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Baird C, Miller H, Hoti K, Hughes J. Clinical impact of a multifaceted intervention aimed at decreasing distress in people living with dementia: evaluating the Reconnect program. Front Psychiatry 2023; 14:1191105. [PMID: 38144480 PMCID: PMC10748381 DOI: 10.3389/fpsyt.2023.1191105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 11/15/2023] [Indexed: 12/26/2023] Open
Abstract
Background To better meet the needs of people living with advanced dementia, Orchard Care Homes, United Kingdom have established an enhanced person focused program, namely the Reconnect program, which provides an enriched psycho-social care to enhance peoples' quality of life and well-being. Here we aimed to review the impact of this program on people living with dementia. Methods In this study the implementation of the Reconnect program was evaluated for two six-month periods (April-September 2020 and April-September 2021). The focus of this evaluation was on three key interventions: increasing meaningful occupation and engagement; improving pain identification and management, and reducing constipation. The Reconnect program was conducted in a single for-profit care home. It involved residents with complex dementia needs who previously not responded to support in alternative settings or found previous care ineffective in relieving their distress and reducing risks they pose to themselves or others. Results A total of 24 people participated in the program during this evaluation. We observed a substantial increase in engagement in meaningful activity per person, including an increase of outdoor access to fresh air. Pain management improved as evidenced by more standardized pain assessments using the PainChek system and coverage of people with either regular and/or "when required" pain management. Constipation relief also improved. For the two comparison periods, distress responses per resident reduced from 14.5 to 10.6 events and use of regular pain relief increased from 21.7 to 48.1%. Use of "when required" benzodiazepine halved from 6 months average of 46 to 23.2 doses given. Benzodiazepine dose reductions increased from 13.3 to 31.8%, while cessations increased from 20 to 50%. We also observed a reduction from 76.3 to 56.3% in antipsychotic use. Their dose reductions increased from 8.3 to 40% and drug cessation was made in 30% of people using antipsychotics (compared to the first period in which no medication cessation was observed). A 91.7% reduction (i.e., from 36 to 3 events) in safeguarding events related to behaviors was also observed. Conclusion Introduction of the Reconnect program, through its interventions focused on meaningful activity engagement, pain management and constipation relief resulted in substantial improvements related to people's distress, safeguarding and psychotropic use.
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Affiliation(s)
| | | | - Kreshnik Hoti
- Faculty of Medicine, University of Prishtina, Pristina, Albania
- Curtin Medical School, Curtin University, Perth, WA, Australia
| | - Jeffery Hughes
- Faculty of Medicine, University of Prishtina, Pristina, Albania
- PainChek Ltd., Sydney, NSW, Australia
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Tevik K, Helvik AS, Stensvik GT, Nordberg MS, Nakrem S. Nursing-sensitive quality indicators for quality improvement in Norwegian nursing homes - a modified Delphi study. BMC Health Serv Res 2023; 23:1068. [PMID: 37803376 PMCID: PMC10557356 DOI: 10.1186/s12913-023-10088-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 09/28/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Use of nursing-sensitive quality indicators (QIs) is one way to monitor the quality of care in nursing homes (NHs). The aim of this study was to develop a consensus list of nursing-sensitive QIs for Norwegian NHs. METHODS A narrative literature review followed by a non-in-person, two-round, six-step modified Delphi survey was conducted. A five-member project group was established to draw up a list of nursing-sensitive QIs from a preliminary list of 24 QIs selected from Minimum Data Set (2.0) (MDS) and the international Resident Assessment Instrument for Long-Term Care Facilities (interRAI LTCF). We included scientific experts (researchers), clinical experts (healthcare professionals in NHs), and experts of experience (next-of-kin of NH residents). The experts rated nursing-sensitive QIs in two rounds on a seven-point Likert scale. Consensus was based on median value and level of dispersion. Analyses were conducted for four groups: 1) all experts, 2) scientific experts, 3) clinical experts, and 4) experts of experience. RESULTS The project group drew up a list of 20 nursing-sensitive QIs. Nineteen QIs were selected from MDS/interRAI LTCF and one ('systematic medication review') from the Norwegian quality assessment system IPLOS ('Statistics linked to individual needs of care'). In the first and second Delphi round, 44 experts (13 researchers, 17 healthcare professionals, 14 next-of-kin) and 28 experts (8 researchers, 10 healthcare professionals, 10 next-of-kin) participated, respectively. The final consensus list consisted of 16 nursing-sensitive QIs, which were ranked in this order by the 'all expert group': 1) systematic medication review, 2) pressure ulcers, 3) behavioral symptoms, 4) pain, 5) dehydration, 6) oral/dental health problems, 7) urinary tract infection, 8) fecal impaction, 9) depression, 10) use of aids that inhibit freedom of movement, 11) participation in activities of interest, 12) participation in social activities, 13) decline in activities of daily living, 14) weight loss, 15) falls, and 16) hearing loss without the use of hearing aids. CONCLUSIONS Multidisciplinary experts were able to reach consensus on 16 nursing-sensitive QIs. The results from this study can be used to implement QIs in Norwegian NHs, which can improve the quality of care.
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Affiliation(s)
- Kjerstin Tevik
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
- The Norwegian National Centre for Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway.
| | - Anne-Sofie Helvik
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- The Norwegian National Centre for Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
| | - Geir-Tore Stensvik
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Marion S Nordberg
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Geriatrics, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Sigrid Nakrem
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- National Ageing Research Institute, Royal Melbourne Hospital, 34-54 Poplar Road, Victoria, 3050, Australia
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Boon JT, Herr K, Schirle L, Dietrich MS, Maxwell CA. People Living With Dementia: Dementia Characteristics and Family Caregiver Pain Assessment. J Gerontol Nurs 2023; 49:17-23. [PMID: 37379047 DOI: 10.3928/00989134-20230615-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
People living with dementia (PLWD) experience pain like other older adults, but with changes due to dementia, they rely more on family caregivers for pain assessment. Many different elements contribute to a pain assessment. Changes in characteristics of PLWD may be associated with changes in the use of these different pain assessment elements. The current study reports associations between PLWD's agitation, cognitive function, and dementia severity and the frequency with which family caregivers use pain assessment elements. In a sample of family caregivers (N = 48), statistically significant associations were found between worsening cognitive function and greater use of rechecking for pain after intervention (rho = 0.36, p = 0.013), and between lower cognitive scores on a subscale of dementia severity and asking others if they have noticed a behavior change in the PLWD (rho = 0.30, p = 0.044). Limited statistically significant associations suggest that, overall, family caregivers of PLWD do not use pain assessment elements more frequently with changes in characteristics of PLWD. [Journal of Gerontological Nursing, 49(7), 17-23.].
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Saragih ID, Suarilah I, Son NT, Lee BO. Efficacy of non-pharmacological interventions to reduce pain in people with dementia: A systematic review and meta-analysis. J Clin Nurs 2022. [PMID: 35880258 DOI: 10.1111/jocn.16444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To identify the efficacy of non-pharmacological interventions designed to reduce pain in people with dementia. BACKGROUND Pain is prevalent among patients with dementia but frequently remains untreated. Although non-pharmacological interventions have been used to reduce pain in people with dementia, the efficacy of these interventions for pain management in people with dementia has not been thoroughly synthesised. DESIGN Systematic review and meta-analysis. METHODS The study was conducted in accordance with PRISMA guidelines and Cochrane criteria for systematic reviews. A comprehensive search was performed using the Academic Search Complete, CINAHL, Cochrane Library, EMBASE, MEDLINE, PubMed, OVID and Web of Science databases, from databases inception to 13 March 2022. The modified Cochrane risk-of-bias tool (ROB-2) was used to evaluate the methodological quality of each included study. Standardised mean differences (SMDs) with 95% confidence intervals (CIs) were synthesised using a random-effects model to assess the efficacy of non-pharmacological interventions for reducing pain in people with dementia (using Stata 16.0). RESULTS The final analysis assessed 12 studies, including 989 persons with dementia. Non-pharmacological interventions were found to reduce pain in 4-8 weeks after the interventions (SMD: -0.32; 95% CI: -0.62 to -0.02). However, the effects of intervention frequency and patient age remain unknown. CONCLUSIONS Non-pharmacological interventions are effective for reducing pain in people with dementia. Further investigations remain necessary to explore the effectiveness of specific non-pharmacological therapies for pain reduction in people with dementia (e.g. aromatherapy, play activity, singing or robotic care). RELEVANCE TO CLINICAL PRACTICE The findings of this study can guide healthcare practitioners when considering the use of non-pharmacological pain management methods for people with dementia and may improve the implementation of these methods in clinical practice. PATIENT OR PUBLIC CONTRIBUTIONS The study suggests non-pharmacological interventions to reduce pain and underlines the relevance of health provider's viewpoints. The types, duration and length of follow-up of non-pharmacological interventions can be offered based on patient's conditions and the standard of clinical practice.
