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Kim D, Chang SO. How do nurses advocate for the remaining time of nursing home residents? A critical discourse analysis. Int J Nurs Stud 2024; 156:104807. [PMID: 38797042 DOI: 10.1016/j.ijnurstu.2024.104807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 04/10/2024] [Accepted: 05/10/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Due to the global aging trend, the number of older people who will spend the last years of their lives in nursing homes is increasing. However, nursing homes have long confronted negative social and public discourses, including stigmas on dementia and life in such facilities. Nevertheless, the remaining time of residents with dementia holds significance, for them and their families, as they seek respect and the ability to make meaningful end-of-life decisions. OBJECTIVE To explore how nursing home nurses advocate for the remaining lifetimes of residents with dementia. DESIGN A qualitative research design. SETTING(S) Four nursing homes in Korea from January 2023 to February 2023. PARTICIPANTS Twenty nurses who provide direct caregiving for residents with dementia and have a minimum of two years' experience in nursing homes were recruited. METHODS This study employed a critical discourse analysis. Twenty interviews conducted with nursing home nurses were examined to explore the connections between the grammatical and lexical aspects of the language used by the nurses to construct their identities as advocates for residents with dementia and the broader sociocultural context. FINDINGS Four discourses regarding nursing home nurses advocating for the value of life of residents with dementia were identified: (1) Bridging perspectives: I am a negotiator between medical treatment and residents' families with differing views; (2) Embracing a shared humanity: Residents are no different from me; they just need professional help; (3) Affirming belongingness: Residents still belong to their families, even when care has been delegated; and (4) Empowering voices for change: We are struggling to provide better care in a challenging reality. CONCLUSIONS This paper highlights the importance of nursing advocacy in safeguarding the remaining time and dignity of individuals with dementia, challenging the stigma surrounding dementia and nursing homes and calling for greater societal and political recognition of the efforts nurses make to preserve the personhood and well-being of these older adults.
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Affiliation(s)
- Dayeong Kim
- College of Nursing and L-HOPE Program for Community-Based Total Learning Health Systems, Korea University, Seoul, Republic of Korea
| | - Sung Ok Chang
- College of Nursing and L-HOPE Program for Community-Based Total Learning Health Systems, Korea University, Seoul, Republic of Korea.
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Sano M, Cummings J, Auer S, Bergh S, Fischer CE, Gerritsen D, Grossberg G, Ismail Z, Lanctôt K, Lapid MI, Mintzer J, Palm R, Rosenberg PB, Splaine M, Zhong K, Zhu CW. Agitation in cognitive disorders: Progress in the International Psychogeriatric Association consensus clinical and research definition. Int Psychogeriatr 2024; 36:238-250. [PMID: 36880250 PMCID: PMC10684256 DOI: 10.1017/s1041610222001041] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
BACKGROUND The International Psychogeriatric Association (IPA) published a provisional consensus definition of agitation in cognitive disorders in 2015. As proposed by the original work group, we summarize the use and validation of criteria in order to remove "provisional" from the definition. METHODS This report summarizes information from the academic literature, research resources, clinical guidelines, expert surveys, and patient and family advocates on the experience of use of the IPA definition. The information was reviewed by a working group of topic experts to create a finalized definition. RESULTS We present a final definition which closely resembles the provisional definition with modifications to address special circumstances. We also summarize the development of tools for diagnosis and assessment of agitation and propose strategies for dissemination and integration into precision diagnosis and agitation interventions. CONCLUSION The IPA definition of agitation captures a common and important entity that is recognized by many stakeholders. Dissemination of the definition will permit broader detection and can advance research and best practices for care of patients with agitation.
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Affiliation(s)
- Mary Sano
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, NYC NY and James J. Peters VAMC, Bronx NY
| | - Jeffrey Cummings
- Joy Chambers-Grundy Professor of Brain Science, Director, Chambers-Grundy Center for Transformative Neuroscience, Co-Director, Pam Quirk Brain Health and Biomarker Laboratory, Department of Brain Health, School of Integrated Health Sciences. University of Nevada Las Vegas (UNLV)
| | - Stefanie Auer
- Centre for Dementia Studies, University for Continuing Education Krems, Austria
| | - Sverre Bergh
- The research centre for age-related functional decline and disease, Innlandet hospital trust, Ottestad, Norway
| | - Corinne E. Fischer
- Faculty of Medicine, Department of Psychiatry, University of Toronto, Canada
| | - Debby Gerritsen
- Department of Primary and Community Care, Radboud university medical center, Radboud Institute for Health Sciences, Radboud Alzheimer Center, Nijmegen, the Netherlands
| | - George Grossberg
- Department of Psychiatry & Behavioral Neuroscience, Division of Geriatric Psychiatry St Louis University School of Medicine
| | - Zahinoor Ismail
- Departments Psychiatry, Neurology, Epidemiology, and Pathology, Hotchkiss Brain Institute & O’Brien Institute for Public Health University of Calgary
| | - Krista Lanctôt
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute; and Departments of Psychiatry and Pharmacology/Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Maria I Lapid
- Mayo Clinic Department of Psychiatry and Psychology, Rochester, MN, USA
| | - Jacobo Mintzer
- Psychiatrist, Ralph. H. Johnson VA Medical Center, Charleston, SC and Professor, College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - Rebecca Palm
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
| | - Paul B. Rosenberg
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Michael Splaine
- Owner Splaine Consulting, Managing Partner, Recruitment Partners LLC
| | - Kate Zhong
- Department of Brain Health, School of Integrated Health Sciences, University of Nevada, Las Vegas
| | - Carolyn W. Zhu
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, NYC, NY and James J. Peters VAMC, Bronx NY
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Wilson EA, King-Oakley E, Richfield EW. Parkinson's disease: symptoms and medications at the end of life. BMJ Support Palliat Care 2024; 13:e912-e915. [PMID: 37463763 DOI: 10.1136/spcare-2023-004389] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/04/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVES People with Parkinson's disease (PwP) have a high palliative symptom burden throughout their disease course, equivalent to advanced malignancy. We aim to establish trends in symptom frequency and prescribing in the 72 hours prior to death for PwP. METHODS Retrospective case note review of PwP who died between February 2019 and September 2020. RESULTS 51 patients were included. 60.78% of patients (n=31) had agitation and 58.82% (n=30) had pain in the final 72 hours. Patients with cognitive impairment were 4.67 times more likely to experience agitation (p=0.035) compared with those without, with higher total midazolam doses (29.18 mg vs 11.4 mg, p=0.21). Terminal motor symptoms were recorded in three patients. 28.57% of patients received the recommended dose of rotigotine for dopaminergic therapy. CONCLUSIONS PwP have a significant symptom burden at the end of life (EOL) with levels of terminal agitation at the higher end of those expected in the general population. There was a trend towards higher doses of sedation, rather than analgesia, in people with coexistent cognitive impairment.Terminal stiffness, despite being seldom documented in the literature, is an important although infrequent symptom.Rotigotine use at EOL remains commonplace and better understanding of its effect and dosing is required.
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Rahemi Z, Bacsu JDR, Sefcik JS, Sadafipoor MS, Demiris G, Adams SA. Advance care planning and outpatient visits among older adults across cognitive levels. AGING AND HEALTH RESEARCH 2023; 3:100166. [PMID: 38076608 PMCID: PMC10703190 DOI: 10.1016/j.ahr.2023.100166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024] Open
Abstract
Advance care planning (ACP) can help reduce end-of-life care challenges for persons with Alzheimer's disease and related dementia and their care partners. Building on our previous work, we examined the impact of ACP on outpatient/doctor visits in older adults with dementia/impaired cognition and normal cognition. Using datasets from the 2014 Health and Retirement Study (HRS), we conducted a cross-sectional study of 17,698 participants aged 51 years and older. Our analyses included survey descriptive and logistic regression procedures. Our findings indicated that having at least one ACP measure was significantly associated with a higher mean number of outpatient visits in both cognition groups. Based on our findings, we recommend considering healthcare access and use as an intervening variable in future ACP research.
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Affiliation(s)
- Zahra Rahemi
- Clemson University School of Nursing, 605 Grove Road, Greenville, SC 29605, USA
| | | | - Justine S. Sefcik
- Drexel University College of Nursing and Health Professions, Philadelphia, PA, USA
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Rahemi Z, Malatyali A, Bacsu JDR, Sefcik JS, Petrovsky DV, Baker ZG, Ma KPK, Smith ML, Adams SA. Healthcare Utilization and Advance Care Planning among Older Adults Across Cognitive Levels. J Appl Gerontol 2023; 42:2294-2303. [PMID: 37525608 PMCID: PMC10828104 DOI: 10.1177/07334648231191667] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
This study examined the impact of advance care planning (ACP) on healthcare utilization among older adults with normal cognition and impaired cognition/dementia. Using datasets from the Health and Retirement Study, we conducted a cross-sectional study on 17,698 participants aged 51 years and older. Our analyses included survey descriptive and logistic regression procedures. ACP measures included a living will and durable power of attorney for healthcare. Healthcare utilization was measured using the days spent in hospitals, hospice care, nursing homes, and home care. Of the participants, 77.8% had normal cognition, and 22% had impaired cognition/dementia. The proportion of impaired cognition/dementia was higher among racially minoritized participants, single/widowed participants, and those who lived alone and were less educated. The results showed that having an ACP was associated with longer stays in hospitals, nursing homes, and home healthcare in all participants.
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Affiliation(s)
- Zahra Rahemi
- School of Nursing, Clemson University, Greenville, SC, USA
| | - Ayse Malatyali
- Nursing Systems Department, College of Nursing, University of Central Florida, Orlando, FL, USA
| | | | - Justine S Sefcik
- College of Nursing and Health Professions, Drexel University College of Nursing and Health Professions, Philadelphia, PA, USA
| | - Darina V Petrovsky
- School of Nursing, Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - Zachary G Baker
- Edson College of Nursing and Health Innovation, Arizona State University, Tempe, AZ, USA
| | - Kris Pui Kwan Ma
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Matthew L Smith
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Swann A Adams
- Department of Biobehavioral and Nursing Science, College of Nursing, University of South Carolina, Columbia, SC, USA
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Nasu K, Miyashita M, Hirooka K, Endo T, Fukahori H. Ambulance use and emergency department visits among people with dementia: A cross-sectional survey. Nurs Health Sci 2023; 25:712-720. [PMID: 37987542 DOI: 10.1111/nhs.13066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 09/29/2023] [Accepted: 10/26/2023] [Indexed: 11/22/2023]
Abstract
This study aimed to explore factors associated with ambulance use and emergency department (ED) visits among people with dementia in the month before death. A web-based survey of bereaved family caregivers of people with dementia was conducted in March 2020. Multivariate logistic regression analyses were conducted with ambulance use and ED visits in the month before death as dependent variables. Age and gender of people with dementia and their family caregivers, home care use, decision-makers, comorbidities, degree of independence in daily living, and caregivers' preparedness for death were independent variables. Data were collected from 817 caregivers of people with dementia who had died at hospitals (52.4%), long-term care facilities (25.0%), or own homes (22.4%). Caregivers' lack of preparedness for death was significantly associated with ambulance use in the month before death. Comorbidites and males with dementia were significantly associated with ED visits in the month before death. Better death preparedness of family caregivers may reduce ambulance use for symptoms that can be more effectively addressed by palliative care than acute care for people with dementia.
