complicated grief, as the PLGT groups demonstrated a steady progression toward improvement collectively and individually. PLGT participants realized statistical and clinical improvement across pre-loss grief measures suggesting that their risk for complicated grief risk was mitigated, and they were better prepared for the death of their PLWD.
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Affiliation(s)
| | - Troy Andersen
- University of Utah College of Social WorkSalt Lake CityUSA
| | - Marilyn Luptak
- University of Utah College of Social WorkSalt Lake CityUSA
| | | | - Eli Iacob
- University of Utah College of NursingSalt Lake CityUSA
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11
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Evans CJ, Yorganci E, Lewis P, Koffman J, Stone K, Tunnard I, Wee B, Bernal W, Hotopf M, Higginson IJ. Processes of consent in research for adults with impaired mental capacity nearing the end of life: systematic review and transparent expert consultation (MORECare_Capacity statement). BMC Med 2020; 18:221. [PMID: 32693800 PMCID: PMC7374835 DOI: 10.1186/s12916-020-01654-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 06/03/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Involving adults lacking capacity (ALC) in research on end of life care (EoLC) or serious illness is important, but often omitted. We aimed to develop evidence-based guidance on how best to include individuals with impaired capacity nearing the end of life in research, by identifying the challenges and solutions for processes of consent across the capacity spectrum. METHODS Methods Of Researching End of Life Care_Capacity (MORECare_C) furthers the MORECare statement on research evaluating EoLC. We used simultaneous methods of systematic review and transparent expert consultation (TEC). The systematic review involved four electronic databases searches. The eligibility criteria identified studies involving adults with serious illness and impaired capacity, and methods for recruitment in research, implementing the research methods, and exploring public attitudes. The TEC involved stakeholder consultation to discuss and generate recommendations, and a Delphi survey and an expert 'think-tank' to explore consensus. We narratively synthesised the literature mapping processes of consent with recruitment outcomes, solutions, and challenges. We explored recommendation consensus using descriptive statistics. Synthesis of all the findings informed the guidance statement. RESULTS Of the 5539 articles identified, 91 met eligibility. The studies encompassed people with dementia (27%) and in palliative care (18%). Seventy-five percent used observational designs. Studies on research methods (37 studies) focused on processes of proxy decision-making, advance consent, and deferred consent. Studies implementing research methods (30 studies) demonstrated the role of family members as both proxy decision-makers and supporting decision-making for the person with impaired capacity. The TEC involved 43 participants who generated 29 recommendations, with consensus that indicated. Key areas were the timeliness of the consent process and maximising an individual's decisional capacity. The think-tank (n = 19) refined equivocal recommendations including supporting proxy decision-makers, training practitioners, and incorporating legislative frameworks. CONCLUSIONS The MORECare_C statement details 20 solutions to recruit ALC nearing the EoL in research. The statement provides much needed guidance to enrol individuals with serious illness in research. Key is involving family members early and designing study procedures to accommodate variable and changeable levels of capacity. The statement demonstrates the ethical imperative and processes of recruiting adults across the capacity spectrum in varying populations and settings.
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Affiliation(s)
- C J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK.
- Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK.
| | - E Yorganci
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - P Lewis
- Centre of Medical Law and Ethics, The Dickson Poon School of Law, King's College London, London, UK
| | - J Koffman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - K Stone
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - I Tunnard
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - B Wee
- Oxford University Hospitals NHS Foundation Trust and Harris Manchester College, University of Oxford, Oxford, UK
| | - W Bernal
- King's College Hospital, London, UK
| | - M Hotopf
- Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - I J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
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12
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Miranda R, van der Steen JT, Smets T, Van den Noortgate N, Deliens L, Payne S, Kylänen M, Szczerbińska K, Gambassi G, Van den Block L. Comfort and clinical events at the end of life of nursing home residents with and without dementia: The six-country epidemiological PACE study. Int J Geriatr Psychiatry 2020; 35:719-727. [PMID: 32128874 DOI: 10.1002/gps.5290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES We aimed to investigate the occurrence rates of clinical events and their associations with comfort in dying nursing home residents with and without dementia. METHODS Epidemiological after-death survey was performed in nationwide representative samples of 322 nursing homes in Belgium, Finland, Italy, the Netherlands, Poland, and England. Nursing staff reported clinical events and assessed comfort. The nursing staff or physician assessed the presence of dementia; severity was determined using two highly discriminatory staff-reported instruments. RESULTS The sample comprised 401 residents with advanced dementia, 377 with other stages of dementia, and 419 without dementia (N = 1197). Across the three groups, pneumonia occurred in 24 to 27% of residents. Febrile episodes (unrelated to pneumonia) occurred in 39% of residents with advanced dementia, 34% in residents with other stages of dementia and 28% in residents without dementia (P = .03). Intake problems occurred in 74% of residents with advanced dementia, 55% in residents with other stages of dementia, and 48% in residents without dementia (P < .001). Overall, these three clinical events were inversely associated with comfort. Less comfort was observed in all resident groups who had pneumonia (advanced dementia, P = .04; other stages of dementia, P = .04; without dementia, P < .001). Among residents with intake problems, less comfort was observed only in those with other stages of dementia (P < .001) and without dementia (P = .003), while the presence and severity of dementia moderated this association (P = .03). Developing "other clinical events" was not associated with comfort. CONCLUSIONS Discomfort was observed in dying residents who developed major clinical events, especially pneumonia, which was not specific to advanced dementia. It is crucial to identify and address the clinical events potentially associated with discomfort in dying residents with and without dementia.
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Affiliation(s)
- Rose Miranda
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam Public Health research institute, Expertise center for Palliative Care, Amsterdam, The Netherlands.,Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University Hospital, Ghent, Belgium
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, UK
| | - Marika Kylänen
- National Institute for Health and Welfare, Helsinki, Finland
| | - Katarzyna Szczerbińska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Giovanni Gambassi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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13
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Harrison KL, Bull JH, Garrett SB, Bonsignore L, Bice T, Hanson LC, Ritchie CS. Community-Based Palliative Care Consultations: Comparing Dementia to Nondementia Serious Illnesses. J Palliat Med 2020; 23:1021-1029. [PMID: 31971857 DOI: 10.1089/jpm.2019.0250] [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] [Indexed: 11/13/2022] Open
Abstract
Background: Little is known about the provision of palliative care to people with dementia (PWD). Objective: To examine demographic and clinical characteristics of PWD versus nondementia serious illnesses receiving community-based palliative care. Design: Retrospective study of people 65+ receiving an initial consultation from a community-based palliative care practice between September 2014 and February 2018 using registry data entered by clinicians into the Quality Data Collection Tool for Palliative Care. Setting: Large not-for-profit organization that provides community-based hospice and palliative care services. Measurements: Demographics, consult characteristics, advance care planning, and caregiver support. Results: Of 3883 older adults receiving a first palliative care consultation from this organization, 22% (855) had a dementia diagnosis. Compared to those with nondementia serious illnesses, PWD were older with more impaired function; 36% had a prognosis of less than six months. More PWD than those without dementia had a proxy decision maker and documented advance directive. A quarter of PWD were full code before consultation; nearly half changed to some limitation afterward. Symptom characteristics were missing for 67% of PWD due to collection through self-report. Caregivers of PWD were responsible for significantly more activities of daily living than caregivers of people with nondementia serious illnesses. Conclusions: This is the first comparison of a large cohort of people with and without dementia receiving a community-based palliative care consult in the United States. Alternative measures of symptom burden should be used in registries to capture data for PWD. Understanding the unique characteristics of PWD will guide future services for this growing population.
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Affiliation(s)
- Krista L Harrison
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA.,Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Janet H Bull
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Four Seasons Compassion for Life Hospice, Flat Rock, North Carolina, USA
| | - Sarah B Garrett
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA.,Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Lindsay Bonsignore
- Four Seasons Compassion for Life Hospice, Flat Rock, North Carolina, USA
| | - Tyler Bice
- Four Seasons Compassion for Life Hospice, Flat Rock, North Carolina, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
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14
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van Engelen MPE, Gossink FT, de Vijlder LS, Meursing JR, Scheltens P, Dols A, Pijnenburg YA. End Stage Clinical Features and Cause of Death of Behavioral Variant Frontotemporal Dementia and Young-Onset Alzheimer's Disease. J Alzheimers Dis 2020; 77:1169-1180. [PMID: 32925036 PMCID: PMC7683069 DOI: 10.3233/jad-200337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Limited literature exists regarding the clinical features of end stage behavioral variant frontotemporal dementia (bvFTD). This data is indispensable to inform and prepare family members as well as professional caregivers for the expected disease course and to anticipate with drug-based and non-pharmacological treatment strategies. OBJECTIVE The aim of the present study was to describe end stage bvFTD in a broad explorative manner and to subsequently evaluate similarities and dissimilarities with the end stage of the most prevalent form of young-onset dementia, Alzheimer's disease (yoAD). METHODS We analyzed medical files on patients, using a mixed model of qualitative and quantitative approaches. Included were previously deceased patients with probable bvFTD and probable yoAD. End stage was defined as the last 6 months prior to death. Primary outcome measures comprised somatic, neurological, and psychiatric symptoms and the secondary outcome measure was cause of death. RESULTS Out of 89 patients, a total of 30 patients were included (bvFTD; n = 12, yoAD; n = 18). Overall, the end stages of bvFTD and yoAD were characterized by a broad spectrum of clinical symptoms including severe autonomic dysfunction and an increased muscle tone. Patients with bvFTD displayed more mutism compared with yoAD while compulsiveness was only present in bvFTD. CONCLUSION Our study describes the full clinical spectrum of end stage bvFTD and yoAD. In this study, symptoms extend far beyond the initial behavioral and cognitive features. By taking both somatic, psychiatric, and neurological features into account, family members and professional caregivers may anticipate (non) pharmacological treatment.