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Affiliation(s)
| | - Ira Suarilah
- College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia
| | - Nguyen Thi Son
- College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Nursing and Midwifery, Hanoi Medical University, Hanoi, Vietnam.,Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Bih-O Lee
- College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
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Manietta C, Labonté V, Thiesemann R, Sirsch EG, Möhler R. Algorithm-based pain management for people with dementia in nursing homes. Cochrane Database Syst Rev 2022; 4:CD013339. [PMID: 35363380 PMCID: PMC8973420 DOI: 10.1002/14651858.cd013339.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND People with dementia in nursing homes often experience pain, but often do not receive adequate pain therapy. The experience of pain has a significant impact on quality of life in people with dementia, and is associated with negative health outcomes. Untreated pain is also considered to be one of the causes of challenging behaviour, such as agitation or aggression, in this population. One approach to reducing pain in people with dementia in nursing homes is an algorithm-based pain management strategy, i.e. the use of a structured protocol that involves pain assessment and a series of predefined treatment steps consisting of various non-pharmacological and pharmacological pain management interventions. OBJECTIVES To assess the effects of algorithm-based pain management interventions to reduce pain and challenging behaviour in people with dementia living in nursing homes. To describe the components of the interventions and the content of the algorithms. SEARCH METHODS We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Science Core Collection (ISI Web of Science), LILACS (Latin American and Caribbean Health Science Information database), ClinicalTrials.gov and the World Health Organization's meta-register the International Clinical Trials Registry Portal on 30 June 2021. SELECTION CRITERIA We included randomised controlled trials investigating the effects of algorithm-based pain management interventions for people with dementia living in nursing homes. All interventions had to include an initial pain assessment, a treatment algorithm (a treatment plan consisting of at least two different non-pharmacological or pharmacological treatment steps to reduce pain), and criteria to assess the success of each treatment step. The control groups could receive usual care or an active control intervention. Primary outcomes for this review were pain-related outcomes, e.g. the number of participants with pain (self- or proxy-rated), challenging behaviour (we used a broad definition that could also include agitation or behavioural and psychological symptoms assessed with any validated instrument), and serious adverse events. DATA COLLECTION AND ANALYSIS Two authors independently selected the articles for inclusion, extracted data and assessed the risk of bias of all included studies. We reported results narratively as there were too few studies for a meta-analysis. We used GRADE methods to rate the certainty of the results. MAIN RESULTS We included three cluster-randomised controlled trials with a total of 808 participants (mean age 82 to 89 years). In two studies, participants had severe cognitive impairment and in one study mild to moderate impairment. The algorithms used in the studies varied in the number of treatment steps. The comparator was pain education for nursing staff in two studies and usual care in one study. We judged the risk of detection bias to be high in one study. The risk of selection bias and performance bias was unclear in all studies. Self-rated pain (i.e. pain rated by participants themselves) was reported in two studies. In one study, all residents in the nursing homes were included, but fewer than half of the participants experienced pain at baseline, and the mean values of self-rated and proxy-rated pain at baseline and follow-up in both study groups were below the threshold of pain that may require treatment. We considered the evidence from this study to be very low-certainty and therefore are uncertain whether the algorithm-based pain management intervention had an effect on self-rated pain intensity compared with pain education (MD -0.27, 95% CI -0.49 to -0.05, 170 participants; Verbal Descriptor Scale, range 0 to 3). In the other study, all participants had mild to moderate pain at baseline. Here, we found low-certainty evidence that an algorithm-based pain management intervention may have little to no effect on self-rated pain intensity compared with pain education (MD 0.4, 95% CI -0.58 to 1.38, 246 participants; Iowa Pain Thermometer, range 0 to 12). Pain was rated by proxy in all three studies. Again, we considered the evidence from the study in which mean pain scores indicated no pain, or almost no pain, at baseline to be very low-certainty and were uncertain whether the algorithm-based pain management intervention had an effect on proxy-rated pain intensity compared with pain education. For participants with mild to moderate pain at baseline, we found low-certainty evidence that an algorithm-based pain management intervention may reduce proxy-rated pain intensity in comparison with usual care (MD -1.49, 95% CI -2.11 to -0.87, 1 study, 128 participants; Pain Assessment in Advanced Dementia Scale-Chinese version, range 0 to 10), but may not be more effective than pain education (MD -0.2, 95% CI -0.79 to 0.39, 1 study, 383 participants; Iowa Pain Thermometer, range 0 to 12). For challenging behaviour, we found very low-certainty evidence from one study in which mean pain scores indicated no pain, or almost no pain, at baseline. We were uncertain whether the algorithm-based pain management intervention had any more effect than education for nursing staff on challenging behaviour of participants (MD -0.21, 95% CI -1.88 to 1.46, 1 study, 170 participants; Cohen-Mansfield Agitation Inventory-Chinese version, range 7 to 203). None of the studies systematically assessed adverse effects or serious adverse effects and no study reported information about the occurrence of any adverse effect. None of the studies assessed any of the other outcomes of this review. AUTHORS' CONCLUSIONS There is no clear evidence for a benefit of an algorithm-based pain management intervention in comparison with pain education for reducing pain intensity or challenging behaviour in people with dementia in nursing homes. We found that the intervention may reduce proxy-rated pain compared with usual care. However, the certainty of evidence is low because of the small number of studies, small sample sizes, methodological limitations, and the clinical heterogeneity of the study populations (e.g. pain level and cognitive status). The results should be interpreted with caution. Future studies should also focus on the implementation of algorithms and their impact in clinical practice.
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Affiliation(s)
- Christina Manietta
- School of Public Health, Bielefeld University, Bielefeld, Germany
- German Center for Neurodegenerative Diseases (DZNE), Witten, Germany
- School of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Valérie Labonté
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | | | - Erika G Sirsch
- Faculty of Nursing Science, PTVH Catholic University, Vallendar, Germany
| | - Ralph Möhler
- School of Public Health, Bielefeld University, Bielefeld, Germany
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine University, Düsseldorf, Germany
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Husebo BS, Vislapuu M, Cyndecka MA, Mustafa M, Patrascu M. Understanding Pain and Agitation Through System Analysis Algorithms in People With Dementia. A Novel Explorative Approach by the DIGI.PAIN Study. FRONTIERS IN PAIN RESEARCH 2022; 3:847578. [PMID: 35369536 PMCID: PMC8970316 DOI: 10.3389/fpain.2022.847578] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/08/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundMany people with dementia (PwD) live and die with undiagnosed and untreated pain and are no longer able to report their suffering. Several pain assessment tools have been developed, tested, and implemented in clinical practice, but nursing home patients are reported to be still in pain. Clinicians and research groups worldwide are seeking novel approaches to encode the prediction, prevalence, and associations to pain in PwD.ParticipantsThe data in this analysis are acquired from the COSMOS study, a cluster-randomized controlled trial (2014 to 2015), aimed to improve the quality of life in nursing home patients (N = 723) through the implementation of a multicomponent intervention. We utilize baseline data of PwD (N = 219) with complete datasets of pain and agitation.MethodSystems analysis explores the relationship between pain and agitation using the Mobilization-Observation-Behavior-Intensity-Dementia (MOBID-2) Pain Scale, Cohen-Mansfield Agitation Inventory (CMAI), and Neuropsychiatric Inventory-Nursing Home version (NPI-NH). For each patient, the individualized continuous time trajectory, and rates of change of pain and agitation are estimated. We determine the relationship between these rates by analyzing them across the entire group.ResultsWe found that the new analysis method can generate individualized estimations for pain and agitation evolution for PwD, as well as their relationship. For 189 of 219 PwD, results show that whenever pain increases or decreases, agitation does too, with the same rate. The method also identifies PwD for whom pain or agitation remains constant while the other varies over time, and patients for whom agitation and pain do not change together. The algorithm is scalable to other variables and compatible with wearable devices and digital sensors.ConclusionWe presented a new approach to clinical data analysis using systems concepts and algorithms. We found that it is possible to quantify and visualize relationships between variables with a precision only dependent on the precision of measurements. This method should be further validated, but incipient results show great potential, especially for wearable-generated continuous data.
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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
- Department of Nursing Home Medicine, Bergen, Norway
- *Correspondence: Bettina S. Husebo
| | - Maarja Vislapuu
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
| | | | - Manal Mustafa
- Oral Health Centre of Expertise in Western Norway, Bergen, Norway
| | - Monica Patrascu
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
- Complex Systems Laboratory, Department of Automatic Control and System Engineering, University Politehnica of Bucharest, Bucharest, Romania
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Iversen WL, Cowan RL, Atalla S, Englehart SS, Gure TR, Moss KO, Ryan CM, Scharre DW, Wright KD, Monroe TB. Treating the most vulnerable: A discursive review of experimental pain in Alzheimer's disease. Nurs Open 2021; 9:942-949. [PMID: 34165251 PMCID: PMC8859087 DOI: 10.1002/nop2.922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/18/2021] [Accepted: 03/29/2021] [Indexed: 11/10/2022] Open
Abstract
AIM The purpose of this manuscript is to summarize research on how experimental pain is experienced by adults with Alzheimer's disease (AD) and to translate results into implications for nurses. DESIGN This discursive review synthesizes the results of three previous research studies exploring experimental pain in adults with AD. METHODS Using a series of fictional clinical vignettes, the authors discuss how the results from three previous papers using acute experimental pain can potentially be translated into clinical practice. The authors also introduce the reader to the concept of research-related psychophysics using introductory definitions and concepts with the impetus to encourage other nurses to consider this research methodology. RESULTS Pain characteristics in AD that differ from cognitively intact controls must be explored to properly address pain in this population. Nurses are well positioned to address these issues in order to provide a high quality of care to adults with AD.
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Affiliation(s)
- Wm Larkin Iversen
- The Ohio State University College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Ronald L Cowan
- Department of Psychiatry, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sebastian Atalla
- The Ohio State University College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Sydney S Englehart
- The Ohio State University College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Tanya R Gure
- Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Karen O Moss
- The Ohio State University College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Claire M Ryan
- Vanderbilt Department of Psychiatry and Behavioral Sciences, Nashville, TN, USA
| | - Douglas W Scharre
- Department of Neurology, Division of Cognitive Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kathy D Wright
- The Ohio State University College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Todd B Monroe
- The Ohio State University College of Nursing, The Ohio State University, Columbus, OH, USA
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Altered nociception in Alzheimer disease is associated with striatal-enriched protein tyrosine phosphatase signaling. Pain 2021; 162:1669-1680. [PMID: 33433143 DOI: 10.1097/j.pain.0000000000002180] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/18/2020] [Indexed: 01/16/2023]
Abstract
ABSTRACT Alzheimer disease (AD) is the most common form of dementia, accounting for approximately 60% of cases. In addition to memory loss, changes in pain sensitivity are found in a substantial proportion of patients with AD. However, the mechanism of nociception deficits in AD is still unclear. Here, we hypothesize that the nociception abnormality in AD is due to the aberrant activation of striatal-enriched protein tyrosine phosphatase (STEP) signaling, which modulates proteins related to nociception transduction. Our results indicated that the transgenic mice carrying human amyloid precursor protein (APP) gene had lower sensitivity to mechanical and thermal stimulation than the wild-type group at the ages of 6, 9, and 12 months. These APP mice exhibited elevated STEP activity and decreased phosphorylation of proteins involved in nociception transduction in hippocampi. The pharmacological inhibition of STEP activity using TC-2153 further reversed nociception and cognitive deficits in the APP mice. Moreover, the phosphorylation of nociception-related proteins in the APP mice was also rescued after STEP inhibitor treatment, indicating the key role of STEP in nociception alteration. In summary, this study identifies a mechanism for the reduced nociceptive sensitivity in an AD mouse model that could serve as a therapeutic target to improve the quality of life for patients with AD.
