Prescription analgesia and adjuvant use by pain severity at admission among nursing home residents with non-malignant pain

Global prevalence of mild cognitive impairment among older adults living in nursing homes: a meta-analysis and systematic review of epidemiological surveys

Mild cognitive impairment (MCI) is the early stage of cognitive impairment between the expected cognitive decline of normal aging and the more serious decline of dementia. This meta-analysis and systematic review explored the pooled global prevalence of MCI among older adults living in nursing homes and its relevant factors. The review protocol was registered in INPLASY (INPLASY202250098). PubMed, Web of Science, Embase, PsycINFO, and CINAHL databases were systematically searched from their respective inception dates to 8 January 2022. The inclusion criteria were made based on the PICOS acronym, as follows: Participants (P): Older adults living in nursing homes; Intervention (I): not applicable; Comparison (C): not applicable; Outcome (O): prevalence of MCI or the data can generate the prevalence of MCI according to study-defined criteria; Study design (S): cohort studies (only baseline data were extracted) and cross-sectional studies with accessible data published in a peer-reviewed journal. Studies involving mixed resources, reviews, systematic reviews, meta-analyses, case studies, and commentaries were excluded. Data analyses were performed using Stata Version 15.0. Random effects model was used to synthesize the overall prevalence of MCI. An 8-item instrument for epidemiological studies was used to assess the quality of included studies. A total of 53 articles were included involving 376,039 participants with a mean age ranging from 64.42 to 86.90 years from 17 countries. The pooled prevalence of MCI in older adults in nursing homes was 21.2% (95% CI: 18.7-23.6%). Subgroup and meta-regression analyses revealed that the screening tools used were significantly associated with MCI prevalence. Studies using the Montreal Cognitive Assessment (49.8%) had a higher prevalence of MCI than those using other instruments. No significant publication bias was found. Several limitations warrant attention in this study; for example, significant heterogeneity between studies remained and some factors associated with the prevalence of MCI were not examined due to insufficient data. Adequate screening measures and allocation of resources are needed to address the high global prevalence of MCI among older adults living in nursing homes.

Pain Impacting Quality of Life in Persons with Dementia Dying in the Nursing Home by Alternative Medicare Payment Model

Background: Medicare alternative payment models were created to improve health care value by controlling costs and improving care quality. Objective: To determine if prevalence of pain affecting quality of life (QoL) differs by Medicare payment model among nursing home (NH) decedents with dementia at the end of life. Setting/Subjects: NH decedents in 2017/2018 in the United States with dementia who self-reported pain on a Minimum Data Set assessment in the last 30 days of life. Measurements: Main outcome was pain impacting QoL (i.e., affecting day-to-day activities or sleep). Multivariable logistic analysis examined the association between payment model (traditional Medicare [TM], Medicare Advantage [MA], or accountable care organizations [ACOs]) and pain impacting QoL after controlling for potential confounders. Results: There were 115,757 NH residents with dementia who self-reported pain in the last 30 days of life. Of those, 17.8% (n = 20,585) reported having pain the last five days from assessment, which varied by Medicare payment model (17.7% in TM, 17.5% in MA, and 19.1% in ACOs; p < 0.001). Among decedents reporting pain, 23.6% of ACO decedents reported pain affecting QoL compared to 22.1% in MA and 21.6% in TM (p = 0.09). After adjustment, decedents in ACOs compared to TM had greater predicted probability of pain affecting QoL (absolute marginal difference 0.017, 95% CI 0.00-0.035, p = 0.05), and persons in MA did not differ from persons in TM (absolute marginal difference 0.005, 95% CI -0.008 to 0.019, p = 0.41). Conclusions and Implications: Among dementia decedents dying with pain, pain impacted QoL in more than one in five persons. All payment models can improve pain management.

Correlates of Opioid Use Among Ontario Long-Term Care Residents and Variation by Pain Frequency and Intensity: A Cross-sectional Analysis

Background

Chronic non-cancer pain is common among older residents of long-term care (LTC) homes and often poorly recognized and treated. With heightened concerns regarding opioid prescribing in recent years, it is important to examine the current prevalence of opioid use and its association with resident characteristics to help identify those potentially at risk of medication harms as well as suboptimal pain management.

Objectives

The aims were to estimate the prevalence and correlates of opioid use among non-palliative LTC residents and explore variation in opioid prevalence and correlates across strata defined by pain frequency and intensity.

Methods

We conducted a population-based cross-sectional study of all older (aged > 65 years) LTC residents (excluding those with cancer or receiving palliative care) in Ontario, Canada during 2018–2019. Health administrative databases were linked with standardized clinical assessment data to ascertain residents’ health and pain characteristics and their opioid and other medication use. Modified Poisson regression models estimated unadjusted and adjusted associations between residents’ characteristics and opioid use, overall and across strata capturing pain frequency and intensity.