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Affiliation(s)
- Katsumi Nasu
- Keio Research Institute at SFC, Fujisawa, Japan
- School of Nursing, Yasuda Women's University, Hiroshima, Japan
| | | | - Kayo Hirooka
- Graduate School of Health Care Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takuro Endo
- International University of Health and Welfare Narita Hospital, Narita, Japan
| | - Hiroki Fukahori
- Faculty of Nursing and Medical Care, Keio University, Fujisawa, Japan
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Davies N, West E, Smith EM, Vickerstaff V, Manthorpe J, Shah M, Rait G, Wilcock J, Ward J, Sampson EL. Development of a decision-support framework to support professionals and promote comfort among older hospital inpatients living with dementia. Health Expect 2023; 27:e13922. [PMID: 38010078 PMCID: PMC10757206 DOI: 10.1111/hex.13922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 10/20/2023] [Accepted: 11/14/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Acute hospital wards can be difficult places for many people living with dementia. Promoting comfort and wellbeing can be challenging in this environment. There is little evidence-based support for professionals working on acute care wards on how to respond to distress and maximise comfort and wellbeing among patients living with dementia. OBJECTIVES Our overall aim was to codesign an evidence-based easy-to-use heuristic decision-support framework, which was acceptable and practical but acknowledges the complex and acute nature of caring for patients with dementia in the hospital. This paper presents the development process and resulting framework. METHODS A codesign study was informed by data from (1) a literature review of the care and management of people living with dementia in acute hospitals; (2) a cohort study of comfort and discomfort in people with dementia in acute hospitals; and (3) interviews with family carers and health care professionals. We synthesised evidence from these data sources and presented to key stakeholders through codesign meetings and workshops to produce our decision-support framework. RESULTS The framework consists of a series of flowcharts and operates using a three-stage process of: (1) assess comfort/discomfort; (2) consider causes of discomfort; and (3) address patient needs to manage the discomfort. CONCLUSION Working with key stakeholders, synthesising diverse quantitative and qualitative evidence to build a clinical framework is a feasible approach to help address the needs of patients living with dementia in an acute hospital setting. The result is a framework which is now ready for evaluation and implementation. PATIENT AND PUBLIC CONTRIBUTION We worked closely with people living with dementia and family carers throughout this study, including the development of the study protocol with input on study development and design, through to inclusion in stakeholder workshops and codesign of the decision support framework.
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Affiliation(s)
- Nathan Davies
- Department of Primary Care and Population Health, Centre for Ageing Population Studies, Royal Free CampusUniversity College LondonLondonUK
| | - Emily West
- Marie Curie Palliative Care Research DepartmentUniversity College LondonLondonUK
| | - Ellen M. Smith
- South West London and St George's Mental Health NHS TrustLondonUK
| | - Victoria Vickerstaff
- Department of Primary Care and Population Health, Centre for Ageing Population Studies, Royal Free CampusUniversity College LondonLondonUK
| | - Jill Manthorpe
- NIHR Applied Research Collaborative (ARC) South LondonKing's College London, StrandLondonUK
- NIHR Policy Research Unit in Health and Social Care WorkforceKing's College London, StrandLondonUK
| | - Malvi Shah
- Department of Primary Care and Population Health, Centre for Ageing Population Studies, Royal Free CampusUniversity College LondonLondonUK
| | - Greta Rait
- Department of Primary Care and Population Health, Centre for Ageing Population Studies, Royal Free CampusUniversity College LondonLondonUK
| | - Jane Wilcock
- Department of Primary Care and Population Health, Centre for Ageing Population Studies, Royal Free CampusUniversity College LondonLondonUK
| | - Jane Ward
- Patient and Public Involvement RepresentativeLonodnUK
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research DepartmentUniversity College LondonLondonUK
- Department of Psychological Medicine, Royal London HospitalEast London NHS Foundation TrustLondonUK
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Bosco A, Di Lorito C, Dunlop M, Booth A, Alexander D, Jones S, Underwood BR, Todd C, Burns A. Experiences of hospice dementia care: A qualitative study of bereaved carers and hospice clinicians. PLoS One 2023; 18:e0286493. [PMID: 37930977 PMCID: PMC10627455 DOI: 10.1371/journal.pone.0286493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/05/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Nearly 50 million people worldwide have dementia and the increasing numbers requiring end-of-life and palliative care, has led to national efforts to define standards of care for this patient group. Little research, however, has been done to date about the experience of hospice care for people with dementia accessing these services. This study explores the views of hospice dementia care for bereaved carers of people with dementia and hospice clinicians. METHODS We used purposive sampling for participant recruitment. Semi-structured qualitative interviews were conducted with bereaved carers and hospice clinical staff. Interviews were audio recorded and the transcriptions were analysed through thematic analysis. A total of 12 participants were interviewed from one service in the Northwest region in the UK. All were female and white British. RESULTS Participants described their experience of hospice dementia care in three main themes: Pre-access to service, roles and responsibility within hospice care, ease and difficulty of last period of end-of-life care. CONCLUSION Rapid response teams delivering hospice home care could represent a better option to inpatient care and may be preferred by patients. This type of service, however, may require joined-up care with other community services, and this type of care needs to be considered and planned. Future studies should evaluate this type of community care.
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Affiliation(s)
- A. Bosco
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Primary Care Unit, University of Cambridge, Cambridge, United Kingdom
- National Institute for Health and Care Research, Applied Research Collaboration- Greater Manchester, Manchester, United Kingdom
| | - C. Di Lorito
- Department of Primary Care and Population Health, Centre for Ageing Population Studies, Royal Free Hospital, University College London, London, United Kingdom
| | - M. Dunlop
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - A. Booth
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - D. Alexander
- East Cheshire Hospice, Macclesfield, Cheshire, United Kingdom
| | - S. Jones
- East Cheshire Hospice, Macclesfield, Cheshire, United Kingdom
| | - B. R. Underwood
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
- Cambridgeshire and Peterborough NHS Foundation Trust, Windsor Unit, Fulbourn Hospital, Cambridge, United Kingdom
| | - C. Todd
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research, Applied Research Collaboration- Greater Manchester, Manchester, United Kingdom
- Manchester Institute for Collaborative Research on Ageing, Manchester, United Kingdom
- Manchester Academic Health Science Centre, Manchester, United Kingdom
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - A. Burns
- Manchester Institute for Collaborative Research on Ageing, Manchester, United Kingdom
- Manchester Academic Health Science Centre, Manchester, United Kingdom
- Division of Neuroscience and Experimental Psychology, The University of Manchester, Manchester, United Kingdom
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Fox S, Drennan J, Guerin S, Kernohan WG, Murphy A, O'Connor N, Rukundo A, Timmons S. A comparison of four dementia palliative care services using the RE-AIM framework. BMC Geriatr 2023; 23:677. [PMID: 37858076 PMCID: PMC10585827 DOI: 10.1186/s12877-023-04343-w] [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: 06/22/2023] [Accepted: 09/22/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Living with a life-limiting illness, people with dementia benefit from palliative care which considers the holistic needs of the person and their family. However, little is known about how palliative care may be best provided to people living with dementia at home in the community. We examined four exemplary dementia palliative care services for people with dementia in the community, to see what activities they were providing, what were the commonalities and differences, and what lessons could be learned. METHODS A long-list of dementia palliative care services in Ireland, Northern Ireland, England, Scotland, and Wales, was identified through a survey, and four exemplar services were chosen based on criteria including: in operation >six months; provides identifiable activities; availability of routinely collected service data; not exclusively for people with dementia in final hours or days of life. Mixed-methods of data collection included interviews, focus-groups and surveys with service staff, surveys of service users, and routinely collected service data. The RE-AIM framework was used to describe and understand the sample of dementia palliative care services. RESULTS The four services had varied organisational structures and were led by different disciplines. However, they all provided common core activities including holistic and person-centred care, early advance care planning with service user involvement, carer support, integrated healthcare services, continuity of care, 24/7 support, bereavement support. All had needs-based referral criteria, accepting any age or dementia sub-type. All supported people with dementia to remain living at home and to have a comfortable, dignified death in their preferred place. CONCLUSIONS An effective dementia palliative care service may take different forms. Whether the service is dementia-led or Specialist Palliative Care-led, efficacy is associated with providing a range of key activities and implementing them effectively. The data collected strongly suggests the benefits of the dementia palliative care services to a person with dementia and their families and offers valuable insight into the key factors for the establishment and successful running of such services.
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Affiliation(s)
- Siobhan Fox
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland.
| | - Jonathan Drennan
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Suzanne Guerin
- School of Psychology, University College Dublin, Dublin, Ireland
| | - W George Kernohan
- Institute of Nursing and Health Research, County Antrim, Ulster University, Shore Road, Newtownabbey, Northern Ireland
| | - Aileen Murphy
- Department of Economics, University College Cork, Cork, Ireland
| | - Niamh O'Connor
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - Aphie Rukundo
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
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Pinkert C, Holle B. Home-based care for people living with dementia at the end of life: the perspective of experts. BMC Palliat Care 2023; 22:123. [PMID: 37658329 PMCID: PMC10472677 DOI: 10.1186/s12904-023-01251-z] [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: 01/24/2023] [Accepted: 08/24/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND In the last phase of their lives, people living with dementia often indicate restlessness, anxiety or pain. Further, their care is considered inadequate, as they are, for example, sometimes overtreated for curative care or undertreated for pain management. These patients also face multiple barriers in accessing palliative care. This qualitative study explores the perception of experts about how people living with dementia in Germany are cared for at home toward the end of their lives. METHODS A total of 12 experts involved in outpatient/palliative care were recruited to constitute a purposive, heterogeneous sample. Interviews, which were structured using an interview guide, were conducted with physicians, nurses, representatives of health insurance funds, welfare associations, municipal counselling centres, scientists and coordinators of outpatient palliative care and voluntary work; the interviews were transcribed and analysed via thematic content analysis, based on Kuckartz's method. RESULTS The analysis of the results led to the establishment of four main categories that focused on formal care arrangements, the roles of relatives in care arrangements, the specifics of dementia, and restrictions on access to palliative care. CONCLUSIONS Suitable end-of-life care for people living with dementia and support for their relatives require resources and the conceptualisation of specific care arrangements to help minimise potential barriers that prevent access to palliative care.
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Affiliation(s)
- Christiane Pinkert
- Deutsches Zentrum für Neurodegenerative Erkrankungen, Standort Witten, Witten, Germany.
- Faculty of Health, School of Nursing Science, Witten/Herdecke University (UW/H), Witten, Germany.
| | - Bernhard Holle
- Deutsches Zentrum für Neurodegenerative Erkrankungen, Standort Witten, Witten, Germany
- Faculty of Health, School of Nursing Science, Witten/Herdecke University (UW/H), Witten, Germany
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11
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Zhao M, Chen Z, Xu T, Fan P, Tian F. Global prevalence of polypharmacy and potentially inappropriate medication in older patients with dementia: a systematic review and meta-analysis. Front Pharmacol 2023; 14:1221069. [PMID: 37693899 PMCID: PMC10483131 DOI: 10.3389/fphar.2023.1221069] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/03/2023] [Indexed: 09/12/2023] Open
Abstract
Background: Older patients with dementia always need multiple drugs due to comorbidities and cognitive impairment, further complicating drug treatment and increasing the risk of potentially inappropriate medication. The objective of our study is to estimate the global prevalence of polypharmacy and potentially inappropriate medication (PIM) and explore the factors of PIM for older patients with dementia. Methods: We searched PubMed, Embase (Ovid), and Web of Science databases to identify eligible studies from inception to 16 June 2023. We conducted a meta-analysis for observational studies reporting the prevalence of potentially inappropriate medication and polypharmacy in older patients with dementia using a random-effect model. The factors associated with PIM were meta-analyzed. Results: Overall, 62 eligible studies were included, of which 53 studies reported the prevalence of PIM and 28 studies reported the prevalence of polypharmacy. The pooled estimate of PIM and polypharmacy was 43% (95% CI 38-48) and 62% (95% CI 52-71), respectively. Sixteen studies referred to factors associated with PIM use, and 15 factors were further pooled. Polypharmacy (2.83, 95% CI 1.80-4.44), diabetes (1.31, 95% CI 1.04-1.65), heart failure (1.17, 95% CI 1.00-1.37), depression (1.45, 95% CI 1.14-1.88), history of cancer (1.20, 95% CI 1.09-1.32), hypertension (1.46, 95% CI 1.05-2.03), ischemic heart disease (1.55, 95% CI 0.77-3.12), any cardiovascular disease (1.11, 95% CI 1.06-1.17), vascular dementia (1.09, 95% CI 1.03-1.16), chronic obstructive pulmonary disease (1.39, 95% CI 1.13-1.72), and psychosis (1.91, 95% CI 1.04-3.53) are positively associated with PIM use. Conclusion: PIM and polypharmacy were highly prevalent in older patients with dementia. Among different regions, the pooled estimate of PIM use and polypharmacy varied widely. Increasing PIM in older patients with dementia was closely associated with polypharmacy. For other comorbidities such as heart failure and diabetes, prescribing should be cautioned.
