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Jan D, Kim KY. End-of-Life Care of Persons with Alzheimer's Disease and Other Dementias. Am J Hosp Palliat Care 2024:10499091241253838. [PMID: 38714329 DOI: 10.1177/10499091241253838] [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: 05/09/2024] Open
Abstract
End-of-life (EOL) care has been a common option for patients with terminal medical conditions such as cancers. However, the utilization of EOL care in Alzheimer disease and other dementing conditions have become available relatively recently. As the end-stage dementia approaches, the clinicians and caregivers become faced with numerous clinical challenges-delirium, neuropbehavioral symptoms, the patient's inability to communicate pain and associated discomfort, food refusal, and so on. In addition to providing quality clinical care to the EOL patients, clinicians should pay special attention to their families, assuring that their loved ones will receive supportive measures to improve quality of life (QOL).
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Affiliation(s)
- Darlon Jan
- Psychiatry Residency Program, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Center for Healthy Aging, Carilion Clinic, Roanoke, VA, USA
| | - Kye Y Kim
- Psychiatry Residency Program, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Center for Healthy Aging, Carilion Clinic, Roanoke, VA, USA
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2
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Unroe KT, Ersek M, Tu W, Floyd A, Becker T, Trimmer J, Lamie J, Cagle J. Using Palliative Leaders in Facilities to Transform Care for People with Alzheimer's Disease (UPLIFT-AD): protocol of a palliative care clinical trial in nursing homes. BMC Palliat Care 2023; 22:105. [PMID: 37496001 PMCID: PMC10369841 DOI: 10.1186/s12904-023-01226-0] [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: 06/30/2023] [Accepted: 07/12/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Palliative care is an effective model of care focused on maximizing quality of life and relieving the suffering of people with serious illnesses, including dementia. Evidence shows that many people receiving care in nursing homes are eligible for and would benefit from palliative care services. Yet, palliative care is not consistently available in nursing home settings. There is a need to test pragmatic strategies to implement palliative care programs in nursing homes. METHODS/DESIGN The UPLIFT-AD (Utilizing Palliative Leaders in Facilities to Transform care for people with Alzheimer's Disease) study is a pragmatic stepped wedge trial in 16 nursing homes in Maryland and Indiana, testing the effectiveness of the intervention while assessing its implementation. The proposed intervention is a palliative care program, including 1) training at least two facility staff as Palliative Care Leads, 2) training for all staff in general principles of palliative care, 3) structured screening for palliative care needs, and 4) on-site specialty palliative care consultations for a one-year intervention period. All residents with at least moderate cognitive impairment, present in the facility for at least 30 days, and not on hospice at baseline are considered eligible. Opt-out consent is obtained from legal decision-makers. Outcome assessments measuring symptoms and quality of care are obtained from staff and family proxy respondents at four time points: pre-implementation (baseline), six months after implementation, at 12 months (conclusion of implementation), and six months after the end of implementation. Palliative care attitudes and practices are assessed through surveys of frontline nursing home staff both pre- and post-implementation. Qualitative and quantitative implementation data, including fidelity assessments and interviews with Palliative Care Leads, are also collected. The study will follow the Declaration of Helsinki. DISCUSSION This trial assesses the implementation and effectiveness of a robust palliative care intervention for residents with moderate-to-advanced cognitive impairment in 16 diverse nursing homes. The intervention represents an innovative, pragmatic approach that includes both internal capacity-building of frontline nursing home staff, and support from external palliative care specialty consultants. TRIAL REGISTRATION The project is registered on ClinicalTrials.gov: NCT04520698.
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Affiliation(s)
- Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
- Regenstrief Institute, Inc, Indianapolis, IN, 46202, USA.
| | - Mary Ersek
- University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
| | - Wanzhu Tu
- Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Regenstrief Institute, Inc, Indianapolis, IN, 46202, USA
- Department of Biostatistics, Indiana University, Indianapolis, IN, 46202, USA
| | | | - Todd Becker
- University of Maryland School of Social Work, Baltimore, MD, 21201, USA
| | - Jessica Trimmer
- University of Maryland School of Social Work, Baltimore, MD, 21201, USA
| | - Jodi Lamie
- Regenstrief Institute, Inc, Indianapolis, IN, 46202, USA
| | - John Cagle
- University of Maryland School of Social Work, Baltimore, MD, 21201, USA
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3
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Sousa MS, Davis W, Blanchard M, Razmovski-Naumovski V, Agar M, Daveson B, Hsm D, Currow DC. Appetite-Related Distress Is Burdensome in the Last Sixty Days of Life of People Receiving Palliative Care: A National Longitudinal Consecutive Cohort Study. J Palliat Med 2021; 25:636-642. [PMID: 34978898 DOI: 10.1089/jpm.2021.0462] [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: 11/12/2022] Open
Abstract
Background: People with life-limiting illnesses experience a range of distressing symptoms. Appetite-related symptoms are common, but studies have found varied prevalence and the distress caused has had limited quantification. Objectives: To examine the clinicodemographic factors and trajectory of appetite-related distress in the last 60 days of life. Design/Setting/Subjects: Consecutive cohort of 109,385 patients (359,038 data points) using specialist palliative care services in the Australian Palliative Care Outcomes Collaboration (PCOC). Measurements: Patient-reported appetite-related distress using the PCOC Symptom Assessment Scale. Results: Diagnoses included cancer (75%), end-stage organ failure (11%), neurodegenerative disease (4%), dementia (3%), and other noncancer (7%). Fifty-eight percent reported some degree of appetite-related distress at least once in the last 60 days of life. Daily mean distress scores did not vary greatly by diagnosis and the distributions of symptom severity were not linked with performance status. There was a sharp decline in mean distress for all diagnostic groups around 7-10 days before death. Moderate to severe distress was associated with nausea-, bowel-, pain-, and breathing-related distress, controlling for key baseline factors. Conclusion: Appetite-related distress is prevalent and burdensome in the 60 days before death and is strongly associated with distress from other cardinal symptoms.
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Affiliation(s)
- Mariana S Sousa
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
| | - Walter Davis
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Megan Blanchard
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Valentina Razmovski-Naumovski
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Meera Agar
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | | | - Dip Hsm
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - David C Currow
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,Palliative Care Outcomes Collaboration, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia.,Wolfson Palliative Care Research Centre, University of Hull, Hull, England
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4
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McAnee G, Norwood K, Rosato M, Leavey G. Assessment of pain in people living with dementia at the end of life: a systematic review. Int J Palliat Nurs 2021; 27:72-85. [PMID: 33886358 DOI: 10.12968/ijpn.2021.27.2.72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND People with dementia may not receive the same quality of palliative care as those with other life-limiting conditions, particularly at end of life (EoL). AIMS To understand the best way to examine pain in people with dementia. METHODS A systematic review of tools to assess pain in patients with dementia near the end of life; PubMed, Medline, Embase, EBSCO Host, CINAHL Plus, Web of Science, Psycinfo, PsycArticles and Scopus were searched. FINDINGS A total of 15 articles were identified, which were qualitatively synthesised. CONCLUSION There are a range of pain assessment tools that are appropriate for use in people with dementia, but all 15 studies used a formal tool. A more robust approach is needed to improve the quality of research for measurement and management of pain in this population.
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Affiliation(s)
- Grainne McAnee
- Bamford Centre for Mental Health and Wellbeing, Ulster University, Northern Ireland, United Kingdom
| | - Kelly Norwood
- School of Psychology, Ulster University, Northern Ireland, United Kingdom
| | - Michael Rosato
- Bamford Centre for Mental Health and Wellbeing, Ulster University, Northern Ireland, United Kingdom
| | - Gerry Leavey
- Bamford Centre for Mental Health and Wellbeing, Ulster University, Northern Ireland, United Kingdom
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5
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Lundin E, Godskesen TE. End-of-life care for people with advanced dementia and pain: a qualitative study in Swedish nursing homes. BMC Nurs 2021; 20:48. [PMID: 33743691 PMCID: PMC7981921 DOI: 10.1186/s12912-021-00566-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 03/11/2021] [Indexed: 11/25/2022] Open
Abstract
Background Of the Swedish people with advanced dementia, the majority die in nursing homes. Unresolved pain can occur in people with a terminal illness such as dementia. However, pain management in people with advanced dementia is often suboptimal and inadequate, with fewer palliative care interventions than offered to cancer patients. Although they are largely responsible for the care of these people, few studies have addressed the experiences of registered nurses in this respect. Therefore, the aim of this study was to describe the experiences of nurses in caring for people with advanced dementia and pain at the end of life. Methods The study had a descriptive explorative design. Individual qualitative, semi-structured interviews were carried out with 13 nurses from 12 nursing homes in Sweden. The results were analysed using thematic content analysis. Results The nurses described communicative, relational and organisational challenges. One major issue involved difficulties communicating with the person with advanced dementia, resulting in uncertain pain assessment. Other difficulties involved the differentiation of pain from anxiety, the balance of benefits and risks with morphine administration, and the creation of good relationships with healthcare personnel and the persons’ relatives. Relatives can greatly affect the assessment and management of pain, both because of their ability to interpret pain behaviour and by questioning the care given. Good pain management was facilitated by good communication and relationships with healthcare staff and relatives, extensive professional nursing experience, and already knowing the person with advanced dementia. Conclusions This study highlights the need for nursing homes to employ specialist nurses who have been trained in the appropriate knowledge and skills to deal with the challenges of end-of-life care for people with advanced dementia and pain. Additionally, there should be resources and strategies available for providing information to family members and for involving them in the decision-making process, as they are often unfamiliar with the multitude of considerations involved in decisions such as whether to administer morphine or not. Supplementary Information The online version contains supplementary material available at 10.1186/s12912-021-00566-7.