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Affiliation(s)
- Marie-Paule E. van Engelen
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Flora T. Gossink
- Department of Old Age Psychiatry, GGZinGeest/VU University Medical Center, Amsterdam, The Netherlands
| | - Lieke S. de Vijlder
- Lisidunahof, nursing home specialized in (young-onset) dementia, Beweging 3.0, Leusden, The Netherlands
| | - Jan R.A. Meursing
- Lisidunahof, nursing home specialized in (young-onset) dementia, Beweging 3.0, Leusden, The Netherlands
| | - Philip Scheltens
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Annemiek Dols
- Department of Old Age Psychiatry, GGZinGeest/VU University Medical Center, Amsterdam, The Netherlands
| | - Yolande A.L. Pijnenburg
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
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15
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Luz P. Osler Centenary Papers: Reflection on the use of antibiotics to treat ‘the old man’s friend’. Postgrad Med J 2019; 95:670. [DOI: 10.1136/postgradmedj-2019-136823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2019] [Indexed: 11/04/2022]
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16
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Tilburgs B, Koopmans R, Vernooij-Dassen M, Adang E, Schers H, Teerenstra S, van de Pol M, Smits C, Engels Y, Perry M. Educating Dutch General Practitioners in Dementia Advance Care Planning: A Cluster Randomized Controlled Trial. J Am Med Dir Assoc 2019; 21:837-842.e4. [PMID: 31759901 DOI: 10.1016/j.jamda.2019.09.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 09/11/2019] [Accepted: 09/17/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Advance care planning (ACP) is seldom initiated with people with dementia (PWD) and mainly focuses on medical end-of-life decisions. We studied the effects of an educational intervention for general practitioners (GPs) aimed at initiating and optimizing ACP, with a focus on discussing medical and nonmedical preferences of future care. DESIGN A single-blinded cluster randomized controlled trial. SETTING AND PARTICIPANTS In 2016, 38 Dutch GPs (all from different practices) completed the study. They recruited 140 PWD, aged ≥65 years at any stage and with any type of dementia, from their practice. METHODS Intervention group GPs were trained in ACP, including shared decision-making and role-playing exercises. Control group GPs provided usual care. The primary outcome was ACP initiation: the proportion of PWD that had at least 1 ACP conversation documented in their medical file. Key secondary outcomes were the number of medical (ie, resuscitation, hospital admission) and nonmedical (ie, activities, social contacts) preferences discussed. At the 6-month follow-up, subjects' medical records were analyzed using random effect logistics and linear models with correction for GP clustering. RESULTS 38 GP clusters (19 intervention; 19 control) included 140 PWD (intervention 73; control 67). Four PWD (2.9%) dropped out on the primary and key secondary outcomes. After 6 months, intervention group GPs initiated ACP with 35 PWD (49.3%), and control group GPs initiated ACP with 9 PWD (13.9%) [odds ratio (OR) 1.99; P = .002]. Intervention group GPs discussed 0.8 more medical [95% confidence interval (CI) 0.3, 1.3; P = .003] and 1.5 more nonmedical (95% CI 0.8, 2.3; P < .001) preferences per person with dementia than control group GPs. CONCLUSIONS AND IMPLICATIONS Our educational intervention increased ACP initiation, and the number of nonmedical and medical preferences discussed. This intervention has the potential to better align future care of PWD with their preferences but because of the short follow-up, the GPs' long-term adoption remains unknown.
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Affiliation(s)
- Bram Tilburgs
- Department of IQ Healthcare, Radboud University Medical Centre Nijmegen, the Netherlands.
| | - Raymond Koopmans
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands; Radboudumc Alzheimer Centre, Nijmegen, the Netherlands; Joachim en Anna, Centre for Specialized Geriatric Care, Nijmegen, the Netherlands
| | - Myrra Vernooij-Dassen
- Department of IQ Healthcare, Radboud University Medical Centre Nijmegen, the Netherlands
| | - Eddy Adang
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Henk Schers
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Steven Teerenstra
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marjolein van de Pol
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Carolien Smits
- Research Group Innovating with Older Adults, Windesheim University of Applied Sciences, Zwolle, the Netherlands
| | - Yvonne Engels
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marieke Perry
- Radboudumc Alzheimer Centre, Nijmegen, the Netherlands; Department of Geriatric Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
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17
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Harrison KL, Ritchie CS, Patel K, Hunt LJ, Covinsky KE, Yaffe K, Smith AK. Care Settings and Clinical Characteristics of Older Adults with Moderately Severe Dementia. J Am Geriatr Soc 2019; 67:1907-1912. [PMID: 31389002 PMCID: PMC6732035 DOI: 10.1111/jgs.16054] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/24/2019] [Accepted: 05/02/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Little population-level evidence exists to guide the development of interventions for people with dementia in non-nursing home settings. We hypothesized people living at home with moderately severe dementia would differ in social, functional, and medical characteristics from those in either residential care or nursing home settings. DESIGN Retrospective cohort study using pooled data from the National Health and Aging Trends Study, an annual survey of a nationally representative sample of Medicare beneficiaries. SETTING US national sample. PARTICIPANTS Respondents newly meeting criteria for incident moderately severe dementia, defined as probable dementia with functional impairment: 728 older adults met our definition between 2012 and 2016. MEASUREMENTS Social characteristics examined included age, sex, race/ethnicity, country of origin, income, educational attainment, partnership status, and household size. Functional characteristics included help with daily activities, falls, mobility device use, and limitation to home or bed. Medical characteristics included comorbid conditions, self-rated health, hospital stay, symptoms, and dementia behaviors. RESULTS Extrapolated to the population, an estimated 3.3 million older adults developed incident moderately severe dementia between 2012 and 2016. Within this cohort, 64% received care at home, 19% in residential care, and 17% in a nursing facility. social, functional, and medical characteristics differed across care settings. Older adults living at home were 2 to 5 times more likely to be members of disadvantaged populations and had more medical needs: 71% reported bothersome pain compared with 60% in residential care or 59% in nursing homes. CONCLUSION Over a 5-year period, 2.1 million people lived at home with incident moderately severe dementia. People living at home had a higher prevalence of demographic characteristics associated with systematic patterns of disadvantage, more social support, less functional impairment, worse health, and more symptoms compared with people living in residential care or nursing facilities. This novel study provides insight into setting-specific differences among people with dementia. J Am Geriatr Soc 67:1907-1912, 2019.
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Affiliation(s)
- Krista L Harrison
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
- San Francisco Campus for Jewish Living, San Francisco, California
| | - Kanan Patel
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Lauren J Hunt
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Department of Physiological Nursing, University of California San Francisco, San Francisco, California
| | - Kenneth E Covinsky
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Kristine Yaffe
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Department of Psychiatry, Neurology, and Epidemiology, University of California, San Francisco, San Francisco, California
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
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18
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Honinx E, van Dop N, Smets T, Deliens L, Van Den Noortgate N, Froggatt K, Gambassi G, Kylänen M, Onwuteaka-Philipsen B, Szczerbińska K, Van den Block L. Dying in long-term care facilities in Europe: the PACE epidemiological study of deceased residents in six countries. BMC Public Health 2019; 19:1199. [PMID: 31470875 PMCID: PMC6717349 DOI: 10.1186/s12889-019-7532-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/05/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND By 2030, 30% of the European population will be aged 60 or over and those aged 80 and above will be the fastest growing cohort. An increasing number of people will die at an advanced age with multiple chronic diseases. In Europe at present, between 12 and 38% of the oldest people die in a long-term care facility. The lack of nationally representative empirical data, either demographic or clinical, about people who die in long-term care facilities makes appropriate policy responses more difficult. Additionally, there is a lack of comparable cross-country data; the opportunity to compare and contrast data internationally would allow for a better understanding of both common issues and country-specific challenges and could help generate hypotheses about different options regarding policy, health care organization and provision. The objectives of this study are to describe the demographic, facility stay and clinical characteristics of residents dying in long-term care facilities and the differences between countries. METHODS Epidemiological study (2015) in a proportionally stratified random sample of 322 facilities in Belgium, Finland, Italy, the Netherlands, Poland and England. The final sample included 1384 deceased residents. The sampled facilities received a letter introducing the project and asking for voluntary participation. Facility manager, nursing staff member and treating physician completed structured questionnaires for all deaths in the preceding 3 months. RESULTS Of 1384 residents the average age at death ranged from 81 (Poland) to 87 (Belgium, England) (p < 0.001) and length of stay from 6 months (Poland, Italy) to 2 years (Belgium) (p < 0.05); 47% (the Netherlands) to 74% (Italy) had more than two morbidities and 60% (England) to 83% (Finland) dementia, with a significant difference between countries (p < 0.001). Italy and Poland had the highest percentages with poor functional and cognitive status 1 month before death (BANS-S score of 21.8 and 21.9 respectively). Clinical complications occurred often during the final month (51.9% England, 66.4% Finland and Poland). CONCLUSIONS The population dying in long-term care facilities is complex, displaying multiple diseases with cognitive and functional impairment and high levels of dementia. We recommend future policy should include integration of high-quality palliative and dementia care.