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Affiliation(s)
| | | | | | - Ping Fan
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fangyuan Tian
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Nocivelli B, Shepherd V, Hood K, Wallace C, Wood F. Identifying barriers and facilitators to the inclusion of older adults living in UK care homes in research: a scoping review. BMC Geriatr 2023; 23:446. [PMID: 37474927 PMCID: PMC10360346 DOI: 10.1186/s12877-023-04126-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/22/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND With an ageing population, older adults will have more complex health and social care needs and many of these older adults will be living in care homes. Despite the growth in care home populations, care home residents are often excluded from research that could potentially benefit their care. The purpose of this scoping review is to explore resident-related barriers and facilitators to including older people living in UK care homes in research and to identify potential approaches to modify such barriers. METHOD The 6-stage scoping review methodology framework proposed by Arksey and O'Malley guided this review. Five electronic databases (MedLine, PsychINFO, Scopus, Web of Science, CINAHL) and grey literature were searched. Identified articles went through two levels of screening, and those deemed relevant were collated, summarised and reported using a thematic analysis approach. RESULTS 90 reports were eligible for inclusion and were synthesised into 7 themes and related subthemes: (1) research design; (2) understanding and beliefs about research (resident and care home staff); (3) communication; (4) relationships; (5) eligibility criteria (resident and care home); (6) preference-based decisions; and (7) care home staff and environment. Given the complex interplay of the factors identified, both direct and indirect factors were included. CONCLUSIONS A number of recurring barriers and facilitators to the inclusion of care home residents in research are reported. However, isolating resident-related barriers was complex as both direct and indirect factors must be considered as influential. Understanding the barriers and facilitators to inclusion will enable these factors to be addressed and increase the evidence-base for care provided to older people living in care homes.
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Affiliation(s)
- Brittany Nocivelli
- Division of Population Medicine, PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, Wales.
| | - Victoria Shepherd
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales
| | - Kerenza Hood
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales
| | - Carolyn Wallace
- School of Care Sciences, University of South Wales, Newport, Wales
| | - Fiona Wood
- Division of Population Medicine, PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, Wales
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13
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Juhrmann ML, San Martin A, Jaure A, Poulos CJ, Clayton JM. Staff perspectives on end-of-life care for people living with dementia in residential aged care homes: qualitative study. Front Psychiatry 2023; 14:1137970. [PMID: 37181908 PMCID: PMC10166813 DOI: 10.3389/fpsyt.2023.1137970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/04/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction People living with dementia in care homes can benefit from palliative approaches to care; however, not all will require specialist palliative care. The generalist aged care workforce is well placed to provide most of this care with adequate training and support systems in place, but little is known about their experiences. Objective To describe staff perspectives on providing quality end-of-life care for people living with dementia in residential care and their families. Methods Focus groups and semi-structured interviews were conducted with residential aged care managerial and frontline staff in Australia who were caring for residents living with dementia and end-of life needs. A comprehensive, then snowballing sampling strategy was used in participating care homes. Transcripts were analyzed using reflexive thematic analysis. Results Fifteen semi-structured interviews and six focus groups were undertaken with 56 participants across 14 sites across two Australian states. Five themes were identified: putting the resident at the center (creating homes not hospitals, knowing the individual, a case management approach); articulating goals to grant wishes (initiating the conversation, broadening death literacy, avoiding hospitalization); a collective call to action (staffing the home, recognizing deterioration and escalating issues, communication channels and engaging GPs, managing medications, psychosocial supports); educating to empower staff (governance and guidance, mentoring juniors, self-care); and facilitating family acceptance (setting expectations, partnering in care, access at all hours). Discussion Aged care staff are committed to providing person-centered palliative and end-of-life care for people living with dementia, recognizing the intrinsic value of each resident, regardless of their declining state. Frontline and managerial staff consider advance care planning, collectively working as part of a multidisciplinary team, access to targeted palliative and end-of-life education and training, and engaging families as key priorities to providing high quality care in care homes.
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Affiliation(s)
- Madeleine L. Juhrmann
- The Palliative Centre, Greenwich Hospital, HammondCare, Greenwich, NSW, Australia
- Faculty of Medicine and Health, Northern Clinical School, University of Sydney, St Leonards, NSW, Australia
| | - Aljon San Martin
- The Palliative Centre, Greenwich Hospital, HammondCare, Greenwich, NSW, Australia
| | - Allison Jaure
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Camperdown, NSW, Australia
| | - Christopher J. Poulos
- Centre for Positive Ageing, HammondCare, Hammondville, NSW, Australia
- Faculty of Medicine and Health, School of Population Health, University of New South Wales, Kensington, NSW, Australia
| | - Josephine M. Clayton
- The Palliative Centre, Greenwich Hospital, HammondCare, Greenwich, NSW, Australia
- Faculty of Medicine and Health, Northern Clinical School, University of Sydney, St Leonards, NSW, Australia
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14
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Volle D. Dementia Care at the End of Life: A Clinically Focused Review. Am J Geriatr Psychiatry 2023; 31:291-303. [PMID: 36456444 DOI: 10.1016/j.jagp.2022.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
With the geriatric population in the United States growing rapidly, the prevalence of dementia is expected to rise concomitantly. As dementia is an invariably progressive and terminal illness, planning for and managing end of life care in dementia is an important part of the overall process of dementia care. Unfortunately, this is often neglected outside of formal palliative and hospice medicine training programs and geriatric psychiatrists are left without preparation on how to manage, as well as counsel patients and families on, this important phase of dementia care. This review aims to explore the potential contributors to this historic disparity in geriatric education and care delivery, as well as its impact, while also attempting to shift the field's focus toward a palliative approach to dementia care. To begin to accomplish this, this review explores the natural illness history/disease trajectory of the various dementing illnesses, as well as the topic of prognostication as it pertains to the end of life for patients with dementia and how this information can be used in advanced care planning and symptom management.
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Affiliation(s)
- Dax Volle
- Department of Psychiatry (DV), Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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15
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Yorganci E, Sleeman KE. Palliative care can benefit people with dementia. BMJ 2023; 380:754. [PMID: 37001899 DOI: 10.1136/bmj.p754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Emel Yorganci
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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16
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Kawashima A, Evans CJ. Needs-based triggers for timely referral to palliative care for older adults severely affected by noncancer conditions: a systematic review and narrative synthesis. BMC Palliat Care 2023; 22:20. [PMID: 36890522 PMCID: PMC9996955 DOI: 10.1186/s12904-023-01131-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 02/01/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Older people with noncancer conditions are less likely to be referred to palliative care services due to the inherent uncertain disease trajectory and a lack of standardised referral criteria. For older adults with noncancer conditions where prognostic estimation is unpredictable, needs-based criteria are likely more suitable. Eligibility criteria for participation in clinical trials on palliative care could inform a needs-based criteria. This review aimed to identify and synthesise eligibility criteria for trials in palliative care to construct a needs-based set of triggers for timely referral to palliative care for older adults severely affected by noncancer conditions. METHODS A systematic narrative review of published trials of palliative care service level interventions for older adults with noncancer conditions. Electronic databases Medline, Embase, CINAHL, PsycINFO, CENTRAL, and ClinicalTrials.gov. were searched from inception to June 2022. We included all types of randomised controlled trials. We selected trials that reported eligibility criteria for palliative care involvement for older adults with noncancer conditions, where > 50% of the population was aged ≥ 65 years. The methodological quality of the included studies was assessed using a revised Cochrane risk-of-bias tool for randomized trials. Descriptive analysis and narrative synthesis provided descriptions of the patterns and appraised the applicability of included trial eligibility criteria to identify patients likely to benefit from receiving palliative care. RESULTS 27 randomised controlled trials met eligibility out of 9,584 papers. We identified six major domains of trial eligibility criteria in three categories, needs-based, time-based and medical history-based criteria. Needs-based criteria were composed of symptoms, functional status, and quality of life criteria. The major trial eligibility criteria were diagnostic criteria (n = 26, 96%), followed by medical history-based criteria (n = 15, 56%), and physical and psychological symptom criteria (n = 14, 52%). CONCLUSION For older adults severely affected by noncancer conditions, decisions about providing palliative care should be based on the present needs related to symptoms, functional status, and quality of life. Further research is needed to examine how the needs-based triggers can be operationalized as referral criteria in clinical settings and develop international consensus on referral criteria for older adults with noncancer conditions.
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Affiliation(s)
- Arisa Kawashima
- Department of Nursing for Advanced Practice, Division of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan.,King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Faculty of Nursing, Midwifery and Palliative Care, London, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Faculty of Nursing, Midwifery and Palliative Care, London, UK. .,Sussex Community NHS Foundation Trust, Brighton, UK.
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Factors associated with the intention to engage in care planning among persons with mild cognitive impairment and dementia. Geriatr Nurs 2023; 50:143-151. [PMID: 36780712 DOI: 10.1016/j.gerinurse.2023.01.018] [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: 10/25/2022] [Revised: 01/17/2023] [Accepted: 01/17/2023] [Indexed: 02/13/2023]
Abstract
This study examined factors associated with the intention to engage in advance care planning among persons with cognitive impairment. This cross-sectional study recruited 116 persons with cognitive impairment by convenience sampling from two teaching hospitals in Northern Taiwan from November 1, 2018, to December 31, 2020. Fewer than 50% of the participants intended to engage in advance care planning, and less than 10% signed the living will for hospice and palliative care. Multivariate linear regression determined factors influencing advance care planning intention included education level, a proxy signed do-not-resuscitate document, belief that family members would provide a signed do-not-resuscitate at their end-of-life, and necessity of explaining future care in advance. It is recommended to popularize advance care planning education and ensure the rights of persons with cognitive impairment to enable them to fully participate in their own care plans through family-centered advance care planning.
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18
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Timmons S, Fox S. Palliative care for people with dementia. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:81-105. [PMID: 36599517 DOI: 10.1016/b978-0-12-824535-4.00013-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Dementia is the most common neurologic disease, affecting approximately 55 million people worldwide. Dementia is a terminal illness, although not always recognized as such. This chapter discusses the key issues in providing palliative care for people with living with dementia and their families. Common palliative care needs and symptoms are presented, including psychosocial, physical, emotional, and spiritual, and the need to actively anticipate and seek symptoms according to the dementia type and stage is emphasized. Families are hugely impacted by a dementia diagnosis, and throughout this chapter, they are considered in the unit of care, and also as a member of the care team. Multiple challenges particular to dementia palliative care are highlighted throughout, such as the lack of timely dementia diagnoses, difficulty with symptom prognostication, the person's inability to verbally express their symptoms and care preferences, and a low threshold for medication side effects. Finally, service models for dementia palliative care in community, residential, and acute hospital settings are discussed, along with the evidence for each. Overall, this chapter reinforces that the individual needs of the person living with dementia and their family must be considered to provide person-centered and comprehensive palliative care, enabling them to live well until death.
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Affiliation(s)
- Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland; Department of Geriatric Medicine, Mercy University Hospital & St. Finbarr's Hospital, Cork, Ireland.
| | - Siobhan Fox
- Centre for Gerontology and Rehabilitation, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
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19
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Dunford E, West E, Sampson EL. Psychometric evaluation of the Pain Assessment in Advanced Dementia scale in an acute general hospital setting. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5830. [PMID: 36317464 PMCID: PMC9828226 DOI: 10.1002/gps.5830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/16/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND People with dementia are at risk of unplanned hospital admissions and commonly have painful conditions. Identifying pain is challenging and may lead to undertreatment. The psychometric properties of the Pain Assessment in Advanced Dementia (PAINAD) scale, in medical inpatients with dementia have not been evaluated. METHODS A secondary data analysis from a longitudinal study of 230 people with dementia admitted to two acute general hospitals in London, UK. Internal consistency, inter-rater reliability, test-retest reliability, concurrent validity, construct validity and discriminant validity of PAINAD were tested at rest and in movement. RESULTS This predominantly female (65.7%) sample had a mean age of 87.2 (Standard Deviation; SD = 5.92) years. Inter-rater reliability showed an intra-class correlation (ICC) of 0.92 at rest and 0.98 in movement, test-retest reliability ICC was 0.54 at rest and 0.66 in movement. Internal consistency was 0.76 at rest and 0.80 in movement (Cronbach's α). Concurrent validity was weak between PAINAD and a self-rating level of pain (Kendall's Tau; τ = 0.29; p > 0.001). There was no correlation between PAINAD and a measure of behavioural and psychological symptoms of dementia, suggesting no evidence of convergent validity. PAINAD scores were higher during movement than rest, providing evidence of discriminant validity (z = -8.01, p < 0.001). CONCLUSIONS We found good inter-rater reliability and internal consistency. The test-retest reliability was modest. This study raises concerns about the validity of the PAINAD in general acute hospitals. This provides an insight into pain assessment in general acute hospitals which may inform further refinements of the PAINAD.