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Affiliation(s)
- Emma Lundin
- Nacka Senior Centre Talliden, Helgesons väg 5, SE-131 37, Nacka, Sweden
| | - Tove E Godskesen
- Centre for Research Ethics & Bioethics, Uppsala University, BMC, Box 564, SE-751 22, Uppsala, Sweden. .,Department of Health Care Sciences, Palliative Research Centre, Ersta Sköndal Bräcke University College, Box 11189, SE-100 61, Stockholm, Sweden.
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Guion V, de Souto Barreto P, Rolland Y. Trajectories of Symptoms in Nursing Home Residents after a Transfer to the Emergency Department. J Nutr Health Aging 2021; 25:318-324. [PMID: 33575722 DOI: 10.1007/s12603-020-1476-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe the trajectories of pain, dyspnea, fever, confusion, agitation and fatigue of nursing home residents' (NHRs) after a transfer to the emergency department (ED). DESIGN Observational multicenter study. SETTING 17 EDs in France. PARTICIPANTS 751 NHRs presenting to EDs over four non-consecutive weeks (one week per season) in 2016. MEASUREMENTS Trajectories of symptoms (binary variables) including pain, dyspnea, fever, agitation, confusion and fatigue at four times: before ED transfer, during the transfer, in the ED and after discharge. RESULTS Group-based multi-trajectory modelling was performed to identify groups of NHRs following similar trajectories of symptoms evolution after a transfer to ED. Five groups were identified. In group 1 (n=190), NHRs presented with confusion and a rising prevalence of fatigue. In group 2 (n=212), NHRs presented with a highly prevalent but declining pain. In group 3 (n=158), NHRs presented with similar peaking pain prevalence, rising confusion and fatigue, and a high but stable agitation prevalence. In group 4 (n=144), NHRs presented with a highly prevalent but declining dyspnea, rising then declining fever, rising confusion, and a high and fluctuating fatigue prevalence. In group 5 (n=47), NHRs presented with a highly prevalent but declining fever, rising then declining dyspnea, stable and high both fatigue and pain prevalence, stable and low prevalence of confusion. CONCLUSION Symptom alleviation in NHRs transferred to ED was better achieved in those with pain, fever or dyspnea rather than in those with confusion, agitation and fatigue. NHRs' resilience through the stress of an ED transfer could be predicted by comorbidity and functional abilities, challenged by acute conditions representing various levels of stress intensity, and evaluated on the course of non-specific symptoms. NHRs' resilience is key to estimate the appropriateness of an ED transfer and should facilitate advance care planning regarding NHRs' hospitalizations.
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Affiliation(s)
- V Guion
- Vincent Guion, Gerontopole, 20 rue du Pont Saint-Pierre, Cité de la Santé, CHU de Toulouse, 31059 Toulouse, France,
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Antibiotic use during end-of-life care: A systematic literature review and meta-analysis. Infect Control Hosp Epidemiol 2020; 42:523-529. [PMID: 33172507 DOI: 10.1017/ice.2020.1241] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND We performed a systematic literature review and meta-analysis measuring the burden of antibiotic use during end-of-life (EOL) care. METHODS We searched PubMed, CINAHL (EBSCO platform), and Embase (Elsevier platform), through July 2019 for studies with the following inclusion criteria in the initial analysis: antibiotic use in the EOL care patients (advanced dementia, cancer, organ failure, frailty or multi-morbidity). If the number of patients in palliative care consultation (PCC) was available, antibiotic use data were pooled to compare the proportion of patients who received antibiotics under PCC compared to those not receiving PCC. Random-effect models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 value. RESULTS Overall, 72 studies met the inclusion criteria and were included in the final review: 22 EOL studies included only patients with cancer; 17 studies included only patients with advanced dementia; and 33 studies included "mixed populations" of EOL patients. Although few studies reported antibiotic using standard metrics (eg, days of therapy), 48 of 72 studies (66.7%) reported antibiotic use in >50% of all patients. When the 3 studies that evaluated antibiotic use in PCC were pooled together, patients under PCC was more likely to receive antibiotics compared to patients not under PCC (pooled odds ratio, 1.73; 95% CI, 1.02-2.93). CONCLUSIONS Future studies are needed to evaluate the benefits and harms of using antibiotics for patients during EOL care in diverse patient populations.
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Palliative care needs and utilization of specialist services for people imminently dying with dementia: A national population-based study. Int J Nurs Stud 2020; 109:103655. [DOI: 10.1016/j.ijnurstu.2020.103655] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 02/05/2023]
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Miranda R, van der Steen JT, Smets T, Van den Noortgate N, Deliens L, Payne S, Kylänen M, Szczerbińska K, Gambassi G, Van den Block L. Comfort and clinical events at the end of life of nursing home residents with and without dementia: The six-country epidemiological PACE study. Int J Geriatr Psychiatry 2020; 35:719-727. [PMID: 32128874 DOI: 10.1002/gps.5290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES We aimed to investigate the occurrence rates of clinical events and their associations with comfort in dying nursing home residents with and without dementia. METHODS Epidemiological after-death survey was performed in nationwide representative samples of 322 nursing homes in Belgium, Finland, Italy, the Netherlands, Poland, and England. Nursing staff reported clinical events and assessed comfort. The nursing staff or physician assessed the presence of dementia; severity was determined using two highly discriminatory staff-reported instruments. RESULTS The sample comprised 401 residents with advanced dementia, 377 with other stages of dementia, and 419 without dementia (N = 1197). Across the three groups, pneumonia occurred in 24 to 27% of residents. Febrile episodes (unrelated to pneumonia) occurred in 39% of residents with advanced dementia, 34% in residents with other stages of dementia and 28% in residents without dementia (P = .03). Intake problems occurred in 74% of residents with advanced dementia, 55% in residents with other stages of dementia, and 48% in residents without dementia (P < .001). Overall, these three clinical events were inversely associated with comfort. Less comfort was observed in all resident groups who had pneumonia (advanced dementia, P = .04; other stages of dementia, P = .04; without dementia, P < .001). Among residents with intake problems, less comfort was observed only in those with other stages of dementia (P < .001) and without dementia (P = .003), while the presence and severity of dementia moderated this association (P = .03). Developing "other clinical events" was not associated with comfort. CONCLUSIONS Discomfort was observed in dying residents who developed major clinical events, especially pneumonia, which was not specific to advanced dementia. It is crucial to identify and address the clinical events potentially associated with discomfort in dying residents with and without dementia.
