Prevalence and Predictors of Symptoms in Persons with Advanced Dementia Living in the Community

End-of-Life Symptoms in Persons Dying With Advanced Dementia in the Community Setting: Findings From IN-PEACE

CONTEXT

The symptom burden in persons dying with advanced dementia outside long-term care facilities has not been well studied.

OBJECTIVES

To determine the symptom burden in persons dying with advanced dementia in the community setting.

METHODS

The sample consisted of patient-caregiver dyads enrolled in the 24-month IN-PEACE trial of home-based care management for advanced dementia. Postmortem interviews were administered to caregivers of persons with advanced dementia who had recently died. The primary outcome was the Comfort Assessment in Dying-End of Life in Dementia (CAD-EOLD) scale. A secondary symptom measure was the Symptom Management in End of Life Dementia (SM-EOLD). Results were analyzed and compared to previous studies using the CAD-EOLD.

RESULTS

Of the 83 persons with dementia who died during 24 months of follow-up, postmortem caregiver interviews were completed in 80 cases of which 79 completed the CAD-EOLD. Patients' mean age was 83.1; 68% were women, 57% white, and 37% African American. Most patients (62%) died at home and only 32% died in a hospital or nursing home. Hospice enrollment occurred in 75% of participants. Symptom management as reflected in CAD-EOLD scores was comparable to previous studies of persons with dementia dying in nursing homes. Compared to baseline SM-EOLD scores, end-of-life symptom scores were 4 points better. Intervention and control group outcomes were similar.

CONCLUSIONS

Some community-dwelling persons with advanced dementia can die at home with symptom management comparable to that received in nursing homes.

A Psychometric Evaluation of the Staff-Reported EOLD-CAD Measure Among Nursing Home Residents With Cognitive Impairment

OBJECTIVES

The End-of-Life Dementia-Comfort Assessment in Dying (EOLD-CAD) scale is one of the few outcome instruments designed to capture symptom burden and well-being among nursing home residents with dementia; however, psychometric evaluations of the EOLD-CAD are limited. Although the instrument is often used to assess outcomes prospectively, it was originally developed and tested as a postmortem assessment. The purpose of this study is to evaluate the instrument properties of the EOLD-CAD using staff reports from a large sample of nursing home residents with cognitive impairment prior to death.

METHODS

Using data from the multi-state UPLIFT clinical trial, this study evaluated the psychometric properties of the EOLD-CAD from 168 nursing home staff members reporting outcomes for 611 living residents with moderate to severe cognitive impairment. Staff also reported on resident quality-of-life using two different single item measures. We conducted confirmatory factor analysis (CFA) and assessed construct validity, inter-item reliability, and observer report bias.

RESULTS

CFA produced a four-factor solution. All factor loadings were > 0.40, ranging from 0.61-0.95 for Physical Distress, 0.71-0.91 for Dying Symptoms, 0.61-0.78 for Emotional Distress, and 0.89-0.94 for Well-Being. Model indices suggest a good fit to the data with root mean square error of approximation (RMSEA) = 0.053 (95% CI = (0.044, 0.062)), comparative fit index (CFI) = 0.971, and standardized root mean square residual (SRMR) = 0.093, with the SRMR slightly above the conventional threshold of > 0.08. Based on intraclass correlation coefficients (ICC), patterns of observer reports were identified among staff who provided data for multiple residents. ICCs were notably high (> 0.60) for Well-Being items. The EOLD-CAD elicited a Cronbach's alpha of 0.73, and the instrument was negatively correlated with items measuring resident quality of life.

CONCLUSIONS

We found that when the EOLD-CAD was completed by nursing home staff familiar with the respective residents, observer-based patterns were detectable. Such patterns were adjusted for in our CFA, from we found that the EOLD-CAD exhibited multidimensionality with a four-factor structure capturing: Physical Distress, Emotional Distress, Dying Symptoms, and Well-Being. In addition to the CFA, the EOLD-CAD demonstrated generally valid and reliable psychometric properties in our population of long-stay nursing home residents with moderate to severe cognitive impairment.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04520698.

Risk Factors Profile in Dementia Patients at a Tertiary Care Hospital in Nepal: A Cross-Sectional Study

Dementia is attributable to 12 known risk factors in 40% cases. This study aimed to assess the prevalence of defined risk factors among people living with dementia. 174 patients with dementia and caregivers were interviewed using semi-structured pro forma, risk factors provided by the Lancet Commission on Dementia (2020), and Dementia Severity Rating Scale (DSRS). The prevalence of 11 known risk factors and associations between the risk factors and dementia severity were assessed. The mean age of the participants was 73.9 years (SD = 8.34 years). The education below intermediate level was 83.3%, 17.8% had hearing loss, 37.9% had hypertension, 24.1% had diabetes, 25.9% and 55.2% had alcohol and nicotine harmful use respectively and 8% had a history of traumatic brain injury and obesity each. There is a substantial prevalence of risk factors among people living with dementia in Nepal but no associations between any of the risk factors and dementia severity.