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Affiliation(s)
- Emma Dunford
- Marie Curie Palliative Care Research DepartmentDivision of PsychiatryUCLLondonUK
| | - Emily West
- Marie Curie Palliative Care Research DepartmentDivision of PsychiatryUCLLondonUK
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research DepartmentDivision of PsychiatryUCLLondonUK,Department of Psychological MedicineEast London NHS Foundation TrustRoyal London HospitalLondonUK
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20
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The Quebec Observatory on End-of-Life Care for People with Dementia: Implementation and Preliminary Findings. Can J Aging 2022; 41:631-640. [PMID: 35137682 DOI: 10.1017/s0714980821000659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Most Canadians with dementia die in long-term care (LTC) facilities. No data are routinely collected in Canada on the quality of end-of-life care provided to this vulnerable population, leading to significant knowledge gaps. The Quebec Observatory on End-of-Life Care for People with Dementia was created to address these gaps. The Observatory is a research infrastructure designed to support the collection of data needed to better understand, and subsequently enhance, care quality for residents dying with dementia. This article reports on the main steps involved in setting up the Observatory, as well as a pilot study that involved 172 residents with dementia who died between 2016 and 2018 in one of 13 participating facilities. It describes the data gathered, methodological changes that were made along the way, feedback from participating facilities, and future developments of the Observatory.
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21
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Understanding social care need through primary care big data: a rapid scoping review. BJGP Open 2022; 6:BJGPO.2022.0016. [PMID: 35788025 PMCID: PMC9904775 DOI: 10.3399/bjgpo.2022.0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/29/2022] [Accepted: 06/28/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND A more comprehensive understanding and measurement of adult social care need could contribute to efforts to develop more effective, holistic personalised care, particularly for those with multiple long-term conditions (MLTC). Progress in this area faces the challenge of a lack of clarity in the literature relating to how social care need is assessed and coded within variables included in primary care databases. AIM To explore how social care need is assessed and coded within variables included in primary care databases. DESIGN & SETTING An exploratory rapid scoping review of peer-reviewed articles and grey literature. METHOD Articles were screened and extracted onto a charting sheet and findings were summarised descriptively. Articles were included if published in English and related to primary and social care using data from national primary care databases. RESULTS The search yielded 4010 articles. Twenty-seven were included. Six articles used the term 'social care need', although related terminology was identified including 'need factors', 'social support', and 'social care support'. Articles mainly focused on specific components of social care need, including levels of social care usage or service utilisation and costs incurred to social care, primary care, and other providers in addressing needs. A limited range of database variables were found measuring social care need. CONCLUSION Further research is needed on how social care need has been defined in a UK context and captured in primary care big databases. There is potential scope to broaden the definition of social care need, which captures social service needs and wider social needs.
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22
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Gómez-Vírseda C, Gastmans C. Euthanasia in persons with advanced dementia: a dignity-enhancing care approach. JOURNAL OF MEDICAL ETHICS 2022; 48:907-914. [PMID: 34016647 DOI: 10.1136/medethics-2021-107308] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/12/2021] [Accepted: 04/20/2021] [Indexed: 06/12/2023]
Abstract
In current Western societies, increasing numbers of people express their desire to choose when to die. Allowing people to choose the moment of their death is an ethical issue that should be embedded in sound clinical and legal frameworks. In the case of persons with dementia, it raises further ethical questions such as: Does the person have the capacity to make the choice? Is the person being coerced? Who should be involved in the decision? Is the person's suffering untreatable? The use of Advance Euthanasia Directives (AED) is suggested as a way to deal with end-of-life wishes of persons with dementia. However, in the Netherlands-the only country in which this practice is legal-the experiences of patients, doctors, and relatives have been far from satisfactory.Our paper analyses this complex ethical challenge from a Dignity-Enhancing Care approach, starting from the Dutch experiences with AED as a case. We first consider the lived experiences of the different stakeholders, seeking out a dialogical-interpretative understanding of care. We aim to promote human dignity as a normative standard for end-of-life care practices. Three concrete proposals are then presented in which this approach can be operationalised in order to deal respectfully with the end-of-life choices of persons with dementia.
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Affiliation(s)
- Carlos Gómez-Vírseda
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Flanders, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Flanders, Belgium
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23
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McLaughlin D, Hasson F, Reid J, Brazil K, Rutherford L, Stone C, van der Steen JT, Ballentine J. Evaluating a partnership model of hospice enabled dementia care: A three-phased monitoring, focus group and interview study. Palliat Med 2022; 36:1351-1363. [PMID: 36065098 PMCID: PMC9606481 DOI: 10.1177/02692163221116763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND People with dementia and their caregivers often lack equitable access to hospice care which is a concern internationally. Domains of best practice in palliative care for this population exist and hospices are urged to become dementia friendly. AIM This study aimed to evaluate the model of 'Hospice Enabled Dementia Partnership' mapped to international domains of best practice. DESIGN Three-phased monitoring, group interview and individual interview study using a formative evaluation framework. SETTINGPARTICIPANTS The partnership model was a collaboration between a large specialist palliative care hospice, a dementia charity and a Health Care Trust in the United Kingdom. Service documents were subjected to documentary review of monitoring activity and key indicators of service success. Group interviews and individual interviews took place with family carers (n = 12), health care professionals involved in delivering the service (n = 32) and senior professionals (n = 5) responsible for service commissioning in palliative or dementia care. RESULTS One hundred people with dementia were referred to the service between May 2016 and December 2017. Thirty-eight of the 42 people who died, achieved their preferred place of care and died at home. Four themes were derived from the data 'Impact of Dementia', 'Value of the Service', 'Information and Learning Needs' and 'Working in Partnership'. CONCLUSIONS Positive outcomes resulted from this best practice model; achievement of preferred place of care and death at home, dual benefits of therapies for patients and families and partnership in cross working and learning between services. Replication of this model should be considered internationally.
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Affiliation(s)
- Dorry McLaughlin
- School of Nursing and Midwifery & Centre for Evidence and Social Innovation, Queen's University, Belfast, Northern Ireland
| | - Felicity Hasson
- Institute of Nursing and Health Research, Ulster University, Shore Road, Newtownabbey, Northern Ireland
| | - Joanne Reid
- School of Nursing and Midwifery & Centre for Evidence and Social Innovation, Queen's University, Belfast, Northern Ireland
| | - Kevin Brazil
- School of Nursing and Midwifery & Centre for Evidence and Social Innovation, Queen's University, Belfast, Northern Ireland
| | - Lesley Rutherford
- School of Nursing and Midwifery & Centre for Evidence and Social Innovation, Queen's University, Belfast, Northern Ireland.,Belfast Health and Social Care Trust, Marie Curie Hospice, Belfast, Northern Ireland
| | - Carol Stone
- Belfast Health and Social Care Trust, Marie Curie Hospice, Belfast, Northern Ireland
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Anderson NE, Robinson J, Goodwin H, Gott M. 'Mum, I think we might ring the ambulance, okay?' A qualitative exploration of bereaved family members' experiences of emergency ambulance care at the end of life. Palliat Med 2022; 36:1389-1395. [PMID: 36154525 DOI: 10.1177/02692163221118204] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In the context of a sudden or unexpected event, people with a life-limiting illness and their family caregivers may be dependent on emergency ambulance services. AIM To explore bereaved family members' experiences of emergency ambulance care at the end of life. DESIGN A qualitative study using reflexive thematic analysis of data collected from semi-structured phone interviews. SETTING/PARTICIPANTS A purposive sample of 38 family caregivers identified from a database of deaths in Aotearoa, New Zealand. RESULTS Emergency ambulance personnel assist, inform and reassure patients and family caregivers managing distressing symptoms, falls, infections, unexpected events and death itself. Family members and patients are aware of the pressure on emergency services and sometimes hesitate to call an ambulance. Associating ambulances with unwanted transport to hospital is also a source of reluctance. CONCLUSIONS The generalist palliative care provided by emergency ambulance personnel is a vital service for patients in the last year of life, and their caregivers. This must be acknowledged in palliative care policy and supported with training, specialist consultation and adequate resources.
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Affiliation(s)
- Natalie Elizabeth Anderson
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand.,Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
| | - Jackie Robinson
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Hetty Goodwin
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand.,Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
| | - Merryn Gott
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
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Brucki SMD, Aprahamian I, Borelli WV, Silveira VCD, Ferretti CEDL, Smid J, Barbosa BJAP, Schilling LP, Balthazar MLF, Frota NAF, Souza LCD, Vale FAC, Caramelli P, Bertolucci PHF, Chaves MLF, Nitrini R, Schultz RR, Morillo LS. Management in severe dementia: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Dement Neuropsychol 2022. [DOI: 10.1590/1980-5764-dn-2022-s107en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
ABSTRACT Alzheimer’s disease (AD) and other neurodegenerative dementias have a progressive course, impairing cognition, functional capacity, and behavior. Most studies have focused on AD. Severe dementia is associated with increased age, higher morbidity-mortality, and rising costs of care. It is fundamental to recognize that severe dementia is the longest period of progression, with patients living for many years in this stage. It is the most heterogeneous phase in the process, with different abilities and life expectancies. This practice guideline focuses on severe dementia to improve management and care in this stage of dementia. As it is a long period in the continuum of dementia, clinical practice should consider non-pharmacological and pharmacological approaches. Multidisciplinary interventions (physical therapy, speech therapy, nutrition, nursing, and others) are essential, besides educational and support to caregivers.
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Affiliation(s)
| | - Ivan Aprahamian
- Faculdade de Medicina de Jundiaí, Brasil; University of Groningen, The Netherlands; Universidade de São Paulo, Brasil
| | | | | | | | | | - Breno José Alencar Pires Barbosa
- Universidade de São Paulo, Brazil; Universidade Federal de Pernambuco, Brasil; Instituto de Medicina Integral Prof. Fernando Figueira, Brasil
| | - Lucas Porcello Schilling
- Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil
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26
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Brucki SMD, Aprahamian I, Borelli WV, Silveira VCD, Ferretti CEDL, Smid J, Barbosa BJAP, Schilling LP, Balthazar MLF, Frota NAF, Souza LCD, Vale FAC, Caramelli P, Bertolucci PHF, Chaves MLF, Nitrini R, Schultz RR, Morillo LS. Manejo das demências em fase avançada: recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Dement Neuropsychol 2022; 16:101-120. [DOI: 10.1590/1980-5764-dn-2022-s107pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/04/2021] [Accepted: 04/27/2022] [Indexed: 11/29/2022] Open
Abstract
RESUMO A doença de Alzheimer (DA) e outras demências neurodegenerativas têm um curso progressivo com comprometimento da cognição, capacidade funcional e comportamento. A maioria dos estudos enfocou a DA. A demência grave está associada ao aumento da idade, maior morbimortalidade e aumento dos custos de cuidados. É fundamental reconhecer que a demência grave é o período mais longo de progressão, com o paciente vivendo muitos anos nesta fase. É a fase mais heterogênea do processo, com diferentes habilidades e expectativa de vida. Esta diretriz de prática concentra-se na demência grave para melhorar o manejo e o cuidado nessa fase da demência. Como um longo período no continuum da demência, as abordagens não farmacológicas e farmacológicas devem ser consideradas. Intervenções multidisciplinares (fisioterapia, fonoaudiologia, nutrição, enfermagem, entre outras) são essenciais, além de educacionais e de apoio aos cuidadores.