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Affiliation(s)
- Rose Miranda
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam Public Health research institute, Expertise center for Palliative Care, Amsterdam, The Netherlands.,Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University Hospital, Ghent, Belgium
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, UK
| | - Marika Kylänen
- National Institute for Health and Welfare, Helsinki, Finland
| | - Katarzyna Szczerbińska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Giovanni Gambassi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Aitken C, Boyd M, Nielsen L, Collier A. Medication use in aged care residents in the last year of life: A scoping review. Palliat Med 2020; 34:832-850. [PMID: 32286162 DOI: 10.1177/0269216320911596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND A substantial number of older adults die in residential aged care facilities, yet little is known about the characteristics of and how best to optimise medication use in the last year of life. AIM The aim of this review was to map characteristics of medication use in aged care residents during the last year of life in order to examine key concepts related to medication safety and draw implications for further research and service provision. DESIGN A scoping review following Arskey and O'Malley's framework was conducted using a targeted keyword search, followed by assessments of eligibility based on title and content of abstracts and full papers. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the scoping review protocol was prospectively registered to the Open Science Framework on 27 November 2018. DATA SOURCES We searched MEDLINE, EMBASE, AMED, CINAHL and Cochrane databases to identify peer-reviewed studies published between 1937 and 2018, written in English and looking at medication use in individuals living in aged care facilities within their last year of life. RESULTS A total of 30 papers were reviewed. Five key overarching themes were derived from the analysis process: (1) access to medicines at the end of life, (2) categorisation and classes: medicines and populations, (3) polypharmacy and total medication numbers, (4) use of symptomatic versus preventive medications and (5) 'inappropriate' medications. CONCLUSION Number of prescriptions or blunt categorisations of medications to assess their appropriateness are unlikely to be sufficient to promote well-being and medication safety for older people in residential aged care in the final stages of life.
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Affiliation(s)
| | - Michal Boyd
- The University of Auckland, Auckland, New Zealand
| | | | - Aileen Collier
- The University of Auckland, Auckland, New Zealand.,Flinders University, Adelaide, SA, Australia.,University of Tasmania, Hobart, TAS, Australia
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Tanghe M, Van Den Noortgate N, Deliens L, Smets T, Onwuteaka-Philipsen B, Szczerbińska K, Finne-Soveri H, Payne S, Gambassi G, Van den Block L, Piers R. Opioid underuse in terminal care of long-term care facility residents with pain and/or dyspnoea: A cross-sectional PACE-survey in six European countries. Palliat Med 2020; 34:784-794. [PMID: 32286149 DOI: 10.1177/0269216320910332] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND/OBJECTIVES Opioids relieve symptoms in terminal care. We studied opioid underuse in long-term care facilities, defined as residents without opioid prescription despite pain and/or dyspnoea, 3 days prior to death. DESIGN AND SETTING In a proportionally stratified randomly selected sample of long-term care facilities in six European Union countries, nurses and long-term care facility management completed structured after-death questionnaires within 3 months of residents' death. MEASUREMENTS Nurses assessed pain/dyspnoea with Comfort Assessment in Dying with Dementia scale and checked opioid prescription by chart review. We estimated opioid underuse per country and per symptom and calculated associations of opioid underuse by multilevel, multivariable analysis. RESULTS Nurses' response rate was 81.6%, 95.7% for managers. Of 901 deceased residents with pain/dyspnoea reported in the last week, 10.6% had dyspnoea, 34.4% had pain and 55.0% had both symptoms. Opioid underuse per country was 19.2% (95% confidence interval: 12.9-27.2) in the Netherlands, 25.2% (18.3-33.6) in Belgium, 29.3% (16.9-45.8) in England, 33.7% (26.2-42.2) in Finland, 64.6% (52.0-75.4) in Italy and 79.1% (71.2-85.3) in Poland (p < 0.001). Opioid underuse was 57.2% (33.0-78.4) for dyspnoea, 41.2% (95% confidence interval: 21.9-63.8) for pain and 37.4% (19.4-59.6) for both symptoms (p = 0.013). Odds of opioid underuse were lower (odds ratio: 0.33; 95% confidence interval: 0.20-0.54) when pain was assessed. CONCLUSION Opioid underuse differs between countries. Pain and dyspnoea should be formally assessed at the end-of-life and taken into account in physicians orders.
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Affiliation(s)
- Marc Tanghe
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Ghent, Belgium
| | - Nele Van Den Noortgate
- Department of Geriatric Medicine, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Bregje Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | | | - Sheila Payne
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Giovanni Gambassi
- Fondazione Policlinico Universitario A. Gemelli, IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Ruth Piers
- Department of Geriatric Medicine, Ghent University and Ghent University Hospital, Ghent, Belgium
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12
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De Schreye R, Smets T, Deliens L, Annemans L, Gielen B, Cohen J. Appropriateness of End-of-Life Care in People Dying With Dementia: Applying Quality Indicators on Linked Administrative Databases. J Am Med Dir Assoc 2020; 21:1093-1101.e1. [PMID: 32037298 DOI: 10.1016/j.jamda.2019.12.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/08/2019] [Accepted: 12/20/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Dementia is a progressive incurable life-limiting illness. Previous research suggests end-of-life care for people with dementia should have a symptomatic focus with an effort to avoid burdensome interventions that would not improve quality of life. This study aims to assess the appropriateness of end-of-life care in people who died with dementia in Belgium and to establish relative performance standards by measuring validated population-level quality indicators. DESIGN We conducted a retrospective observational study. SETTING AND PARTICIPANTS We included all persons deceased with dementia in 2015 in Belgium. Data from 8 administratively collected population-level databases was linked. MEASURES We used a validated set of 28 quality indicators for end-of-life dementia care. We compared quality indicator scores across 14 healthcare regions to establish relative benchmarks. RESULTS In Belgium in 2015, 10,629 people died with dementia. For indicators of appropriate end-of-life care, people who died with dementia had on average 1.83 contacts with their family physician in the last week before death, whereas 68.4% died at home or in their nursing home of residence. For indicators of inappropriate end-of-life care, 32.4% were admitted to the hospital and 36.3% underwent diagnostic testing in the last 30 days before death, whereas 25.1% died in the hospital. In the last 30 days, emergency department admission varied between 19% and 31%, dispensing of gastric protectors between 18% and 42%, and antihypertensives between 40% and 53% between healthcare regions, with at least 25% of health regions below 46%. CONCLUSIONS AND IMPLICATIONS Our study found indications of appropriate as well as inappropriate end-of-life care in people with dementia, including high rates of family physician contact, as well as high percentages of diagnostic testing, and emergency department and hospital admissions. We also found high risk-adjusted variation for multiple quality indicators, indicating opportunity for quality improvement in end-of-life dementia care.
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Affiliation(s)
- Robrecht De Schreye
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Ghent, Belgium.
| | - Tinne Smets
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Ghent, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Ghent, Belgium; Department of Medical Oncology, Ghent University, Ghent, Belgium
| | - Lieven Annemans
- Department of Public Health, Ghent University, Ghent, Belgium
| | | | - Joachim Cohen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Ghent, Belgium
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Eisenmann Y, Golla H, Schmidt H, Voltz R, Perrar KM. Palliative Care in Advanced Dementia. Front Psychiatry 2020; 11:699. [PMID: 32792997 PMCID: PMC7394698 DOI: 10.3389/fpsyt.2020.00699] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/02/2020] [Indexed: 12/20/2022] Open
Abstract
Dementia syndrome is common and expected to increase significantly among older people and characterized by the loss of cognitive, psychological and physical functions. Palliative care is applicable for people with dementia, however they are less likely to have access to palliative care. This narrative review summarizes specifics of palliative care in advanced dementia. Most people with advanced dementia live and die in institutional care and they suffer a range of burdensome symptoms and complications. Shortly before dying people with advanced dementia suffer symptoms as pain, eating problems, breathlessness, neuropsychiatric symptoms, and complications as respiratory or urinary infections and frequently experience burdensome transitions. Pharmacological and nonpharmacological interventions may reduce symptom burden. Sensitive observation and appropriate assessment tools enable health professionals to assess symptoms and needs and to evaluate interventions. Due to lack of decisional capacity, proxy decision making is often necessary. Advanced care planning is an opportunity establishing values and preferences and is associated with comfort and decrease of burdensome interventions. Family carers are important for people with advanced dementia they also experience distress and are in need for support. Recommendations refer to early integration of palliative care, recognizing signs of approaching death, symptom assessment and management, advanced care planning, person-centered care, continuity of care, and collaboration of health care providers.