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Kennedy M, Koehl J, Shenvi CL, Greenberg A, Zurek O, LaMantia M, Lo AX. The agitated older adult in the emergency department: a narrative review of common causes and management strategies. J Am Coll Emerg Physicians Open 2020; 1:812-823. [PMID: 33145525 PMCID: PMC7593470 DOI: 10.1002/emp2.12110] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 12/12/2022] Open
Abstract
Agitation and aggression are common in older emergency department (ED) patients, can impede the expedient diagnosis of potentially life-threatening conditions, and can adversely impact ED functioning and efficiency. Agitation and aggression in older adults may be due to multiple causes, but chief among them are primary psychiatric disorders, substance use, hyperactive delirium, and symptoms of dementia. Understanding the etiology of agitation in an older adult is critical to proper management. Effective non-pharmacologic modalities are available for the management of mild to moderate agitation and aggression in patients with dementia. Pharmacologic management is indicated for agitation related to a psychiatric condition, severe agitation where a patient is at risk to harm self or others, and to facilitate time-sensitive diagnostic imaging, procedures, and treatment. Emergency physicians have several pharmacologic agents at their disposal, including opioid and non-opioid analgesics, antipsychotics, benzodiazepines, ketamine, and combination agents. Emergency physicians should be familiar with geriatric-specific dosing, contraindications, and common adverse effects of these agents. This review article discusses the common causes and non-pharmacologic and pharmacologic management of agitation in older adults, with a specific focus on dementia, delirium, and pain.
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Affiliation(s)
- Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Jennifer Koehl
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of PharmacyMassachusetts General HospitalBostonMassachusettsUSA
| | - Christina L. Shenvi
- Department of Emergency MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Allyson Greenberg
- Department of PharmacyNorthwestern Memorial HospitalChicagoIllinoisUSA
- Department of Emergency MedicineNorthwestern Memorial HospitalChicagoIllinoisUSA
| | - Olivia Zurek
- Department of PsychiatryMassachusetts General HospitalBostonMassachusettsUSA
- Department of PsychiatryHarvard Medical SchoolBostonMassachusettsUSA
| | - Michael LaMantia
- Division of Geriatric MedicineUniversity of VermontBurlingtonVermontUSA
| | - Alexander X. Lo
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
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Starr LT, Magan KC. Model of Empathic Pain Assessment and Treatment in Persons With Dementia. Res Gerontol Nurs 2020; 13:264-276. [PMID: 32286670 DOI: 10.3928/19404921-20200402-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 02/04/2020] [Indexed: 12/21/2022]
Abstract
The current article presents an evidence-based model for understanding clinical empathy's relationship with the assessment and treatment of pain in persons with advanced dementia. A literature review informed creation of an interdisciplinary conceptual framework of clinician empathy in pain assessment and treatment among persons with advanced dementia. Driven by observation of behaviors indicating pain in persons with dementia unable to self-report, the model represents the cognitive, affective, ethical, and behavioral components of clinical empathy involved in assessing and treating pain, relevant patient outcomes, and contextual factors influencing empathy and outcomes; and provides a framework for testing clinical empathy interventions to improve adverse outcomes in persons with advanced dementia. Understanding the relationship between clinician empathy and the assessment and treatment of pain in persons with advanced dementia may improve care quality and help reduce pain behaviors in this patient population. This model may be used to inform pain research in persons with dementia and develop clinical interventions and clinician education programs. [Research in Gerontological Nursing, 13(5), 264-276.].
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Bullock L, Chew-Graham CA, Bedson J, Bartlam B, Campbell P. The challenge of pain identification, assessment, and management in people with dementia: a qualitative study. BJGP Open 2020; 4:bjgpopen20X101040. [PMID: 32457099 PMCID: PMC7330220 DOI: 10.3399/bjgpopen20x101040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/10/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Painful conditions are common in older adults, including people with dementia. The symptoms associated with dementia (for example, diminished language capacity, memory impairment, and behavioural changes), however, may lead to the suboptimal identification, assessment, and management of pain. Research has yet to qualitatively explore pain management for community-dwelling people with dementia. AIM To explore pain identification, assessment, and management for community-dwelling people with dementia. DESIGN & SETTING A qualitative study was undertaken, set in England. METHOD Semi-structured interviews took place with people with dementia, family caregivers, GPs, and old-age psychiatrists. Data were analysed thematically. RESULTS Interviews were conducted with eight people with dementia, nine family caregivers, nine GPs, and five old-age psychiatrists. Three themes were identified that related to pain identification and assessment: gathering information to identify pain; the importance of knowing the person; and the use of pain assessment tools. A further three themes were identified that related to pain management: non-drug strategies; concerns related to analgesic medications; and responsibility of the caregiver to manage pain. CONCLUSION Identifying and assessing the pain experienced by people with dementia was challenging. Most people with dementia, family caregivers, and healthcare professionals supported non-drug strategies to manage pain. The minimal concerns associated with non-drug strategies contrasted the multifactorial concerns associated with analgesic treatment for people with dementia. Given the complexity of pain identification, assessment, and management, primary care should work together with family caregivers and community services, with case finding for pain being considered in all assessment and management plans.
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Affiliation(s)
- Laurna Bullock
- School of Primary Community and Social Care, Keele University, Keele, UK
| | - Carolyn A Chew-Graham
- School of Primary Community and Social Care, Keele University, Keele, UK
- Midlands Partnership NHS Foundation Trust, St Georges' Hospital, Stafford, UK
| | - John Bedson
- School of Primary Community and Social Care, Keele University, Keele, UK
| | - Bernadette Bartlam
- School of Primary Community and Social Care, Keele University, Keele, UK
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technical University Singapore, Singapore, UK
| | - Paul Campbell
- School of Primary Community and Social Care, Keele University, Keele, UK
- Midlands Partnership NHS Foundation Trust, St Georges' Hospital, Stafford, UK
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Kutschar P, Berger S, Brandauer A, Freywald N, Osterbrink J, Seidenspinner D, Gnass I. Nursing Education Intervention Effects on Pain Intensity of Nursing Home Residents with Different Levels of Cognitive Impairment: A Cluster-Randomized Controlled Trial. J Pain Res 2020; 13:633-648. [PMID: 32273749 PMCID: PMC7105359 DOI: 10.2147/jpr.s237056] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 03/07/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Pain management in nursing homes is challenging and pain prevalence remains high. The objective of this study was to improve the pain situation of nursing home residents following a nursing-related educational intervention within a cluster-randomized controlled trial (2016-2018). PARTICIPANTS Clusters were nursing homes from one nursing home operator in Bavaria, Germany. Nursing home residents who were permanently registered in the facilities, at least 60 years of age, and who themselves or their legal guardians provided informed consent were included. INTERVENTION In addition to the implementation of pain nurses and pain care assistants, staff of the intervention group received an educational intervention in pain management, containing classroom (quality circles) and web-based training for nurses. METHODS Based on the Mini-Mental State Examination (MMSE), residents were either interviewed (MMSE 10-30) using self-report instruments or observed (MMSE 0-9) by proxy assessment. The primary outcome in residents able to self-report was maximum pain intensity according to Brief Pain Inventory (BPI); in those not able to self-report treatment-relevant pain above cut-off (≥2) on the Pain Assessment in Advanced Dementia (PAINAD). RESULTS Out of 20 randomly selected clusters, 9 nursing homes from the control, and 6 nursing homes from the intervention group participated. Multilevel linear (n=347 residents, MMSE 10-30) and logistic regression (n=222 residents, MMSE 0-9) analyses were conducted. Maximum pain intensity was higher after intervention (B=1.32, p<0.01), decreased with a better quality of life (B=-0.07, p<0.001), and was lower when dementia diagnoses were present (B=-1.12, p<0.01). PAINAD scores before and after intervention did not differ significantly (OR=0.89, p=0.724), but chances to exhibit treatment-related pain were higher with decreasing MMSE (OR=0.94, p<0.05). CONCLUSION While no significant positive intervention effect was measured, findings suggest nurses' raised awareness towards pain management. Overall results indicate that large-scale educational interventions seem to be less effective in complex nursing home settings without also including specific individual-based intervention measures.
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Affiliation(s)
- P Kutschar
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - S Berger
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - A Brandauer
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - N Freywald
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - J Osterbrink
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
- Brooks College of Health, University of North Florida, Jacksonville, FL, USA
| | - D Seidenspinner
- Nursing Science and Practice Development, University Hospital of Munich-Großhadern (LMU), Munich, Germany
| | - I Gnass
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
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13
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Law WY, Kwok TCY. Letter to Kajiwara et al. 'Letter in response to "Impacts of a multicomponent intervention programme on neuropsychiatric symptoms in people with dementia and psychological health of caregivers: a feasibility pilot study"'. Int J Geriatr Psychiatry 2020; 35:331. [PMID: 31828840 DOI: 10.1002/gps.5230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/07/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Wai Yan Law
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Timothy C Y Kwok
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
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14
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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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15
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MacNeil-Vroomen JL, Nagurney JM, Allore HG. Comorbid conditions and emergency department treat and release utilization in multimorbid persons with cognitive impairment. Am J Emerg Med 2020; 38:127-131. [PMID: 31337598 PMCID: PMC6917961 DOI: 10.1016/j.ajem.2019.07.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND There is an increasing focus in the emergency department (ED) on addressing the needs of persons with cognitive impairment, most of whom have multiple chronic conditions. We investigated which common comorbidities among multimorbid persons with cognitive impairment conferred increased risk for ED treat and release utilization. METHODS We examined the association of 16 chronic conditions on use of ED treat and release visit utilization among 1006 adults with cognitive impairment and ≥ 2 comorbidities using the nationally-representative National Health and Aging Trends Study merged with Fee-For-Service Medicare claims data, 2011-2015. RESULTS At baseline, 28.5% had ≥6 conditions and 35.4% were ≥ 85 years old. After controlling for sex, age, race, education, urban-living, number of disabled activities of daily living, and sampling strata, we found significantly increased adjusted risk ratios (aRR) of ED treat and release visits for persons with depression (aRR 1.38 95% CI 1.15-1.65) representing 78/100 person-years, and osteoarthritis or rheumatoid arthritis (aRR 1.32 95% CI 1.12-1.57) representing 71/100 person-years. At baseline 93.9% had ≥1 informal caregiver and 69.7% had a caregiver that helped with medications or attended physician visits. CONCLUSION These results show that multimorbid cognitively impaired older adults with depression or osteoarthritis or rheumatoid arthritis are at higher risk of ED treat and release visits. Future ED research with multimorbid cognitively impaired persons may explore behavioral aspects of depression and/or pain and flairs associated with osteoarthritis or rheumatoid arthritis, as well as the role of informal caregivers in the care of these conditions.