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Affiliation(s)
| | - Ivan Aprahamian
- Faculdade de Medicina de Jundiaí, Brasil; University of Groningen, The Netherlands; Universidade de São Paulo, Brasil
| | | | | | | | | | - Breno José Alencar Pires Barbosa
- Universidade de São Paulo, Brazil; Universidade Federal de Pernambuco, Brasil; Instituto de Medicina Integral Prof. Fernando Figueira, Brasil
| | - Lucas Porcello Schilling
- Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil
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Kroenke K, Gao S, Mosesso KM, Hickman SE, Holtz LR, Torke AM, Johnson NM, Sachs GA. Prevalence and Predictors of Symptoms in Persons with Advanced Dementia Living in the Community. J Palliat Med 2022; 25:1376-1385. [PMID: 35357951 PMCID: PMC9492904 DOI: 10.1089/jpm.2021.0402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 11/12/2022] Open
Abstract
Background: Behavioral, psychological, and physical symptoms are prevalent in advanced dementia, as well as major contributors to poor quality of life, health care costs, caregiver burden, and nursing home placement. Objectives: To determine the frequency and severity of symptoms in persons with advanced dementia living in the community, as well as the association between symptoms and satisfaction with care, and the identification of factors associated with symptom burden. Design: Baseline data from a clinical trial testing the effectiveness of collaborative care home-based management for patients with advanced dementia. Setting/Subjects: Two hundred and one patient-caregiver dyads from an urban area in the United States, who were still residing in the community. Measurements: Caregivers completed the Symptom Management in End-of-Life Dementia (SM-EOLD) and Satisfaction with Care in End-of-Life Dementia (SWC-EOLD) scales. Results: Patients' mean age was 83.1; 67.7% were women, and most were either White (50.2%) or African American (43.8%). Most (88.1%) had severe dementia (Functional Assessment Staging Tool [FAST] stage 6 or 7). SM-EOLD mean score was 29.3 (on 0-45 scale) and SWC-EOLD score was 32.6 (on 10-40 scale). Pain, agitation, anxiety, and resistiveness to care were present at least weekly in ≥40% of patients. Multivariable linear regression modeling showed that higher neuropsychiatric symptom severity (assessed by the Neuropsychiatric Inventory), increased caregiver strain, and higher medical comorbidity were all independently associated with increased symptom burden. Satisfaction with care was high and had only a modest correlation (r = 0.20) with symptom burden. Conclusions: Community-dwelling patients with advanced dementia and their caregivers may benefit from home-based palliative care interventions to identify and manage burdensome symptoms.
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Affiliation(s)
- Kurt Kroenke
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Sujuan Gao
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kelly M. Mosesso
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Susan E. Hickman
- Community and Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Laura R. Holtz
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Alexia M. Torke
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Nina M. Johnson
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Greg A. Sachs
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
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Surakka LK, Hökkä M, Törrönen K, Mäntyselkä P, Lehto JT. Paramedics' experiences and educational needs when participating end-of-life care at home: A mixed method study. Palliat Med 2022; 36:1217-1227. [PMID: 35922966 DOI: 10.1177/02692163221105593] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Paramedics face end-of-life care patients during emergency calls and more recently through planned protocols. However, paramedics experiences and educational needs concerning preplanned end-of-life care at home remain largely unknown. AIM To describe experiences and educational needs of the paramedics included in the end-of-life care protocol. DESIGN A mixed method study with a questionnaire including open ended questions and numeric evaluations on a Likert scale. SETTING/PARTICIPANTS The questionnaire was delivered to and answered by all the 192 paramedics working in North Karelia fire and rescue department during the time of the data collection in 2017. RESULTS Over 80% of the paramedics agreed that the protocol helped them to take care of the patients and to improve the quality of end-of-life care. Visits to the patients were considered useful and the end-of-life care as a meaningful work by 76.5% and 62.5% of the paramedics, respectively. The paramedics expressed challenges in psychosocial aspects, communication, symptom management, and their role in end-of-life care. Encountering and communication with the families as well as managing the most common symptoms were emphasized as educational needs. Using a patient controlled analgesia device emerged as an example of practical educational aspect. CONCLUSIONS Paramedics considered end-of-life care at home meaningful but called for more competency in supporting and encountering the families and in symptom management. Our results can be utilized when developing end-of-life care protocols and education for the paramedics. Patients' and families' views on the paramedics' participation in end-of-life care should be evaluated in the future.
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Affiliation(s)
- Leena K Surakka
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland.,Siun Sote - North Karelia Social and Health Services Joint Authority, Palliative Care Center, Joensuu, Finland
| | - Minna Hökkä
- Kajaani University of Applied Sciences, Kajaani, Finland.,Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Kari Törrönen
- Fire and Rescue Department, Siun Sote - North Karelia Social and Health Services Joint Authority, Joensuu, Finland
| | - Pekka Mäntyselkä
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland.,Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland
| | - Juho T Lehto
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Oncology, Palliative Care Centre, Tampere University Hospital, Tampere, Finland
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Experiences of Carers and People with Dementia from Ethnic Minority Groups Managing Eating and Drinking at Home in the United Kingdom. Nutrients 2022; 14:nu14122395. [PMID: 35745124 PMCID: PMC9230659 DOI: 10.3390/nu14122395] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/29/2022] [Accepted: 06/04/2022] [Indexed: 12/02/2022] Open
Abstract
Eating and drinking difficulties, such as loss of appetite and swallowing problems, are common in dementia, but little is known about the experiences of ethnic minority groups who are managing these difficulties at home. The purpose of our study was to explore the meaning of food, the impact of dementia on eating and drinking, and carers’ experiences of support. We undertook semi-structured interviews with 17 carers and people with dementia from ethnic minority backgrounds living in England, using thematic analysis to analyse the data. Food/drink had strong links to identity, culture and emotions. Providing culturally familiar foods, celebrating traditional festivals and supporting previous food-related roles promoted reminiscence, which encouraged the people living with dementia to eat and drink, as did social interactions, although these could lead to distress in those with more advanced dementia. Food choices were also influenced by carer strain, generational differences and the impact of health conditions. Despite a strong sense of duty to care for relatives at home, there was low awareness of community support services. The carers expressed a need for culturally tailored support for managing dementia-related eating and drinking difficulties at home. Healthcare professionals must provide contextually relevant advice to carers, being mindful of how cultural backgrounds can affect dietary choices.
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Mogan C, Harrison Dening K, Dowrick C, Lloyd-Williams M. Health and social care services for people with dementia at home at the end of life: A qualitative study of bereaved informal caregivers' experiences. Palliat Med 2022; 36:976-985. [PMID: 35466787 PMCID: PMC9174574 DOI: 10.1177/02692163221092624] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND More people are dying at home with dementia and Alzheimer's disease. While informal caregivers are the main providers of care for people with dementia dying at home, they require support from health and social care services. However, little is known about how they experience these services. AIM To explore informal caregivers' views and experiences of health and social care services when looking after a person with dementia at home at the end-of-life. DESIGN A qualitative interview study. Data were analysed using thematic analysis. SETTING/PARTICIPANTS Twenty-nine bereaved informal caregivers who had looked after a person with dementia at home during the last 6 months of life. RESULTS Specialist palliative care for people with dementia dying at home is rare and care is mostly managed by General Practitioners and domiciliary care workers. Four overarching themes were identified: Poor continuity of care; Lack of expertise; Limited advance care planning; and Loss of autonomy. CONCLUSIONS End-of-life care at home for people with dementia must be proactively planned with an emphasis on advance care planning. Policy makers should recognise the critical role of domiciliary care services in end-of-life care and ensure that they are adequately qualified and trained.
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Affiliation(s)
- Caroline Mogan
- Academic Palliative and Supportive Care Studies Group (APSCSG), Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | | | - Christopher Dowrick
- Academic Palliative and Supportive Care Studies Group (APSCSG), Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Mari Lloyd-Williams
- Academic Palliative and Supportive Care Studies Group (APSCSG), Primary Care and Mental Health, University of Liverpool, Liverpool, UK
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Yorganci E, Stewart R, Sampson EL, Sleeman KE. Patterns of unplanned hospital admissions among people with dementia: from diagnosis to the end of life. Age Ageing 2022; 51:afac098. [PMID: 35581158 PMCID: PMC9113942 DOI: 10.1093/ageing/afac098] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND hospitalisations are sentinel events for people with dementia. How patterns of unplanned hospital admissions change among people with dementia after diagnosis is relatively unknown. OBJECTIVE to describe patterns of unplanned hospital admissions of people with dementia from diagnosis until death/study end. METHODS retrospective cohort study using mental healthcare provider data of people diagnosed with dementia in London, UK (1995-2017), linked to mortality and hospital data. The primary outcome was the rate of unplanned hospital admissions after diagnosis until death/study end. We calculated the cumulative incidence of unplanned hospital admissions. The rates of unplanned hospital admissions and the percentage of time spent as an inpatient were stratified by time from first dementia diagnosis. RESULTS for 19,221 people with dementia (61.4% female, mean age at diagnosis 81.0 years (standard deviation, SD 8.5)), the cumulative incidence of unplanned hospital admissions (n = 14,759) was 76.8% (95% CI 76.3%-77.3%). Individuals remained in the study for mean 3.0 (SD 2.6) years, and 12,667 (65.9%) died. Rates and lengths of unplanned hospital admissions remained relatively low and short in the months after the dementia diagnosis, increasing only as people approached the end of life. Percentage of time spent as an inpatient was <3% for people who were alive at the study end but was on average 19.6 and 13.3% for the decedents in the last 6 and 12 months of life, respectively. CONCLUSIONS the steep rise in hospitalisations before death highlights the need for improved community care and services for people with dementia who are approaching the end of life.
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Affiliation(s)
- Emel Yorganci
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, London, UK
| | - Robert Stewart
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Mental Health of Older Adults, South London and Maudsley NHS Foundation Trust, London, UK
| | - Elizabeth L Sampson
- Department of Psychological Medicine, Royal London Hospital, East London NHS Foundation Trust, London, UK
- Division of Psychiatry, University College London, London, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, London, UK
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Leniz J, Gulliford M, Higginson IJ, Bajwah S, Yi D, Gao W, Sleeman KE. Primary care contacts, continuity, identification of palliative care needs, and hospital use: a population-based cohort study in people dying with dementia. Br J Gen Pract 2022; 72:BJGP.2021.0715. [PMID: 35817583 PMCID: PMC9282808 DOI: 10.3399/bjgp.2021.0715] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/02/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Reducing hospital admissions among people dying with dementia is a policy priority. AIM To explore associations between primary care contacts, continuity of primary care, identification of palliative care needs, and unplanned hospital admissions among people dying with dementia. DESIGN AND SETTING This was a retrospective cohort study using the Clinical Practice Research Datalink linked with hospital records and Office for National Statistics data. Adults (>18 years) who died between 2009 and 2018 with a diagnosis of dementia were included in the study. METHOD The association between GP contacts, Herfindahl-Hirschman Index continuity of care score, palliative care needs identification before the last 90 days of life, and multiple unplanned hospital admissions in the last 90 days was evaluated using random-effects Poisson regression. RESULTS In total, 33 714 decedents with dementia were identified: 64.1% (n = 21 623) female, mean age 86.6 years (SD 8.1), mean comorbidities 2.2 (SD 1.6). Of these, 1894 (5.6%) had multiple hospital admissions in the last 90 days of life (increase from 4.9%, 95% confidence interval [CI] = 4.2 to 5.6 in 2009 to 7.1%, 95% CI = 5.7 to 8.4 in 2018). Participants with more GP contacts had higher risk of multiple hospital admissions (incidence risk ratio [IRR] 1.08, 95% CI = 1.05 to 1.11). Higher continuity of care scores (IRR 0.79, 95% CI = 0.68 to 0.92) and identification of palliative care needs (IRR 0.66, 95% CI = 0.56 to 0.78) were associated with lower frequency of these admissions. CONCLUSION Multiple hospital admissions among people dying with dementia are increasing. Higher continuity of care and identification of palliative care needs are associated with a lower risk of multiple hospital admissions in this population, and might help prevent these admissions at the end of life.