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Affiliation(s)
- Yvonne Eisenmann
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Heidrun Golla
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Holger Schmidt
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Clinical Trials Center (ZKS), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Health Services Research, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Klaus Maria Perrar
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
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Progress in advance care planning among nursing home residents dying with advanced dementia-Does it make any difference in end-of-life care? Arch Gerontol Geriatr 2019; 86:103955. [PMID: 31561064 DOI: 10.1016/j.archger.2019.103955] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 08/29/2019] [Accepted: 09/12/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Increased awareness of the clinical course of nursing home residents with advanced dementia and advance care planning (ACP) has become the cornerstone of good palliative care. OBJECTIVE The aim of our study is to describe changes in ACP in the form of physician treatment orders (PTOs), symptom prevalence and possible burdensome interventions among nursing home (NH) residents who died between 2004-2009 and 2010-2013 METHODS: Retrospective study RESULTS: The number of PTOs regarding forgoing antibiotics or parenteral antibiotics, forgoing artificial nutrition or hydration or forgoing hospitalisation doubled between 2004-2009 and 2010-2013 (38.1% vs. 64.9%, p < 0.001; 40.0% vs. 81.7%, p < 0.001; 28.1% vs. 69.5%, p < 0.001, respectively). PTOs were also done significantly earlier in 2010-2013 than in 2004-2009. The prevalence of distressing symptoms and possible burdensome interventions remained unchanged, although the prevalence of consistency with the PTOs was high. CONCLUSION Despite the increased number of PTOs, this had little effect on symptom prevalence and possible burdensome interventions experienced by NH residents in the last days of life.
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15
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Tanghe M, Van Den Noortgate N, Pivodic L, Deliens L, Onwuteaka-Philipsen B, Szczerbinska K, Finne-Soveri H, Collingridge-Moore D, Gambassi G, Van den Block L, Piers R. Opioid, antipsychotic and hypnotic use in end of life in long-term care facilities in six European countries: results of PACE. Eur J Public Health 2019; 29:74-79. [PMID: 30285189 PMCID: PMC6345144 DOI: 10.1093/eurpub/cky196] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Opioids, antipsychotics and hypnotics are recommended for comfort care in dying. We studied their prescription during the last 3 days in residents deceased in the long-term care facility (LTCF). Methods In a retrospective, cross-sectional survey in Belgium, England, Finland, Italy, the Netherlands and Poland, LTCFs, selected by proportional stratified random sampling, reported all deaths over the previous 3 months. The nurse most involved in the residents’ care reviewed the chart for opioid, antipsychotic and hypnotic prescription, cause of death and comorbidities. Multivariable logistic regression was performed to adjust for resident characteristics. Results Response rate was 81.6%. We included 1079 deceased residents in 322 LCTFs. Opioid prescription ranged from 18.5% (95% CI: 13.0–25.8) of residents in Poland to 77.9% (95% CI: 69.5–84.5) in the Netherlands, antipsychotic prescription from 4.8% (95% CI: 2.4–9.1) in Finland to 22.4% (95% CI: 14.7–32.4) in Italy, hypnotic prescription from 7.8% (95% CI: 4.6–12.8) in Finland to 47.9% (95% CI: 38.5–57.3) in the Netherlands. Differences in opioid, antipsychotic and hypnotic prescription between countries remained significant (P < 0.001) when controlling for age, gender, length of stay, cognitive status, cause of death in multilevel, multivariable analyses. Dying from cancer showed higher odds for receiving opioids (OR 3.51; P < 0.001) and hypnotics (OR 2.10; P = 0.010). Conclusions Opioid, antipsychotic and hypnotic prescription in the dying phase differed significantly between six European countries. Further research should determine the appropriateness of their prescription and refine guidelines especially for LTCF residents dying of non-cancer diseases.
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Affiliation(s)
- Marc Tanghe
- End-of-Life Care Research Group, Ghent University, Ghent, Belgium
| | | | - Lara Pivodic
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | | | | | - Giovanni Gambassi
- Fondazione Policlinico Universitario A. Gemelli, IRCCS and Università Cattolica del Sacro Cuore, Roma, Italy
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Ruth Piers
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium
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16
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Armstrong MJ, Alliance S, Taylor A, Corsentino P, Galvin JE. End-of-life experiences in dementia with Lewy bodies: Qualitative interviews with former caregivers. PLoS One 2019; 14:e0217039. [PMID: 31145749 PMCID: PMC6542529 DOI: 10.1371/journal.pone.0217039] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/05/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Dementia caregivers describe knowing what to expect as an unmet need and many are unaware that dementia can be a terminal condition. Dementia with Lewy bodies (DLB) is a common neurodegenerative dementia with unique features which may affect the end of life (EOL). Given the paucity of data on EOL experiences in dementia and unique aspects of DLB affecting EOL, we investigated EOL experiences as reported by caregivers of individuals with DLB. METHOD We conducted telephone interviews with caregivers and family members of individuals who died with DLB in the last 5 years using a semi-structured questionnaire to identify and describe EOL experiences. We used a qualitative descriptive approach to analyze interview transcripts and identify common themes. RESULTS Thirty individuals participated in interviews. Key themes included lack of knowledge regarding what to expect, end-of-life time course (including end-of-life symptoms, declines after hospitalization and falls, and varied EOL trajectories), advance care planning, lack of family understanding, hospice, views regarding right-to-die, medications at the end of life, approaching end of life, the death experience, and activities that enhanced end of life. Lack of communication between health care teams and families and difficulty predicting death timing were two frequently expressed challenges. CONCLUSIONS Study results emphasize the need for improved EOL counseling in DLB, recognition of EOL symptoms, earlier hospice involvement, tailoring EOL care to DLB-specific needs, and clinician-family communication. Suggestions for patient and family education are provided. Further research should confirm predictors of approaching EOL in DLB, identify strategies to improve physician recognition of EOL, and develop tools to aid communication and quality EOL care.
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Affiliation(s)
- Melissa J. Armstrong
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, United States of America
- McKnight Brain Institute, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
| | - Slande Alliance
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, United States of America
| | - Angela Taylor
- Lewy Body Dementia Association, Lilburn, Georgia, United States of America
| | - Pamela Corsentino
- Lewy Body Dementia Association, Lilburn, Georgia, United States of America
| | - James E. Galvin
- Comprehensive Center for Brain Health, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States of America
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17
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Boyd M, Frey R, Balmer D, Robinson J, McLeod H, Foster S, Slark J, Gott M. End of life care for long-term care residents with dementia, chronic illness and cancer: prospective staff survey. BMC Geriatr 2019; 19:137. [PMID: 31117991 PMCID: PMC6532195 DOI: 10.1186/s12877-019-1159-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/14/2019] [Indexed: 11/10/2022] Open
Abstract
Background Little is known about the quality of end of life care in long-term care (LTC) for residents with different diagnostic trajectories. The aim of this study was to compare symptoms before death in LTC for those with cancer, dementia or chronic illness. Methods After-death prospective staff survey of resident deaths with random cluster sampling in 61 representative LTC facilities across New Zealand (3709 beds). Deaths (n = 286) were studied over 3 months in each facility. Standardised questionnaires - Symptom Management (SM-EOLD) and Comfort Assessment in End of life with Dementia (CAD-EOLD) - were administered to staff after the resident’s death. Results Primary diagnoses at the time of death were dementia (49%), chronic illness (30%), cancer (17%), and dementia and cancer (4%). Residents with cancer had more community hospice involvement (30%) than those with chronic illness (12%) or dementia (5%). There was no difference in mean SM-EOLD in the last month of life by diagnosis (cancer 26.9 (8.6), dementia 26.5(8.2), chronic illness 26.9(8.6). Planned contrast analyses of individual items found people with dementia had more pain and those with cancer had less anxiety. There was no difference in mean CAD-EOLD scores in the week before death by diagnosis (total sample 33.7(SD 5.2), dementia 34.4(SD 5.2), chronic illness 33.0(SD 5.1), cancer 33.3(5.1)). Planned contrast analyses showed significantly more physical symptoms for those with dementia and chronic illness in the last month of life than those with cancer. Conclusions Overall, symptoms in the last week and month of life did not vary by diagnosis. However, sub-group planned contrast analyses found those with dementia and chronic illness experienced more physical distress during the last weeks and months of life than those with cancer. These results highlight the complex nature of LTC end of life care that requires an integrated gerontology/palliative care approach.
