Daily Pain That Was Excruciating at Some Time in the Previous Week: Prevalence, Characteristics, and Outcomes in Nursing Home Residents

Pressure injury pain over time among nursing home residents. Geriatr Nurs 2024;59:362-371. [PMID: 39127012 DOI: 10.1016/j.gerinurse.2024.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

OBJECTIVE

Examine pressure injury (PrI) pain severity, stability, and current treatment of PrI pain among nursing home (NH) residents using two assessment tools and a descriptive cohort study design.

BACKGROUND

PrI pain affects quality of life of NH residents yet, best assessment methods, stability of PrI pain, and how to take care of the pain are not well known.

METHODS

Data collected from 33 residents with PrI (stages 1-4) from 4 NHs. All PrI were staged and assessed using the Bates-Jensen Wound Assessment Tool (BWAT) to determine severity. Verbal Response Scale (VRS) and Pain Assessment in Advanced Dementia (PAINAD) were used to assess general and PrI pain 3 times a day for two days within one week. Data classified as: no, mild, moderate, or severe pain. Proportions of participants with different levels of PrI pain were calculated. T tests were conducted to examine differences across time; VRS and PAINAD were examined for agreement.

RESULTS

Participants were 74 % female, 49 % white, 58 % cognitively intact, 58 % functionally dependent, and had mean age of 82 years old. The majority (52 %; n = 17) were full thickness PrI, stage 3 (n = 5), stage 4 (n = 7), unstageable (n = 5). The majority of participants (82 %; n = 27) reported PrI pain on at least one of six assessments over the two days; with 57 % mild, 26 % moderate and 16 % severe pain. More severe pain occurred in afternoon. No differences existed across days. Although there was a positive relationship between VRS and PAINAD in pain assessments (r = 0.38, P<.05), the agreement between the two scales, as indicated by Cohen's kappa (K = 0.19, p=.28), was found to be poor. Of those with PrI pain, 22 % had pain documented in the Minimum Data Set (MDS). Only 42 % of participants who reported PrI pain received pain medication within 12 h of initial pain assessment. Out of 28 participants who received routine pain medication for general pain, 18 of them reported experiencing no pain.

CONCLUSION

While VRS and PAINAD scores exhibited a relationship, their agreement was limited. Documentation of PrI pain on the Minimum Data Set (MDS) was found to be inadequate. Notably, 40 % of participants reported higher levels of PrI pain in the afternoon, suggesting this time may be opportune for PrI pain assessment and management. Interestingly, participants who received medication for general pain did not report PrI pain, suggesting that treatment of general pain may effectively alleviate PrI pain symptoms.

Comparative Analysis of Palliative Care Needs Identified in Inpatient Rehabilitation and Skilled Nursing Facilities by Multidisciplinary Team Members

OBJECTIVE

Assess access to, need for, and beliefs surrounding specialized palliative care (PC).

DESIGN

Observational, comparative analysis needs assessment survey.

SETTING

Four inpatient rehabilitation facilities (IRFs) or skilled nursing facilities with long-term care (SNFs/LTC) that provide subacute rehabilitation within 1 tertiary care system.

PARTICIPANTS

Allied health professionals, physicians, nursing, case managers, social workers, spiritual care (n=198).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Frequency of patient needs, attitudes about current systems, individual beliefs, and barriers to PC. Confidence in management, communicating, and navigating primary PC competencies among clinical pathway employees.

RESULTS

Of 198 respondents, 37% said PC was available at their facility. Those in IRF reported higher frequencies of grief/unmet spiritual needs of patients compared with SNF/LTC (P≤.001). Conversely, SNF/LTC reported higher frequencies of agitation, poor appetite, and end-of-life care (P≤.003). Respondents in SNF/LTC felt more confident managing end-of-life care, explaining what hospice and PC are and appropriateness for referral to each, discussing advance directives, determining appropriate decision-makers, and navigating ethical decisions than in IRFs (P≤.007). SNF/LTC participants reported higher effectiveness of their current system involving PC and ease of hospice transition compared with IRFs (P≤.008). A majority agreed that PC does not take away patient hope, could prevent recurrent hospitalizations, improve symptom management, communication, and patient and family satisfaction. The most common reported barriers to PC consultation were (1) attitudes and beliefs of staff or patients and families, (2) system issues with access, cost, or prognosis communication, and (3) lack of understanding of PC role.

CONCLUSIONS

A gap exists in PC access in IRF and SNF/LTC despite patient needs and staff beliefs. Future studies should focus on identifying which patients should be referred to PC in the post-acute setting and what outcomes can be used as a guide to meet the needs of this growing area of practice.

Development and testing of a standardized pain interview assessment for use in post-acute care

OBJECTIVES

Pain is highly prevalent among patients in post-acute care (PAC) settings and can affect quality of life, treatment outcomes, and transitions in care. Routine, accurate assessment of pain across settings is important for pain management and care planning; however, existing PAC assessment instruments do not assess patient pain in a standardized manner.

METHODS

We developed and tested a set of pain interview data elements for use across PAC settings (skilled nursing facilities, inpatient rehabilitation facilities, long term care hospitals, home health agencies) as part of a larger effort undertaken by the Centers for Medicare & Medicaid Services to develop standardized assessment data elements to meet the requirements of the IMPACT Act of 2014. The interview assessed six pain constructs: presence; frequency; interference with sleep; interference with rehabilitation therapies [if applicable]; interference with daily activities; worst pain; and pain relief from treatments/medications). A total of 3031 PAC patients at 143 PAC settings (across 14 U.S. geographic/metropolitan areas in 10 states) participated in a national field test of standardized data elements from November 2017 to August 2018. We assessed item response distributions, time to complete interviews, inter-assessor agreement, and, for a subset of patients, change in responses between admission and discharge assessments. We also conducted focus groups with nurse assessors about their experiences administering the items.

RESULTS

For patients reporting any pain, average time to complete the pain interview was 3.1 min (SD = 1.3), and interrater reliability was excellent for all data elements (kappa range: 0.95-0.99). Findings were similar across types of PAC settings. Qualitative data from nurses emphasized ease of administration and high perceived clinical utility.

CONCLUSION

Findings provide support for feasibility of implementing a standardized pain interview assessment in PAC settings. This tool can support tracking of patient needs across settings and interoperability of data in electronic medical records.