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Affiliation(s)
- Javiera Leniz
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Martin Gulliford
- Department of Population Health Sciences, Faculty of Life Science & Medicine, King's College London, London
| | - Irene J Higginson
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Sabrina Bajwah
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Deokhee Yi
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Wei Gao
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Katherine E Sleeman
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
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Mechanisms and contextual influences on the implementation of advance care planning for older people in long-term care facilities: A realist review. Int J Nurs Stud 2022; 133:104277. [PMID: 35717924 DOI: 10.1016/j.ijnurstu.2022.104277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 01/10/2023]
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Elyn A, Gardette V, Renoux A, Sourdet S, Nourhashemi F, Sanou B, Dutech M, Muller P, Gallini A. Potential determinants of unfavourable healthcare utilisation trajectories during the last year of life of people with incident Alzheimer Disease or Related Syndromes: a nationwide cohort study using administrative data. Age Ageing 2022; 51:6554096. [PMID: 35348586 DOI: 10.1093/ageing/afac053] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/11/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND people approaching the end-of-life frequently face inappropriate care. With Alzheimer Disease or Related Syndromes (ADRS), end-of-life is characterised by progressive decline, but this period remains difficult to identify. This leads to a lack of anticipation and sometimes with unfavourable healthcare utilisation trajectories (HUTs). OBJECTIVE to quantify unfavourable HUTs during the last year of life and identify their potential determinants in both community and nursing-home settings. DESIGN nationwide cohort study using administrative database. SETTING French community and nursing-home residents. SUBJECTS incident ADRS people identified in 2012, who died up to 31 December 2017. METHODS we used multidimensional clustering to identify 15 clusters of HUTs, using 11 longitudinal healthcare dimensions during the last year of life. Clusters were qualitatively assessed by pluri-disciplinary experts as favourable or unfavourable HUTs. Individual and contextual potential determinants of unfavourable HUTs were studied by setting using logistic random-effect regression models. RESULTS 62,243 individuals died before 31 December 2017; 46.8% faced unfavourable end-of-life HUTs: 55.2% in the community and 31.8% in nursing-homes. Individual potential determinants were identified: younger age, male gender, ADRS identification through hospitalisation, shorter survival, life-limiting comorbidities, psychiatric disorders, acute hospitalisations and polypharmacy. In the community, deprivation and autonomy were identified as potential determinants. Contextual potential determinants raised mostly in the community, such as low nurse or physiotherapist accessibilities. CONCLUSIONS Nearly half of people with ADRS faced unfavourable HUTs during their last year of life. Individual potential determinants should help anticipate advance care planning and palliative care needs assessment. Contextual potential determinants suggest geographical disparities and health inequalities.
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Affiliation(s)
- Antoine Elyn
- CERPOP, UMR1295, Unité Mixte INSERM - Université Toulouse III Paul Sabatier, Axe Maintain, Aging Research Team, University Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31000 Toulouse, France
- Pain Evaluation and Treatment Center, Neurosciences Department, University Hospital of Toulouse, Place du Dr Joseph Baylac, TSA 40031, 31059 Toulouse Cedex 9, France
- Forms – Occitanie’s Multiprofessional Health Care Centers Federation, 7 Clos de la Tuilerie, 31560 Nailloux, France
- University Toulouse III Paul Sabatier, 118 Route de Narbonne, F-31062 Toulouse Cedex 9, France
| | - Virginie Gardette
- CERPOP, UMR1295, Unité Mixte INSERM - Université Toulouse III Paul Sabatier, Axe Maintain, Aging Research Team, University Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31000 Toulouse, France
- University Toulouse III Paul Sabatier, 118 Route de Narbonne, F-31062 Toulouse Cedex 9, France
- Department of Epidemiology, University Hospital of Toulouse, 37 Allées Jules Guesde, 31000 Toulouse, France
| | - Axel Renoux
- Department of Epidemiology, University Hospital of Toulouse, 37 Allées Jules Guesde, 31000 Toulouse, France
| | - Sandrine Sourdet
- CERPOP, UMR1295, Unité Mixte INSERM - Université Toulouse III Paul Sabatier, Axe Maintain, Aging Research Team, University Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31000 Toulouse, France
- University Toulouse III Paul Sabatier, 118 Route de Narbonne, F-31062 Toulouse Cedex 9, France
- Geriatrics & Internal Medicine, University Hospital of Toulouse, Hôpital La Grave, Cité de la Santé, Place Lange, TSA 60033, 31059 Toulouse Cedex 9, France
| | - Fati Nourhashemi
- CERPOP, UMR1295, Unité Mixte INSERM - Université Toulouse III Paul Sabatier, Axe Maintain, Aging Research Team, University Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31000 Toulouse, France
- University Toulouse III Paul Sabatier, 118 Route de Narbonne, F-31062 Toulouse Cedex 9, France
- Geriatrics & Internal Medicine, University Hospital of Toulouse, Hôpital La Grave, Cité de la Santé, Place Lange, TSA 60033, 31059 Toulouse Cedex 9, France
| | - Brigitte Sanou
- Réseau Relience - Territorial Network for Home-based Palliative Care, Chronic Pain and Chronic Disease, 39 Impasse de la Flambère, 31300 Toulouse, France
| | - Michel Dutech
- Forms – Occitanie’s Multiprofessional Health Care Centers Federation, 7 Clos de la Tuilerie, 31560 Nailloux, France
| | - Philippe Muller
- Department of Epidemiology, University Hospital of Toulouse, 37 Allées Jules Guesde, 31000 Toulouse, France
- CNRS UMR 5505 IRIT – Toulouse Institute for Research in Computer Science, University Toulouse III Paul Sabatier, 118 Route de Narbonne, F-31062 Toulouse Cedex 9, France
| | - Adeline Gallini
- CERPOP, UMR1295, Unité Mixte INSERM - Université Toulouse III Paul Sabatier, Axe Maintain, Aging Research Team, University Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31000 Toulouse, France
- University Toulouse III Paul Sabatier, 118 Route de Narbonne, F-31062 Toulouse Cedex 9, France
- Department of Epidemiology, University Hospital of Toulouse, 37 Allées Jules Guesde, 31000 Toulouse, France
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Timmons S, Fox S, Drennan J, Guerin S, Kernohan WG. Palliative care for older people with dementia-we need a paradigm shift in our approach. Age Ageing 2022; 51:6554093. [PMID: 35333919 PMCID: PMC8955433 DOI: 10.1093/ageing/afac066] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Indexed: 11/14/2022] Open
Abstract
Older people with dementia have multiple palliative care needs, with pain, agitation, dyspnoea, aspiration and pressure ulcers being common and persistent in advanced dementia. Anticipating the person's possible symptoms requires knowledge of the whole person, including the type of dementia, which is problematic when the dementia type is often not documented. A palliative care approach to dementia should look at symptoms across the four pillars of palliative care, but in reality, we tend to over-focus on physical and psychological symptoms, while spiritual and emotional needs can be overlooked, especially around the time of diagnosis, where such needs may be significant. Advance care planning (ACP) is a central tenet of good dementia palliative care, as the person may lose their ability to communicate and make complex decisions over time. Despite this, care planning is often approached too late, and with the person's family rather than with the person; much of the literature on ACP in dementia is based on proxy decision-making for people in residential care. Thus, we need a paradigm shift in how we approach dementia, beginning with timely diagnosis that includes the dementia type, and with services able to assess and meet emotional and spiritual needs especially around the time of diagnosis, and with timely ACP as an integral part of our overall approach.
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Affiliation(s)
- Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
- Address correspondence to: Suzanne Timmons, Centre for Gerontology and Rehabilitation, Block 13, St. Finbarr’s Hospital, Douglas Road, Cork, Ireland.
| | - Siobhan Fox
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | | | - Suzanne Guerin
- School of Psychology, University College Dublin, Dublin, Ireland
| | - W George Kernohan
- Institute of Nursing and Health Research, Ulster University, Belfast, Northern Ireland
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Navia RO, Constantine LA. Palliative care for patients with advanced dementia. Nursing 2022; 52:19-26. [PMID: 35196277 DOI: 10.1097/01.nurse.0000820024.83629.ee] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Dementia is currently the seventh leading cause of death and one of the major causes of disability and dependency among older adults globally. Its final stages are complicated by a multitude of problems that can cause immense suffering. This article explores the interconnection between advanced dementia and palliative care and the role of nurses in providing end-of-life care for these patients.
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Affiliation(s)
- R Osvaldo Navia
- R. Osvaldo Navia is the chief of Geriatrics, Palliative Medicine and Hospice; the Grace Kinney Mead Chair of Geriatrics; an attending at the Rockefeller Neuroscience Institute; and an assistant professor at West Virginia University School of Medicine
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Halevi Hochwald I, Arieli D, Radomyslsky Z, Danon Y, Nissanholtz-Gannot R. Emotion work and feeling rules: Coping strategies of family caregivers of people with end stage dementia in Israel-A qualitative study. DEMENTIA 2022; 21:1154-1172. [PMID: 35130758 PMCID: PMC9189436 DOI: 10.1177/14713012211069732] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background End stage dementia is an inevitable phase following a prolonged deterioration. Family
caregivers for people with end stage dementia who live in their home can experience an
emotional burden. Emotion work and “feeling-rules” refers to socially shared norms and
self-management of feelings, as well as projecting emotions appropriate for the
situation, aiming at achieving a positive environment as a resource for supporting
others’ wellbeing. Objectives Exploring and describing the experience of family caregivers of people with end stage
dementia at home, in Israel, unpacking their emotional coping and the
emotional-strategies they use, and placing family caregivers' emotion work in a cultural
context. Method We conducted fifty qualitative interviews using semi structured interviews analyzed
through a thematic content analysis approach. Findings Four characteristics of emotion work were identified: (1) sliding between detachment
and engagement, (2) separating the person from their condition (3), adoption of
caregiving as a social role and a type of social reinforcement, and (4) using the
caregiving role in coping with loneliness and emptiness. The emotional coping strategies
are culturally contextualized, since they are influenced by the participants’ cultural
background. Discussion This article’s focus is transparent family caregivers' emotion work, a topic which has
rarely been discussed in the literature is the context of caring for a family member
with dementia at home. In our study, emotion work appears as a twofold concept: the
emotion work by itself contributed to the burden, since family caregivers' burden
experience can evolve from the dissonance between their “true” feelings of anger and
frustration and their expected “acceptable” feelings (“feeling-rules”) formed by
cultural norms. However, emotion work was also a major source of coping and finding
strength and self-meaning. Understanding and recognizing the emotion work and the
cultural and religious influence in this coping mechanism can help professionals who
treat people with end stage dementia to better support family-caregivers.
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Affiliation(s)
- Inbal Halevi Hochwald
- Department of health systems management, Ariel University, Ariel, Israel; School of Nursing, Max Stern Yezreel Valley College, Israel
| | - Daniella Arieli
- School of Nursing, Max Stern Yezreel Valley, Israel; Department of Sociology and Anthropology, Max Stern Yezreel Valley College, Israel
| | - Zorian Radomyslsky
- Department of health systems management, Ariel University, Ariel, Israel; Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Yehuda Danon
- Department of health systems management, 42732Ariel University, Ariel, Israel
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Kukafka R, Davies N, Aworinde J, Yorganci E, Anderson JE, Evans C. Implementation of eHealth to Support Assessment and Decision-making for Residents With Dementia in Long-term Care: Systematic Review. J Med Internet Res 2022; 24:e29837. [PMID: 35113029 PMCID: PMC8855285 DOI: 10.2196/29837] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND As dementia progresses, symptoms and concerns increase, causing considerable distress for the person and their caregiver. The integration of care between care homes and health care services is vital to meet increasing care needs and maintain quality of life. However, care home access to high-quality health care is inequitable. eHealth can facilitate this by supporting remote specialist input on care processes, such as clinical assessment and decision-making, and streamlining care on site. How to best implement eHealth in the care home setting is unclear. OBJECTIVE The aim of this review was to identify the key factors that influence the implementation of eHealth for people living with dementia in long-term care. METHODS A systematic search of Embase, PsycINFO, MEDLINE, and CINAHL was conducted to identify studies published between 2000 and 2020. Studies were eligible if they focused on eHealth interventions to improve treatment and care assessment or decision-making for residents with dementia in care homes. Data were thematically analyzed and deductively mapped onto the 6 constructs of the adapted Consolidated Framework for Implementation Research (CFIR). The results are presented as a narrative synthesis. RESULTS A total of 29 studies were included, focusing on a variety of eHealth interventions, including remote video consultations and clinical decision support tools. Key factors that influenced eHealth implementation were identified across all 6 constructs of the CFIR. Most concerned the inner setting construct on requirements for implementation in the care home, such as providing a conducive learning climate, engaged leadership, and sufficient training and resources. A total of 4 novel subconstructs were identified to inform the implementation requirements to meet resident needs and engage end users. CONCLUSIONS Implementing eHealth in care homes for people with dementia is multifactorial and complex, involving interaction between residents, staff, and organizations. It requires an emphasis on the needs of residents and the engagement of end users in the implementation process. A novel conceptual model of the key factors was developed and translated into 18 practical recommendations on the implementation of eHealth in long-term care to guide implementers or innovators in care homes. Successful implementation of eHealth is required to maximize uptake and drive improvements in integrated health and social care.