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Affiliation(s)
- Michal Boyd
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand. .,Freemasons' Department of Geriatric Medicine, The University of Auckland, Auckland, New Zealand.
| | - Rosemary Frey
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Deborah Balmer
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Jackie Robinson
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Heather McLeod
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Susan Foster
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Julia Slark
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Merryn Gott
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
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18
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Park M, Yeom HA, Yong SJ. Hospice care education needs of nursing home staff in South Korea: a cross-sectional study. BMC Palliat Care 2019; 18:20. [PMID: 30755208 PMCID: PMC6373091 DOI: 10.1186/s12904-019-0405-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 02/04/2019] [Indexed: 12/02/2022] Open
Abstract
Background While the importance of hospice care education in nursing homes is recognized, the volume of research on the specific educational needs of caregivers in hospice care in nursing homes is still lacking. This study aimed to assess educational needs in hospice care among the nursing home staff in South Korea, and to examine factors related to their education needs. Methods This is a cross-sectional descriptive study. A total of 324 nursing staff members recruited from 15 nursing homes in South Korea participated in this cross-sectional study. Measurements included demographic information, organizational characteristics, education experiences in hospice care, and educational needs in hospice care based on questionnaires developed by Whittaker and colleagues. Data were analyzed using descriptive statistics, t-test, ANOVA, and multiple regression techniques. Results In the present study, 70.6% (n = 218) of respondents reported that they had previous experience with education in hospice care and expressed their continued need for further education. The provision of care in the last days of a patient’s life was the most frequent issue identified by nursing home staff for further education. Factors predicting educational needs in hospice care included provision of hospice care services in nursing homes and the existence of hospice care team meetings in the institution. Multiple regression analysis resulted in 14.3% of explained variance in the educational needs of nursing home staff in hospice care. Conclusions Nursing home staff members showed high levels of need for training in hospice care. Therefore, it is imperative for nursing home administrators to initiate and support well-suited hospice care education for multi-level care workers on an ongoing basis.
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Affiliation(s)
- Mihyun Park
- The Catholic University of Korea College of Nursing, 222 Banpo-Daero, Seocho-Gu, Seoul, 06591, South Korea
| | - Hye-Ah Yeom
- The Catholic University of Korea College of Nursing, 222 Banpo-Daero, Seocho-Gu, Seoul, 06591, South Korea.
| | - Sr Jinsun Yong
- The Catholic University of Korea College of Nursing, 222 Banpo-Daero, Seocho-Gu, Seoul, 06591, South Korea.,WHO Collaborating Centre for Training in Hospice and Palliative Care, The Research Institute for Hospice and Palliative Care, The Catholic University of Korea, Seoul, South Korea
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19
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Bamford C, Lee R, McLellan E, Poole M, Harrison-Dening K, Hughes J, Robinson L, Exley C. What enables good end of life care for people with dementia? A multi-method qualitative study with key stakeholders. BMC Geriatr 2018; 18:302. [PMID: 30514221 PMCID: PMC6280541 DOI: 10.1186/s12877-018-0983-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 11/15/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND People with advanced dementia often experience suboptimal end of life care (EoLC) with inadequate pain control, increased hospitalisation, and fewer palliative care interventions compared to those with cancer. Existing policy, guidance and recommendations are based largely on expert opinion because of a shortage of high quality, empirical research. Previous studies have tended to consider the views and experience of particular groups. Whilst providing important evidence, they do not take into account the diversity of perspectives of different stakeholders. The Supporting Excellence in End of life care in Dementia (SEED) programme involved multiple stakeholder groups and an integrative analysis to identify key components of good EoLC for people with dementia and to inform a new intervention. METHODS The views of national experts, service managers, frontline staff, people with dementia and family carers were explored using a range of qualitative methods (semi-structured interviews, focus groups, discussions and observations of routine care). The large dataset comprises 116 interviews, 12 focus groups and 256 h of observation. Each dataset was initially analysed thematically prior to an integrative analysis, which drew out key themes across stakeholder groups. RESULTS Through the integrative analysis seven key factors required for the delivery of good EoLC for people with dementia were identified: timely planning discussions; recognition of end of life and provision of supportive care; co-ordination of care; effective working relationships with primary care; managing hospitalisation; continuing care after death; and valuing staff and ongoing learning. These factors span the entire illness trajectory from planning at a relatively early stage in the illness to continuing care after death. CONCLUSIONS This unique study has confirmed the relevance of much of the content of existing end of life frameworks to dementia. It has highlighted seven key areas that are particularly important in dementia care. The data are being used to develop an evidence-based intervention to support professionals to deliver better EoLC in dementia.
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Affiliation(s)
- Claire Bamford
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | - Richard Lee
- Department of Social Work, Education and Community Wellbeing, Faculty of Health & Life Sciences, Northumbria University, Newcastle-upon-Tyne, UK
| | - Emma McLellan
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | - Marie Poole
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | | | - Julian Hughes
- Bristol Medical School, Population and Health Sciences, University of Bristol, Bristol, BS8 2PS UK
| | - Louise Robinson
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | - Catherine Exley
- Health and Life Sciences, Northumbria University, Room NB266, Northumberland Building, College Street, Newcastle upon Tyne, NE1 8ST UK
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20
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Sanvezzo VMDS, Montandon DS, Esteves LSF. Instruments for the functional assessment of elderly persons in palliative care: an integrative review. REVISTA BRASILEIRA DE GERIATRIA E GERONTOLOGIA 2018. [DOI: 10.1590/1981-22562018021.180033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Objective: to identify validated instruments that can be used for the functional assessment of elderly persons in Palliative Care. Method: an integrative review focused on identifying instruments for the functional assessment of elderly persons in palliative care was carried out by searching publications in periodicals indexed in seven electronic databases. Descriptors, keywords and Boolean operators were used for a cross-database search in November 2017. A total of 357 abstracts were identified, from which 53 articles were selected for reading, of which 21 met the inclusion criteria. Results: this strategy allowed the identification of eight scales and one test for the functional assessment of elderly persons in palliative care. Conclusion: eight scales and a functional test which also provide guidelines for improving the quality of life of elderly people in palliative care were identified, demonstrating that it is practically impossible to disassociate physical functional performance from social and psychological aspects.
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21
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De Roo ML, Tanghe MF, Van Den Noortgate NJ, Piers RD. Development and Validation of the Symptom Assessment to Improve Symptom Control for Institutionalized Elderly Scale. J Am Med Dir Assoc 2017; 19:148-153.e5. [PMID: 29042266 DOI: 10.1016/j.jamda.2017.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/18/2017] [Accepted: 08/21/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To validate a newly developed multiple symptom self-assessment tool in nursing homes. DESIGN Thirty prevalent symptoms identified in the literature were classified by a 2-round Delphi procedure to a top 10 of the most relevant, burdensome symptoms. Because no existing symptom scale fully covered this top 10, we developed a new scale, consisting of a horizontal numerical scale for the top 10 symptoms, with the possibility to add and rate 3 other symptoms. This scale was validated. SETTING AND PARTICIPANTS Hundred seventy-four participants, mean age 85 (±5.94) years, were recruited from 7 nursing homes (86%) and 3 acute geriatric wards (14%). METHODS To test the construct validity, participants with and without a palliative status were enrolled. Participants completed the Symptom Assessment to Improve Symptom Control for Institutionalized Elderly (SATISFIE) scale on day 0 and day 1 (intrarater reliability). Nurses completed the scale on day 0 (inter-rater reliability). Descriptive statistics described the characteristics of the study population and symptom scores. Differences in symptom scores between palliative and nonpalliative participants were analyzed with the Mann-Whitney U test. Intrarater and inter-rater reliability were calculated by means of an intraclass correlation coefficient. Factor analysis searched for possible symptom clusters. Feasibility was evaluated by measuring the assessment time and by providing a questionnaire for the nurses. RESULTS In the nonpalliative group (n = 130), the highest self-rated median scores were pain on day 1 [median 3, interquartile range (IQR) 0-5] and pain on day 2. In the palliative group (n = 44), the highest median self-rated scores were fatigue on day 1 [median 5 (IQR 0-6)], lack of energy on day 1 and 2 [both median 5 (IQR 0-8)]; and depressed feeling on day 2 [median 3 (IQR 0-5)]. Nurse assessments median scores were the highest for depressed feeling [median 5 (IQR 1-7)], fatigue [median 4.5 (IQR 0-6.5)], and lack of energy, [median 3 (IQR 0-6)] in the palliative group. In the nonpalliative group, none of the median scores was 3 or more. Intraclass correlation coefficients for intrarater reliability varied between 0.65 and 0.89 and for inter-rater reliability (patients-nurses) between 0.18 and 0.63. Mean assessment time for nurses was 2.0 minutes [standard deviation (SD) = 1.01]. For participants, it decreased from 10.5 minutes (SD = 5.41) at the first assessment to 7.5 minutes (SD = 3.72) at the second assessment. Nurses determined the SATISFIE instrument to be useful, applicable in daily practice, and sufficiently comprehensible for the patients. CONCLUSIONS The SATISFIE scale is a valid and feasible instrument for regular, multiple symptom assessment in institutionalized older persons.