Legalization of Medical Cannabis and Site of Death: Evidence From National Vital Statistics Mortality Data

We examined whether Medical Marijuana Legislation (MML) was associated with site of death. Using state-level data (1992-2018) from the National Vital Statistics System (NVSS), we employed difference-in-differences method to compare changes in death rate among older adults at four sites-nursing home (NH), hospital, home, hospice/other-over time in states with and without MML. Heterogeneity analyses were conducted by timing of MML adoption, and by decedent characteristics. Results show a negative association between MML implementation and NH deaths. Among early adopters (states with weakly regulated programs) and decedents with musculoskeletal disorders, there was a positive association between MML implementation and hospital deaths, whereas among late adopters (states with "medicalized" programs), there was a positive association between MML implementation and hospice deaths. Decline in NH deaths may reflect increased likelihood of transfers due to threat of Federal enforcement, penalties for poor outcomes, and liability concerns. Future studies should examine these associations further.

Cultural and Ethical Barriers to Cancer Treatment in Nursing Homes and Educational Strategies: A Scoping Review

(1) Background: The aging of the population, the increase in the incidence of cancer with age, and effective chronic oncological treatments all lead to an increased prevalence of cancer in nursing homes. The aim of the present study was to map the cultural and ethical barriers associated with the treatment of cancer and educational strategies in this setting. (2) Methods: A systematic scoping review was conducted until April 2021 in MEDLINE, Embase, and CINAHL. All articles assessing continuum of care, paramedical education, and continuing education in the context of older cancer patients in nursing homes were reviewed. (3) Results: A total of 666 articles were analyzed, of which 65 studies were included. Many factors interfering with the decision to investigate and treat, leading to late- or unstaged disease, palliative-oriented care instead of curative, and a higher risk of unjustified transfers to acute care settings, were identified. The educational strategies explored in this context were generally based on training programs. (4) Conclusions: These results will allow the co-construction of educational tools intended to develop knowledge and skills to improve diagnostic and therapeutic decision-making, the consistency of care, and, ultimately, the quality of life of older cancer patients in nursing homes.

Racial/Ethnic Differences in Staff-Assessed Pain Behaviors Among Newly Admitted Nursing Home Residents

CONTEXT

Nonverbal pain behaviors are effective indicators of pain among persons who have difficulty communicating. In nursing homes, racial/ethnic differences in self-reported pain and pain management have been documented.

OBJECTIVES

We sought to examine racial/ethnic differences in nonverbal pain behaviors and pain management among residents with staff-assessed pain.

METHODS

We used the U.S. national Minimum Data Set 3.0 and identified 994,510 newly admitted nursing home residents for whom staff evaluated pain behaviors and pain treatments between 2010 and 2016. Adjusted prevalence ratios (aPRs) and 95% CIs estimated using robust Poisson models compared pain behaviors and treatments across racial/ethnic groups.

RESULTS

Vocal complaints were most commonly recorded (18.3% non-Hispanic black residents, 19.3% of Hispanic residents, and 30.3% of non-Hispanic white residents). Documentation of pain behaviors was less frequent among non-Hispanic black and Hispanic residents than non-Hispanic white residents (e.g., vocal complaints: aPR_Black: 0.76; 95% CI: 0.73-0.78; with similar estimates for other pain behaviors). Non-Hispanic blacks (47.3%) and Hispanics (48.6%) were less likely to receive any type of pharmacologic pain intervention compared with non-Hispanic white residents (59.3%) (aPR_Black: 0.87; 95% CI: 0.86-0.88; aPR_Hispanics: 0.87; 95% CI: 0.84-0.89).

CONCLUSION

Among residents requiring staff assessment of pain because they are unable to self-report, nursing home staff documented pain and its treatment less often in Non-Hispanic blacks and Hispanics than in non-Hispanic white residents. Studies to understand the role of differences in expression of pain, explicit bias, and implicit bias are needed to inform interventions to reduce disparities in pain documentation and treatment.

Utilization of Health Care Resources by Long-term Care Residents as a Function of Pain Status

OBJECTIVE

We estimated the association between the presence of pain and health care utilization among older adults residing in long-term care (LTC) facilities.

MATERIALS AND METHODS

Using administrative health data maintained by the Saskatchewan ministry of health and time-to-event analyses with multivariable frailty models, we tested for differences in health care use (hospitalization, physician and specialist visits, and prescription drug dispensations) as a function of pain status among LTC residents after admission to an LTC. Specifically, we contrasted LTC residents with daily pain or less than daily pain but with moderate or severe intensity (ie, clinically significant pain group; CSP) to residents with no pain or nondaily mild pain (NP/NDMP group).

RESULTS

Our cohort consisted of 24,870 Saskatchewan LTC residents between 2004 and 2015 with an average age of 85 years (63.2% female; 63.0% in urban facilities). Roughly one third had CSP at their LTC admission date. Health care use after admission to LTC was strongly associated with pain status, even after adjusting for residents' demographic and facility characteristics, prior comorbidities and health care utilization 1 year before the study index date. In any given quarter, compared with NP/NDMP residents, those with CSP had an increased risk of hospitalization, specialist visit, follow-up general practitioner visit, and onset of polypharmacy (ie, 3 or more medication classes).

DISCUSSION

To our knowledge, this is the first large-scale project to examine the utilization of health care resources as a function of pain status among LTC facility residents. Improved pain management in LTC facilities could lead to reduced health care use.

Nonmalignant Pain Symptom Subgroups in Nursing Home Residents

CONTEXT

Despite many nursing home residents experiencing pain, research about the multidimensional nature of nonmalignant pain in these residents is scant.

OBJECTIVES

To identify and describe pain symptom subgroups and to evaluate whether subgroups differed by sex.

METHODS

Using Minimum Data Set 3.0 data (2011-2012), we identified newly admitted nursing home residents reporting pain (n = 119,379). A latent class analysis included 13 indicators: markers for pain (i.e., severity, frequency, impacts sleep, and function) and depressive symptoms. Sex was evaluated as a grouping variable. Multinomial logistic models identified the association between latent class membership and covariates, including age and cognitive impairment.

RESULTS

Four latent subgroups were identified: severe (15.2%), moderate frequent (26.4%), moderate occasional with depressive symptoms (26.4%), and moderate occasional without depressive symptoms (32.0%). Measurement invariance by sex was ruled out. Depressed mood, sleep disturbances, and fatigue distinguished subgroups. Age ≥75 years was inversely associated with belonging to the severe, moderate frequent, or moderate occasional with depressive symptoms subgroups. Residents with severe cognitive impairment had reduced odds of membership in the severe pain subgroup (adjusted odds ratio [aOR]: 0.84; 95% confidence interval [CI]: 0.78-0.90) and moderate frequent pain subgroup (aOR: 0.60; 95% CI: 0.56-0.64) but increased odds in the moderate occasional pain with depressive symptoms subgroup (aOR: 1.12; 95% CI: 1.06-1.18).