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Affiliation(s)
- Janet L MacNeil-Vroomen
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven 06511, CT, United States of America; Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam 110Z AZ, the Netherlands.
| | - Justine M Nagurney
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston 02215-5321, MA, United States of America
| | - Heather G Allore
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven 06511, CT, United States of America; Department of Biostatistics, Yale School of Public Health, New Haven 06511, CT, United States of America
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16
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Pergolizzi JV, Raffa RB, Paladini A, Varrasi G, LeQuang JA. Treating pain in patients with dementia and the possible concomitant relief of symptoms of agitation. Pain Manag 2019; 9:569-582. [DOI: 10.2217/pmt-2019-0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Dementia is an irreversible, progressive form of cognitive dysfunction that can affect memory, learning ability, thinking, orientation, comprehension, calculation, linguistic skills and executive function but which does not impair consciousness. Pain prevalence is high among the elderly who are also at elevated risk for dementia. Pain control for dementia patients is important but can be challenging for clinicians as cognitive deficits can make it difficult to identify, localize and assess pain. Cerebral changes associated with dementia may change how people process and experience pain in ways that are not entirely elucidated. Agitation is a frequent symptom of dementia and may be associated with untreated pain as agitation and aggression symptoms decrease when pain is effectively addressed.
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Affiliation(s)
| | - Robert B Raffa
- University of Arizona, Department of Pharmacy, Tucson, AZ 85721, USA
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Herrmann N, Ruthirakuhan M, Gallagher D, Verhoeff NPLG, Kiss A, Black SE, Lanctôt KL. Randomized Placebo-Controlled Trial of Nabilone for Agitation in Alzheimer's Disease. Am J Geriatr Psychiatry 2019; 27:1161-1173. [PMID: 31182351 DOI: 10.1016/j.jagp.2019.05.002] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate the efficacy and safety of nabilone for agitation in patients with moderate-to-severe Alzheimer's disease (AD). DESIGN This 14-week randomized double-blind crossover trial compared nabilone to placebo (6 weeks each) with a 1-week washout between phases. SETTING Patients were recruited from a long-term care facility and geriatric psychiatry clinics. PARTICIPANTS Patients had AD (standardized Mini-Mental State Examination [sMMSE ≤24]) and agitation (Neuropsychiatric Inventory-Nursing Home version [NPI-NH]-agitation/aggression subscore ≥3). INTERVENTION Nabilone (target 1-2 mg) versus placebo. MEASUREMENTS The primary outcome was agitation (Cohen Mansfield Agitation Inventory [CMAI]). Secondary outcomes included NPI-NH total, NPI-NH caregiver distress, cognition (sMMSE and Severe Impairment Battery [SIB] or Alzheimer's Disease Assessment Scale of Cognition), global impression (Clinician's Global Impression of Change [CGIC]), and adverse events. RESULTS Thirty-nine patients (mean ± SD age = 87 ± 10, sMMSE = 6.5 ± 6.8, CMAI = 67.9 ± 17.6, NPI-NH total = 34.3 ± 15.8, 77% male, nabilone dose = 1.6 ± 0.5 mg) were randomized. There were no crossover or treatment-order effects. Using a linear mixed model, treatment differences (95% CI) in CMAI (b = -4.0 [-6.5 to -1.5], t(30.2) = -3.3, p = 0.003), NPI-NH total (b = -4.6 [-7.5 to -1.6], t(32.9) = -3.1, p = 0.004), NPI-NH caregiver distress (b = -1.7 [-3.4 to -0.07, t(33.7) = -2.1, p = 0.041), and sMMSE (b = 1.1 [0.1-2.0], t(22.6) = 2.4, p = 0.026) all favored nabilone. However, in those who completed the SIB (n = 25) treatment differences favored placebo (b = -4.6 [-7.3 to -1.8], t(20.7) = -4.8, p = 0.003). CGIC improvement during nabilone (47%) and placebo (23%) was not significantly different (McNemar's test, exact p = 0.09). There was more sedation during nabilone (45%) compared to placebo (16%) phases (McNemar's test, exact p = 0.02), but treatment-limiting sedation was not significantly different (McNemar's test, exact p = 0.22). CONCLUSIONS Nabilone may be an effective treatment for agitation. However, sedation and cognition should be closely monitored.
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Affiliation(s)
- Nathan Herrmann
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Myuri Ruthirakuhan
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Damien Gallagher
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Alex Kiss
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Sandra E Black
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Krista L Lanctôt
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.
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18
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Griffioen C, Husebo BS, Flo E, Caljouw MAA, Achterberg WP. Opioid Prescription Use in Nursing Home Residents with Advanced Dementia. PAIN MEDICINE 2019; 20:50-57. [PMID: 29136228 DOI: 10.1093/pm/pnx268] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 10/04/2017] [Indexed: 11/14/2022]
Abstract
Background Although proper pain treatment may require opioids, discussion continues about possible undertreatment or overtreatment in persons with advanced dementia. Objective To investigate the prevalence of pain, frequency of opioid prescription use, and factors associated with strong opioid prescription use in nursing homes. Design Cross-sectional study. Setting and Subjects Eighteen Norwegian nursing homes; 327 persons with advanced dementia and behavioral disturbances participated. Methods Potential factors associated with strong opioid prescription use were assessed: demographics (age, gender), medical conditions (comorbidity, number of medications), pain (Mobilization-Observation-Behaviour-Intensity-Dementia-2 Pain Scale ≥ 3, pain-related diagnoses, analgesic prescription use), functioning (activities of daily living, Mini-Mental State Examination) and behavior (Neuropsychiatric Inventory-Nursing Home version, Cohen-Mansfield Agitation Inventory). Factors with P < 0.10, age, and gender were included in multivariate regression analysis. Results The prevalence of moderate to severe pain was 62.1%. Of all participants, 19.3% (N = 63) were prescribed opioids, and of these, 79.4% (N = 50) were still in pain; 66.7% of the opioid prescriptions were less than or equal to the lowest dosage of fentanyl patches (12 mcg/h) or buprenorphine (5 or 10 mcg/h). Pain (odds ratio [OR] = 1.26, 95% confidence interval [CI] = 1.12-1.42), total number of pain-related diagnoses (OR = 1.47, 95% CI = 1.14-1.90), and depression and anxiety (OR = 1.05, 95% CI = 1.01-1.11) were positively associated with an opioid prescription. Stroke was negatively associated (OR = 0.43, 95% CI = 0.19-0.99). Conclusions Strong opioid prescription use was mainly associated with pain. However, in this population, despite the relatively prevalent use of strong prescription opioids, pain was still prevalent. This emphasizes the challenge of proper pain treatment and need for regular evaluation of pain and pain management.
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Affiliation(s)
- Charlotte Griffioen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.,Novicare, Elderly Care, Best, the Netherlands
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Elisabeth Flo
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Monique A A Caljouw
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Rababa M, Aldalaykeh M. Responding to Varying Levels of Certainty about Pain in People with Dementia after Initial Pain Assessment. Dement Geriatr Cogn Dis Extra 2019; 9:271-280. [PMID: 31572423 PMCID: PMC6751429 DOI: 10.1159/000501030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 05/15/2019] [Indexed: 01/14/2023] Open
Abstract
Introduction Pain is still inadequately treated in people with dementia (PWD) due to the complexity of assessing it. Pain assessment in PWD is still challenging because of patient-related or nurse-related factors. The patient-related factors have been studied extensively. However, the nurse-related factors, e.g., nurses' certainty regarding suspected pain in PWD, have been given little attention by researchers. Purpose This study aims to investigate how the degree of nurses' certainty is compromised after pain assessment and how this affects levels of pain and agitation in PWD. Method A descriptive, correlational design was used, and a convenience sample of 104 nursing home residents with dementia were recruited. Results This study found that nurses' certainty after the pain assessment mediates the relationship between the type of pain assessment and patient outcomes when the nurses had a high initial certainty. When nurses had a low initial certainty, their certainty after the assessment and the type of assessment predicted the levels of pain and agitation in PWD. Conclusion Understanding how nurses' certainty can be compromising after pain assessment and how this relates to pain management in PWD is crucial.
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20
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Scuteri D, Rombolà L, Morrone LA, Bagetta G, Sakurada S, Sakurada T, Tonin P, Corasaniti MT. Neuropharmacology of the Neuropsychiatric Symptoms of Dementia and Role of Pain: Essential Oil of Bergamot as a Novel Therapeutic Approach. Int J Mol Sci 2019; 20:E3327. [PMID: 31284573 PMCID: PMC6651821 DOI: 10.3390/ijms20133327] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 06/24/2019] [Accepted: 07/05/2019] [Indexed: 01/03/2023] Open
Abstract
Aging of the population makes of dementia a challenge for health systems worldwide. The cognitive disturbance is a serious but not the only issue in dementia; behavioral and psychological syndromes known as neuropsychiatric symptoms of dementia remarkably reduce the quality of life. The cluster of symptoms includes anxiety, depression, wandering, delusions, hallucinations, misidentifications, agitation and aggression. The pathophysiology of these symptoms implicates all the neurotransmitter systems, with a pivotal role for the glutamatergic neurotransmission. Imbalanced glutamatergic and GABAergic neurotransmissions, over-activation of the extrasynaptic N-methyl-D-aspartate (NMDA) receptors and alterations of the latter have been linked to the development of neuropsychiatric symptoms experienced by almost the entire demented population. Drugs with efficacy and safety for prevention or long term treatment of these disorders are not available yet. Aromatherapy provides the best evidence for positive outcomes in the control of agitation, the most resistant symptom. Demented patients often cannot verbalize pain, resulting in unrelieved symptoms and contributing to agitation. Bergamot essential oil provides extensive preclinical evidence of analgesic properties. Incidentally, the essential oil of bergamot induces anxyolitic-like effects devoid of sedation, typical of benzodiazepines, with a noteworthy advantage for demented patients. These data, together with the reported safety profile, form the rational basis for bergamot as a neurotherapeutic to be trialed for the control of behavioral and psychological symptoms of dementia.