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Affiliation(s)
- Elisabeth Honinx
- Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Nanja van Dop
- Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Tinne Smets
- Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Luc Deliens
- Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Nele Van Den Noortgate
- Department of Geriatric Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - Katherine Froggatt
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4YW UK
| | - Giovanni Gambassi
- Department of Internal Medicine, Istituto di Medicina Interna e Geriatria, Università Cattolica del Sacro Cuore, Largo F. Vito, 1, 00135 Rome, Italy
| | - Marika Kylänen
- National Institute for Health and Welfare, Mannerheimintie 166, P.O. Box 30, FI-00271 Helsinki, Finland
| | - Bregje Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, Expertise Center for Palliative Care, VU University Medical Center, Van der Boechorstraat 7, 1081 BT Amsterdam, The Netherlands
| | - Katarzyna Szczerbińska
- Department of Sociology of Medicine, Chair of Epidemiology and Preventive Medicine, Medical Faculty, Jagiellonian University Medical College, ul. Kopernika 7a, 31-034 Kraków, Poland
| | - Lieve Van den Block
- Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
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Minaglia C, Giannotti C, Boccardi V, Mecocci P, Serafini G, Odetti P, Monacelli F. Cachexia and advanced dementia. J Cachexia Sarcopenia Muscle 2019; 10:263-277. [PMID: 30794350 PMCID: PMC6463474 DOI: 10.1002/jcsm.12380] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 11/20/2018] [Indexed: 12/22/2022] Open
Abstract
Cachexia is a complex metabolic process that is associated with several end-stage organ diseases. It is known to be also associated with advanced dementia, although the pathophysiologic mechanisms are still largely unknown. The present narrative review is aimed at presenting recent insights concerning the pathophysiology of weight loss and wasting syndrome in dementia, the putative mechanisms involved in the dysregulation of energy balance, and the interplay among the chronic clinical conditions of sarcopenia, malnutrition, and frailty in the elderly. We discuss the clinical implications of these new insights, with particular attention to the challenging question of nutritional needs in advanced dementia and the utility of tube feeding in order to optimize the management of end-stage dementia.
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Affiliation(s)
- Cecilia Minaglia
- Department of Internal Medicine and Medical Specialties (DIMI), Section of Geriatrics, University of Genoa, Genoa, Italy
| | - Chiara Giannotti
- Department of Internal Medicine and Medical Specialties (DIMI), Section of Geriatrics, University of Genoa, Genoa, Italy
| | - Virginia Boccardi
- Department of Medicine, Institute of Gerontology and Geriatrics, University of Perugia, Perugia, Italy
| | - Patrizia Mecocci
- Department of Medicine, Institute of Gerontology and Geriatrics, University of Perugia, Perugia, Italy
| | - Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.,Section of Psychiatry, I.R.C.C.S. Ospedale Policlinico San Martino, Genoa, Italy
| | - Patrizio Odetti
- Department of Internal Medicine and Medical Specialties (DIMI), Section of Geriatrics, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Fiammetta Monacelli
- Department of Internal Medicine and Medical Specialties (DIMI), Section of Geriatrics, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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20
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Tan B, Fox S, Kruger C, Lynch M, Shanagher D, Timmons S. Investigating the healthcare utilisation and other support needs of people with young-onset dementia. Maturitas 2019; 122:31-34. [DOI: 10.1016/j.maturitas.2019.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 12/12/2018] [Accepted: 01/10/2019] [Indexed: 10/27/2022]
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21
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Berry SD, Rothbaum RR, Kiel DP, Lee Y, Mitchell SL. Association of Clinical Outcomes With Surgical Repair of Hip Fracture vs Nonsurgical Management in Nursing Home Residents With Advanced Dementia. JAMA Intern Med 2018; 178:774-780. [PMID: 29801122 PMCID: PMC5997966 DOI: 10.1001/jamainternmed.2018.0743] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE The decision whether to surgically repair a hip fracture in nursing home (NH) residents with advanced dementia can be challenging. OBJECTIVE To compare outcomes, including survival, among NH residents with advanced dementia and hip fracture according to whether they underwent surgical hip fracture repair. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective cohort study of 3083 NH residents with advanced dementia and hip fracture, but not enrolled in hospice care, using nationwide Medicare claims data linked with Minimum Data Set (MDS) assessments from January 1, 2008, through December 31, 2013. METHODS Residents with advanced dementia were identified using the MDS. Medicare claims were used to identify hip fracture and to determine whether the fracture was managed surgically. Survival between surgical and nonsurgical residents was compared using multivariable Cox proportional hazards with inverse probability of treatment weighting (IPTW). All analyses took place between November 2015 and January 2018. Among 6-month survivors, documented pain, antipsychotic drug use, physical restraint use, pressure ulcers, and ambulatory status were compared between surgical and nonsurgical groups. RESULTS Among 3083 residents with advanced dementia and hip fracture (mean age, 84.2 years; 79.2% female [n = 2441], 28.5% ambulatory [n = 879]), 2615 (84.8%) underwent surgical repair. By 6-month follow-up, 31.5% (n = 824) and 53.8% (n = 252) of surgically and nonsurgically managed residents died, respectively. After IPTW modeling, surgically managed residents were less likely to die than residents without surgery (adjusted hazard ratio [aHR], 0.88; 95% CI, 0.79-0.98). Among 2007 residents who survived 6 months, residents with surgical vs nonsurgical management had less docmented pain (29.0% [n = 465] vs 30.9% [n = 59]) and fewer pressure ulcers (11.2% [n = 200] vs 19.0% [n = 41]). In IPTW models, surgically managed residents reported less pain (aHR, 0.78; 95% CI, 0.61-0.99) and pressure ulcers (aHR, 0.64; 95% CI, 0.47-0.86). There was no difference between antipsychotic drug use and physical restraint use between the groups. Few survivors remained ambulatory (10.7% [n = 55] of surgically managed vs 4.8% [n = 1] without surgery). CONCLUSIONS AND RELEVANCE Surgical repair of a hip fracture was associated with lower mortality among NH residents with advanced dementia and should be considered together with the residents' goals of care in management decisions. Pain and other adverse outcomes were common regardless of surgical management, suggesting the need for broad improvements in the quality of care provided to NH residents with advanced dementia and hip fracture.
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Affiliation(s)
- Sarah D Berry
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Roslindale, Massachusetts
| | - Randi R Rothbaum
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.,Division of Geriatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Douglas P Kiel
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Roslindale, Massachusetts
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice & Center for Gerontology, Brown University School of Public Health, Providence, Rhode Island
| | - Susan L Mitchell
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Roslindale, Massachusetts
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22
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Boyd PA, Wilks SE, Geiger JR. Activities of Daily Living Assessment among Nursing Home Residents with Advanced Dementia: Psychometric Reevaluation of the Bristol Activities of Daily Living Scale. HEALTH & SOCIAL WORK 2018; 43:101-108. [PMID: 29554326 DOI: 10.1093/hsw/hly010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 05/21/2017] [Indexed: 06/08/2023]
Abstract
The purpose of this study was to conduct psychometric reevaluation of the Bristol Activities of Daily Living Scale (BADL) among a population logistically difficult to observe beyond cross-sectional analysis: nursing home residents with advanced dementia (AD). Data from observation-based measures were collected by nursing home staff at two intervals within a three-month time frame among 43 residents identified with AD via medical records and nursing home staff. Three broad properties of BADL were examined: factor structure, reliability, and validity. Principal components analysis determined underlying components. BADL internal consistency was assessed by Cronbach's and Guttman coefficients; test-retest reliability was also observed. Convergent validity was assessed by correlating BADL with theoretically linked measures of quality of life (QOL) and social engagement. Compared with the original evaluation, BADL showed inconsistent factor structure at interval 1 but comparable at interval 2. Reliability coefficients at both intervals were robust and comparable to the original evaluation. BADL demonstrated significant convergence with QOL and social engagement. Psychometric potency of BADL was confirmed, suggesting practice applicability with this AD population. Future research calls for further examination of tools to guide effective interventions with this vulnerable population.