CONCLUSION

Identifying subgroups of residents with different patterns of pain and depressive symptoms highlights the need to consider physical and psychological components of pain. Expanding knowledge about pain symptom subgroups may provide a promising avenue to improve pain management in nursing home residents.

Living a Life Full of Pain: Older Pain Clinic Patients' Experience of Living With Chronic Low Back Pain

Chronic low back pain (CLBP) is older adults' most common pain complaint and is associated with many physical and psychosocial consequences, which have been quantitatively examined. However, little research has qualitatively examined the experience itself of CLBP in later life. Study objective was to understand older adults' lived CLBP experience. Guided by van Manen's phenomenological method, 21 pain clinic patients aged 66 to 83 completed semistructured interviews. Under the main theme "living a life full of pain," results are reflected in four existential subthemes: (a) Corporeality: The pain is relentless and constantly monitored, (b) Temporality: To live with pain is to live by pacing day and night, (c) Relationality: Pain creates limits that can be tested or obeyed, and (d) Spatiality: Manipulating the space around me to accommodate the pain. Findings improve understanding of the patient experience of late life CLBP and highlights the importance of empathy and patient-centeredness when treating older adults.

Non-Hispanic Black-White disparities in pain and pain management among newly admitted nursing home residents with cancer

Background

Racial disparities in pain management persist across health care settings and likely extend into nursing homes. No recent studies have evaluated racial disparities in pain management among residents with cancer in nursing homes at time of admission.

Methods

Using a cross-sectional study design, we compared reported pain and pain management between non-Hispanic White and non-Hispanic Black newly admitted nursing home residents with cancer (n=342,920) using the de-identified Minimum Data Set version 3.0. Pain management strategies included the use of scheduled analgesics, pro re nata analgesics, and non-pharmacological methods. Presence of pain was based on self-report when residents were able, and staff report when unable. Robust Poisson models provided estimates of adjusted prevalence ratios (aPR) and 95% CIs for reported pain and pain management strategies.

Results

Among nursing home residents with cancer, ~60% reported pain with non-Hispanic Blacks less likely to have both self-reported pain (aPR [Black versus White]: 0.98, 95% CI: 0.97–0.99) and staff-reported pain (aPR: 0.89, 95% CI: 0.86–0.93) documentation compared with Non-Hispanic Whites. While most residents received some pharmacologic pain management, Blacks were less likely to receive any compared with Whites (Blacks: 66.6%, Whites: 71.1%; aPR: 0.98, 95% CI: 0.97–0.99), consistent with differences in receipt of non-pharmacologic treatments (Blacks: 25.8%, Whites: 34.0%; aPR: 0.98, 95 CI%: 0.96–0.99).

Conclusion

Less pain was reported for Black compared with White nursing home residents and White residents subsequently received more frequent pain management at admission. The extent to which unequal reporting and management of pain persists in nursing homes should be further explored.

Developing and testing a nursing home end -of -life care chart audit tool

BACKGROUND

Nursing home (NH) administrators need tools to measure the effectiveness of care delivered at the end of life so that they have objective data on which to evaluate current practices, and identify areas of resident care in need of improvement.

METHODS

A three-phase mixed methods study was used to develop and test an empirically derived chart audit tool aimed at assessing the care delivered along the entire dying trajectory.

RESULTS

The Auditing Care at the End of Life (ACE) instrument contains 27 questions captured across 6 domains, which are indicative of quality end-of-life care for nursing home residents.

CONCLUSIONS

By developing a brief chart audit tool that captures best practices derived from expert consensus and the research literature, NH facilities will be equipped with one means for monitoring and assessing the care delivered to dying residents.

Impact of Nursing Home Palliative Care Teams on End-of-Life Outcomes: A Randomized Controlled Trial

BACKGROUND

Deficits in end-of-life care in nursing homes (NHs) are reported, but the impact of palliative care teams (PCTeams) on resident outcomes remains largely untested.

OBJECTIVE

Test the impact of PCTeams on end-of-life outcomes.

RESEARCH DESIGN

Multicomponent strategy employing a randomized, 2-arm controlled trial with a difference-in-difference analysis, and a nonrandomized second control group to assess the intervention's placebo effect.

SUBJECTS

In all, 25 New York State NHs completed the trial (5830 decedent residents) and 609 NHs were in the nonrandomized group (119,486 decedents).

MEASURES

Four risk-adjusted outcome measures: place of death, number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms. The Minimum Data Set, vital status files, staff surveys, and in-depth interviews were employed. For each outcome, a difference-in-difference model compared the pre-post intervention periods using logistic and Poisson regressions.

RESULTS

Overall, we found no statistically significant effect of the intervention. However, independent analysis of the interview data found that only 6 of the 14 treatment facilities had continuously working PCTeams throughout the study period. Decedents in homes with working teams had significant reductions in the odds of in-hospital death compared to the other treatment [odds ratio (OR), 0.400; P<0.001), control (OR, 0.482; P<0.05), and nonrandomized control NHs (0.581; P<0.01). Decedents in these NHs had reduced rates of depressive symptoms (OR, 0.191; P≤0.01), but not pain or hospitalizations.

CONCLUSIONS

The intervention was not equally effective for all outcomes and facilities. As homes vary in their ability to adopt new care practices, and in their capacity to sustain them, reforms to create the environment in which effective palliative care can become broadly implemented are needed.

Pain and pharmacologic pain management in long-stay nursing home residents

Previous studies estimate that >40% of long-stay nursing home (NH) residents experience persistent pain, with 20% of residents in pain receiving no analgesics. Strengthened NH surveyor guidance and improved pain measures on the Minimum Data Set 3.0 were introduced in March 2009 and October 2010, respectively. This study aimed to provide estimates after the important initiatives of (1) prevalence and correlates of persistent pain; and (2) prevalence and correlates of untreated or undertreated persistent pain. We identified 1,387,405 long-stay residents in U.S. NHs between 2011 and 2012 with 2 Minimum Data Set assessments 90 days apart. Pain was categorized as persistent (pain on both assessments), intermittent (pain on either assessment), or none. Pharmacologic pain management was classified as untreated pain (no scheduled or as needed medications received) or potentially undertreated (no scheduled received). Modified Poisson models adjusting for resident clustering within NHs provided adjusted prevalence ratios (APRs) estimates and 95% confidence intervals (CIs). The prevalence of persistent and intermittent pain was 19.5% and 19.2%, respectively, but varied substantially by age, sex, race and ethnicity, cognitive impairment, and cancer. Of residents in persistent pain, 6.4% and 32.0% were untreated and undertreated, respectively. Racial and ethnic minorities (non-Hispanic blacks vs whites, APR = 1.19, 95% CI: 1.13-1.25) and severely cognitively impaired residents (severe vs no/mild APR = 1.51, 95% CI: 1.44-1.57) had an increased prevalence of untreated and undertreated pain. One in 5 NH residents has persistent pain. Although this estimate is greatly improved, many residents may be undertreated. The disturbing disparities in untreated and undertreated pain need to be addressed.