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Affiliation(s)
- Damiana Scuteri
- Preclinical and Translational Pharmacology, Department of Pharmacy, Health Science and Nutrition, University of Calabria, 87036 Rende, Italy
| | - Laura Rombolà
- Preclinical and Translational Pharmacology, Department of Pharmacy, Health Science and Nutrition, University of Calabria, 87036 Rende, Italy
| | - Luigi Antonio Morrone
- Preclinical and Translational Pharmacology, Department of Pharmacy, Health Science and Nutrition, University of Calabria, 87036 Rende, Italy
| | - Giacinto Bagetta
- Preclinical and Translational Pharmacology, Department of Pharmacy, Health Science and Nutrition, University of Calabria, 87036 Rende, Italy.
| | - Shinobu Sakurada
- Department of Physiology and Anatomy, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, 4-4-1 Komatsushima, Aoba-ku, Sendai 981-8558, Japan
| | - Tsukasa Sakurada
- Daiichi College of Pharmaceutical Sciences-First Department of Pharmacology Fukuoka, Fukuoka 815-8511, Japan
| | - Paolo Tonin
- Regional Center for Serious Brain Injuries, S. Anna Institute, 88900 Crotone, Italy
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Gilmore-Bykovskyi AL, Block L, Hovanes M, Mirr J, Kolanowski A. Analgesic Use Patterns Among Patients With Dementia During Transitions From Hospitals to Skilled Nursing Facilities. Res Gerontol Nurs 2019; 12:61-69. [PMID: 30703217 DOI: 10.3928/19404921-20190122-01] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/28/2018] [Indexed: 01/09/2023]
Abstract
Gaps in pain management, including discontinuity in analgesic medication prescribing, frequently complicate transitions from hospital to skilled nursing facilities (SNFs) for patients with dementia. The objective of the current study was to examine analgesic medication use and prescribing patterns in the last 48 hours of hospitalization and upon discharge to SNF among stroke and hip fracture patients with dementia. Of 318 patients who received an analgesic medication within the last 48 hours of hospitalization, 23% experienced potentially abrupt discontinuations upon discharge. These rates varied by medication, with acetaminophen with codeine (27%), hydromorphone (19%), and acetaminophen with hydrocodone (19%) having the highest rates of potentially abrupt discontinuations. Conversely, 38% of patients experienced potentially abrupt additions of an analgesic medication upon discharge. Findings suggest that changes to analgesic regimens prior to and upon discharge may be common practice, potentially hindering care continuity and pain control during transitions. [Res Gerontol Nurs. 2019; 12(2):61-69.].
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Feast AR, White N, Lord K, Kupeli N, Vickerstaff V, Sampson EL. Pain and delirium in people with dementia in the acute general hospital setting. Age Ageing 2018; 47:841-846. [PMID: 30165420 PMCID: PMC6201828 DOI: 10.1093/ageing/afy112] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/06/2018] [Accepted: 07/16/2018] [Indexed: 12/30/2022] Open
Abstract
Background Pain and delirium are common in people with dementia admitted to hospitals. These are often under-diagnosed and under-treated. Pain is implicated as a cause of delirium but this association has not been investigated in this setting. Objective To investigate the relationship between pain and delirium in people with dementia, on admission and throughout a hospital admission. Design Exploratory secondary analysis of observational prospective longitudinal cohort data. Setting Two acute hospitals in the UK. Methodology Two-hundred and thirty participants aged ≥70 years were assessed for dementia severity, delirium ((Confusion Assessment Method (CAM), pain (Pain Assessment in Advanced Dementia (PAINAD)) scale and prescription of analgesics. Logistic and linear regressions explored the relationship between pain and delirium using cross-sectional data. Results Pain at rest developed in 49%, and pain during activity for 26% of participants during their inpatient stay. Incident delirium developed in 15%, of participants, and 42% remained delirious for at least two assessments. Of the 35% of participants who were delirious and unable to self-report pain, 33% of these participants experienced pain at rest, and 56 experienced pain during activity. The odds of being delirious were 3.26 times higher in participants experiencing pain at rest (95% Confidence Interval 1.03-10.25, P = 0.044). Conclusion An association between pain at rest and delirium was found, suggesting pain may be a risk factor for delirium. Since pain and delirium were found to persist and develop during an inpatient stay, regular pain and delirium assessments are required to manage pain and delirium effectively.
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Affiliation(s)
- Alexandra R Feast
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Nicola White
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Kathryn Lord
- Faculty of Health Studies, Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- The Research Department of Primary Care and Population Health, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
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Tse MM, Lau JL, Kwan R, Cheung D, Tang AS, Ng SS, Lee PH, Yeung SS. Effects of play activities program for nursing home residents with dementia on pain and psychological well-being: Cluster randomized controlled trial. Geriatr Gerontol Int 2018; 18:1485-1490. [DOI: 10.1111/ggi.13509] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 07/05/2018] [Accepted: 07/14/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Mimi M.Y. Tse
- School of Nursing, The Hong Kong Polytechnic University; Kowloon Hong Kong
| | - Joyce L. Lau
- School of Nursing, The Hong Kong Polytechnic University; Kowloon Hong Kong
| | - Rick Kwan
- School of Nursing, The Hong Kong Polytechnic University; Kowloon Hong Kong
| | - Daphne Cheung
- School of Nursing, The Hong Kong Polytechnic University; Kowloon Hong Kong
| | - Angel S.K. Tang
- School of Nursing, The Hong Kong Polytechnic University; Kowloon Hong Kong
| | - Shamay S.M. Ng
- Department of Rehabilitation Sciences; The Hong Kong Polytechnic University; Kowloon Hong Kong
| | - Paul H. Lee
- School of Nursing, The Hong Kong Polytechnic University; Kowloon Hong Kong
| | - Suey S.Y. Yeung
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences; Vrije Universiteit; Amsterdam The Netherlands
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The Role of Nurses' Uncertainty in Decision-Making Process of Pain Management in People with Dementia. PAIN RESEARCH AND TREATMENT 2018; 2018:7281657. [PMID: 30155298 PMCID: PMC6093080 DOI: 10.1155/2018/7281657] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/27/2018] [Accepted: 07/13/2018] [Indexed: 11/18/2022]
Abstract
Pain in people with dementia (PWD) is underassessed and undertreated. Treatment of pain in people with dementia goes awry because of poor assessment, poor treatment, and factors related to nursing decision-making skills. Several theoretical models addressed the role of nurses' critical thinking and decision-making skills in pain treatment, like the cognitive continuum theory (CCT) and the adaptive pain management (APT). Only the Response to Certainty of Pain (RCP) model was the first model to posit relationships between nurses' uncertainty, pain assessment, and patient outcomes. Gilmore-Bykovskyi and Bowers developed the RCP, which incorporates the concept of uncertainty and how it relates to the problem of unrelieved pain in PWD. The RCP model has the potential to provide good understanding of the problem of unrelieved pain in people with dementia. It also could help to develop a research study that brings comfort to an often neglected and vulnerable population.
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Monacelli F, Signori A, Roffredo L, Pace K, Nencioni A, Pickering G, Nicolas M, Odetti P. Algoplus® Scale in Older Patients with Dementia: A Reliable Real-World Pain Assessment Tool. J Alzheimers Dis 2018; 56:519-527. [PMID: 27935555 DOI: 10.3233/jad-160790] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pain is still a neglected clinical issue in elderly people with dementia and/or communicative disorders, with an unacceptable higher rate of under diagnosis and under treatment. Cognitive deficit and emotional and psychological disturbances entangle pain symptoms, affecting patient self-report. So far, observational pain tools do not have fully adequate clinimetric properties and quality requirements for easy-to-use daily rating. Older patients with dementia represent a clinical challenge. The assessment of pain is important for improving clinical outcomes, such as functional status, frailty trajectories, comorbidity, and quality of life. The PAINAID scale appears to be the most accurate pain tool in people with dementia along with the Algoplus® scale, a recently developed tool to rapidly assess acute pain in hospitals settings. The present study aimed to assess the clinimetric properties of the Algoplus®, as compared to PAINAID, for detecting acute pain in a real-world cohort of hospitalized older patients with dementia.
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Affiliation(s)
- Fiammetta Monacelli
- DIMi, Department of Internal Medicine and Medical Specialties, Section of Geriatrics, University of Genoa, Genoa, Italy
| | - Alessio Signori
- DISSAL, Department of Health Science, University of Genoa, Genoa, Italy
| | - Laura Roffredo
- DIMi, Department of Internal Medicine and Medical Specialties, Section of Geriatrics, University of Genoa, Genoa, Italy
| | - Katiuscia Pace
- IRCCS AUO San Martino Hospital, Section of Geriatrics, Genoa, Italy
| | - Alessio Nencioni
- DIMi, Department of Internal Medicine and Medical Specialties, Section of Geriatrics, University of Genoa, Genoa, Italy
| | - Gisele Pickering
- Département de Pharmacologie, Faculté de Médecine, INSERM CIC 501 and U766, Université d'Auvergne, CHU Clermont-Ferrand, Clermont-Ferrand, France.,Collectif Doloplus, Centre de Soins Palliatifs, CHR Metz-Thionville, Thionville, France
| | - Macian Nicolas
- Département de Pharmacologie, Faculté de Médecine, INSERM CIC 501 and U766, Université d'Auvergne, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Patrizio Odetti
- DIMi, Department of Internal Medicine and Medical Specialties, Section of Geriatrics, University of Genoa, Genoa, Italy
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Scales K, Zimmerman S, Miller SJ. Evidence-Based Nonpharmacological Practices to Address Behavioral and Psychological Symptoms of Dementia. THE GERONTOLOGIST 2018; 58:S88-S102. [PMID: 29361069 PMCID: PMC5881760 DOI: 10.1093/geront/gnx167] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Indexed: 12/26/2022] Open
Abstract
Background and Objectives To draw from systematic and other literature reviews to identify, describe, and critique nonpharmacological practices to address behavioral and psychological symptoms of dementia (BPSDs) and provide evidence-based recommendations for dementia care especially useful for potential adopters. Research Design and Methods A search of systematic and other literature reviews published from January 2010 through January 2017. Nonpharmacological practices were summarized to describe the overall conceptual basis related to effectiveness, the practice itself, and the size and main conclusions of the evidence base. Each practice was also critically reviewed to determine acceptability, harmful effects, elements of effectiveness, and level of investment required, based on time needed for training/implementation, specialized care provider requirements, and equipment/capital requirements. Results Nonpharmacological practices to address BPSDs include sensory practices (aromatherapy, massage, multi-sensory stimulation, bright light therapy), psychosocial practices (validation therapy, reminiscence therapy, music therapy, pet therapy, meaningful activities), and structured care protocols (bathing, mouth care). Most practices are acceptable, have no harmful effects, and require minimal to moderate investment. Discussion and Implications Nonpharmacological practices are person-centered, and their selection can be informed by considering the cause and meaning of the individual's behavioral and psychological symptoms. Family caregivers and paid care providers can implement evidence-based practices in home or residential care settings, although some practices require the development of more specific protocols if they are to become widely used in an efficacious manner.