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Affiliation(s)
| | - Nathan Davies
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom.,Centre for Dementia Palliative Care Research, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
| | | | - Emel Yorganci
- Cicely Saunders Institute, King's College London, London, United Kingdom
| | - Janet E Anderson
- School of Health Sciences, City, University of London, London, United Kingdom
| | - Catherine Evans
- Cicely Saunders Institute, King's College London, London, United Kingdom.,Sussex Community National Health Service Foundation Trust, Brighton General Hospital, Brighton, United Kingdom
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Chen PJ, Smits L, Miranda R, Liao JY, Petersen I, Van den Block L, Sampson EL. Impact of home healthcare on end-of-life outcomes for people with dementia: a systematic review. BMC Geriatr 2022; 22:80. [PMID: 35081914 PMCID: PMC8793202 DOI: 10.1186/s12877-022-02768-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 01/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Home healthcare (HHC) comprises clinical services provided by medical professionals for people living at home with various levels of care needs and health conditions. HHC may reduce care transitions from home to acute hospitals, but its long-term impact on homebound people living with dementia (PLWD) towards end-of-life remains unclear. We aim to describe the impact of HHC on acute healthcare utilization and end-of-life outcomes in PLWD. METHODS Design: Systematic review of quantitative and qualitative original studies which examine the association between HHC and targeted outcomes. INTERVENTIONS HHC. PARTICIPANTS At least 80% of study participants had dementia and lived at home. MEASUREMENTS Primary outcome was acute healthcare utilization in the last year of life. Secondary outcomes included hospice palliative care, advance care planning, continuity of care, and place of death. We briefly reviewed selected national policy to provide contextual information regarding these outcomes. RESULTS From 6831 articles initially identified, we included five studies comprising data on 4493 participants from USA, Japan, and Italy. No included studies received a "high" quality rating. We synthesised core properties related to HHC at three implementational levels. Micro-level: HHC may be associated with a lower risk of acute healthcare utilization in the early period (e.g., last 90 days before death) and a higher risk in the late period (e.g. last 15 days) of the disease trajectory toward end-of-life in PLWD. HHC may increase palliative care referrals. Advance care planning was an important factor influencing end-of-life outcomes. Meso-level: challenges for HHC providers in medical decision-making and initiating palliative care for PLWD at the end-of-life may require further training and external support. Coordination between HHC and social care is highlighted but not well examined. Macro-level: reforms of national policy or financial schemes are found in some countries but the effects are not clearly understood. CONCLUSIONS This review highlights the dearth of dementia-specific research regarding the impact of HHC on end-of-life outcomes. Effects of advance care planning during HHC, the integration between health and social care, and coordination between primary HHC and specialist geriatric/ palliative care services require further investigation.
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Affiliation(s)
- Ping-Jen Chen
- grid.83440.3b0000000121901201Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Rd, Bloomsbury, London, W1T 7BN UK ,grid.412027.20000 0004 0620 9374Department of Family Medicine and Division of Geriatrics and Gerontology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan ,grid.412019.f0000 0000 9476 5696School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Lisanne Smits
- grid.83440.3b0000000121901201Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Rd, Bloomsbury, London, W1T 7BN UK ,grid.7177.60000000084992262Faculty of Medicine, University of Amsterdam, Amsterdam, the Netherlands
| | - Rose Miranda
- grid.8767.e0000 0001 2290 8069End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium ,grid.8767.e0000 0001 2290 8069Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jung-Yu Liao
- grid.412019.f0000 0000 9476 5696Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Irene Petersen
- grid.83440.3b0000000121901201Research Department of Primary Care and Population Health, University College London, London, UK
| | - Lieve Van den Block
- grid.8767.e0000 0001 2290 8069End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium ,grid.8767.e0000 0001 2290 8069Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Elizabeth L. Sampson
- grid.83440.3b0000000121901201Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Rd, Bloomsbury, London, W1T 7BN UK ,grid.439355.d0000 0000 8813 6797Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
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Steel A, Hopwood H, Goodwin E, Sampson EL. Multidisciplinary residential home intervention to improve outcomes for frail residents. BMC Health Serv Res 2022; 22:58. [PMID: 35022056 PMCID: PMC8756619 DOI: 10.1186/s12913-021-07407-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 12/13/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Residential homes provide accommodation and assistance with personal care only and are not required to have registered nurses on site. However, their residents often have a combination of comorbidity, polypharmacy, frailty and mental-health conditions with poor access to healthcare to meet these needs. Integrated healthcare for older people is a key NHS priority in the Long-Term Plan and the Five-Year Forward View. We describe development and implementation of multi-disciplinary intervention to integrate healthcare and promote interprofessional education. METHODS A multi-disciplinary residential home quality improvement project in two cycles by a team comprising senior and trainee general practitioners, trainees in geriatrics, psychiatry, pharmacist and residential home senior staff. The intervention was underpinned by the framework for enhanced health in care homes including Comprehensive Geriatric Assessment (CGA) and mental-health review. Each intervention session included an educational presentation by a team member consideration of each resident in a pre-evaluation multi-disciplinary discussion followed by a structured clinical assessment and discussion of proposed management. RESULTS Three residential homes participated with a total 34 residents receiving intervention. In one residential home, there was a 75% reduction in admissions for those reviewed and a reduction in overall admission costs. Polypharmacy was reduced by an average of 2 medications per resident across the three sites. There was a 63% increase in cardio-pulmonary resuscitation decisions and 76% increase in advance care planning discussions. CONCLUSION This was an effective model for multi-disciplinary trainees working with a perceived impact on physical and mental health, and valuable opportunities for sharing learning.
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Affiliation(s)
- Anna Steel
- Barnet Hospital, Wellhouse Lane, Barnet, EN5 3DJ, UK.
| | - Helen Hopwood
- Barnet Enfield and Haringey Mental Health Trust, North Middlesex University Hospital, Sterling Way, London, N18 1QX, UK
| | - Elizabeth Goodwin
- Brunswick Park Medical Centre, Brunswick Park Road, London, N11 1EY, UK
| | - Elizabeth L Sampson
- Barnet Enfield and Haringey Mental Health Trust, North Middlesex University Hospital, Sterling Way, London, N18 1QX, UK
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, 6th Floor. Wing B. Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
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Nimmons D, Armstrong M, Pigott J, Walters K, Schrag A, Ogunleye D, Dowridge W, Read J, Davies N. Exploring the experiences of people and family carers from under-represented groups in self-managing Parkinson's disease and their use of digital health to do this. Digit Health 2022; 8:20552076221102261. [PMID: 35651731 PMCID: PMC9149607 DOI: 10.1177/20552076221102261] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 04/05/2022] [Accepted: 05/05/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Digital health is thought to enable people to better manage chronic
conditions, such as Parkinson's. However, little is known about how people
from under-represented groups with chronic conditions use digital health to
self-manage. Objective The objective of our study was to explore the experiences of people and
family carers from under-represented groups in self-managing Parkinson's,
including their use of digital health to do this. Methods Semi-structured interviews (n = 18, including four dyadic) were conducted
remotely, with 16 people with Parkinson's and six family carers in
2020–2021. Participants were purposively sampled from under-represented
groups: belong to an ethnic minority, or having significant physical or
sensory impairment. Interviews were audio-recorded, transcribed and analysed
using thematic analysis. Results Three main themes of importance were developed: ‘self-management support’,
‘digital health use to support self-management’ and ‘identity, attitudes and
characteristics’. Participants received medical, psychological, social and
practical self-management support. Some participants used digital health
resources, e.g., Parkinson's UK website. Digital literacy was the biggest
barrier to using digital health, regardless of background, often dependant
on previous occupation and confidence. Few ethnic minority participants
thought race or culture alters self-management ability and most believed
there was no need for digital health interventions to be tailored to an
individual's race or culture. Some felt inclusivity was important in terms
of diverse images of people. A range of considerations were identified to
optimise digital health, such as assistive equipment for people with sensory
impairment. Conclusions Barriers to using digital health for self-management were primarily dependent
on personal factors including digital literacy and attitudes but rarely race
or culture. We recommend the optimisation of digital health interventions by
providing assistive technology at low cost, and visual inclusiveness should
be promoted by including images of people from diverse backgrounds.
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Affiliation(s)
- Danielle Nimmons
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, UCL, UK
| | - Megan Armstrong
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, UCL, UK
| | | | - Kate Walters
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, UCL, UK
| | - Anette Schrag
- Department of Neurology, Institute of Neurology, UCL, UK
| | - Della Ogunleye
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, UCL, UK
| | - Wesley Dowridge
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, UCL, UK
| | - Joy Read
- Department of Neurology, Institute of Neurology, UCL, UK
| | - Nathan Davies
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, UCL, UK
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Abstract
Systems for end of life care around the world vary in availability, structure, and funding. When available, most end of life care is in the hospice model with an interdisciplinary team approach to care of people who are expected to die within months and whose primary goal is to maximize quality of life. Symptom management near the end of life is guided by prognosis and individual priorities. People dying with neurologic disease are likely to have impaired communication or mobility that adds to the complexity of prognostication and symptom management. Neurologic specialists have important roles to play in end of life care due to their unique understanding of disease prognosis as well as end of life symptom burden and management. Neurologic specialists need to become strong advocates for the importance of end of life care by being actively involved in the hospice movement and by addressing current disparities in access to care.
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Affiliation(s)
- Farrah N Daly
- EvenBeam Neuropalliative Care, Leesburg, VA, United States.
| | - Usha Ramanathan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Abstract
BACKGROUND Dementia is a life-limiting condition that affects 50 million people globally. Existing definitions of end of life do not account for the uncertain trajectory of dementia. People living with dementia may live in the advanced stage for several years, or even die before they reach the advanced stage of dementia. AIM To identify how end of life in people with dementia is measured and conceptualised, and to identify the factors that contribute towards identifying end of life in people with dementia. DESIGN Systematic review and narrative synthesis. DATA SOURCES Electronic databases MEDLINE, EMBASE, PsychInfo and CINAHL, were searched in April 2020. Eligible studies included adults with any dementia diagnosis, family carers and healthcare professionals caring for people with dementia and a definition for end of life in dementia. RESULTS Thirty-three studies met the inclusion criteria. Various cut-off scores from validated tools, estimated prognoses and descriptive definitions were used to define end of life. Most studies used single measure tools which focused on cognition or function. There was no pattern across care settings in how end of life was defined. Healthcare professionals and family carers had difficulty recognising when people with dementia were approaching the end of life. CONCLUSION End-of-life care and research that focuses only on cognitive and functional decline may fail to recognise the complexities and unmet needs relevant to dementia and end of life. Research and clinical practice should adopt a needs-based approach for people with dementia and not define end of life by stage of disease.