Improving palliative care through teamwork (IMPACTT) in nursing homes: Study design and baseline findings

BACKGROUND

The 2014 Institute of Medicine report recommended that healthcare providers caring for individuals with advanced illness have basic palliative care competencies in communication, inter-professional collaboration, and symptom management. Nursing homes, where one in three American decedents live and die, have fallen short of these competency goals. We implemented an intervention study to examine the efficacy of nursing home-based integrated palliative care teams in improving the quality of care processes and outcomes for residents at the end of life.

METHODS/DESIGN

This paper describes the design, rationale, and challenges of a two-arm randomized controlled trial of nursing home-based palliative care teams in 31 facilities. The impact of the intervention on residents' outcomes is measured with four risk-adjusted quality indicators: place of death (nursing home or hospital), number of hospitalizations, and self-reported pain and depression in the last 90-days of life. The effect of the intervention is also evaluated with regard to staff satisfaction and impact on care processes (e.g. palliative care competency, communication, coordination). Both secondary (e.g. the Minimum Data Set) and primary (e.g. staff surveys) data are employed to examine the effect of the intervention.

DISCUSSION

Several challenges in conducting a complex, nursing home-based intervention have been identified. While sustainability of the intervention without research funding is not clear, we surmise that without changes to the payment model that put palliative care services in this care setting on par with the more "skilled" care, it will not be reasonable to expect any widespread efforts to implement facility-based palliative care services.

An Exploration of Nursing Home Organizational Processes

The purpose of this study is to explore the relationship between nursing home staffs' perceptions of organizational processes (communication, teamwork, and leadership) with characteristics (turnover, tenure, and educational preparation) of the nursing home administrator (NHA) and director of nursing (DON). NHAs and DONs rate communication, teamwork, and leadership significantly higher than direct care staff do (registered nurses, licensed practical nurses, certified nurse aides [CNAs]). CNAs have the lowest ratings of communication and teamwork. Turnover of the NHA and DON is significantly and negatively associated with communication and teamwork. Two thirds of DONs surveyed hold less than a baccalaureate degree; this does not influence staffs' ratings of communication, teamwork, and leadership. Findings from this study highlight the need to explore differences in perceptions between administrative and direct care staff and how these may or may not influence staff development and quality improvement activities in nursing homes.

Nursing Homes and Suffering: Part of the Problem or Part of the Solution?

The quality of residents’ life is now widely recognized as a principle measure of the quality of care provided by nursing homes. This article is focused on the profound psychosocial and existential suffering that was experienced by many of the nursing home residents who were part of a larger study that examined end-of-life experiences in nursing homes. Data were collected using a case study approach, incorporating observations, interviews, and document review. Qualitative content analysis was used to analyze data. The narratives of two residents are used as exemplars. Through these narratives, specific examples of physical, psychosocial, and existential suffering are revealed. Suffering as an essential aspect of the human condition is explored within the context of nursing homes as systems of care for older adults. Attention to suffering is integral to quality of life, yet few nursing homes have integrated the diagnosis and relief of suffering into their routine work.

Normalizing suffering: A meta-synthesis of experiences of and perspectives on pain and pain management in nursing homes

Older people who live in nursing homes commonly suffer from pain. Therefore, relieving suffering among older people that stems from pain demands knowledge improvement through an integration of international knowledge. This study aimed to integrate current international findings and strengthen the understanding of older people's experiences of and perspectives on pain and pain management in nursing homes. A meta-synthesis study using Noblit and Hare's interpretative meta-ethnography approach was conducted. Empirical research papers from journals were collected from various databases. The search process and appraisal determined six articles for inclusion. Two studies were conducted in the US and one each in Iceland, Norway, the UK, and Australia. The older people's experiences of pain as well as perspectives on pain management from all involved (older people, their family members, and healthcare staff) were integrated into a theoretical model using three themes of "identity of pain," "recognition of pain," and "response to pain." The metaphor of "normalizing suffering" was devised to illustrate the meaning of pain experiences and pain management in nursing homes. Society's common attitude that pain is unavoidable and therefore acceptable in old age in society-among older people themselves as well as those who are responsible for reporting, acknowledging, and relieving pain-must change. The article emphasizes that pain as a primary source of suffering can be relieved, provided that older people are encouraged to report their pain. In addition, healthcare staff require sufficient training to take a person-centered approach towards assessment and management of pain that considers all elements of pain.

Pain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial

OBJECTIVE

To enhance pain practices in nursing homes (NHs) using pain assessment and management algorithms and intense diffusion strategies.

DESIGN

A cluster, randomized controlled trial. The intervention consisted of intensive training and support for the use of recommended pain assessment and management practices using algorithms (ALGs). Control facilities received pain education (EDU) only.

SETTING

Twenty-seven NHs in the greater Puget Sound area participated. Facilities were diverse in terms of size, quality, and ownership.

PARTICIPANTS

Data were collected from 485 NH residents; 259 for the intervention and 226 for the control group.

MEASUREMENTS

Resident outcomes were nursing assistant (proxy) report and self-reported resident pain intensity. Process outcomes were adherence to recommended pain practices. Outcomes were measured at baseline, completion of the intervention (ALG) or training (EDU), and again 6 months later.

RESULTS

Among 8 comparisons of outcome measures between ALG and EDU (changes in 4 primary pain measures compared at 2 postintervention time points) there was only 1 statistically significant but small treatment difference in proxy- or self-reported pain intensity. Resident-reported worst pain decreased by an average of 0.8 points from baseline to 6 months among the EDU group and increased by 0.2 points among the ALG (P = .005), a clinically nonsignificant difference. There were no statistically significant differences in adherence to clinical guideline practice recommendations between ALG and EDU following the intervention.

CONCLUSIONS

Future research needs to identify and test effective implementation methods for changing complex clinical practices in NHs, including those to reduce pain.

Nursing Home Staff Palliative Care Knowledge and Practices: Results of a Large Survey of Frontline Workers

CONTEXT

Deficits in quality end-of-life care for nursing home (NH) residents are well known. Palliative care is promoted as an approach to improve quality. The Palliative Care Survey (PCS) is designed to measure NH staff palliative care knowledge and practice.