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Affiliation(s)
| | - Sheryl Zimmerman
- School of Social Work, The University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill
| | - Stephanie J Miller
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill
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Tampi RR, Hassell C, Joshi P, Tampi DJ. Analgesics in the management of behavioral and psychological symptoms of dementia: a perspective review. Drugs Context 2017; 6:212508. [PMID: 29209402 PMCID: PMC5706593 DOI: 10.7573/dic.212508] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/17/2017] [Accepted: 10/17/2017] [Indexed: 11/30/2022] Open
Abstract
The objective of this review was to assess the efficacy and tolerability of analgesics in reducing behavioral and psychological symptoms of dementia (BPSD) among older adults from published randomized controlled trials (RCTs). A literature search was conducted of PubMed, MEDLINE, SCOPUS, PsycINFO, and Cochrane collaboration databases for RCTs in the English language that evaluated the use of analgesics in reducing the severity of BPSD among older adults. Additionally, references of full-text articles that were included in this review were searched for extra studies. We identified a total of three unique RCTs that evaluated the use of analgesics among individuals with BPSD. One of the identified RCTs resulted in a total of three additional published papers in the literature, resulting in a total of six papers to be included in this review. All three RCTs identified some benefit for the use of analgesics in reducing BPSD. The analgesics appeared to be well tolerated in the included studies. Major study limitations include the use of data exclusively from published RCTs and limiting the search to English language publications. Additionally, we did not utilize statistical methods to evaluate the treatment outcomes including tolerability. In conclusion, available evidence although limited indicates that analgesics may reduce BPSD among some individuals with dementia living in nursing homes and are well tolerated.
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Affiliation(s)
- Rajesh R Tampi
- Department of Psychiatry, MetroHealth, Cleveland, OH, USA
| | - Corey Hassell
- Quinnipiac University School of Medicine, Hamden, CT, USA
| | - Pallavi Joshi
- Northwell Health-Staten Island University Hospital, Staten Island, NY, USA
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Kratz T. The Diagnosis and Treatment of Behavioral Disorders in Dementia. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:447-454. [PMID: 28705297 PMCID: PMC5523798 DOI: 10.3238/arztebl.2017.0447] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 11/13/2016] [Accepted: 03/02/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Behavioral disorders such as aggressiveness, agitation, delusions, disinhibition, affect lability, and apathy arise in more than 90% of patients with dementia. Behavioral disorders are a major challenge and the greatest stress factor in everyday life for nursing personnel and for family members caring for the patient. METHODS This review is based on relevant publications retrieved by a selective literature search in the PubMed, Cochrane Library, and German S3 guideline databases with the search terms "behavioral disorders," "non-cognitive disorders," and "challenging behavior," in conjunction with "dementia" and "behavioral and psychological symptoms of dementia." RESULTS Behavioral disorders regularly accompany dementing illness and have identifiable and treatable somatic and environment-related causes. They should be treated symptomatically, both with non-pharmacological measures and with drugs. Memory therapy (d = 0.47), ergotherapy (d = 0.72), music therapy (d = 0.62), and physical exercise (d = 0.68) are effective, as are antidementia drugs (galantamine: p = 0.04, donepezil: p = 0.01, rivastigmine: p = 0.02, memantine: p = 0.004). Risperidone is the drug of choice to combat agitation and aggressiveness (d = 0.33) as well as dementia and hallucinations (d = 0.5). Citalopram can be recommended for the treatment of depression in patients with dementia (p = 0.05). CONCLUSION Because of an improved evidence base, the latest version of the German S3 guideline on the diagnosis and treatment of dementia places greater emphasis on non-pharmacological treatments for behavioral disorders in dementia than it did in the past. The global efficacy of such treatments against behavioral disorders is well documented. Nonetheless, because of the heterogeneity of interventions and varying standards of assessment, the evidence for the utility of certain specific methods in the treatment of specific behavioral disorders is still limited. More research is needed in this area.
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Affiliation(s)
- Torsten Kratz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Evangelisches Krankenhaus “Königin Elisabeth” Herzberge, Berlin
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Koppitz A, Bosshard G, Blanc G, Hediger H, Payne S, Volken T. Pain Intervention for people with Dementia in nursing homes (PID): study protocol for a quasi-experimental nurse intervention. BMC Palliat Care 2017; 16:27. [PMID: 28431539 PMCID: PMC5399861 DOI: 10.1186/s12904-017-0200-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 04/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is estimated that 19 to 83% of people with dementia suffer from pain that is inadequately treated in the last months of life. A large number of healthcare workers who care for these people in nursing homes lack appropriate expertise and may therefore not always recognise, assess and treat pain in those with dementia who have complex problems on time, properly and efficiently. The aim of this intervention trial is to identify care needs of people with dementia suffering from pain living in a nursing home. METHODS A quasi-experimental nurse-led intervention trial based on a convenience sample of four nursing homes in the Swiss Canton of Zurich examines the effects on dementia patients (n = 411), the healthcare institution and the qualification level of the healthcare workers compared to historical controls, using an event analysis and a multilevel analysis. Healthcare workers will be individually trained how to assess, intervene and evaluate acute and chronic pain. There are three data-monitoring cycles (T0, T1, T2) and two intervention cycles (I1, I2) with a total study duration of 425 days. There is also a process evaluation based on Dobbins analyses that analyse in particular the potentials for change in clinical practice of change agents. DISCUSSION The aim of the intervention trial is to improve pain management strategies in older people with dementia in nursing homes. Clinically significant findings will be expected that will help reduce suffering in the sense of "total pain" for people with dementia. The joint intra- and interdisciplinary collaboration between practice and supply-oriented (nursing) research will have both a lasting effect on the efficiency measurement and provide scientifically sound results. Nursing homes can integrate the findings from the intervention trial into their internal quality control process. The potential for improvements can be directly influenced by the nursing home itself. TRIAL REGISTRATION Registration trial number: DRKS00009726 on DRKS, registered 10 January 2017, retrorespectively registered. Clearance certificate is available of the ethics committees of the canton of Thurgau, Switzerland, number: TG K201-02, and Zurich, Switzerland, number: ZH 01-2016.
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Affiliation(s)
- Andrea Koppitz
- Zurich University of Applied Sciences, School of Health Professions, Institute of Nursing, Technikumstrasse 81, 8401, Winterthur, Switzerland.
| | - Georg Bosshard
- University Hospital Zurich, Clinic for Geriatric Medicine and Centre on Aging and Mobility at the University of Zurich, Gloriastrasse 25, 8091, Zurich, Switzerland
| | - Geneviève Blanc
- Zurich University of Applied Sciences, School of Health Professions, Institute of Nursing, Technikumstrasse 81, 8401, Winterthur, Switzerland
| | - Hannele Hediger
- Zurich University of Applied Sciences, School of Health Professions, Institute of Nursing, Technikumstrasse 81, 8401, Winterthur, Switzerland
| | - Sheila Payne
- Lancaster University, International Observatory on End of Life Care, Division of Health Research, Faculty of Health and Medicine, Lancaster, LA1 4YG, UK
| | - Thomas Volken
- Zurich University of Applied Sciences, School of Health Professions, Institute of health science, Technikumstrasse 81, 8401, Winterthur, Switzerland
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Kutschar P, Bauer Z, Gnass I, Osterbrink J. Does item overlap render measured relationships between pain and challenging behaviour trivial? Results from a multicentre cross-sectional study in 13 German nursing homes. Nurs Inq 2017; 24. [DOI: 10.1111/nin.12182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Patrick Kutschar
- Institute of Nursing Science and Practice; Paracelsus Medical University; Salzburg Austria
| | - Zsuzsa Bauer
- Institute of Nursing Science and Practice; Paracelsus Medical University; Salzburg Austria
| | - Irmela Gnass
- Institute of Nursing Science and Practice; Paracelsus Medical University; Salzburg Austria
| | - Jürgen Osterbrink
- Institute of Nursing Science and Practice; Paracelsus Medical University; Salzburg Austria
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van der Linde RM, Dening T, Stephan BCM, Prina AM, Evans E, Brayne C. Longitudinal course of behavioural and psychological symptoms of dementia: systematic review. Br J Psychiatry 2016; 209:366-377. [PMID: 27491532 PMCID: PMC5100633 DOI: 10.1192/bjp.bp.114.148403] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 02/27/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND More information about the pattern of behavioural and psychological symptoms of dementia (BPSD) in the course of dementia is needed to inform patients and clinicians and to design future interventions. AIMS To determine the persistence and incidence of BPSD and their relation to cognitive function, in individuals with dementia or in cohorts investigated for dementia onset. METHOD A systematic literature review analysed the baseline prevalence, persistence and incidence of 11 symptoms. The review was conducted according to established guidelines with the exception that we could not exclude the possibilities of bias in the studies examined. RESULTS The 59 included studies showed considerable heterogeneity in their objectives and methods. The symptoms hyperactivity and apathy showed high persistence and incidence; depression and anxiety low or moderate persistence and moderate incidence; and psychotic symptoms low persistence with moderate or low incidence. CONCLUSIONS Despite heterogeneity across studies in terms of setting, focus and length of follow-up, there were clinically relevant differences in the longitudinal courses of different BPSD. Apathy was the only symptom with high baseline prevalence, persistence and incidence during the course of dementia.
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Affiliation(s)
- Rianne M. van der Linde
- Correspondence: R. van der Linde, Department of Public Health and Primary Care, Herchel Smith Building, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK.
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Stubbs B, Thompson T, Solmi M, Vancampfort D, Sergi G, Luchini C, Veronese N. Is pain sensitivity altered in people with Alzheimer's disease? A systematic review and meta-analysis of experimental pain research. Exp Gerontol 2016; 82:30-8. [DOI: 10.1016/j.exger.2016.05.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/19/2016] [Accepted: 05/30/2016] [Indexed: 11/24/2022]
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Koppitz A, Bosshard G, Kipfer S, Imhof L. Decision-making in caring for people with dementia at the end of life in nursing homes. Int J Palliat Nurs 2016; 22:68-75. [DOI: 10.12968/ijpn.2016.22.2.68] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Andrea Koppitz
- Deputy Head of Nursing Research and Development, Institute of Nursing, Zurich University of Applied Sciences, Switzerland
| | - Georg Bosshard
- Long Term Care Physician, University Hospital of Zurich, Clinic for Geriatric Medicine, and Centre on Ageing and Mobility, University of Zurich
| | - Stephanie Kipfer
- Research Associate, Haute École De Santé, Health Department, Fribourg, Switzerland
| | - Lorenz Imhof
- Head of Nursing Research and Development, Institute of Nursing, Zurich University of Applied Sciences
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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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Pain, agitation, and behavioural problems in people with dementia admitted to general hospital wards: a longitudinal cohort study. Pain 2015; 156:675-683. [PMID: 25790457 PMCID: PMC4381983 DOI: 10.1097/j.pain.0000000000000095] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pain was common but difficult to detect in hospitals in patients with dementia who had difficulties with self-report. It was associated with aggression and anxiety. Pain is underdetected and undertreated in people with dementia. We aimed to investigate the prevalence of pain in people with dementia admitted to general hospitals and explore the association between pain and behavioural and psychiatric symptoms of dementia (BPSD). We conducted a longitudinal cohort study of 230 people, aged above 70, with dementia and unplanned medical admissions to 2 UK hospitals. Participants were assessed at baseline and every 4 days for self-reported pain (yes/no question and FACES scale) and observed pain (Pain Assessment in Advanced Dementia scale [PAINAD]) at movement and at rest, for agitation (Cohen–Mansfield Agitating Inventory [CMAI]) and BPSD (Behavioural Pathology in Alzheimer Disease Scale [BEHAVE-AD]). On admission, 27% of participants self-reported pain rising to 39% on at least 1 occasion during admission. Half of them were able to complete the FACES scale, this proportion decreasing with more severe dementia. Using the PAINAD, 19% had pain at rest and 57% had pain on movement on at least 1 occasion (in 16%, this was persistent throughout the admission). In controlled analyses, pain was not associated with CMAI scores but was strongly associated with total BEHAVE-AD scores, both when pain was assessed on movement (β = 0.20, 95% confidence interval [CI] = 0.07-0.32, P = 0.002) and at rest (β = 0.41, 95% CI = 0.14-0.69, P = 0.003). The association was the strongest for aggression and anxiety. Pain was common in people with dementia admitted to the acute hospital and associated with BPSD. Improved pain management may reduce distressing behaviours and improve the quality of hospital care for people with dementia.