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Affiliation(s)
- Paula August Boyd
- Paula August Boyd, LMSW, is a social worker, Seaside Healthcare, Metairie, LA. Scott E. Wilks,PhD, is associate professor and Jennifer R. Geiger, MSW, is a doctoral candidate, School of Social Work, Louisiana State University, Baton Rouge
| | - Scott E Wilks
- Paula August Boyd, LMSW, is a social worker, Seaside Healthcare, Metairie, LA. Scott E. Wilks,PhD, is associate professor and Jennifer R. Geiger, MSW, is a doctoral candidate, School of Social Work, Louisiana State University, Baton Rouge
| | - Jennifer R Geiger
- Paula August Boyd, LMSW, is a social worker, Seaside Healthcare, Metairie, LA. Scott E. Wilks,PhD, is associate professor and Jennifer R. Geiger, MSW, is a doctoral candidate, School of Social Work, Louisiana State University, Baton Rouge
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Moore KJ, Davis S, Gola A, Harrington J, Kupeli N, Vickerstaff V, King M, Leavey G, Nazareth I, Jones L, Sampson EL. Experiences of end of life amongst family carers of people with advanced dementia: longitudinal cohort study with mixed methods. BMC Geriatr 2017; 17:135. [PMID: 28673257 PMCID: PMC5496359 DOI: 10.1186/s12877-017-0523-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/15/2017] [Indexed: 11/19/2022] Open
Abstract
Background Many studies have examined the mental health of carers of people with dementia. Few have examined their experiences in the advanced stages of disease and into bereavement. We aimed to understand the experiences of carers during advanced dementia exploring the links between mental health and experiences of end of life care. Methods Mixed methods longitudinal cohort study. Thirty-five family carers of people with advanced dementia (6 at home, 29 in care homes) were recruited and assessed monthly for up to nine months or until the person with dementia died, then at two and seven months into bereavement. Assessments included: Hospital Anxiety and Depression Scale, Short Form 12 health–related quality of life, 22-item Zarit Burden Interview, Brief Coping Orientation to Problems Experienced, Inventory of Complicated Grief and Satisfaction with Care at End of Life in Dementia. Subsequently, 12 carers (34%) were bereaved and 12 undertook a qualitative interview two months after death; these data were analysed thematically. We analysed quantitative and qualitative data independently and then merged findings at the point of interpretation. Results At study entry psychological distress was high; 26% reached caseness for depression and 41% for anxiety and median complicated grief scores were 27 [IQR 22–37] indicating that on average 11 of the 16 grief symptoms occurred at least monthly. Physical health reflected population norms (mean = 50) and median burden scores were 17 [IQR 9–30]. Three qualitative themes were identified: the importance of relationships with care services, understanding of the progression of dementia, and emotional responses to advanced dementia. An overarching theme tying these together was the carer’s ability to control and influence end of life care. Conclusions While carers report high levels of psychological distress during advanced dementia, the experience of end of life care in dementia may be amenable to change with the provision of sensitive and timely information about the natural progression of dementia. Regular health status updates and end of life discussions can help families understand dementia progression and prepare for end of life. The extent to which our findings reflect practice across the UK or internationally warrants further investigation.
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Affiliation(s)
- Kirsten J Moore
- Marie Curie Palliative Care Research Department, University College London, London, UK.
| | - Sarah Davis
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Anna Gola
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Jane Harrington
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Michael King
- Division of Psychiatry, University College London, London, UK
| | - Gerard Leavey
- Bamford Centre for Mental Health & Wellbeing, University of Ulster, Magee Campus, Derry Londonderry, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, UCL Royal Free Site, London, UK
| | - Louise Jones
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, University College London, London, UK
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Wilks SE, Boyd PA, Bates SM, Cain DS, Geiger JR. Montessori-Based Activities Among Persons with Late-Stage Dementia: Evaluation of Mental and Behavioral Health Outcomes. DEMENTIA 2017; 18:1373-1392. [PMID: 28449593 DOI: 10.1177/1471301217703242] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Literature regarding Montessori-based activities with older adults with dementia is fairly common with early stages of dementia. Conversely, research on said activities with individuals experiencing late-stage dementia is limited because of logistical difficulties in sampling and data collection. Given the need to understand risks and benefits of treatments for individuals with late-stage dementia, specifically regarding their mental and behavioral health, this study sought to evaluate the effects of a Montessori-based activity program implemented in a long-term care facility. METHOD Utilizing an interrupted time series design, trained staff completed observation-based measures for 43 residents with late-stage dementia at three intervals over six months. Empirical measures assessed mental health (anxiety, psychological well-being, quality of life) and behavioral health (problem behaviors, social engagement, capacity for activities of daily living). RESULTS Group differences were observed via repeated measures ANOVA and paired-samples t-tests. The aggregate, longitudinal results-from baseline to final data interval-for the psychological and behavioral health measures were as follows: problem behaviors diminished though not significantly; social engagement decreased significantly; capacities for activities of daily living decreased significantly; quality of life increased slightly but not significantly; anxiety decreased slightly but not significantly; and psychological well-being significantly decreased. CONCLUSION Improvements observed for quality of life and problem behaviors may yield promise for Montessori-based activities and related health care practices. The rapid physiological and cognitive deterioration from late-stage dementia should be considered when interpreting these results.
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Parsons C. Polypharmacy and inappropriate medication use in patients with dementia: an underresearched problem. Ther Adv Drug Saf 2017; 8:31-46. [PMID: 28203365 PMCID: PMC5298466 DOI: 10.1177/2042098616670798] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Multimorbidity and polypharmacy are increasingly prevalent across healthcare systems and settings as global demographic trends shift towards increased proportions of older people in populations. Numerous studies have demonstrated an association between polypharmacy and potentially inappropriate prescribing (PIP), and have reported high prevalence of PIP across settings of care in Europe and North America and, as a consequence, increased risk of adverse drug reactions, healthcare utilization, morbidity and mortality. These studies have not focused specifically on people with dementia, despite the high risk of adverse drug reactions and PIP in this patient cohort. This narrative review considers the evidence currently available in the area, including studies examining prevalence of PIP in older people with dementia, how appropriateness of prescribing is assessed, the medications most commonly implicated, the clinical consequences, and research priorities to optimize prescribing for this vulnerable patient group. Although there has been a considerable research effort to develop criteria to assess medication appropriateness in older people in recent years, the majority of tools do not focus on people with dementia. Of the limited number of tools available, most focus on the advanced stages of dementia in which life expectancy is limited. The development of tools to assess medication appropriateness in people with mild to moderate dementia or across the full spectrum of disease severity represents an important gap in the research literature and is beginning to attract research interest, with recent studies considering the medication regimen as a whole, or misprescribing, overprescribing or underprescribing of certain medications/medication classes, including anticholinergics, psychotropics, antibiotics and analgesics. Further work is required in development and validation of criteria to assess prescribing appropriateness in this vulnerable patient population, to determine prevalence of PIP in large cohorts of people with the full spectrum of dementia variants and severities, and to examine the impact of PIP on health outcomes.
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Affiliation(s)
- Carole Parsons
- Queen’s University Belfast, 97 Lisburn Road, Belfast, Northern Ireland BT9 7BL, UK
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26
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Eicher S, Theill N, Geschwindner H, Moor C, Wettstein A, Bieri-Brüning G, Hock C, Martin M, Wolf H, Riese F. The last phase of life with dementia in Swiss nursing homes: the study protocol of the longitudinal and prospective ZULIDAD study. BMC Palliat Care 2016; 15:80. [PMID: 27557934 PMCID: PMC4997715 DOI: 10.1186/s12904-016-0151-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 08/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The proportion of older people with advanced dementia who will die in nursing homes is constantly growing. However, little is known about the dying phase, the type of symptoms, the management of symptoms and the quality of life and dying in people with advanced dementia. The ZULIDAD (Zurich Life and Death with Advanced Dementia) study aims at extending the current scientific knowledge by providing first data from Switzerland. METHODS The ZULIDAD study employs a prospective design to study nursing home residents with advanced dementia for three years or until their death in eleven nursing homes in Zurich. Observational data from quarterly questionnaires for relatives and primary nurses is combined with data from the Resident Assessment Instrument - Minimum Data Set (RAI-MDS). Special focus is put on 1) the cross-sectional analysis of baseline and post-mortem data regarding quality of life and quality of dying and how the perceptions of these measures differ between relatives and primary nurses, 2) the longitudinal analyses of established health outcome measures (e.g., EOLD, MSSE, BISAD, QUALID) in order to understand their trajectories and 3) international comparisons of cross-sectional and longitudinal data. DISCUSSION The ZULIDAD study is one of the few existing prospective studies on end-of-life care in dementia and it is the first prospective study to describe the situation in Switzerland. Its multi-perspective approach allows a comprehensive approximation to central health outcome measures at the end of life such as pain, suffering or quality of life. Providing insights into the current provision of care, it can serve as a basis for improving dementia end-of-life care in Switzerland and internationally.
