European palliative care guidelines: how well do they meet the needs of people with impaired cognition?

Barriers to Palliative Care Access in Patients With Intellectual Disability: A Scoping Review

There is limited knowledge about inequalities regarding palliative care access among patients with intellectual disability. The present scoping review aimed to identify the existing barriers that limit access to palliative care (PC) in patients with intellectual disability.

METHODS

We conducted a literature review on publications since 2014 from three databases (MEDLINE, Biomed Central, and Elsevier Scopus), along with hand searches in scientific journals. The review included peer-reviewed studies written in English and Spanish language with quantitative and qualitative study designs. The participants were patients with intellectual disability and health professionals who had worked with them or had experience in palliative care.

RESULTS

22 studies met the selection criteria. The barriers identified were under referral to palliative care, reduced access, communication, and limited knowledge and experience by health professionals.

CONCLUSION

Patients with intellectual disability do not get referred to PC frequently. Health professionals and caregivers do not recognize when it is necessary to make a referral, and they need to improve their communication abilities. Also, health care workers need more training in PC, pain management, anticipation of death, and use of opioids. More research and education on the palliative care needs and care for patients with intellectual disabilities is needed.

Managing a Dual Diagnosis of Cancer and Dementia in an Acute Setting: Considerations, Implications, and Future Recommendations

OBJECTIVES

To present an overview of the issues related to the well-being of people affected by cancer and dementia. To highlight the evidence from dementia care that can help improve the care experiences of people with dementia and cancer.

DATA SOURCES

Electronic databases such as PubMed and CINAHL were used to retrieve relevant literature published between 2010 and 2020.

CONCLUSION

Having a dual diagnosis of dementia and cancer poses several challenges across the cancer care pathway. Communication, treatment decision-making, environment ,and time-related issues were all identified. The literature suggests the need for evidence-based guidelines taking into consideration the person and the environment to support this population.

IMPLICATIONS FOR NURSING PRACTICE

To address these challenges and offer an optimal care experience for this group and their families, solutions need to focus both on the workforce and the environment. Offering dementia education for professionals working in acute cancer care, as well as adapting local environments that facilitate people navigate the space can be a starting point to offer person-centered, rights-based dementia sensitive care.

Experiencing improved assessment and control of pain in end-of-life care when using the Abbey Pain Scale systematically

Aim

To describe staff's reflections on aspects influencing pain assessment at end-of-life (EoL) care in nursing homes before and after the implementation of the Abbey Pain Scale (APS).

Background

People with cognitive impairment in the EoL care often suffer from underdiagnosed and undertreated pain due to the lack of knowledge and guidelines for systematic pain assessment.

Methods

Semi-structured focus group interviews were conducted and analysed using qualitative content analysis.

Results

The staff described their experiences before the implementation of APS as striving to achieve control of pain by trusting in themselves and the team, while the experiences after the implementation of APS were described as improving symptom control with remaining weak confidence in the team.

Conclusions

Implementation of APS was experienced as improving systematic pain assessment. Efforts to establish clear routines and improve confidence in the care team would be prioritized to optimize pain assessment and pain relief in EoL care.

The palliative care needs of adults with intellectual disabilities and their access to palliative care services: A systematic review

BACKGROUND

There is evidence that people with intellectual disabilities experience healthcare inequalities, including access to specialist palliative care, but to date, there has not been a systematic review of empirical evidence.

AIM

To identify the palliative care needs of adults with intellectual disabilities and the barriers and facilitators they face in accessing palliative care.

DESIGN

Systematic review using a narrative synthesis approach (International prospective register of systematic reviews (PROSPERO) registration number: CRD42019138974).

DATA SOURCES

Five databases were searched in June 2019 (MEDLINE, Embase, PsycINFO, the Cochrane library and CINAHL) along with hand searches and a search of the grey literature. All study designs were included.

RESULTS

A total of 52 studies were identified, all of which were conducted in high-income countries, the majority in the United Kingdom (n = 28). From a total of 2970 participants across all studies, only 1% were people with intellectual disabilities and 1.3% were family members; the majority (97%) were health/social care professionals. Identified needs included physical needs, psychosocial and spiritual needs, and information and communication needs. Barriers and facilitators were associated with education (e.g. staff knowledge, training and experience), communication (e.g. staff skill in assessing and addressing needs of people with communication difficulties), collaboration (e.g. importance of sustained multidisciplinary approach) and health and social care delivery (e.g. staffing levels, funding and management support).