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How do healthcare workers judge pain in older palliative care patients with delirium near the end of life? Palliat Support Care 2015; 14:151-8. [DOI: 10.1017/s1478951515000929] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:Pain and delirium are commonly reported in older people with advanced cancer. However, assessing pain in this population is challenging, and there is currently no validated assessment tool for this task. The present retrospective cohort study was conducted to understand how healthcare workers (HCWs; nurses and physicians) determine that older cancer patients with delirium are in pain.Method:We reviewed the medical records of consecutive palliative care inpatients, 65 years of age and above (N= 113), in order to identify patient-based cues used by HCWs to make pain judgments and to examine how the cues differ by delirium subtype and outcome.Results:We found that HCWs routinely make judgments about pain in older patients with delirium using a repertoire of strategies that includes patient self-report and observations of spontaneous and evoked behavior. Using these strategies, HCWs judged pain to be highly prevalent in this inpatient palliative care setting.Significance of results:These novel findings will inform the development of valid and reliable tools to assess pain in older cancer patients with delirium.
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Cai FF, Zhang H. Effect of therapeutic touch on agitated behavior in elderly patients with dementia: A review. Int J Nurs Sci 2015. [DOI: 10.1016/j.ijnss.2015.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Baeta-Corral R, Defrin R, Pick CG, Giménez-Llort L. Tail-flick test response in 3×Tg-AD mice at early and advanced stages of disease. Neurosci Lett 2015; 600:158-63. [DOI: 10.1016/j.neulet.2015.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 05/26/2015] [Accepted: 06/02/2015] [Indexed: 12/15/2022]
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Flo E, Gulla C, Husebo BS. Effective pain management in patients with dementia: benefits beyond pain? Drugs Aging 2015; 31:863-71. [PMID: 25373921 DOI: 10.1007/s40266-014-0222-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This current opinion aims to provide a literature overview of the associations between pain and neuropsychiatric symptoms and the efficacy of pain management for both pain and neuropsychiatric symptoms in patients with dementia. In addition, international guidelines and recommendations for pain management have been collated, and important developing research areas are highlighted. Pain is, in general, under-recognized and undertreated in people with dementia and may therefore trigger or exacerbate neuropsychiatric symptoms. While there is an abundance of pain assessment instruments intended for people with dementia, few have been adequately tested for their feasibility, reliability and validity. In patients with dementia, vocalizations, facial expressions and body movements may be the only valid expressions of pain. Further, pain has been related to the neuropsychiatric symptoms of agitation, aggression, mood syndrome and sleep problems. Unfortunately, health personnel may misinterpret these symptoms as neuropsychiatric symptoms of dementia. A differential assessment of dementia, its presenting neuropsychiatric symptoms and the potential presence of pain is crucial to provide the correct treatment. To achieve this, use of pain assessment tools that are responsive to change and are validated for use in patients with dementia is a prerequisite. To date, there have been few studies, with inconsistent findings on the association between pain and neuropsychiatric symptoms. To ensure a better differential assessment of pain and neuropsychiatric symptoms, and consequently more accurate treatment for patients with dementia, studies with adequate statistical power and high-quality study designs, including randomized controlled trials, are needed.
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Affiliation(s)
- Elisabeth Flo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Pbox 7800, 5020, Bergen, Norway,
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Fowler JH, Dannecker K, Stanley M, Wilson N, Snow AL, Kunik ME. Preventing aggression and other secondary features of dementia in elderly persons: Three case studies. Bull Menninger Clin 2015; 79:95-115. [PMID: 26035086 DOI: 10.1521/bumc.2015.79.2.95] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Dementia and Alzheimer's disease are associated with behavioral symptoms that can be costly and troublesome to caregivers. Behavioral strategies to prevent aggression in people with dementia (PWDs) are necessary to decrease caregiver burden and relieve other behavioral disturbances in PWDs, such as depression. On the basis of their previous study that identified pain as a possible cause of aggression, the authors developed a behavioral in-home intervention designed to teach caregiver(s) how to recognize signs of pain and distress in PWDs. The authors present a description of the Preventing Aggression in Veterans with Dementia (PAVeD) intervention and illustrate its use and results with three case studies. Results indicate that this intervention may help prevent the development of aggression and pain in PWDs, reduce caregiver burden, and help manage other behavioral symptoms associated with dementia.
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Affiliation(s)
| | | | | | | | - A Lynn Snow
- 3 Center for Mental Health and Aging, The University of Alabama, and the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama
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Chen YH, Lin LC. The Credibility of Self-reported Pain Among Institutional Older People with Different Degrees of Cognitive Function in Taiwan. Pain Manag Nurs 2015; 16:163-72. [DOI: 10.1016/j.pmn.2014.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 05/29/2014] [Accepted: 05/29/2014] [Indexed: 10/24/2022]
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Abstract
BACKGROUND Agitation is a common experience for people living with dementia, particularly as day-to-day function and cognition start to decline more. At the present time there are limited pharmacological options for relieving agitation and little is known about the safety and efficacy of opioid drugs in this setting. OBJECTIVES To determine the clinical efficacy and safety of opioids for agitation in people with dementia. SEARCH METHODS We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group Specialized Register, on 13 June 2014 using the terms: narcotic OR opioid OR opium OR morphine OR buprenorphine OR codeine OR dextromoramide OR diphenoxylate OR dipipanone OR dextropropoxyphene OR propoxyphene OR diamorphine OR dihydrocodeine OR alfentanil OR fentanyl OR remifentanil OR meptazinol OR methadone OR nalbuphine OR oxycodone OR papaveretum OR pentazocine OR meperidine OR pethidine OR phenazocine OR hydrocodone OR hydromorphone OR levorphanol OR oxymorphone OR butorphanol OR dezocine OR sufentanil OR ketobemidone.ALOIS contains records of clinical trials identified from monthly searches of a number of major healthcare databases such as MEDLINE, EMBASE and PscyINFO, as well as numerous trial registries and grey literature sources. SELECTION CRITERIA Randomised, controlled trials of opioids compared to placebo for agitation in people with dementia. DATA COLLECTION AND ANALYSIS Two authors independently assessed the studies identified by the search against the inclusion criteria. MAIN RESULTS There are currently no completed randomised, placebo controlled trials of opioids for agitation in dementia. There are two potentially relevant trials still in progress. AUTHORS' CONCLUSIONS We found insufficient evidence to establish the clinical efficacy and safety of opioids for agitation in people with dementia. There remains a lack of data to determine if or when opioids either relieve or exacerbate agitation. More evidence is needed to guide the effective, appropriate and safe use of opioids in dementia.
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Affiliation(s)
- Richard Brown
- Kent and Medway NHS Partnership TrustCommunity Mental Health Team for Older PeopleGregory HouseLittlebourne RoadCanterburyKentUKCT1 1TD
| | | | - Bridget Candy
- Marie Curie Palliative Care Research Department, UCL Division of PsychiatryCharles Bell House67 ‐ 73 Riding House StreetLondonUKW1W 7EJ
| | - Elizabeth L Sampson
- UCL Division of PsychiatryMarie Curie Palliative Care Research DepartmentCharles Bell House67‐73 Riding House StreetLondonUKW1W 7EJ
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Hendriks SA, Smalbrugge M, Galindo-Garre F, Hertogh CMPM, van der Steen JT. From admission to death: prevalence and course of pain, agitation, and shortness of breath, and treatment of these symptoms in nursing home residents with dementia. J Am Med Dir Assoc 2015; 16:475-81. [PMID: 25736822 DOI: 10.1016/j.jamda.2014.12.016] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/18/2014] [Accepted: 12/19/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Burdensome symptoms frequently develop as part of the dementia trajectory and influence quality of life. We explore the course of symptoms and their treatment during nursing home stay to help target adequate symptom management. DESIGN Data were collected as part of the Dutch End of Life in Dementia study, a longitudinal observational study with up to 3.5 years of follow-up. Physicians performed assessments at baseline, semiannually, and shortly after death of pain, agitation, shortness of breath, and treatment provided for these symptoms. SETTING Long-term care facilities (28) in the Netherlands. PARTICIPANTS Newly admitted nursing home residents (372) in variable stages of dementia. MEASUREMENTS We described prevalence and course of symptoms, and treatment provided for these symptoms. We used generalized estimating equations to evaluate the longitudinal change in symptoms and their treatment, and the associations between the symptoms of pain and agitation, as well as between stage of dementia and symptoms. RESULTS Pain was common (varying from 47% to 68% across the semiannual assessments) and frequently persistent (36%-41% of all residents); it increased to 78% in the last week of life. Agitation was the most common symptom (57%-71%), and also frequently persistent (39%-53%), yet it decreased to 35% in the last week of life. Shortness of breath was less common (16%-26%), but it increased to 52% at the end of life. Pain was not significantly associated with agitation. Advanced dementia was associated with more pain only. Treatment changed in particular at the end of life. Pain was treated mostly with acetaminophen (34%-52%), and at the end of life with parenteral opioids (44%). Agitation was mostly treated nonpharmacologically (78%-92%), and at the end of life anxiolytics were the most frequently prescribed treatment (62%). Overall, aerosolized bronchodilators were the most frequently prescribed treatment for shortness of breath (29%-67%), but at the end of life, this was morphine (69%). CONCLUSION Pain and agitation were common and frequently persisted in residents with dementia during nursing home stay, but symptom management intensified only at the end of life. Symptom control may be suboptimal from admission, and a stronger focus on symptom control is needed at an earlier stage than the end of life.