Empowering informal caregivers and nurses to take a person-centred view: adaptation and clinical utility of the Integrated Palliative Outcome Scale (IPOS-Dem) for use in acute and community care settings

BACKGROUND

Dementia is a progressive and terminal illness. Symptoms are present for people with dementia across all stages, leading to poor quality of life and considerable carer burden. In acute and community care services, no holistic, person-centred outcome tools are available for nurses and informal caregivers to measure symptoms and needs from the person`s with dementia point of view. We therefore undertook validation (exploring semantic/conceptual equivalence, content validity, and views on clinical utility) for a measure (IPOS-Dem) in the community and acute care setting in Switzerland.

METHODS

This was a rigorous, multi-step, cross-sectional, multi-method study conducted with nurses and relatives caring for people with dementia in the community and acute care setting. Multiple components were aligned: 1) forward and backward translation from German to Swiss German to achieve semantic equivalence; 2) focus groups to explore clinical utility and conceptual equivalence; 3) cognitive debriefing to review content validity. An expert review was included at the end of each phase.

RESULTS

Six people from the public and 24 nurses/relatives were included. Semantic equivalence was achieved after making 14 changes to the wording of items. Participants judged the IPOS-Dem (CH) as a clinically useful intervention in the domains of appropriateness, accessibility, practicability, and acceptability for the following reasons: (1) it enables support for informal caregivers, (2) it provides an overview of the priorities of care, thus supporting symptom review, (3) it allows nurses with different qualifications to contribute critical observations, thus fostering communication and teamwork, and (4) it increases an awareness of change in symptoms throughout the disease trajectory. In the cognitive debriefing interviews, setting and respondent-dependent differences in the conceptual understanding of item descriptors were observed for 11 of 31 items.

CONCLUSION

In this novel work, we demonstrate the newly-translated and culturally-adapted IPOS-Dem (CH) is a relevant and comprehensive measure for persons with mild to severe dementia. It can aid a generalist workforce across settings to assess palliative care-relevant symptoms and concerns.

Pain prevalence and pain relief in end-of-life care - a national registry study

BACKGROUND

Despite pain control being a top priority in end-of-life care, pain continues to be a troublesome symptom and comprehensive data on pain prevalence and pain relief in patients with different diagnoses are scarce.

METHODS

The Swedish Register of Palliative Care (SRPC) was used to retrieve data from 2011 to 2022 about pain during the last week of life. Data were collected regarding occurrence of pain, whether pain was relieved and occurrence of severe pain, to examine if pain differed between patients with cancer, heart failure, chronic obstructive pulmonary disease (COPD) and dementia. Binary logistic regression models adjusted for sex and age were used.

RESULTS

A total of 315 000 patients were included in the study. Pain during the last week of life was more commonly seen in cancer (81%) than in dementia (69%), heart failure (68%) or COPD (57%), also when controlled for age and sex, p < 0.001. Severe forms of pain were registered in 35% in patients with cancer, and in 17-21% in non-cancer patients. Complete pain relief (regardless of pain intensity) was achieved in 73-87% of those who experienced pain, depending on diagnosis. The proportion of patients with complete or partial pain relief was 99.8% for the whole group.

CONCLUSIONS

The occurrence of pain, including severe pain, was less common in patients with heart failure, COPD or dementia, compared to patients with cancer. Compared with cancer, pain was more often fully relieved for patients with dementia, but less often in heart failure and COPD. As severe pain was seen in about a third of the cancer patients, the study still underlines the need for better pain management in the imminently dying.

TRIAL REGISTRATION

No trial registration was made as all patients were deceased and all data were retrieved from The Swedish Register of Palliative Care database.

Are nurse`s needs assessment methods robust enough to recognise palliative care needs in people with dementia? A scoping review

BACKGROUND

People with dementia are most at risk of experiencing serious health related suffering, if they do not have a palliative care approach introduced early enough in the illness. It can be challenging for nurses to assess experienced needs of people, who are thought no longer able to self-report such as people with dementia. Assessment help to understand the care the patient and their family need promptly. It is unknown how nurses recognise holistic palliative care needs in people with dementia during routine care.

METHODS

Scoping review where EMBASE, MEDLINE, CINAHL, PsycInfo databases, and references were searched with an advanced search strategy, which was built on three concepts (nurses, dementia, and nursing assessment) using corresponding Medical Subject Headings. Data were charted in a piloted extraction form, based on the assessment domains within the nursing process followed by summarise and synthesise results narratively.

RESULTS

37 out of 2,028 qualitative and quantitative articles published between 2000 and 2021, and relating to 2600 + nurses, were identified. Pain was sole focus of assessment in 29 articles, leaving 8 articles to describe assessment of additional needs (e.g., discomfort). Nurses working in a nursing home assess pain and other needs by observing the persons with dementia behaviour during routine care. Nurses in the acute care setting are more likely to assess symptoms with standard assessment tools at admission and evaluate symptoms by observational methods. Across settings, about one third of pain assessments are supported by person-centred pain assessment tools. Assessments were mostly triggered when the person with dementia vocalised discomfort or a change in usual behaviour was observed. Nurses rely on family members and colleagues to gain more information about needs experienced by people with dementia.

CONCLUSION

There is a scarcity of evidence about techniques and methods used by nurses to assess needs other than pain experienced by people with dementia. A holistic, person-centred screening tool to aid real-time observations at the bedside and used in conversations with health care professionals and families/friends, may improve need recognition other than pain, to ensure holistic needs could then be addressed timely to improve care in people with dementia.