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Affiliation(s)
- Maaike L De Roo
- Department of Geriatrics, Ghent University Hospital, Gent, Belgium
| | - Marc F Tanghe
- Department of Geriatrics, Ghent University Hospital, Gent, Belgium.
| | | | - Ruth D Piers
- Department of Geriatrics, Ghent University Hospital, Gent, Belgium
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22
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De Witt Jansen B, Brazil K, Passmore P, Buchanan H, Maxwell D, McIlfatrick SJ, Morgan SM, Watson M, Parsons C. 'There's a Catch-22' - The complexities of pain management for people with advanced dementia nearing the end of life: A qualitative exploration of physicians' perspectives. Palliat Med 2017; 31:734-742. [PMID: 28659013 DOI: 10.1177/0269216316673549] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pain management is a cornerstone of palliative care. The clinical issues encountered by physicians when managing pain in patients dying with advanced dementia, and how these may impact on prescribing and treatment, are unknown. AIM To explore physicians' experiences of pain management for patients nearing the end of life, the impact of these on prescribing and treatment approaches, and the methods employed to overcome these challenges. DESIGN Qualitative, semi-structured interview study exploring barriers to and facilitators of pain management, prescribing and treatment decisions, and training needs. Thematic analysis was used to elicit key themes. SETTING/PARTICIPANTS A total of 23 physicians, responsible for treating patients with advanced dementia approaching the end of life, were recruited from primary care ( n = 9), psychiatry ( n = 7) and hospice care ( n = 7). RESULTS Six themes emerged: diagnosing pain, complex prescribing and treatment approaches, side effects and adverse events, route of administration, importance of sharing knowledge and training needs. Knowledge exchange was often practised through liaison with physicians from other specialities. Cross-speciality mentoring and the creation of knowledge networks were believed to improve pain management in this patient population. CONCLUSION Pain management in end-stage dementia is complex, requiring cross-population of knowledge between palliative care specialists and non-specialists, in addition to collateral information provided by other health professionals and patients' families. Regular, cost- and time-effective mentoring and ongoing professional development are perceived to be essential in empowering physicians to meet clinical challenges in this area.
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Affiliation(s)
| | - Kevin Brazil
- 2 School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Peter Passmore
- 3 Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Hilary Buchanan
- 4 Patient and Public Involvement Representative, Carer for a person living with dementia, Belfast, UK
| | | | - Sonja J McIlfatrick
- 6 Institute of Nursing and Health Research, Ulster University, Coleraine, UK.,7 All Ireland Institute of Hospice and Palliative Care, Our Lady's Hospice and Care Services, Dublin, Ireland
| | | | | | - Carole Parsons
- 1 School of Pharmacy, Queen's University Belfast, Belfast, UK
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23
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Verhofstede R, Smets T, Cohen J, Eecloo K, Costantini M, Van Den Noortgate N, Deliens L. End-of-Life Care and Quality of Dying in 23 Acute Geriatric Hospital Wards in Flanders, Belgium. J Pain Symptom Manage 2017; 53:693-702. [PMID: 28042062 DOI: 10.1016/j.jpainsymman.2016.10.363] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 10/18/2016] [Accepted: 10/30/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe the nursing and medical interventions performed in the last 48 hours of life and the quality of dying of patients dying in acute geriatric hospital wards. METHODS Cross-sectional descriptive study between October 1, 2012 and September 30, 2013. Twenty-three acute geriatric wards in 13 hospitals in Flanders, Belgium. Patients hospitalized for more than 48 hours before dying in the participating wards. Structured after-death questionnaires, filled out by the nurse, the physician, and the family carer most involved in end-of-life care. Main outcome measures were several nursing and medical interventions reported to be performed in the last 48 hours of life and the quality of dying. RESULTS Of 993 patients, we included 338 (mean age 85.7 years; 173 women). Almost 58% had dementia and nearly half were unable to communicate in the last 48 hours of their life. The most frequently continued or started nursing and medical interventions in the last 48 hours of life were measuring temperature (91.6%), repositioning (83.3%), washing (89.5%), oxygen therapy (49.7%), and intravenous fluids and nutrition (30%). Shortness of breath, lack of serenity, lack of peace, and lack of calm were symptoms reported most frequently by nurses and family carers. CONCLUSION Many nursing and medical interventions are continued or started in the last hours of a patient's life, which may not always be in their best interests. Furthermore, patients dying in acute geriatric wards are often affected by several symptoms.
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Affiliation(s)
- Rebecca Verhofstede
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium.
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Kim Eecloo
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Massimo Costantini
- Palliative Care Unit, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium; Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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24
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Jansen BDW, Brazil K, Passmore P, Buchanan H, Maxwell D, McIlfatrick SJ, Morgan SM, Watson M, Parsons C. Exploring healthcare assistants' role and experience in pain assessment and management for people with advanced dementia towards the end of life: a qualitative study. BMC Palliat Care 2017; 16:6. [PMID: 28103847 PMCID: PMC5247820 DOI: 10.1186/s12904-017-0184-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/10/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Pain assessment and management are key aspects in the care of people with dementia approaching the end of life but become challenging when patient self-report is impaired or unavailable. Best practice recommends the use of observational pain assessments for these patients; however, difficulties have been documented with health professionals' use of these tools in the absence of additional collateral patient knowledge. No studies have explored the role, perspectives and experiences of healthcare assistants in pain assessment and management in dementia; this study provides insight into this important area. METHODS A qualitative approach was adopted, using key informant interviews with healthcare assistants caring for people with advanced dementia approaching the end of life in hospice, nursing home and acute care settings. Thematic analysis was the analytic approach taken to interpretation of interview data. Data were collected between June 2014 and September 2015. RESULTS Fourteen participants took part in the study. Participants' average length of caring experience was 15.4 years and most were female. Three key themes emerged: recognising pain, reporting pain, and upskilling. Participants were often the first to notice obvious causes of pain and to detect changes in patient norms which signified hidden causes of pain. Comprehensive knowledge of resident norms enabled participants to observe for behavioural and nonverbal indicators of pain and distinguish these from non-pain related behaviours. Pain reporting was heavily impacted by relationships with professional staff and the extent to which participants felt valued in their role. Positive relationships resulted in comprehensive pain reports; negative relationships led to perfunctory or ambiguous reporting. Participants emphasised a desire for further training and upskilling, including in the use and reporting of basic pain tools. CONCLUSIONS Healthcare assistants are frontline staff who have a key role in direct patient care, spending a considerable amount of time with patients in comparison to other health professionals. These staff are often first to notice changes in patients that may signify pain and to alert professional staff. However, to ensure the quality of these reports, further efforts must be made in reversing stigma attached to this role and in upskilling these members of the healthcare team.
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Affiliation(s)
| | | | - Peter Passmore
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Belfast, UK
| | - Hilary Buchanan
- Patient and Public Involvement Representative, Carer for a person living with dementia, Belfast, UK
| | | | - Sonja J McIlfatrick
- Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK.,All Ireland Institute of Hospice and Palliative Care, Our Lady's Hospice and Care Services, Dublin, Ireland
| | | | | | - Carole Parsons
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK.
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25
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van der Maaden T, de Vet HCW, Achterberg WP, Boersma F, Schols JMGA, Mehr DR, Galindo-Garre F, Hertogh CMPM, Koopmans RTCM, van der Steen JT. Improving comfort in people with dementia and pneumonia: a cluster randomized trial. BMC Med 2016; 14:116. [PMID: 27515720 PMCID: PMC4981997 DOI: 10.1186/s12916-016-0663-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 07/27/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Pneumonia in people with dementia has been associated with severe discomfort. We sought to assess the effectiveness of a practice guideline for optimal symptom relief for nursing home residents with dementia and pneumonia. METHODS A single-blind, multicenter, cluster randomized controlled trial was conducted in 32 Dutch nursing homes. Outcomes were assessed on the patient level. The main outcome measures were discomfort and symptoms: discomfort (DS-DAT: Discomfort Scale-Dementia of Alzheimer Type), (lack of) comfort (EOLD-CAD: End Of Life in Dementia-Comfort Assessment in Dying), pain (PAINAD: Pain Assessment in Advanced Dementia), and respiratory distress (RDOS: Respiratory Distress Observation Scale). Outcomes were scheduled daily from diagnosis until 10 days later and a final time between 13-15 days from diagnosis by trained observers who were blinded to the intervention and the residents' condition and treatment. In a pre-intervention phase, usual care was provided to all homes. In the intervention phase, matched clusters of homes were randomized to either the control (n = 16) or intervention condition (n = 16). RESULTS Between 1 January 2012 and 1 May 2015, 464 episodes of pneumonia were included. Outcomes were obtained for 399 episodes in 367 residents. Longitudinal multilevel linear regression analyses were performed on log-transformed outcomes, so coefficients should be interpreted as a ratio, and a coefficient of 1 means no difference. The practice guideline in the intervention phase did not reduce the level of discomfort and symptoms: DS-DAT: 1.11 (95 % CI 0.93-1.31), EOLD-CAD: 1.01 (95 % CI 0.98-1.05), PAINAD: 1.04 (95 % CI 0.93-1.15), RDOS: 1.11 (95 % CI 0.90-1.24). However, in both the intervention and control groups, lack of comfort and respiratory distress gradually decreased during the entire 3.5 years of data collection, and were lower in the intervention phase compared to the pre-intervention phase: DS-DAT: 0.93 (95 % CI 0.85-1.01), EOLD-CAD: 0.98 (95 % CI 0.97-1.00), PAINAD: 0.96 (95 % CI 0.91-1.01), RDOS: 0.92 (95 % CI 0.87-0.98). CONCLUSIONS When compared to usual care, the practice guideline for optimal symptom relief did not relieve discomfort and symptoms in nursing home residents with dementia and pneumonia. However, discomfort and symptoms decreased gradually throughout the data collection in both the intervention homes and the control homes. An intervention that focuses on creating awareness may be more effective than a physician practice guideline. TRIAL REGISTRATION The Netherlands National Trial Register (ID number NTR5071 . Registered 10 March 2015).