Results

Among 75,020 eligible residents (mean age 85.1 years; 70% female), the prevalence of opioid use was 18.5% and pain was 29.4%. Opioid use ranged from 12.2% for residents with no current pain to 55.7% for those with severe pain. In adjusted models, residents newly admitted to LTC (adjusted risk ratio [aRR] = 0.60, 95% confidence interval [CI] 0.57–0.62) and with moderate to severe cognitive impairment (aRR = 0.69, 95% CI 0.66–0.72) or dementia (aRR = 0.76, 95% CI 0.74–0.79) were significantly less likely to receive an opioid, whereas residents with select conditions (e.g., arthritis, aRR = 1.37, 95% CI 1.32–1.41) and concurrently using gabapentinoids (aRR = 1.80, 95% CI 1.74–1.86), benzodiazepines (aRR = 1.33, 95% CI 1.28–1.38), or antidepressants (aRR = 1.31, 95% CI 1.27–1.35) were significantly more likely to receive an opioid. The associations observed for residents newly admitted, with dementia, and concurrently using gabapentinoids, benzodiazepines, or antidepressants were largely consistent across all pain strata.

Conclusions

Our findings describe resident sub-groups at potentially higher risk of adverse health outcomes in relation to both opioid use and non-use. LTC clinical and policy changes informed by research are required to ensure the appropriate recognition and management of non-cancer pain in this setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-022-00972-9.

Clinical Observation of MRI Scanning Combined with Clinical Nursing for Surgical Breast Cancer Patients

The aim of this study was to explore the application effect of perioperative nursing care for patients with breast cancer. In this paper, 100 breast cancer patients with lymphatic spread treated by breast surgery in September 2019 to December were selected as the evaluation objects. They were divided into two groups according to preoperative imaging examination, 50 cases in each group. Group A was examined by B-ultrasound before axillary lymphadenectomy, group B was examined by MRI before axillary lymphadenectomy, and group C was examined by B-ultrasound and MRI before axillary lymphadenectomy. The facts in the three groups of disease findings were compared. Compared with the control group, the proportion of negative emotions (such as stress and depression) in the control group decreased (P<0.05). The decrease in blood cortisol was higher than in the control group (P < 0.05). Improving the existing cancer surgery can improve the patient's heart rate and reduce blood cortisol so as to improve the patient's joint function and quality of life. The difficulty of nursing patients will also be reduced, which is medically necessary.

Priority-Setting to Address the Geriatric Pharmacoparadox for Pain Management: A Nursing Home Stakeholder Delphi Study

BACKGROUND

Evidence to guide clinical decision making for pain management in nursing home residents is scant.

OBJECTIVE

Our objective was to explore the extent of consensus among expert stakeholders regarding what analgesic issues should be prioritized for comparative-effectiveness studies of beneficial and adverse effects of analgesic regimens in nursing home residents.

METHODS

Two stakeholder panels (nurses only and a mix of clinicians/researchers) were engaged (n = 83). During a three-round online modified Delphi process, participants rated and commented on the need for new evidence on nonopioid analgesic regimens and opioid regimens, short-term adverse effects, long-term adverse effects, comorbid conditions, and other factors in the nursing home setting (9-point scale; 1 = not essential to 9 = very essential to obtain new evidence). The quantitative data were analyzed to determine the existence of consensus using an approach from the RAND/UCLA Appropriateness Method User's Manual. The qualitative data, consisting of participant explanations of their numeric ratings, were thematically analyzed by an experienced qualitative researcher.

RESULTS

For nursing home residents, evidence generation was deemed essential for opioids, gabapentin (alone or with serotonin norepinephrine reuptake inhibitors [SNRIs]), and nonsteroid anti-inflammatory drugs with SNRIs. Experts prioritized the following outcomes as essential: long-term adverse effects, including delirium, cognitive decline, and decline in activities of daily living (ADLs). Kidney disease and depression were deemed essential conditions to consider in studies of pain medications. Coprescribing analgesic regimens with benzodiazepines, sedating medications, serotonergic medications, and non-SNRI antidepressants were considered essential areas of study. Experts noted that additional study was essential in residents with moderate/severe cognitive impairment and limitations in ADLs.

CONCLUSIONS

Stakeholder priorities for more evidence reflect concerns related to treating medically complex residents with complex drug regimens and included long-term adverse effects, coprescribing, and sedating medications. Carefully conducted observational studies are needed to address the vast evidence gap for nursing home residents.