OBJECTIVES

To comparing palliative care knowledge and practices across NH staff roles using the PCS, and to examine relationships between facility characteristics and PCS scores.

METHODS

The PCS was administered to frontline NH staff-certified nursing assistants (CNAs), licensed practical nurses (LPNs), registered nurses (RNs), and social workers (SWs)-in 51 facilities in 2012. Descriptive statistics were calculated by job role. Linear mixed effects models were used to identify facility and individual factors associated with palliative care practice and knowledge.

RESULTS

The analytic sample included 1200 surveys. CNAs had significantly lower practice and knowledge scores compared to LPNs, RNs, and SWs (P < 0.05). LPNs had significantly lower psychological, end-of-life, and total knowledge scores than RNs (P < 0.05 for all). Although knowledge about physical symptoms was uniformly high, end-of-life knowledge was notably low for all staff. A one-point higher facility star rating was significantly associated with a 0.06 increase in family communication score (P = 0.003; 95% CI: 0.02-0.09; SE = 0.02). Higher penetration of hospice in the NH was associated with higher end-of-life knowledge (P = 0.003; parameter estimate = 0.006; 95% CI: 0.002-0.010; SE = 0.002). Sixty-two percent of respondents stated that, with additional training, they would be interested in being leaders in palliative care.

CONCLUSION

Given observed differences in palliative care practice and knowledge scores by staff training, it appears the PCS is a useful tool to assess NH staff. Low end-of-life knowledge scores represent an important target for quality improvement.

Psychometric properties of the Orientation to Life Questionnaire in nursing home residents

AIM

Older residents of nursing homes have several illnesses and face various challenges regarding losses of physical and mental functioning. Thus, coping and the quality of life are vital aspects in long-term care. Sense of coherence is considered an important resource for coping and the quality of life, and sense of coherence therefore needs to be validly and reliably measured in this population. We investigated the dimensionality, reliability and construct validity of the Orientation to Life Questionnaire in assessing sense of coherence among cognitively intact nursing home (NH) residents.

METHODS

We collected cross-sectional data from 227 cognitively intact NH residents (30 NHs) with one-on-one interviews. We performed confirmative factor analysis and correlations with the selected construct.

RESULTS AND CONCLUSION

In accordance with the salutogenic theory of sense of coherence, the three-factor model revealed the best fit to our data. In particular, item OLQ2, defined as 'concerns the experience of being surprised by the behaviour of people whom you know well', seemed troublesome. Removing this item resulted in good fit to the present data. Rewording or deleting item OLQ2 seems needed to get a reliable instrument measuring sense of coherence among nursing home residents.

Pain Assessment Strategies in Home Care and Nursing Homes in Mid-Norway: A Cross-sectional Survey

The prevalence of pain ranges from 27.8% to 86.5% in nursing homes and 42% to 50% in home care. Pain assessment is the first step toward effective pain management. The aim of this study was to explore the use of pain assessment strategies (verbal, numeric, and observation rating scales and standardized questions) in home care and nursing homes. The study was a descriptive cross-sectional survey. Health care providers who were responsible for the patients' medications replied to a questionnaire. In-home care and nursing homes in 11 randomly selected municipalities in Mid-Norway were included. Three hundred ninety-two individuals were included in this study (70% response rate): 271 (69%) from nursing homes and 121 (31%) from home care. The respondents working in home care had a higher educational level than those in working in nursing homes. Pain assessment instruments were not used frequently in nursing homes and home care. Verbal and numeric rating scales were used significantly more frequently in home care than in nursing homes. Registered nurses (RNs) in nursing homes used standardized questions significantly more often than did RNs in home care. RNs and social educators in home care self-reported less competence in treating the patients' total pain experience than did those in nursing homes. Workplace (working in home care) and regular training in the use of pain assessment tools explained more than 20% of the variation in the use of pain assessment tools. Regular training in the use of pain assessment tools is needed for health care workers in home care and nursing homes.

Bodily pain intensity in nursing home residents with pressure ulcers: analysis of national minimum data set 3.0

Clinical reports suggest that superficial pressure ulcers produce pain, but that pain decreases as the wound advances in stage. This study of the relationship between pressure ulcer stage and bodily pain intensity in nursing home residents was a secondary analysis of the national Minimum Data Set 3.0 assessment data in long-term care facilities, collected from nursing home residents at least 65 years of age. Data were examined from residents with pressure ulcers who completed a bodily pain intensity interview between January and March 2012 (N = 41,680) as part of the MDS comprehensive assessment. After adjusting for other variables (e.g., cognition, functional impairment, presence of comorbidities, use of scheduled pain medication, and sociodemographic variables), bodily pain intensity for those with more severe pressure ulcers in comparison to those with Stage I ulcers was higher by 11% (Stage II), 14% (Stage III), 24% (Stage IV), and 22% (suspected deep tissue injury). Because multivariate analysis showed that greater bodily pain intensity was associated with an advanced stage of pressure ulcer, health care providers should assess bodily pain intensity and order appropriate pain management for nursing home residents with pressure ulcers, particularly for those with advanced pressure ulcers who are vulnerable to greater bodily pain intensity.

[Resident assessment instrument. Application options and relevance for Germany]

The Resident Assessment Instrument (RAI) is a structured and standardized instrument to improve the quality of long-term care. It is based on the Minimum Data Set (MDS) 3.0 to generate clinical data for nursing planning. Further practical applications are calculation of the costs of nursing care (using a classification of residents), measurement and transparency of nursing home quality (using quality indicators) and epidemiological surveys (using uniform data from assessments). The RAI is used nationwide in the USA, to some extent in other countries and in Germany predominantly in the context of research. The paper briefly describes the historical development of the different RAI variations (particularly with respect to the MDS), presents the central utilization options and ends with a critical discussion of possibilities and limits of the RAI.

Hospice use among nursing home and non-nursing home patients

BACKGROUND

For nursing home patients, hospice use and associated costs have grown dramatically. A better understanding of hospice in all care settings, especially how patients move across settings, is needed to inform debates about appropriateness of use and potential policy reform.

OBJECTIVE

Our aim was to describe characteristics and utilization of hospice among nursing home and non-nursing home patients.

DESIGN AND PARTICIPANTS

Medicare, Medicaid and Minimum Data Set data, 1999-2008, were merged for 3,771 hospice patients aged 65 years and above from a safety net health system. Patients were classified into four groups who received hospice: 1) only in nursing homes; 2) outside of nursing homes; 3) crossover patients utilizing hospice in both settings; and 4) "near-transition" patients who received hospice within 30 days of a nursing home stay.