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Affiliation(s)
- Tessa van der Maaden
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands. .,Department of General Practice & Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands.
| | - Henrica C W de Vet
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Froukje Boersma
- Department of General Practice, Elderly Care Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Jos M G A Schols
- Department of Family Medicine and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - David R Mehr
- Department of Family and Community Medicine, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Francisca Galindo-Garre
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Department of General Practice & Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands.,Joachim en Anna, center for specialized geriatric care, Nijmegen, The Netherlands.,Radboudumc Alzheimer Center, Nijmegen, The Netherlands
| | - 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 Centre, Nijmegen, The Netherlands. .,Radboudumc Alzheimer Center, Nijmegen, The Netherlands.
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26
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Hanson E, Hellström A, Sandvide Å, Jackson GA, MacRae R, Waugh A, Abreu W, Tolson D. The extended palliative phase of dementia – An integrative literature review. DEMENTIA 2016; 18:108-134. [PMID: 27460046 DOI: 10.1177/1471301216659797] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This article presents an integrative literature review of the experience of dementia care associated with the extended palliative phase of dementia. The aim was to highlight how dementia is defined in the literature and describe what is known about the symptomatology and management of advanced dementia regarding the needs and preferences of the person with dementia and their family carer/s. There was no consistent definition of advanced dementia. The extended palliative phase was generally synonymous with end-of-life care. Advanced care planning is purported to enable professionals to work together with people with dementia and their families. A lack of understanding of palliative care among frontline practitioners was related to a dearth of educational opportunities in advanced dementia care. There are few robust concepts and theories that embrace living the best life possible during the later stages of dementia. These findings informed our subsequent work around the concept, ‘Dementia Palliare’.
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Affiliation(s)
- Elizabeth Hanson
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
| | - Amanda Hellström
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
| | - Åsa Sandvide
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
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27
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Sandvik RK, Selbaek G, Bergh S, Aarsland D, Husebo BS. Signs of Imminent Dying and Change in Symptom Intensity During Pharmacological Treatment in Dying Nursing Home Patients: A Prospective Trajectory Study. J Am Med Dir Assoc 2016; 17:821-7. [PMID: 27321869 DOI: 10.1016/j.jamda.2016.05.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/04/2016] [Accepted: 05/04/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To investigate whether it is possible to determine signs of imminent dying and change in pain and symptom intensity during pharmacological treatment in nursing home patients, from day perceived as dying and to day of death. DESIGN Prospective, longitudinal trajectory trial. SETTING Forty-seven nursing homes within 35 municipalities of Norway. PARTICIPANTS A total of 691 nursing home patients were followed during the first year after admission and 152 were assessed carefully in their last days of life. MEASUREMENTS Time between admission and day of death, and symptom severity by Edmonton symptom assessment system (ESAS), pain (mobilization-observation-behavior-intensity-dementia-2), level of dementia (clinical dementia rating scale), physical function (Karnofsky performance scale), and activities of daily living (physical self-maintenance scale). RESULTS Twenty-five percent died during the first year after admission. Increased fatigue (logistic regression, odds ratio [OR] 1.8, P = .009) and poor appetite (OR 1.2, P = .005) were significantly associated with being able to identify the day a person was imminently dying, which was possible in 61% of the dying (n = 82). On that day, the administration of opioids, midazolam, and anticholinergics increased significantly (P < .001), and was associated with amelioration of symptoms, such as pain (mixed-models linear regression, 60% vs 46%, P < .001), anxiety (44% vs 31%, P < .001), and depression (33% vs 15%, P < .001). However, most symptoms were still prevalent at day of death, and moderate to severe dyspnea and death rattle increased from 44% to 53% (P = .040) and 8% to 19% (P < .001), respectively. Respiratory symptoms were not associated with opioids or anticholinergics. CONCLUSION Pharmacological treatment ameliorated distressing symptoms in dying nursing home patients; however, most symptoms, including pain and dyspnea, were still common at day of death. Results emphasize critical needs for better implementation of guidelines and staff education. TRIAL REGISTRATION ClinicalTrials.govNCT01920100.
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Affiliation(s)
- Reidun K Sandvik
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway; Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway; Institute for Nursing Subjects, Bergen University College, Bergen, Norway.
| | - Geir Selbaek
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway; Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tonsberg, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Sverre Bergh
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
| | - Dag Aarsland
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology & Neuroscience King's College, London, UK; Center for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway; Municipality of Bergen, Bergen, Norway
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28
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Shimada C, Hirayama R, Wakui T, Nakazato K, Obuchi S, Ishizaki T, Takahashi R. Reconsidering long-term care in the end-of-life context in Japan. Geriatr Gerontol Int 2016; 16 Suppl 1:132-9. [DOI: 10.1111/ggi.12736] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Chiho Shimada
- Human Care Research Team; Tokyo Metropolitan Institute of Gerontology (TMIG); Tokyo Japan
| | - Ryo Hirayama
- Human Care Research Team; Tokyo Metropolitan Institute of Gerontology (TMIG); Tokyo Japan
- Japan Society for the Promotion of Science (JSPS); Tokyo Japan
| | - Tomoko Wakui
- Human Care Research Team; Tokyo Metropolitan Institute of Gerontology (TMIG); Tokyo Japan
| | - Kazuhiro Nakazato
- Human Care Research Team; Tokyo Metropolitan Institute of Gerontology (TMIG); Tokyo Japan
| | - Shuichi Obuchi
- Human Care Research Team; Tokyo Metropolitan Institute of Gerontology (TMIG); Tokyo Japan
| | - Tatsuro Ishizaki
- Human Care Research Team; Tokyo Metropolitan Institute of Gerontology (TMIG); Tokyo Japan
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29
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Jones L, Candy B, Davis S, Elliott M, Gola A, Harrington J, Kupeli N, Lord K, Moore K, Scott S, Vickerstaff V, Omar RZ, King M, Leavey G, Nazareth I, Sampson EL. Development of a model for integrated care at the end of life in advanced dementia: A whole systems UK-wide approach. Palliat Med 2016; 30:279-95. [PMID: 26354388 PMCID: PMC4766969 DOI: 10.1177/0269216315605447] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [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 The prevalence of dementia is rising worldwide and many people will die with the disease. Symptoms towards the end of life may be inadequately managed and informal and professional carers poorly supported. There are few evidence-based interventions to improve end-of-life care in advanced dementia. AIM To develop an integrated, whole systems, evidence-based intervention that is pragmatic and feasible to improve end-of-life care for people with advanced dementia and support those close to them. DESIGN A realist-based approach in which qualitative and quantitative data assisted the development of statements. These were incorporated into the RAND/UCLA appropriateness method to achieve consensus on intervention components. Components were mapped to underlying theory of whole systems change and the intervention described in a detailed manual. SETTING/PARTICIPANTS Data were collected from people with dementia, carers and health and social care professionals in England, from expert opinion and existing literature. Professional stakeholders in all four countries of the United Kingdom contributed to the RAND/UCLA appropriateness method process. RESULTS A total of 29 statements were agreed and mapped to individual, group, organisational and economic/political levels of healthcare systems. The resulting main intervention components are as follows: (1) influencing local service organisation through facilitation of integrated multi-disciplinary care, (2) providing training and support for formal and informal carers and (3) influencing local healthcare commissioning and priorities of service providers. CONCLUSION Use of in-depth data, consensus methods and theoretical understanding of the intervention components produced an evidence-based intervention for further testing in end-of-life care in advanced dementia.