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Affiliation(s)
- Stefanie Eicher
- University Research Priority Program “Dynamics of Healthy Aging”, University of Zurich, Andreasstrasse 15, 8050 Zurich, Switzerland
- Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland
| | - Nathan Theill
- University Research Priority Program “Dynamics of Healthy Aging”, University of Zurich, Andreasstrasse 15, 8050 Zurich, Switzerland
- Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Lenggstr. 31, 8032 Zurich, Switzerland
| | - Heike Geschwindner
- City of Zurich Nursing Homes, Walchestrasse 31, 8021 Zurich, Switzerland
| | - Caroline Moor
- Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland
| | - Albert Wettstein
- Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland
| | | | - Christoph Hock
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Lenggstr. 31, 8032 Zurich, Switzerland
| | - Mike Martin
- University Research Priority Program “Dynamics of Healthy Aging”, University of Zurich, Andreasstrasse 15, 8050 Zurich, Switzerland
- Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland
- Department of Psychology, University of Zurich, Binzmuehlestrasse 14, 8050 Zurich, Switzerland
| | - Henrike Wolf
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Lenggstr. 31, 8032 Zurich, Switzerland
| | - Florian Riese
- University Research Priority Program “Dynamics of Healthy Aging”, University of Zurich, Andreasstrasse 15, 8050 Zurich, Switzerland
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Lenggstr. 31, 8032 Zurich, Switzerland
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Hanson E, Hellström A, Sandvide Å, Jackson GA, MacRae R, Waugh A, Abreu W, Tolson D. The extended palliative phase of dementia – An integrative literature review. DEMENTIA 2016; 18:108-134. [PMID: 27460046 DOI: 10.1177/1471301216659797] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This article presents an integrative literature review of the experience of dementia care associated with the extended palliative phase of dementia. The aim was to highlight how dementia is defined in the literature and describe what is known about the symptomatology and management of advanced dementia regarding the needs and preferences of the person with dementia and their family carer/s. There was no consistent definition of advanced dementia. The extended palliative phase was generally synonymous with end-of-life care. Advanced care planning is purported to enable professionals to work together with people with dementia and their families. A lack of understanding of palliative care among frontline practitioners was related to a dearth of educational opportunities in advanced dementia care. There are few robust concepts and theories that embrace living the best life possible during the later stages of dementia. These findings informed our subsequent work around the concept, ‘Dementia Palliare’.
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Affiliation(s)
- Elizabeth Hanson
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
| | - Amanda Hellström
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
| | - Åsa Sandvide
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
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Geros-Willfond KN, Ivy SS, Montz K, Bohan SE, Torke AM. Religion and Spirituality in Surrogate Decision Making for Hospitalized Older Adults. JOURNAL OF RELIGION AND HEALTH 2016; 55:765-777. [PMID: 26337437 PMCID: PMC4779068 DOI: 10.1007/s10943-015-0111-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
We conducted semi-structured interviews with 46 surrogate decision makers for hospitalized older adults to characterize the role of spirituality and religion in decision making. Three themes emerged: (1) religion as a guide to decision making, (2) control, and (3) faith, death and dying. For religious surrogates, religion played a central role in end of life decisions. There was variability regarding whether God or humans were perceived to be in control; however, beliefs about control led to varying perspectives on acceptance of comfort-focused treatment. We conclude that clinicians should attend to religious considerations due to their impact on decision making.
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Affiliation(s)
| | - Steven S Ivy
- Fairbanks Center for Medical Ethics, Indiana University (IU) Health, Indianapolis, IN, USA
- Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, IU Health, Indianapolis, IN, USA
| | - Kianna Montz
- IU Center for Aging Research, Regenstrief Institute, Inc., 410 W. 10th St., Indianapolis, IN, 46202, USA
| | - Sara E Bohan
- Critical Care and Pulmonary Medicine, Community Hospital Network, Indianapolis, IN, USA
| | - Alexia M Torke
- Fairbanks Center for Medical Ethics, Indiana University (IU) Health, Indianapolis, IN, USA.
- Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, IU Health, Indianapolis, IN, USA.
- IU Center for Aging Research, Regenstrief Institute, Inc., 410 W. 10th St., Indianapolis, IN, 46202, USA.
- Indiana University School of Medicine, Indianapolis, IN, USA.
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Agar M, Beattie E, Luckett T, Phillips J, Luscombe G, Goodall S, Mitchell G, Pond D, Davidson PM, Chenoweth L. Pragmatic cluster randomised controlled trial of facilitated family case conferencing compared with usual care for improving end of life care and outcomes in nursing home residents with advanced dementia and their families: the IDEAL study protocol. BMC Palliat Care 2015; 14:63. [PMID: 26589957 PMCID: PMC4654825 DOI: 10.1186/s12904-015-0061-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 11/10/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Care for people with advanced dementia requires a palliative approach targeted to the illness trajectory and tailored to individual needs. However, care in nursing homes is often compromised by poor communication and limited staff expertise. This paper reports the protocol for the IDEAL Project, which aims to: 1) compare the efficacy of a facilitated approach to family case conferencing with usual care; 2) provide insights into nursing home- and staff-related processes influencing the implementation and sustainability of case conferencing; and 3) evaluate cost-effectiveness. DESIGN/METHODS A pragmatic parallel cluster randomised controlled trial design will be used. Twenty Australian nursing homes will be randomised to receive either facilitated family case conferencing or usual care. In the intervention arm, we will train registered nurses at each nursing home to work as Palliative Care Planning Coordinators (PCPCs) 16 h per week over 18 months. The PCPCs' role will be to: 1) use evidence-based 'triggers' to identify optimal time-points for case conferencing; 2) organise, facilitate and document case conferences with optimal involvement from family, multi-disciplinary nursing home staff and community health professionals; 3) develop and oversee implementation of palliative care plans; and 4) train other staff in person-centred palliative care. The primary endpoint will be symptom management, comfort and satisfaction with care at the end of life as rated by bereaved family members on the End of Life in Dementia (EOLD) Scales. Secondary outcomes will include resident quality of life (Quality of Life in Late-stage Dementia [QUALID]), whether a palliative approach is taken (e.g. hospitalisations, non-palliative medical treatments), staff attitudes and knowledge (Palliative Care for Advanced Dementia [qPAD]), and cost effectiveness. Processes and factors influencing implementation, outcomes and sustainability will be explored statistically via analysis of intervention 'dose' and qualitatively via semi-structured interviews. The pragmatic design and complex nature of the intervention will limit blinding and internal validity but support external validity. DISCUSSION The IDEAL Project will make an important contribution to the evidence base for dementia-specific case conferencing in nursing homes by considering processes and contextual factors as well as overall efficacy. Its strengths and weaknesses will both lie in its pragmatic design. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12612001164886. Registered 02/11/2012.
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Affiliation(s)
- Meera Agar
- Discipline of Palliative and Supportive Services, Flinders University, Adelaide, Australia.
- South West Sydney Clinical School, and Improving Palliative Care through Clinical trials (ImPACCT), University of New South Wales, Sydney, Australia.
- Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, Australia.
- Ingham Institute of Applied Medical Research, Sydney, Australia.
| | - Elizabeth Beattie
- Dementia Collaborative Research Centre, Queensland University of Technology, Brisbane, Australia.
- School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Australia.
| | - Tim Luckett
- South West Sydney Clinical School, and Improving Palliative Care through Clinical trials (ImPACCT), University of New South Wales, Sydney, Australia.
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, Australia.
- University of Technology Sydney (UTS) Faculty of Health, Building 10, Level 7, 235-253 Jones St, Ultimo, NSW 2007, Australia.
| | - Jane Phillips
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, Australia.
| | - Georgina Luscombe
- School of Rural Health, Faculty of Medicine, The University of Sydney, Sydney, Australia.
| | - Stephen Goodall
- Centre for health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, Australia.
| | - Geoffrey Mitchell
- Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Australia.
| | - Dimity Pond
- School of Medicine and Public Health, Faculty of Health, University of Newcastle, Newcastle, Australia.
| | | | - Lynnette Chenoweth
- Faculty of Health, University of Technology Sydney, Sydney, Australia.
- Centre for Healthy Brain Ageing, University of New South Wales, Sydney, Australia.
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Shepherd V, Nuttall J, Hood K, Butler CC. Setting up a clinical trial in care homes: challenges encountered and recommendations for future research practice. BMC Res Notes 2015; 8:306. [PMID: 26179284 PMCID: PMC4504165 DOI: 10.1186/s13104-015-1276-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 07/13/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Older adults in care homes have increasingly complex health care needs, and care provision should be evidence-based whenever possible. However, recruitment of frail, older people to research is a complex process and often results in care home residents being excluded from research participation. This paper draws on the experience of setting up a randomised controlled trial to determine the effectiveness of probiotics on antibiotic-associated diarrhoea in care home residents [Probiotics for Antibiotic Associated Diarrhoea in Care Homes (PAAD) Study] in Wales. FINDINGS Significant challenges were encountered setting up a clinical trial in care homes. There were a number of barriers and facilitative factors encountered that were unique to this research setting. The classification of the study intervention (a widely available food supplement with a low risk safety profile) as an investigational medicinal product, with the associated requirements including obtaining statutory approvals and research governance, had a major impact. CONCLUSION The process for setting up a clinical trial of an investigational medicinal product in care homes has been more complex and time consuming than the process for setting up an observational study in the same setting, and clinical trials in other health care settings. We recommend regulatory changes to ensure approvals processes are more proportionate to risk and context, to ensure that care home residents have the opportunity to participate in research and are able to help generate much needed evidence to underpin care. Recommendations made may inform future research practice. TRIAL REGISTRATION ISRCTN 25324586.