MAIN MEASURES

Differences in demographics, hospice diagnoses and length of stay, utilization and costs are presented with descriptive statistics.

KEY RESULTS

Nursing home hospice patients were older, and more likely to be women and to have dementia (p < 0.0001). Nearly one-third (32.3 %) of crossover patients had hospice stays > 6 months, compared with the other groups (16 % of nursing home hospice only, 10.7 % of non-nursing home hospice and 7.6 % of those with near transitions) (p < 0.0001). Overall, 27.7 % of patients had a hospice stay <1 week, but there were marked differences between groups-48 % of near-transition patients vs. 7.4 % of crossover patients had these short hospice stays (p < 0.0001). Crossover and near-transition hospice patients had higher costs to Medicare compared to other groups (p < 0.05).

CONCLUSIONS

Dichotomizing hospice users only into nursing home vs. non-nursing home patients is difficult, due to transitions across settings. Hospice patients with transitions accrue higher costs. The impact of changes to the hospice benefit on patients who live or move through nursing homes near the end of life should be carefully considered.

IASP global year against pain in older persons: highlighting the current status and future perspectives in geriatric pain

This year represents the international year against pain in older persons and it is opportune, therefore, to reflect upon the current status and possible future directions in pain-management practice for this large and growing segment of the population. Epidemiologic studies show a very high prevalence of persistent pain, often exceeding 50% of community-dwelling older persons and up to 80% of nursing home residents. Recently, there has been a major push to develop age-appropriate pain assessment tools, including several observer-rated scales of behavioral pain indicators for use in those with dementia. There has also been the release of several comprehensive guidelines for the assessment and management of pain in older persons, although the current evidence-base used to guide clinical practice is extremely limited. Unfortunately, despite these advances, pain remains grossly under treated in older persons, regardless of the healthcare setting. With the demographic imperative of a rapidly aging society, much greater attention is now being devoted to the problem of geriatric pain, with new initiatives in healthcare planning, calls for better professional education in geriatrics and pain management as well as new directions and funding resources for research into this important problem. Of course, this increased awareness must still be translated into action, not just because better pain relief for older adults is an ethically desirable outcome, but out of the sheer necessity of dealing with the millions of older persons who will suffer from persistent and bothersome pain in the years to come.

Relationship between pain and chronic illness among seriously ill older adults: expanding role for palliative social work

Confronting the issue of pain among chronically ill older adults merits serious attention in light of mounting evidence that pain in this population is often undertreated or not treated at all (Institute of Medicine, 2011 ). The relationship between pain and chronic illness among adults age 50 and over was examined in this study through the use of longitudinal data from the University of Michigan Health and Retirement Study, sponsored by the National Institute on Aging and the Social Security Administration. Findings suggested positive associations between pain and chronic disease, pain and multimorbidity, as well as an inverse association between pain and education. Policy implications for workforce development and public health are many, and amplification of palliative social work roles to relieve pain and suffering among seriously ill older adults at all stages of the chronic illness trajectory is needed.

Geriatric palliative care in long-term care settings with a focus on nursing homes

Almost 1.7 million older Americans live in nursing homes, representing a large proportion of the frailest, most vulnerable elders needing long-term care. In the future, increasing numbers of older adults are expected to spend time and to die in nursing homes. Thus, understanding and addressing the palliative care needs of this population are critical. The goals of this paper are to describe briefly the current state of knowledge about palliative care needs, processes, and outcomes for nursing home residents; identify gaps in this knowledge; and propose priorities for future research in this area.

Current state of pain care for hospitalized patients at end of life

We report findings on the current state of pain care in hospitals for end-of-life (EOL) patients using longitudinal data from 8 diverse medical-surgical units located in 4 different Midwestern hospitals over 24 months. We identified 1425 EOL care episodes, 596 (41.3%) of which had a pain diagnosis. The percentage of EOL patients with pain varied significantly across units (P < .001) and was even lower (27.7%) for those with "acute confusion." Additionally, 30% of EOL patients had severe or significant pain at death or discharge to hospice and only 42.7% actually met the expected pain-related outcome ratings. Pain often improved within 48 hours of admission (P < .005), the improvement, however, stagnated following this initial time period (P = .92). A sizable gap between pain science and clinical practice continues.

Pain and persistent pain in nursing home residents in Norway

The objective of this study was to examine the nature of pain and persistence of pain in nursing home residents. The study was carried out with 201 participants drawn from six nursing homes in Norway. The participants rated their pain on 5 different days within a 14-day period on the modified McGill Pain Questionnaire regarding the intensity and location of pain. Four patterns in the persistence of pain were extracted, with the results showing approximately 50% of the participants experiencing persistent pain of a moderate to intense level. Pain ratings and persistent pain were significantly associated with number of body areas with pain, sleeping problems, number of medical diagnoses, and number of medications. The findings of this study suggest that both persistence and fluctuation of pain within short time periods may be related to inadequacy in pain management in nursing home residents, and fill the gap in the literature regarding patterns of persistent pain in nursing home residents.

Cancer in nursing homes: characteristics and health-related quality of life among cognitively intact residents with and without cancer

BACKGROUND

Studies are lacking on how cancer influences physical, mental, and social functioning beyond comorbidity among older people without cognitive impairment in nursing homes (NHs).

OBJECTIVE

The objective was to study the sociodemographic characteristics and health-related quality of life (HRQOL) among NH residents with and without a cancer diagnosis, adjusting for comorbidity.

METHODS

This was a cross-sectional observation study: 30 NHs; 227 residents 65 to 102 years old: 60 with cancer and 167 without, at least 6 months' residence. All had Clinical Dementia Rating of 0.5 or less and could converse. Health-related quality of life was measured using the 36-item Short-Form Health Survey in face-to-face interviews. Sociodemographic variables and medical diagnoses were obtained from records. Possible differences in HRQOL, controlled for age, gender, marital status, education, length of stay, and comorbidity, were examined by multiple linear regression analyses.

RESULTS

The most common cancer diagnoses were breast cancer among women (20%) and prostate cancer among men (12%). More residents with cancer were married (P = .007), reported more bodily pain (P = .17) and scored lower on all other HRQOL subscales, except for role-emotional. General health was worse than that of the residents without cancer (P = .04) after adjusting for sociodemographic variables but not for comorbidity (P = .06).

CONCLUSION

Cognitively intact NH residents with cancer reported more pain and worse general health but better role limitation related to emotional problems compared with residents without cancer. The difference in general health was partly due to comorbidity.