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Affiliation(s)
- Simone A Hendriks
- Department of General Practice and Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Martin Smalbrugge
- Department of General Practice and Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Francisca Galindo-Garre
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of General Practice and Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Jenny T van der Steen
- Department of General Practice and Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
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Mjørud M, Kirkevold M, Røsvik J, Engedal K. Principal component analysis of the Norwegian version of the quality of life in late-stage dementia scale. Dement Geriatr Cogn Disord 2015; 37:265-75. [PMID: 24356496 DOI: 10.1159/000356497] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2013] [Indexed: 11/19/2022] Open
Abstract
AIMS To investigate which factors the Quality of Life in Late-Stage Dementia (QUALID) scale holds when used among people with dementia (pwd) in nursing homes and to find out how the symptom load varies across the different severity levels of dementia. METHODS We included 661 pwd [mean age ± SD, 85.3 ± 8.6 years; 71.4% women]. The QUALID and the Clinical Dementia Rating (CDR) scale were applied. A principal component analysis (PCA) with varimax rotation and Kaiser normalization was applied to test the factor structure. Nonparametric analyses were applied to examine differences of symptom load across the three CDR groups. RESULTS The mean QUALID score was 21.5 (±7.1), and the CDR scores of the three groups were 1 in 22.5%, 2 in 33.6% and 3 in 43.9%. The results of the statistical measures employed were the following: Crohnbach's α of QUALID, 0.74; Bartlett's test of sphericity, p <0.001; the Kaiser-Meyer-Olkin measure, 0.77. The PCA analysis resulted in three components accounting for 53% of the variance. The first component was 'tension' ('facial expression of discomfort', 'appears physically uncomfortable', 'verbalization suggests discomfort', 'being irritable and aggressive', 'appears calm', Crohnbach's α = 0.69), the second was 'well-being' ('smiles', 'enjoys eating', 'enjoys touching/being touched', 'enjoys social interaction', Crohnbach's α = 0.62) and the third was 'sadness' ('appears sad', 'cries', 'facial expression of discomfort', Crohnbach's α 0.65). The mean score on the components 'tension' and 'well-being' increased significantly with increasing severity levels of dementia. CONCLUSION Three components of quality of life (qol) were identified. Qol decreased with increasing severity of dementia.
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Affiliation(s)
- Marit Mjørud
- Norwegian Centre for Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
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Takai Y, Yamamoto-Mitani N, Abe Y, Suzuki M. Literature review of pain management for people with chronic pain. Jpn J Nurs Sci 2014; 12:167-83. [DOI: 10.1111/jjns.12065] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 09/16/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Yukari Takai
- Department of Adult Nursing/Palliative Care Nursing; Division of Health Sciences and Nursing; Graduate School of Medicine; the University of Tokyo; Tokyo Ibaraki Japan
| | - Noriko Yamamoto-Mitani
- Department of Adult Nursing/Palliative Care Nursing; Division of Health Sciences and Nursing; Graduate School of Medicine; the University of Tokyo; Tokyo Ibaraki Japan
| | - Yoshiki Abe
- School of Nursing; University of Tsukuba; Tsukuba Ibaraki Japan
| | - Mizue Suzuki
- Faculty of Nursing; Hamamatsu University School of Medicine; Hamamatsu Sizuoka Japan
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Husebo BS, Ostelo R, Strand LI. The MOBID-2 pain scale: reliability and responsiveness to pain in patients with dementia. Eur J Pain 2014; 18:1419-30. [PMID: 24799157 PMCID: PMC4230478 DOI: 10.1002/ejp.507] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) pain scale is a staff-administered pain tool for patients with dementia. This study explores MOBID-2's test-retest reliability, measurement error and responsiveness to change. METHODS Analyses are based upon data from a cluster randomized trial including 352 patients with advanced dementia from 18 Norwegian nursing homes. Test-retest reliability between baseline and week 2 (n = 163), and weeks 2 and 4 (n = 159) was examined in patients not expected to change (controls), using intraclass correlation coefficient (ICC2.1 ), standard error of measurement (SEM) and smallest detectable change (SDC). Responsiveness was examined by testing six priori-formulated hypotheses about the association between change scores on MOBID-2 and other outcome measures. RESULTS ICCs of the total MOBID-2 scores were 0.81 (0-2 weeks) and 0.85 (2-4 weeks). SEM and SDC were 1.9 and 3.1 (0-2 weeks) and 1.4 and 2.3 (2-4 weeks), respectively. Five out of six hypotheses were confirmed: MOBID-2 discriminated (p < 0.001) between change in patients with and without a stepwise protocol for treatment of pain (SPTP). Moderate association (r = 0.35) was demonstrated with Cohen-Mansfield Agitation Inventory, and no association with Mini-Mental State Examination, Functional Assessment Staging and Activity of Daily Living. Expected associations between change scores of MOBID-2 and Neuropsychiatric Inventory - Nursing Home version were not confirmed. CONCLUSION The SEM and SDC in connection with the MOBID-2 pain scale indicate that the instrument is responsive to a decrease in pain after a SPTP. Satisfactory test-retest reliability across test periods was demonstrated. Change scores ≥ 3 on total and subscales are clinically relevant and are beyond measurement error.
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Affiliation(s)
- B S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Norway; Centre for Age-Related Medicine, Stavanger University Hospital, Norway
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Drageset J, Corbett A, Selbaek G, Husebo BS. Cancer-related pain and symptoms among nursing home residents: a systematic review. J Pain Symptom Manage 2014; 48:699-710.e1. [PMID: 24703946 DOI: 10.1016/j.jpainsymman.2013.12.238] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 12/14/2013] [Accepted: 12/19/2013] [Indexed: 11/28/2022]
Abstract
CONTEXT Many older nursing home (NH) residents with cancer experience pain and distressing symptoms. Although some develop cancer during their time in the institution, an increasing number are admitted during their final stages of their lives. Numerous studies have evaluated various treatment approaches, but how pain and symptoms are assessed and managed in people with cancer with and without dementia is unclear. OBJECTIVES The objective of this review was to summarize the evidence on cancer-related symptoms among NH residents with and without dementia. METHODS We systematically searched the PubMed (1946-2012), Embase (1974-2012), CINAHL (1981-2012), AgeLine, and Cochrane Library (1998-2012) databases using the search terms neoplasms, cancer, tumor, and nursing home. The inclusion criteria were studies including NH residents with a diagnosis of cancer and outcome measures including pain and cancer-related symptoms. RESULTS We identified 11 studies (cross-sectional, longitudinal, clinical trial, and qualitative studies). Ten studies investigated the prevalence and treatment of cancer-related symptoms such as vomiting, nausea, urinary tract infections, and depression. Studies clearly report a high prevalence of pain and reduced prescribing and treatment, regardless of the cognitive status. Only one small study included people with cancer and a diagnosis of dementia. Studies of new cancer diagnoses in NHs could not be identified. CONCLUSION This review clearly reports a high prevalence of pain and reduced drug prescribing and treatment among NH residents with cancer. This issue appears to be most critical among people with severe dementia, emphasizing the need for better guidance and evidence on pain assessment for these individuals.
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Affiliation(s)
- Jorunn Drageset
- Faculty for Health and Social Science, Bergen University College, Bergen, Norway; Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.
| | - Anne Corbett
- Wolfson Centre for Age-Related Diseases, King's College London, London, United Kingdom
| | - Geir Selbaek
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway; Akershus University Hospital, Lørenskog, Norway
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway; Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
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The response of agitated behavior to pain management in persons with dementia. Am J Geriatr Psychiatry 2014; 22:708-17. [PMID: 23611363 DOI: 10.1016/j.jagp.2012.12.006] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 12/08/2012] [Accepted: 12/12/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Behavioral disturbances and pain are common in nursing home (NH) patients with dementia. An association between pain and increased agitation has been suggested, and recently a significant reduction of agitation has been demonstrated by pain treatment in patients with moderate to severe dementia. We now examined which specific agitated behaviors respond to individualized pain treatment. DESIGN Cluster randomized clinical trial. SETTING 60 clusters (i.e., clusters defined as single independent NH units) in 18 NHs within five municipalities of Western Norway. PARTICIPANTS 352 patients with moderate to severe dementia and clinically significant behavioral disturbances. INTERVENTION The control group received usual treatment and care. According to a predefined scheme for 8 weeks, all patients in the intervention group received individual daily pain treatment with acetaminophen, extended release morphine, buprenorphine transdermal patch, and/or pregabaline. MEASUREMENTS Cohen-Mansfield Agitation Inventory subscales and items. RESULTS Analyses demonstrated that Factor 3 (Verbally agitated behaviors) showed the largest significant difference (DF = 1204.0, t = -4.308, p <0.001), followed by Factor 2 (Physically non-aggressive behaviors) (DF = 1198.0, t = -2.672, p = 0.008), and Factor 1 (Aggressive behaviors) (DF = 1196.0, t = -2.093, p = 0.037) after 8 weeks, by a linear random intercept mixed model in two-way repeated-measures configuration with adjustment for heteroscedasticity. CONCLUSION We found that verbal agitation behaviors such as complaining, negativism, repetitious sentences and questions, constant request for attention, and cursing or verbal aggression responded to pain treatment. In addition, restlessness and pacing were sensible to analgesics. Such behaviors should therefore lead to an assessment of pain, and pain treatment. Further studies comparing how pain treatment should be balanced against other strategies including psychotropic drugs are needed.
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Chen YH, Lin LC, Chen KB, Liu YC. Validation of a causal model of agitation among institutionalized residents with dementia in Taiwan. Res Nurs Health 2014; 37:11-20. [PMID: 24414938 DOI: 10.1002/nur.21573] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2013] [Indexed: 12/21/2022]
Abstract
The aim of this study was to test a causal model of the predictors of agitation among 405 nursing home residents in Taiwan with varying degrees of cognitive impairment. Chart review and behavioral observations were used to assess residents' physical and psychosocial condition. The final version of the model had a good fit. Cognitive function and depression had direct effects on agitation, and pain and functional ability had indirect effects on agitation via depression. Additionally, cognitive function and pain influenced functional ability directly, which in turn influenced depression and ultimately influenced agitation. The results suggest that effective management of agitation in demented residents requires identifying the needs underlying the behavior rather than directly treating the behavior itself.
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Affiliation(s)
- Yi-Heng Chen
- School of Nursing, Mackay Medical College, New Taipei, Taiwan, ROC
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Rantala M, Kankkunen P, Kvist T, Hartikainen S. Barriers to Postoperative Pain Management in Hip Fracture Patients with Dementia as Evaluated by Nursing Staff. Pain Manag Nurs 2014; 15:208-19. [DOI: 10.1016/j.pmn.2012.08.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 08/17/2012] [Accepted: 08/17/2012] [Indexed: 10/27/2022]
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