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Affiliation(s)
- Victoria Shepherd
- South East Wales Trials Unit, School of Medicine, Cardiff University, 7th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Jacqui Nuttall
- South East Wales Trials Unit, School of Medicine, Cardiff University, 7th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Kerenza Hood
- South East Wales Trials Unit, School of Medicine, Cardiff University, 7th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6NW, UK.
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, 5th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
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De Roo ML, Albers G, Deliens L, de Vet HCW, Francke AL, Van Den Noortgate N, Van den Block L. Physical and Psychological Distress Are Related to Dying Peacefully in Residents With Dementia in Long-Term Care Facilities. J Pain Symptom Manage 2015; 50:1-8. [PMID: 25847852 DOI: 10.1016/j.jpainsymman.2015.02.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 01/27/2015] [Accepted: 02/02/2015] [Indexed: 11/28/2022]
Abstract
CONTEXT Although dying peacefully is considered an important outcome of high-quality palliative care, large-scale quantitative research on dying peacefully and the factors associated with a peaceful death is lacking. OBJECTIVES To gain insight into how many residents with dementia in long-term care facilities die peacefully, according to their relatives, and whether that assessment is correlated with observed physical and psychological distress. METHODS This was a retrospective cross-sectional study of deceased nursing home residents in a representative sample of long-term care facilities in Flanders, Belgium (2010). Structured post-mortem questionnaires were completed by relatives of the resident, who were asked to what extent they agreed that the resident "appeared to be at peace" during the dying process. Spearman correlation coefficients gave the correlations between physical and psychological distress (as measured using the Symptom Management at the End of Life with Dementia and Comfort Assessment in Dying at the End of Life with Dementia scales) and dying peacefully (as measured using the Quality of Dying in Long Term Care instrument). RESULTS The sample comprised 92 relatives of deceased residents with dementia. In 54% of cases, relatives indicated that the resident died peacefully. Weak-to-moderate correlations (0.2-0.57) were found between dying peacefully and physical distress in the last week of life. Regarding psychological distress, weak-to-moderate correlations were found for both the last week (0.33-0.44) and last month of life (0.28-0.47). CONCLUSION Only half of the residents with dementia died peacefully as perceived by their relatives. Relatives' assessment of whether death was peaceful is related to both physical and psychological distress. Further qualitative research is recommended to gain more in-depth insights into the aspects on which relatives base their judgment of dying peacefully.
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Affiliation(s)
- Maaike L De Roo
- Department of Public and Occupational Health & Expertise Center of Palliative Care, EMGO Institute for Health and Care Research, Vrije University Medical Center, Amsterdam, The Netherlands.
| | - Gwenda Albers
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Luc Deliens
- Department of Public and Occupational Health & Expertise Center of Palliative Care, EMGO Institute for Health and Care Research, Vrije University Medical Center, Amsterdam, The Netherlands; End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Henrica C W de Vet
- Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Anneke L Francke
- Department of Public and Occupational Health & Expertise Center of Palliative Care, EMGO Institute for Health and Care Research, Vrije University Medical Center, Amsterdam, The Netherlands; NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | | | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
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The IOM Report on Dying in America: A Call to Action for Nursing Homes. J Am Med Dir Assoc 2015; 16:90-2. [DOI: 10.1016/j.jamda.2014.11.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 11/10/2014] [Indexed: 11/21/2022]
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Supiano KP, Andersen TC, Haynes LB. Sudden-On-Chronic Death and Complicated Grief in Bereaved Dementia Caregivers: Two Case Studies of Complicated Grief Group Therapy. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2015; 11:267-282. [PMID: 26654061 DOI: 10.1080/15524256.2015.1107810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Caring for a person with Alzheimer's disease is challenging and often has negative health and mental health effects that, for 7-20% of caregivers, persist into bereavement in the form of complicated grief. Complicated grief is a state of prolonged and ineffective mourning. An under-recognized phenomenon in dementia care and bereavement is "sudden-on-chronic death." In these situations, the caregiver is preparing for a gradual dying process from dementia, but the care recipient dies instead from a sudden death. In this study, an application of complicated grief group therapy for bereaved dementia caregivers with complicated grief is presented, and the effect of therapy with two bereaved caregivers who experienced the sudden death of their spouses who had a diagnosis of dementia is described. The unique treatment elements of complicated grief group therapy facilitated resolution of the 'trauma-like" features of bereavement and progression to a healthy grief process.
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Affiliation(s)
| | - Troy C Andersen
- b University of Utah College of Social Work , Salt Lake City , Utah , USA
| | - Lara Burns Haynes
- a University of Utah College of Nursing , Salt Lake City , Utah , USA
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Development and Application of Medication Appropriateness Indicators for Persons with Advanced Dementia: A Feasibility Study. Drugs Aging 2014; 32:67-77. [DOI: 10.1007/s40266-014-0226-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Retrospective and prospective data collection compared in the Dutch End Of Life in Dementia (DEOLD) study. Alzheimer Dis Assoc Disord 2014; 28:88-94. [PMID: 23632265 DOI: 10.1097/wad.0b013e318293b380] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Studying end of life in dementia patients is challenging because of ill-defined prognoses and frequent inability to self-report. We aim to quantify and compare (1) feasibility and (2) sampling issues between prospective and retrospective data collection specific to end-of-life research in long-term care settings. The observational Dutch End of Life in Dementia study (DEOLD; 2007 to 2011) used both prospective data collection (28 facilities; 17 nursing home organizations/physician teams; questionnaires between January 2007 and July 2010, survival until July 2011) and retrospective data collection (exclusively after death; 6 facilities; 2 teams, questionnaires between November 2007 and March 2010). Prospective collection extended from the time of admission to the time after death or conclusion of the study. Prospectively, we recruited 372 families: 218 residents died (59%) and 184 (49%) had complete physician and family after-death assessments. Retrospectively, 119 decedents were enrolled, with 64 (54%) complete assessments. Cumulative data collection over all homes lasted 80 and 8 years, respectively. Per complete after-death assessments in a year, the prospective data collection involved 37.9 beds, whereas this was 7.9 for the retrospective data collection. Although age at death, sex, and survival curves were similar, prospectively, decedents' length of stay was shorter (10.3 vs. 31.4 mo), and fewer residents had advanced dementia (39% vs. 54%). Regarding feasibility, we conclude that prospective data collection is many fold more intensive and complex per complete after-death assessment. Regarding sampling, if not all are followed until death, it results in right censoring and in different, nonrepresentative samples of decedents compared with retrospective data collection. Future work may adjust or stratify for dementia severity and length of stay as key issues to promote comparability between studies.
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Bute JJ, Petronio S, Torke AM. Surrogate decision makers and proxy ownership: challenges of privacy management in health care decision making. HEALTH COMMUNICATION 2014; 30:799-809. [PMID: 25175060 PMCID: PMC5003017 DOI: 10.1080/10410236.2014.900528] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
This study explored the communicative experiences of surrogates who served as decision makers for patients who were unable to convey health information and choices about treatment options. Drawing on assumptions from communication privacy management theory (Petronio, 2002), 35 surrogates were interviewed to explore how they navigated the role of guardian of patients' private health information while the patient was hospitalized. This research determined that not only are surrogates guardians and thereby co-owners of the patients' private health information, they actually served in a "proxy ownership" role. Surrogates described obstacles to both obtaining and sharing private health information about the patient, suggesting that their rights as legitimate co-owners of the patients' information were not fully acknowledged by the medical teams. Surrogates also described challenges in performing the proxy ownership role when they were not fully aware of the patient's wishes. Theoretical and practical implications of these challenges are discussed.
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Affiliation(s)
- Jennifer J. Bute
- Department of Communication Studies, IU School of Liberal Arts, Indiana University-Purdue University Indianapolis, Cavanaugh Hall 307J, 425 University Blvd, Indianapolis, IN 46202, 317-274-2090
| | - Sandra Petronio
- IU School of Liberal Arts, Department of Communication Studies, IU School of Medicine, Campus of Indiana University-Purdue University, Indianapolis (IUPUI)
- Charles Warren Fairbanks Center for Medical Ethics, IU Health,
| | - Alexia M. Torke
- Indiana University, Indiana University Center for Aging Research, Regenstrief Institute, Inc., Fairbanks Center for Medical Ethics, HITS Building Suite 2000, 410 W. 10th St., Indianapolis, IN 46202, 317-423-5649,
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Elliott M, Harrington J, Moore K, Davis S, Kupeli N, Vickerstaff V, Gola A, Candy B, Sampson EL, Jones L. A protocol for an exploratory phase I mixed-methods study of enhanced integrated care for care home residents with advanced dementia: the Compassion Intervention. BMJ Open 2014; 4:e005661. [PMID: 24939815 PMCID: PMC4067896 DOI: 10.1136/bmjopen-2014-005661] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION In the UK approximately 700,000 people are living with, and a third of people aged over 65 will die with, dementia. People with dementia may receive poor quality care towards the end of life. We applied a realist approach and used mixed methods to develop a complex intervention to improve care for people with advanced dementia and their family carers. Consensus on intervention content was achieved using the RAND UCLA appropriateness method and mapped to sociological theories of process and impact. Core components are: (1) facilitation of integrated care, (2) education, training and support, (3) investment from commissioners and care providers. We present the protocol for an exploratory phase I study to implement components 1 and 2 in order to understand how the intervention operates in practice and to assess feasibility and acceptability. METHODS AND ANALYSIS An 'Interdisciplinary Care Leader (ICL)' will work within two care homes, alongside staff and associated professionals to facilitate service integration, encourage structured needs assessment, develop the use of personal and advance care plans and support staff training. We will use qualitative and quantitative methods to collect data for a range of outcome and process measures to detect effects on individual residents, family carers, care home staff, the intervention team, the interdisciplinary team and wider systems. Analysis will include descriptive statistics summarising process and care home level data, individual demographic and clinical characteristics and data on symptom burden, clinical events and quality of care. Qualitative data will be explored using thematic analysis. Findings will inform a future phase II trial. ETHICS AND DISSEMINATION Ethical approval was granted (REC reference 14/LO/0370). We shall publish findings at conferences, in peer-reviewed journals, on the Marie Curie Cancer Care website and prepare reports for dissemination by organisations involved with end-of-life care and dementia.