IMPLICATIONS FOR PRACTICE

Nurses should pay attention to HRQOL among NH residents with cancer and especially observe and ensure pain treatment.

Addressing methodological challenges in implementing the nursing home pain management algorithm randomized controlled trial

BACKGROUND

Unrelieved pain among nursing home (NH) residents is a well-documented problem. Attempts have been made to enhance pain management for older adults, including those in NHs. Several evidence-based clinical guidelines have been published to assist providers in assessing and managing acute and chronic pain in older adults. Despite the proliferation and dissemination of these practice guidelines, research has shown that intensive systems-level implementation strategies are necessary to change clinical practice and patient outcomes within a health-care setting. One promising approach is the embedding of guidelines into explicit protocols and algorithms to enhance decision making.

PURPOSE

The goal of the article is to describe several issues that arose in the design and conduct of a study that compared the effectiveness of pain management algorithms coupled with a comprehensive adoption program versus the effectiveness of education alone in improving evidence-based pain assessment and management practices, decreasing pain and depressive symptoms, and enhancing mobility among NH residents.

METHODS

The study used a cluster-randomized controlled trial (RCT) design in which the individual NH was the unit of randomization. The Roger's Diffusion of Innovations theory provided the framework for the intervention. Outcome measures were surrogate-reported usual pain, self-reported usual and worst pain, and self-reported pain-related interference with activities, depression, and mobility.

RESULTS

The final sample consisted of 485 NH residents from 27 NHs. The investigators were able to use a staggered enrollment strategy to recruit and retain facilities. The adaptive randomization procedures were successful in balancing intervention and control sites on key NH characteristics. Several strategies were successfully implemented to enhance the adoption of the algorithm. LIMITATIONS/LESSONS: The investigators encountered several methodological challenges that were inherent to both the design and implementation of the study. The most problematic issue concerned the measurement of outcomes in persons with moderate to severe cognitive impairment. It was difficult to identify valid, reliable, and sensitive outcome measures that could be applied to all NH residents regardless of the ability to self-report. Another challenge was the inability to incorporate advances in implementation science into the ongoing study

CONCLUSIONS

Methodological challenges are inevitable in the conduct of an RCT. The need to optimize internal validity by adhering to the study protocol is compromised by the emergent logistical issues that arise during the course of the study.

The role of the CNA Pain Assessment Tool (CPAT) in the pain management of nursing home residents with dementia

Implementation and testing of the CPAT in two hundred fifteen dementia residents of three regional skilled nursing facilities. To examine the effect of incorporating the CPAT into an AMDA long-term care pain management clinical practice guideline on nursing home residents with dementia. To evaluate changes in CPAT scores after treatment for pain. A non-randomized pre and post intervention design was used. Main outcome measures of the number of falls, episodes of distressed behavior and rates of antipsychotic usage were compared pre and post CPAT/AMDA guideline implementation. CPAT score changes were calculated after pain management. Falls and verbally aggressive behavior were reduced post intervention but did not achieve statistical significance. Antipsychotic usage declined significantly post intervention. CPAT scores declined significantly after treatment for pain. The implementation of a CPAT/AMDA guideline in skilled nursing facilities may reduce falls, verbally aggressive behaviors and antipsychotic usage in residents with dementia. The CPAT is useful in evaluating the effects of pain treatment in nursing home residents with dementia.

Does hospice improve quality of care for persons dying from dementia?

OBJECTIVES

To examine the effectiveness of hospice services for persons dying from dementia from the perspective of bereaved family members.

DESIGN

Mortality follow-back survey.

SETTING

Death certificates were drawn from five states (AL, FL, TX, MA, and MN).

PARTICIPANTS

Bereaved family members listed as the next of kin on death certificates when dementia was listed as the cause of death.

MEASUREMENTS

Ratings of the quality of end-of-life care, perceptions of unmet needs, and opportunities to improve end-of-life care. Two questions were also asked about the peacefulness of dying and quality of dying.

RESULTS

Of 538 respondents, 260 (48.3%) received hospice services. Family members of decedents who received hospice services reported fewer unmet needs and concerns with quality of care (adjusted odds ratio (AOR)=0.49, 95% confidence interval (CI)=0.33-0.74) and a higher rating of the quality of care (AOR=2.0, 95% CI=1.53-2.72). They also noted better quality of dying than those without hospice services.

CONCLUSION

Bereaved family members of people with dementia who received hospice reported higher perceptions of the quality of care and quality of dying.

Clinical pharmacology of analgesic medicines in older people: impact of frailty and cognitive impairment

Pain is highly prevalent in frail older people who often have multiple co-morbidities and multiple medicines. Rational prescribing of analgesics in frail older people is complex due to heterogeneity in drug disposition, comorbid medical conditions, polypharmacy and variability in analgesic response in this population. A critical issue in managing older people with pain is the need for judicious choice of analgesics based on a comprehensive medical and medication history. Care is needed in the selection of analgesic medicine to avoid drug-drug or drug-disease interactions. People living with dementia and cognitive impairment have suboptimal pain relief which in part may be related to altered pharmacodynamics of analgesics and challenges in the systematic assessment of pain intensity in this patient group. In the absence of rigorously controlled trials in frail older people and those with cognitive impairment a pharmacologically-guided approach can be used to optimize pain management which requires a systematic understanding of the pharmacokinetics and pharmacodynamics of analgesics in frail older people with or without changes in cognition.

Strategies and innovative models for delivering palliative care in nursing homes

The goals of palliative care address critical issues for individuals with complex and serious illness residing in nursing homes, including pain and symptom management, communication, preparation for death, decisions about treatment preferences, and caregiver support. Because of the uncertain prognosis associated with chronic nonmalignant diseases such as dementia, many nursing home residents are either not referred to hospice or have very short or very long hospice stays. The integration of palliative care into nursing homes offers a potential solution to the challenges relating to hospice eligibility, staffing, training, and obtaining adequate reimbursement for care that aligns with resident and surrogate's preferences and needs. However, the delivery of palliative care in nursing homes is hindered by both regulatory and staffing barriers and, as a result, is rare. In this article, we draw on interviews with nursing home executives, practitioners, and researchers to describe the barriers to nursing home palliative care. We then describe 3 existing and successful models for providing nonhospice palliative care to nursing home residents and discuss their ongoing strengths and challenges. We conclude with specific policy proposals to expedite the integration of palliative care into the nursing home setting.