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Affiliation(s)
- Bria Browne
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Kirsten J Moore
- Marie Curie Palliative Care Research Department, University College London, London, UK
- National Ageing Research Institute, Parkville, Victoria, Australia
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, University College London, London, UK
- Barnet, Enfield and Haringey Mental Health Trust, North Middlesex University Hospital, London, UK
| | - Nathan Davies
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
- Marie Curie Palliative Care Research Department, University College London, London, UK
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Tzeng HM, Knight G. Could negative behaviors by patients with dementia be positive communication? Seeking ways to understand and interpret their nonverbal communication. Nurs Forum 2021; 57:318-322. [PMID: 34812493 PMCID: PMC9299486 DOI: 10.1111/nuf.12674] [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: 08/12/2021] [Revised: 10/15/2021] [Accepted: 11/09/2021] [Indexed: 11/30/2022]
Abstract
In interactions with caregivers, patients with dementia have communication challenges that are common and worrisome to families. Family and professional caregivers find it challenging to “guess” or “interpret” what their patients with dementia are trying to tell them. In this creative controversy article, we discuss how family and professional caregivers can seek to understand and correctly interpret the nonverbal communications of patients with dementia (behaviors, actions, facial expressions, and vocal sounds). Equipping family and professional caregivers with the resources to interpret the nonverbal communications of patients with dementia requires a commitment to in‐service and family education in healthcare facilities. Nurses could play a critical role in raising the awareness among the public about the potential changes and declines in verbal communications of the patients with dementia.
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Affiliation(s)
- Huey-Ming Tzeng
- School of Nursing, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
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Development, feasibility, and acceptability of an intervention to improve care for agitation in people living in nursing homes with dementia nearing the end-of-life. Int Psychogeriatr 2021; 33:1069-1081. [PMID: 32928327 DOI: 10.1017/s1041610220001647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To develop a staff training intervention for agitation in people with severe dementia, reaching end-of-life, residing in nursing homes (NHs), test feasibility, acceptability, and whether a trial is warranted. DESIGN Feasibility study with pre- and post-intervention data collection, qualitative interviews, and focus groups. SETTING Three NHs in South East England with dementia units, diverse in terms of size, ownership status, and location. PARTICIPANTS Residents with a dementia diagnosis or scoring ≥2 on the Noticeable Problems Checklist, rated as "severe" on Clinical Dementia Rating Scale, family carers, and staff (healthcare assistants and nurses). INTERVENTION Manualized training, delivered by nonclinical psychology graduates focusing on agitation in severe dementia, underpinned by a palliative care framework. MEASUREMENTS Main outcomes were feasibility of recruitment, data collection, follow-up, and intervention acceptability. We collected resident, family carer, and staff demographics. Staff provided data on resident's agitation, pain, quality of life, and service receipt. Staff reported their sense of competence in dementia care. Family carers reported on satisfaction with end-of-life care. In qualitative interviews, we explored staff and family carers' views on the intervention. RESULTS The target three NHs participated: 28 (49%) residents, 53 (74%) staff, and 11 (85%) family carers who were eligible to participate consented. Eight-four percent of staff attended ≥3 sessions, and we achieved 93% follow-up. We were able to complete quantitative interviews. Staff and family carers reported the intervention and delivery were acceptable and helpful. CONCLUSIONS The intervention was feasible and acceptable indicating a larger trial for effectiveness may be warranted.
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Leniz J, Higginson IJ, Yi D, Ul-Haq Z, Lucas A, Sleeman KE. Identification of palliative care needs among people with dementia and its association with acute hospital care and community service use at the end-of-life: A retrospective cohort study using linked primary, community and secondary care data. Palliat Med 2021; 35:1691-1700. [PMID: 34053356 PMCID: PMC8532216 DOI: 10.1177/02692163211019897] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospital admissions among people dying with dementia are common. It is not known whether identification of palliative care needs could help prevent unnecessary admissions. AIM To examine the proportion of people with dementia identified as having palliative care needs in their last year of life, and the association between identification of needs and primary, community and hospital services in the last 90 days. DESIGN Retrospective cohort study using Discover, an administrative and clinical dataset from 365 primary care practices in London with deterministic individual-level data linkage to community and hospital records. SETTING/PARTICIPANTS People diagnosed with dementia and registered with a general practitioner in North West London (UK) who died between 2016 and 2019. The primary outcome was multiple non-elective hospital admissions in the last 90 days of life. Secondary outcomes included contacts with primary and community care providers. We examined the association between identification of palliative care needs with outcomes. RESULTS Among 5804 decedents with dementia, 1953 (33.6%) were identified as having palliative care needs, including 1141 (19.7%) identified before the last 90 days of life. Identification of palliative care needs before the last 90 days was associated with a lower risk of multiple hospital admissions (Relative Risk 0.70, 95% CI 0.58-0.85) and more contacts with the primary care practice, community nurses and palliative care teams in the last 90 days. CONCLUSIONS Further investigation of the mechanisms underlying the association between identification of palliative care needs and reduced hospital admissions could help reduce reliance on acute care for this population.
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Affiliation(s)
- Javiera Leniz
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Zia Ul-Haq
- Discover-Now, Imperial College Health Partners, London, UK
| | - Amanda Lucas
- Discover-Now, Imperial College Health Partners, London, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Peisah C, Sampson EL, Rabheru K, Wand A, Lapid M. The Human Rights of Older People With Mental Health Conditions and Psychosocial Disability to a Good Death and Dying Well. Am J Geriatr Psychiatry 2021; 29:1041-1046. [PMID: 34175232 DOI: 10.1016/j.jagp.2021.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 12/17/2022]
Abstract
The human right to a good death and dying well is as important as the right to life. At stake at the end of life are human rights to dignity, autonomy, self-determination and respect for will and preferences, equitable access to quality health care that is needs-based, and respect for family and relationships. Older people with dementia, those with serious mental illness, and those with intellectual disability are vulnerable to "bad deaths" due to violations of these rights. In this paper we explore why this is so and examine existing and potential solutions. A human rights-approach to end-of-life care and policy for older persons with mental health conditions and psychosocial disability is one that is needs-based, encompassing physical and mental health, palliative care, social, and spiritual support services provided in the context of inclusive living. Most importantly, end of life care must be self-determined, and not "one size fits all." An important remedy to existing violations is to strengthen human rights frameworks to cater specifically to older persons' needs with a UN convention on the rights of older persons. Finally, as health professionals we have important contributions to make at the coalface by accepting our responsibilities in the area of death and dying. With the concept of the palliative psychiatrist gaining traction and recognition that death is our business, we add that human rights is also our business.
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Affiliation(s)
- Carmelle Peisah
- School of Psychiatry, Faculty Medicine & Ageing Futures Institute, University of New South Wales, Capacity Australia (CP), Sydney, Australia.
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London (ELS), London, United Kingdom
| | | | - Anne Wand
- Specialty of Psychiatry, Faculty Medicine and Health, University of Sydney (AW), Sydney, Australia; Discipline of Psychiatry, Faculty of Medicine, University of New South Wales (AW), New South Wales, Australia
| | - Maria Lapid
- Department of Psychiatry and Psychology, Mayo Clinic (ML), Rochester, MN
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Psychotropic prescribing for English care home residents with dementia compared with national guidance: findings from the MARQUE national longitudinal study. BJPsych Open 2021. [PMCID: PMC8485345 DOI: 10.1192/bjo.2021.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Despite policy pressure and concerns regarding the use of antipsychotics and benzodiazepines, many care home residents with dementia are prescribed psychotropic medication, often off licence. This is the first large study to report psychotropic prescribing and ‘as required’ administration patterns in English care homes. Aims To explore the prevalence and associates of psychotropic prescription in care home residents with dementia and compare the results with national guidance. Method We collected data in a longitudinal cohort study of residents with diagnosed or probable dementia in 86 care homes in England in 2014–2016. We reported the prevalence of psychotropic (antipsychotics, anxiolytics/hypnotics, antidepressants) prescriptions and drug receipt. We explored the associations between resident factors (sociodemographic, agitation [Cohen–Mansfield Agitation Inventory], dementia severity [Clinical Dementia Rating]) and care home factors (type, ownership, size, dementia registration/specialism, quality rating) in prescription and ‘as required’ administration, using multilevel regression models. Results We analysed data from 1425 residents. At baseline, 822 residents (57.7%, 95% CI: 55.1–60.2) were prescribed a psychotropic drug, 310 residents (21.8% 95% CI: 19.7–24.0) were prescribed an anxiolytic/hypnotic, 232 (94.3%, 95% CI: 90.6–96.6) were prescribed one antipsychotic and 14 (5.7%, 95% CI: 3.4–9.4) were prescribed two antipsychotics. The median prescription duration during the study was 1 year. Residents with clinically significant agitation were prescribed more antipsychotics (odds ratio [OR] = 2.00, 95% CI: 1.64–2.45) and anxiolytics/hypnotics (OR = 2.81, 95% CI: 2.31–3.40). Conclusions Antipsychotics and anxiolytics/hypnotics are more commonly prescribed for people with dementia in care homes than in the community, and prescribing may not reflect guidelines. Policies which advocate reduced use of psychotropics should better support psychosocial interventions.
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Whitehead PB, Gamaluddin S, DeWitt S, Stewart C, Kim KY. Caring for Patients With Dementia at End of Life. Am J Hosp Palliat Care 2021; 39:716-724. [PMID: 34519251 DOI: 10.1177/10499091211046247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Care of the dementia patient continues to be challenging. It is a terminal condition that many times goes undiagnosed leading to improper evidence-based interventions. Healthcare professionals (HCPs) should initiate goals of care conversations early with patients and their families in order to align treatment preferences. Early integration of palliative medicine is an important intervention that can lead to better manage symptoms and lessen the strain on loved ones. Additionally, early enrollment into hospice should be encouraged with loved ones to promote quality of life as defined by the patient.
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Affiliation(s)
- Phyllis B Whitehead
- Carilion Roanoke Memorial Hospital Palliative Care Service, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | | | - Sarah DeWitt
- Carilion Roanoke Memorial Hospital Palliative Care Service, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Christi Stewart
- Carilion Roanoke Memorial Hospital Palliative Care Service, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Carilion Center for Healthy Aging, Roanoke, VA, USA
| | - Kye Y Kim
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Carilion Center for Healthy Aging, Roanoke, VA, USA
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La Frenais F, Vickerstaff V, Cooper C, Livingston G, Stone P, Sampson EL. Factors influencing prescription and administration of analgesic medication: A longitudinal study of people with dementia living in care homes. Int J Geriatr Psychiatry 2021; 36:1354-1361. [PMID: 33719098 DOI: 10.1002/gps.5526] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/25/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To (1) describe the prescription and administration of regular and 'as required' (pro re nata [PRN]) analgesics in English care homes, (2) investigate individual and care home factors associated with analgesic use. METHODS We collected data (2014-2016) at 0-, 4-, and 12-months nested in a longitudinal cohort study of 86 English care homes about residents with diagnosed or probable dementia. We describe analgesics prescribed as regular or PRN medication, by class, and PRN administration. We explored individual differences (sociodemographic; dementia severity [Clinical Dementia Rating]), and care home differences (type; ownership; number of beds; dementia-registered/specialist; Care Quality Commission rating) in prescription and administration using multilevel regression models. RESULTS Data were available for 1483 residents. At baseline, 967 residents (67.9%) were prescribed analgesics: 426 residents (28.7%) prescribed regular analgesics and 670 (45.2%) prescribed PRN. Paracetamol was the most prescribed analgesic (56.7%), with PRN prescriptions more common than regular (39.7% vs. 16.6%). Across all study visits, 344 residents (mean = 41.9%) with a PRN prescription did not receive any analgesic in the 2 weeks prior to data collection. Male residents and those with severe dementia received fewer analgesics. Care homes differences in PRN administration were not explained by the modelled variables. CONCLUSIONS Pain management in English care homes largely relies on PRN paracetamol that is frequently prescribed but infrequently administered. Care homes differ in how often they administer PRN analgesics. Some care home residents particularly those with more severe dementia are likely to have untreated pain.
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Affiliation(s)
- Francesca La Frenais
- Division of Psychiatry, University College London, London, UK
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Claudia Cooper
- Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, St. Pancras Hospital, London, UK
| | - Gill Livingston
- Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, St. Pancras Hospital, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, University College London, London, UK
- Marie Curie Palliative Care Research Department, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, London, UK
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