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Affiliation(s)
- Louise Jones
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Sarah Davis
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Margaret Elliott
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Anna Gola
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Jane Harrington
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Kathryn Lord
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Kirsten Moore
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Sharon Scott
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK St Christopher's Hospice, Sydenham, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London (UCL), London, UK
| | - Michael King
- Division of Psychiatry, University College London (UCL), London, UK
| | - Gerard Leavey
- The Bamford Centre for Mental Health and Well Being, University of Ulster, Londonderry, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London (UCL), London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
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30
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Husebo BS, Achterberg W, Flo E. Identifying and Managing Pain in People with Alzheimer's Disease and Other Types of Dementia: A Systematic Review. CNS Drugs 2016; 30:481-97. [PMID: 27240869 PMCID: PMC4920848 DOI: 10.1007/s40263-016-0342-7] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Pain in patients with Alzheimer's disease is a complex issue; these patients suffer from the common causes of acute and chronic pain, and some also have neuropathic or nociceptive pain. Whatever the mechanism of pain in these patients, their pain will require careful assessment and management, to insure the correct type and level of analgesia is given. The objective of this systematic review was the identification of studies that have investigated the efficacy of different analgesics on pain intensity or pain-related behavior during nursing home stay and at the end of life. METHODS A search using pain, pain treatment, and dementia MESH terms and keywords was conducted (October 15, 2015) in MEDLINE, EMBASE, PsychINFO, CINAHL, and Cochrane libraries. RESULTS Our search yielded 3138 unique hits, published between 1990 and October 2015. We read titles and abstracts, identified 124 papers for full-text evaluation, and included 12 papers to reflect and synthesize the following questions: (1) Which pain assessment tools for people with dementia are responsive to change in pain intensity scores? (2) Which analgesics are efficacy-tested by controlled trials including people with dementia living in nursing homes, including at the end of life? (3) Which outcome measures have been used to identify pain, pain behavior, and/or treatment efficacy in people with dementia? CONCLUSION Despite increased use of analgesics, pain is still prevalent in people with dementia. Validated pain tools are available but not implemented and not fully tested on responsiveness to treatment. Official guidelines for pain assessment and treatment addressing people with dementia living in a nursing home are lacking. The efficacy of analgesic drug use on pain or neuropsychiatric behavior related to dementia has been hardly investigated.
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Affiliation(s)
- Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.
- Section for Nursing Home Medicine, Municipality of Bergen, Bergen, Norway.
| | - Wilco Achterberg
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Elisabeth Flo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
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31
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van der Steen JT, Sampson EL, Van den Block L, Lord K, Vankova H, Pautex S, Vandervoort A, Radbruch L, Shvartzman P, Sacchi V, de Vet HCW, Van Den Noortgate NJA. Tools to Assess Pain or Lack of Comfort in Dementia: A Content Analysis. J Pain Symptom Manage 2015. [PMID: 26212095 DOI: 10.1016/j.jpainsymman.2015.05.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CONTEXT There is need for tools to help detect pain or lack of comfort in persons unable to communicate. However, pain and (dis)comfort tools have not been compared, and it is unclear to what extent they discriminate between pain and other possible sources of discomfort, or even if items differ. OBJECTIVES To map and compare items in tools that assess pain and the broader notion of discomfort or comfort in people with severe dementia or at the end of life. METHODS Using qualitative content analysis with six classifications, we categorized each item of four thoroughly tested observational pain tools (Pain Assessment in Advanced Dementia [PAINAD], Pain Assessment Checklist for Seniors with Limited Ability to Communicate [PACSLAC], Doloplus-2, and draft Pain Assessment in Impaired Cognition [PAIC]), and four discomfort tools (including distress, comfort, and quality of life in severe dementia or at the end of life; Discomfort Scale-Dementia Alzheimer Type [DS-DAT], Disability Distress Assessment Tool [DisDAT], End-of-Life in Dementia-Comfort Assessment in Dying with Dementia [EOLD-CAD], and Quality of Life in Late-Stage Dementia [QUALID] scale). We calculated median proportions to compare distributions of categories of pain and discomfort tools. RESULTS We found that, despite variable content across tools, items from pain and discomfort tools overlapped considerably. For example, positive elements such as smiling and spiritual items were more often included in discomfort tools but were not unique to these. Pain tools comprised more "mostly descriptive" (median 0.63 vs. 0.44) and fewer "highly subjective" items (0.06 vs. 0.18); some used time inconsistently, mixing present and past observations. CONCLUSION This analysis may inform a more rigorous theoretical underpinning and (re)development of pain and discomfort tools and calls for empirical testing of a broad item pool for sensitivity and specificity in detecting and discriminating pain from other sources of discomfort.
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Affiliation(s)
- Jenny T van der Steen
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of General Practice & Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands.
| | - Elizabeth L Sampson
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom; Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, London, United Kingdom
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Belgium, Brussels, Belgium
| | - Kathryn Lord
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
| | - Hana Vankova
- Faculty of Humanities and Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Sophie Pautex
- Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - An Vandervoort
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Belgium, Brussels, Belgium
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany; Center for Palliative Care, Malteser Hospital Seliger Gerhard Bonn/Rhein-Sieg, Bonn, Germany
| | - Pesach Shvartzman
- Pain and Palliative Medicine Unit, Division of Community Health, Department of Family Medicine, Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Valentina Sacchi
- Lincolnshire Partnership Foundation Trust, Lincoln, Lincolnshire, United Kingdom
| | - Henrica C W de Vet
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
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32
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van der Maaden T, van der Steen JT, de Vet HCW, Hertogh CMPM, Koopmans RTCM. Prospective Observations of Discomfort, Pain, and Dyspnea in Nursing Home Residents With Dementia and Pneumonia. J Am Med Dir Assoc 2015; 17:128-35. [PMID: 26410108 DOI: 10.1016/j.jamda.2015.08.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 08/14/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To describe observations of suffering in patients with dementia from the diagnosis of pneumonia until cure or death. DESIGN Prospective observational study between January 2012 and May 2014. SETTING Dutch nursing homes (32). PARTICIPANTS Nursing home patients with dementia and pneumonia (n = 193). MEASUREMENTS Independent observers performed observations of patients with dementia scheduled 13 times within the 15 days following diagnosis of pneumonia; twice daily in the first 2 days- to observe discomfort (Discomfort Scale-Dementia of Alzheimer Type; range 0-27), comfort (End Of Life in Dementia-Comfort Assessment in Dying; range 14-42), pain (Pain Assessment in Advanced Dementia; range 0-10), and dyspnea (Respiratory Distress Observation Scale; range 0-16). RESULTS Observational data were obtained for 208 cases of pneumonia in 193 patients. In 71.2% of cases, patients received 1 or more treatments to relieve symptoms such as antipyretics, opioids, or oxygen; 89.4% received antibiotics. Discomfort was highest 1 day after diagnosis [mean Discomfort Scale-Dementia of Alzheimer Type score 8.1 (standard deviation, SD 5.8)], then declined, and stabilized around day 10 [mean 4.5 (SD 4.1)], or increased in the days preceding death. Observed pain and dyspnea followed a comparable pattern. Discomfort patterns did not differ much between cases treated with and without antibiotics. CONCLUSIONS Pneumonia in patients with dementia involved elevated levels of suffering during 10 days following diagnosis and in the days preceding death. Overall observed discomfort was low compared with prior Dutch studies, and the number of treatments to relieve symptoms was higher. Future studies should examine whether symptoms of pneumonia can be relieved even more, and what treatments are the most effective.
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Affiliation(s)
- Tessa van der Maaden
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of General Practice and Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Jenny T van der Steen
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of General Practice and Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands.
| | - Henrica C W de Vet
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of General Practice and Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands; Joachim en Anna, Center for Specialized Geriatric Care, Nijmegen, The Netherlands; Radboud Alzheimer Center, Nijmegen, The Netherlands
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33
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Expectation Conversations About the Very Predictable Events in Advanced Dementia. J Am Med Dir Assoc 2015; 16:724-7. [DOI: 10.1016/j.jamda.2015.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 05/12/2015] [Indexed: 11/21/2022]
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