Screening cognitive impairment among institutionalized older Chinese men in Taiwan: a new minimum data set-based dementia screening tool is needed

Dementia screening is of great importance in various health settings for older people, long-term care facilities are no exception. The need for an effective dementia screening tool being culture sensitive is important. Minimum data set (MDS) is a population instrument for health care management in the world, which also covers dementia screening. The main purpose of this study was to evaluate the effectiveness of the MDS-based dementia screening tools among older Chinese men in the Veteran Home in Taiwan. Overall, 576 participants (mean age: 80.9±5.3 years, all males, 92.7% physically independent), 18.6% had cognitive impairment according to the mini-mental state examination (MMSE) (mean score: 26.7±3.9). However, the prevalence of cognitive impairment was 5.5% by MDS cognitive performance scale (CPS) and 18.9% by MDS cognition scale (MDS-COGS). The screening results of CPS and MDS-COGS were highly interrelated (γ=0.93, p<0.001), and MMSE scores were also significantly associated with CPS and MDS-COGS status (γ=-0.50, p<0.001 and γ=-0.52, p<0.001, respectively). Although the prevalence of cognitive impairment by MMSE and MDS-COGS are similar, the results are significantly inconsistent (p<0.001). In conclusion, both MDS-COGS and CPS were significantly correlated with MMSE scores, but significant inconsistence was noted between screening results of MMSE, CPS and MDS-COGS. Further study is needed to develop MDS-based dementia screening tools for older Chinese men in Taiwan.

Rated cognition in nursing home residents with multiple sclerosis: cross-sectional and longitudinal analyses

PURPOSE

To examine cognitive change in nursing home residents with multiple sclerosis (MS) over the first year of a nursing home stay and to predict cognition functioning in these residents at admission and the 1-year annual assessment.

METHOD

In the first part of this study, the cognitive functioning of nursing home residents with MS (n = 1890) and without MS (n = 22,985) were compared. In the second part, demographic and other variables were used to predict cognition at the admission and 1-year annual assessment for MS residents.

RESULTS

Nursing home residents with MS had better cognitive functioning than residents without MS at admission and 1 year later. Regression analyses demonstrated that higher education and pain predicted higher Minimum Data Set Cognition Scale (MDS-Cog) at admission and at 1 year later, but poorer activities of daily living predicted worse MDS-Cog at admission and 1 year later. For the longitudinal analysis, MDS-Cog at the admission assessment was an independent predictor of MDS-Cog scores at the 1-year annual assessment.

CONCLUSIONS

Nursing home residents with MS have significantly better cognitive functioning than non-MS residents and, over the first year of a nursing home stay, higher education and pain, but lower activities of daily living, predict poorer cognitive functioning.

Assessing and treating pain in hospices: current state of evidence-based practices

The aim of this study was to report on current provider evidence-based assessment and treatment practices for older adults with cancer in community-based hospice settings. Using the Cancer Pain Practices Index, a tool developed by the researchers to measure evidence-based pain management practices, patients received an average of 32% of those key evidence-based practices (EBPs) that were applicable to their situations. When examining individual practices, most of the patients had their pains assessed at admission using a valid pain scale (69.7%) and had primary components of a comprehensive assessment completed at admission (52.7%); most patients with admission reports of pain had an order for pain medication (83.5%). However, data revealed a number of practice gaps, including additional components of a comprehensive assessment completed within 48 hours of admission (0%); review of the pain treatment plan at each reassessment (35.7%); reassessment of moderate or greater pain (5.3%); consecutive pain reports of 5 or greater followed by increases in pain medication (15.8%); monitoring of analgesic-induced side effects (19.3%); initiation of a bowel regimen for patients with an opioid order (32.3%); and documentation of both nonpharmacological therapies (22.5%) and written pain management plans (0.6%). Findings highlight positive EBPs and areas for improving the translation of EBPs into practice. Data suggest that cancer pain is not being documented as consistently assessed, reassessed, or treated in a manner consistent with current EBP recommendations for older adults with cancer in community-based hospices.

Correspondence of verbal descriptor and numeric rating scales for pain intensity: an item response theory calibration

BACKGROUND

Assessing pain intensity in older adults is critical and challenging. There is debate about the most effective way to ask older adults to describe their pain severity, and clinicians vary in their preferred approaches, making comparison of pain intensity scores across settings difficult.

METHODS

A total of 3,676 residents from 71 community nursing homes across eight states were asked about pain presence. The 1,960 residents who reported pain within the past 5 days (53% of total, 70% female; age: M = 77.9, SD = 12.4) were included in analyses. Those who reported pain were also asked to provide a rating of pain intensity using either a verbal descriptor scale (VDS; mild, moderate, severe, and very severe and horrible), a numeric rating scale (NRS; 0 = no pain to 10 = worst pain imaginable), or both. We used item response theory (IRT) methods to identify the correspondence between the VDS and the NRS response options by estimating item parameters for these and five additional pain items.

RESULTS

The sample reported moderate amounts of pain on average. Examination of the IRT location parameters for the pain intensity items indicated the following approximate correspondence: VDS mild approximately NRS 1-4, VDS moderate approximately NRS 5-7, VDS severe approximately NRS 8-9, and VDS very severe, horrible approximately NRS 10.

CONCLUSION

This IRT calibration provides a crosswalk between the two response scales so that either can be used in practice depending on the preference of the clinician and respondent.

Willingness of older Korean-American adults to use hospice

Responding to an urgent need for more research on end-of-life concerns of racial and ethnic minorities, the present study explored predictors of willingness of older Korean-American adults (N=675) to use hospice. Guided by Andersen's behavioral health model, the study considered predisposing factors (age, sex, marital status, education), potential health needs (chronic conditions, functional disability), and enabling factors (health insurance, acculturation, prior awareness of hospice). Nearly three-quarters of the sample answered yes to the following statement and question, "Hospice is a program that helps people who are dying by making them feel comfortable and free of pain when they can no longer be cured of their disease. If you needed hospice services, would you use them?" A greater willingness was observed in younger persons (odds ratio (OR)=0.96, 95% confidence interval (CI)=0.93-0.98) and those with higher levels of education (OR=1.67, 95% CI=1.12-2.48), more chronic conditions (OR=1.23, 95% CI=1.05-1.44), health insurance (OR=0.59, 95% CI=0.37-0.94), higher levels of acculturation (OR=1.07, 95% CI=1.03-1.10), and prior awareness of hospice (OR=4.43, 95% CI=2.85-6.90). The present study highlights the role of prior awareness in shaping individuals' attitudes toward services, calling attention to a need for community education and outreach programs for racial and ethnic minorities, with specific emphasis on dissemination of information and greater awareness of hospice services.