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Affiliation(s)
- Margaret Elliott
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Jane Harrington
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Kirsten Moore
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Sarah Davis
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Anna Gola
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Louise Jones
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
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Albers G, Van den Block L, Vander Stichele R. The burden of caring for people with dementia at the end of life in nursing homes: a postdeath study among nursing staff. Int J Older People Nurs 2014; 9:106-17. [DOI: 10.1111/opn.12050] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/31/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Gwenda Albers
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) & Ghent University; Brussels Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) & Ghent University; Brussels Belgium
| | - Robert Vander Stichele
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) & Ghent University; Brussels Belgium
- Heymans Institute of Pharmacology; Ghent University; Ghent Belgium
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Hendriks SA, Smalbrugge M, Hertogh CMPM, van der Steen JT. Dying with dementia: symptoms, treatment, and quality of life in the last week of life. J Pain Symptom Manage 2014; 47:710-20. [PMID: 23916680 DOI: 10.1016/j.jpainsymman.2013.05.015] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 05/18/2013] [Accepted: 05/22/2013] [Indexed: 11/25/2022]
Abstract
CONTEXT Burdensome symptoms present frequently in dementia at the end of life, but we know little about the symptom control provided, such as type and dosage of medication. OBJECTIVES To investigate symptom prevalence and prescribed treatment, explore associations with quality of life (QOL) in the last week of life, and examine symptom prevalence by cause of death of nursing home residents with dementia. METHODS Within two weeks after death, physicians completed questionnaires about symptoms and treatment in the last week for 330 nursing home residents with dementia in the Dutch End of Life in Dementia study (2007-2011). We used linear regression to assess associations with QOL, measured by the Quality of Life in Late-Stage Dementia scale. Causes of death were abstracted from death certificates. RESULTS Pain was the most common symptom (52%), followed by agitation (35%) and shortness of breath (35%). Pain and shortness of breath were mostly treated with opioids and agitation mainly with anxiolytics. At the day of death, 77% received opioids, with a median of 90 mg/24 hours (oral equivalents), and 21% received palliative sedation. Pain and agitation were associated with a lower QOL. Death from respiratory infection was associated with the largest symptom burden. CONCLUSION Symptoms are common in dementia at the end of life, despite the large majority of residents receiving opioids. Dosages may be suboptimal with regard to weighing of effects and side effects. Future research may employ observation on a day-to-day basis to better assess effectiveness of symptom control and possible side effects.
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Affiliation(s)
- Simone A Hendriks
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Martin Smalbrugge
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Jenny T van der Steen
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
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De Roo ML, van der Steen JT, Galindo Garre F, Van Den Noortgate N, Onwuteaka-Philipsen BD, Deliens L, Francke AL. When do people with dementia die peacefully? An analysis of data collected prospectively in long-term care settings. Palliat Med 2014; 28:210-9. [PMID: 24292158 DOI: 10.1177/0269216313509128] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Little is known about dying peacefully with dementia in long-term care facilities. Dying peacefully may be influenced by characteristics of the palliative care provided and characteristics of the long-term care setting. If so, dying peacefully may serve as a quality indicator for palliative care in dementia. AIM This study aims to describe whether residents with dementia in Dutch long-term care facilities die peacefully and to assess which characteristics of the resident, the palliative care provided and the facilities are associated with dying peacefully. DESIGN AND SETTING We analysed existing data from the Dutch End of Life in Dementia study, collected between January 2007 and July 2010 in 34 long-term care facilities in the Netherlands. We used descriptive statistics and Generalised Estimating Equation models. RESULTS The sample consisted of 233 residents with dementia. Family members indicated that the resident died peacefully in 56% of cases. This percentage ranged from 17% to 80% across facilities. Residents were more likely to die peacefully if they had an optimistic attitude, if family found that there were enough nurses available and if residents died in facilities with a moderate (versus no) perceived influence of religious affiliation on end-of-life decision-making policies. CONCLUSIONS Only half of the residents with dementia in Dutch long-term care facilities die peacefully, as perceived by relatives. In addition to residents' optimistic attitude, facility characteristics are associated with dying peacefully, which suggests that 'the percentage of relatives who indicate that the patient died peacefully' can function as a quality indicator.
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Affiliation(s)
- Maaike L De Roo
- 1Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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Sternberg S, Bentur N, Shuldiner J. Quality of Care of Older People Living with Advanced Dementia in the Community in Israel. J Am Geriatr Soc 2014; 62:269-75. [DOI: 10.1111/jgs.12655] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Goldfeld KS, Grabowski DC, Caudry DJ, Mitchell SL. Health insurance status and the care of nursing home residents with advanced dementia. JAMA Intern Med 2013; 173:2047-53. [PMID: 24061265 PMCID: PMC3859713 DOI: 10.1001/jamainternmed.2013.10573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Nursing home residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve the quality of life. Fragmentation in health care has contributed to poor coordination of care for acutely ill nursing home residents. OBJECTIVE To compare patterns of care and quality outcomes for nursing home residents with advanced dementia covered by managed care with those covered by traditional fee-for-service Medicare. DESIGN, SETTING, AND PARTICIPANTS Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life (CASCADE) was a prospective cohort study including 22 nursing homes in the Boston, Massachusetts, area that monitored 323 nursing home residents for 18 months to better understand the course of advanced dementia at or near the end of life. Data from CASCADE and Medicare were linked to determine the health insurance status of study participants. EXPOSURES The health insurance status of the resident, either managed care or traditional fee for service. MAIN OUTCOMES AND MEASURES The outcomes included survival, symptoms related to comfort, treatment of pain and dyspnea, presence of pressure ulcers, presence of a do-not-hospitalize order, treatment of pneumonia, hospital transfer (admission or emergency department visit) for an acute illness, hospice referral, primary care visits, and family satisfaction with care. RESULTS Residents enrolled in managed care (n = 133) were more likely to have do-not-hospitalize orders compared with those in traditional Medicare fee for service (n = 158) (63.7% vs 50.9%; adjusted odds ratio, 1.9; 95% CI, 1.1-3.4), were less likely to be transferred to the hospital for acute illness (3.8% vs 15.7%; adjusted odds ratio, 0.2; 95% CI, 0.1-0.5), had more primary care visits per 90 days (mean [SD], 4.8 [2.6] vs 4.2 [5.0]; adjusted rate ratio, 1.3; 95% CI, 1.1-1.6), and had more nurse practitioner visits (3.0 [2.1] vs 0.8 [2.6]; adjusted rate ratio, 3.0; 95% CI, 2.2-4.1). Survival, comfort, and other treatment outcomes did not differ significantly across groups. CONCLUSIONS AND RELEVANCE Medicare managed-care programs may offer a promising approach to ensure that nursing homes are able to provide appropriate, less burdensome, and affordable care, especially at the end of life.
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Affiliation(s)
- Keith S Goldfeld
- Department of Population Health, New York University School of Medicine, New York
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Lopez RP, Mazor KM, Mitchell SL, Givens JL. What is family-centered care for nursing home residents with advanced dementia? Am J Alzheimers Dis Other Demen 2013; 28:763-8. [PMID: 24085250 PMCID: PMC4120188 DOI: 10.1177/1533317513504613] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To understand family members' perspectives on person- and family-centered end-of-life care provided to nursing home (NH) residents with advanced dementia, we conducted a qualitative follow-up interview with 16 respondents who had participated in an earlier prospective study, Choices, Attitudes, and Strategies for Care of Advance Dementia at End of Life (CASCADE). Family members of NH residents (N = 16) with advanced dementia participated in semistructured qualitative interviews that inquired about overall NH experience, communication, surrogate decision making, emotional reaction, and recommendations for improvement. Analysis identified 5 areas considered important by family members: (1) providing basic care; (2) ensuring safety and security; (3) creating a sense of belonging and attachment; (4) fostering self-esteem and self-efficacy; and (5) coming to terms with the experience. These themes can provide a framework for creating and testing strategies to meet the goal of person- and family-centered care.
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Affiliation(s)
- Ruth Palan Lopez
- MGH Institute of Health Professions, School of Nursing, Boston, MA, USA
| | - Kathleen M. Mazor
- Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
| | - Susan L. Mitchell
- Hebrew SeniorLife, Institute for Aging Research, Boston, MA, USA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jane L. Givens
- Hebrew SeniorLife, Institute for Aging Research, Boston, MA, USA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Goldfeld KS, Hamel MB, Mitchell SL. The cost-effectiveness of the decision to hospitalize nursing home residents with advanced dementia. J Pain Symptom Manage 2013; 46:640-51. [PMID: 23571207 PMCID: PMC3708971 DOI: 10.1016/j.jpainsymman.2012.11.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 11/14/2012] [Accepted: 12/07/2012] [Indexed: 11/23/2022]
Abstract
CONTEXT Nursing home (NH) residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve quality of life. Cost-effectiveness analyses of decisions to hospitalize these residents have not been reported. OBJECTIVES To estimate the cost-effectiveness of 1) not having a do-not-hospitalize (DNH) order and 2) hospitalization for suspected pneumonia in NH residents with advanced dementia. METHODS NH residents from 22 NHs in the Boston area were followed in the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study conducted between February 2003 and February 2009. We conducted cost-effectiveness analyses of aggressive treatment strategies for advanced dementia residents living in NHs when they suffer from acute illness. Primary outcome measures included quality-adjusted life days (QALD) and quality-adjusted life years, Medicare expenditures, and incremental net benefits (INBs) over 15 months. RESULTS Compared with a less aggressive strategy of avoiding hospital transfer (i.e., having DNH orders), the strategy of hospitalization was associated with an incremental increase in Medicare expenditures of $5972 and an incremental gain in quality-adjusted survival of 3.7 QALD. Hospitalization for pneumonia was associated with an incremental increase in Medicare expenditures of $3697 and an incremental reduction in quality-adjusted survival of 9.7 QALD. At a willingness-to-pay level of $100,000/quality-adjusted life years, the INBs of the more aggressive treatment strategies were negative and, therefore, not cost effective (INB for not having a DNH order, -$4958 and INB for hospital transfer for pneumonia, -$6355). CONCLUSION Treatment strategies favoring hospitalization for NH residents with advanced dementia are not cost effective.
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Affiliation(s)
- Keith S Goldfeld
- Department of Population Health, New York University School of Medicine, New York, New York, USA.
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Goldfeld K. Twice-weighted multiple interval estimation of a marginal structural model to analyze cost-effectiveness. Stat Med 2013; 33:1222-41. [DOI: 10.1002/sim.6017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 09/26/2013] [Accepted: 09/30/2013] [Indexed: 11/11/2022]
Affiliation(s)
- K.S. Goldfeld
- Department of Population Health; NYU School of Medicine; New York NY U.S.A
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Supiano KP, Luptak M. Complicated grief in older adults: a randomized controlled trial of complicated grief group therapy. THE GERONTOLOGIST 2013; 54:840-56. [PMID: 23887932 DOI: 10.1093/geront/gnt076] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE This study compared the efficacy of complicated grief therapy (CGT; Shear, K. [2003]. Complicated grief: A guidebook for therapists [Liberty Version]. New York State Office of Mental Heath; Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F. 3rd [2005]. Treatment of complicated grief: A randomized controlled trial. The Journal of the American Medical Association, 293, 2601-2608) administered as group therapy (CGGT) with standard group therapy (treatment as usual [TAU]) in older adults presenting with complicated grief (CG). METHODS The design was a 2×4, prospective, randomized controlled clinical trial. The independent variable was group type, with 1 group receiving experimental methods based on the work of Shear et al. (Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F. 3rd. [2005]. Treatment of complicated grief: a randomized controlled trial. The Journal of the American Medical Association, 293, 2601-2608), CGGT versus. TAU. The dependent variable was treatment response. RESULTS CGGT participants demonstrated higher treatment response than TAU participants. Although participants in both groups showed improvement in CG measures, CGGT participants realized significantly greater improvement. More importantly, when CG was measured on Prolonged Grief Disorder Scale, nearly half of CGGT participants realized clinically significant improvement. All CGGT completers had Brief Grief Questionnaire scores upon follow-up that, had they scored at that level at pretest, would have disqualified them for study enrollment. IMPLICATIONS The high level of clinical significance suggests that CGGT participants were effectively treated for CG. This study offers evidence that CGGT holds promise for treatment of CG in older adults and merits inquiry in other populations.
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Affiliation(s)
| | - Marilyn Luptak
- College of Social Work, University of Utah, Salt Lake City
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Scales for the evaluation of end-of-life care in advanced dementia: sensitivity to change. Alzheimer Dis Assoc Disord 2013; 26:358-63. [PMID: 22273800 DOI: 10.1097/wad.0b013e318247c41b] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The paucity of valid and reliable instruments designed to measure end-of-life experiences limits advanced dementia and palliative care research. Two end-of-life in dementia (EOLD) scales that evaluate the experiences of severely cognitively impaired persons and their health care proxies (HCP) have been developed: (1) symptom management (SM) and (2) satisfaction with care (SWC). The aim of this study was to examine the sensitivity of the EOLD scales in detecting significant differences in clinically relevant outcomes in nursing home residents with advanced dementia. The SM-EOLD scale was sensitive to detecting changes in comfort among residents with pneumonia, pain, dyspnea, and receiving burdensome interventions. The SWC-EOLD scale was sensitive to detecting changes in HCP satisfaction with the care of residents when addressing whether the health care provider spent >15 minutes discussing the resident's advanced care planning, whether the physician counseled about the resident's live expectancy, whether the resident resided in a special care unit, and whether the physician counseled possible resident health problems. This study extends the psychometric properties of the EOLD scales by showing the sensitivity to clinically meaningful change in these scales to specific outcomes related to end-of-life care and quality of life among residents with end-stage advanced dementia and their HCPs.
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Vandervoort A, Van den Block L, van der Steen JT, Volicer L, Vander Stichele R, Houttekier D, Deliens L. Nursing home residents dying with dementia in Flanders, Belgium: a nationwide postmortem study on clinical characteristics and quality of dying. J Am Med Dir Assoc 2013; 14:485-92. [PMID: 23523319 DOI: 10.1016/j.jamda.2013.01.016] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 01/17/2013] [Accepted: 01/22/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVES There is a lack of large-scale, nationwide data describing clinical characteristics and quality of dying of nursing home residents dying with dementia. We set out to investigate quality of end-of-life care and quality of dying of nursing home residents with dementia in Flanders, Belgium. DESIGN/SETTING/PARTICIPANTS To obtain representativity, we conducted a postmortem study (2010) using random cluster sampling. In selected nursing homes, all deceased residents with dementia in a period of 3 months were reported. For each case, a structured questionnaire was filled in by the nurse most involved in care, the family physician, and the nursing home administrator. We used the Cognitive Performance Scale and Global Deterioration Scale to assess dementia. Main outcome measures were health status, clinical complications, symptoms at the end of life, and quality of dying. MEASUREMENTS Health status, clinical complications, symptoms at the end of life, and quality of dying. RESULTS We identified 198 deceased residents with dementia in 69 nursing homes (58% response rate). Age distribution was the same as all deceased residents with dementia in Flanders, 2010. Fifty-four percent had advanced dementia. In the last month of life, 95.5% had 1 or more sentinel events (eg, eating/drinking problems, febrile episodes, or pneumonia); most frequently reported symptoms were pain, fear, anxiety, agitation, and resistance to care. In the last week, difficulty swallowing and pain were reported most frequently. Pressure sores were present in 26.9%, incontinence in 89.2%, and cachexia in 45.8%. Physical restraints were used in 21.4% of cases, and 10.0% died outside the home. Comparing stages of dementia revealed few differences between groups regarding clinical complications, symptoms, or quality of dying. CONCLUSION Regardless of the dementia stage, many nursing home residents develop serious clinical complications and symptoms in the last phase of life, posing major challenges to the provision of optimum end-of-life care.
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Affiliation(s)
- An Vandervoort
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium.
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Sources of stress for family members of nursing home residents with advanced dementia. Alzheimer Dis Assoc Disord 2013; 26:254-9. [PMID: 22037596 DOI: 10.1097/wad.0b013e31823899e4] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The sources of stress for families of nursing home (NH) residents with advanced dementia have not been well described. Semistructured interviews were conducted with 16 family members previously enrolled in the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study, a prospective cohort of 323 NH residents with advanced dementia and their family members. Questions were asked pertaining to the experience of having a family member in the NH, communication with health-care professionals, surrogate decision making, emotional distress, and recommendations for improvement in care. Transcripts were analyzed using the constant comparative method. The majority of the participants were women (63%), children of the resident (94%), and white (94%). The average age was 62 years. Four themes emerged: (1) inadequate resident personal care, resulting in family member vigilance and participation in care; (2) stress at the time of NH admission; (3) lack of communication with NH physicians; and (4) challenges of surrogate decision making, including the need for education to support advance care planning and end-of-life decisions. Our results support the provision of emotional support to families upon resident admission, education regarding prognosis to guide decision making, improved resident care, and greater communication with health care professionals.
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