CONCLUSION

This review highlights the specific problems in providing equitable palliative care for adults with intellectual disabilities, but there is a lack of research into strategies to improve practice. This should be prioritised using methods that include people with intellectual disabilities and families.

Characteristics of People with Dementia vs Other Conditions on Admission to Inpatient Palliative Care

OBJECTIVES

Our aim was to (1) describe the clinical characteristics and symptoms of people diagnosed with dementia at the time of admission to inpatient palliative care; and (2) compare the nature and severity of these palliative care-related problems to patients with other chronic diseases.

DESIGN

Descriptive study using assessment data on point of care outcomes (January 1, 2013, to December 31, 2018).

SETTING

A total of 129 inpatient palliative care services participating in the Australian Palliative Care Outcomes Collaboration.

PARTICIPANTS

A total of 29,971 patients with a primary diagnosis of dementia (n = 1,872), lung cancer (n = 19,499), cardiovascular disease (CVD, n = 5,079), stroke (n = 2,659), or motor neuron disease (MND, n = 862).

MEASUREMENTS

This study reported the data collected at the time of admission to inpatient palliative care services including patients' self-rated levels of distress from seven common physical symptoms, clinician-rated symptom severity, functional dependency, and performance status. Other data analyzed included number of admissions, length of inpatient stay, and palliative care phases.

RESULTS

At the time of admission to inpatient palliative care services, relative to patients with lung cancer, CVD, and MND, people with dementia presented with lower levels of distress from most symptoms (odds ratios [ORs] range from .15 to .80; P < .05 for all) but higher levels of functional impairment (ORs range from 3.02 to 8.62; P < .001 for all), and they needed more assistance with basic activities of daily living (ORs range from 3.83 to 12.24; P < .001 for all). The trends were mostly the opposite direction when compared with stroke patients. Patients with dementia tended to receive inpatient palliative care later than those with lung cancer and MND.

CONCLUSION

The unique pattern of palliative care problems experienced by people with dementia, as well as the skills of the relevant health services, need to be considered when deciding on the best location of care for each individual. Access to appropriately trained palliative care clinicians is important for people with high levels of physical or psychological concerns, irrespective of the care setting or diagnosis. J Am Geriatr Soc 68:1825-1833, 2020.

Strategies for Pain Assessment in Adult Patients With Delirium: A Scoping Review

CONTEXT

Pain and delirium are highly prevalent in the same patient groups. Disturbances in attention, awareness, and cognition are characteristics for delirium and can compromise pain assessment.

OBJECTIVES

The aim of this review was to examine and map models and understandings of pain and delirium as well as pain assessment instruments and strategies for adult patients with delirium.

METHODS

A scoping review of all publications that reported on pain assessment in adult patients with delirium was conducted with no time and language constraints, searching Medline, CINAHL, Scopus, Embase, and PsycINFO and systematically assessing for inclusion. Standardized data extraction and a narrative synthesis followed.

RESULTS

A total of 90 publications were included in the final analysis. Despite being recommended for practice, no evidence for the use of self-report or behavioral pain assessment instruments in patients with delirium was identified, with the exception of limited evidence for the validity of the Critical Care Pain Observation Tool and Behavioral Pain Scale in delirious intensive care patients. Proxy ratings of pain and comprehensive pain assessment hierarchies were also recommended, but not supported by evidence. Current models and/or understandings of pain and delirium were not applied in most publications.

CONCLUSION

The current literature is insufficient to guide clinical practice in pain assessment in patients with delirium. Future research will be needed to address the validity of existing pain assessment instruments, apply theoretical and conceptual understandings of pain and delirium, and build on prior studies to close evidence gaps.

Guiding practitioners through end of life care for people with dementia: The use of heuristics

Background

End of life care (EOLC) for people with dementia can present a multitude of challenges and difficult decisions for practitioners. These challenges may include assessment and management of difficulties with eating and swallowing, responding to agitation, treating pain, and managing recurrent infections. Practitioners sometimes lack both confidence in making end of life decisions and guidance. This study developed an alternative to lengthy guidelines, in the form of heuristics which were tested in clinical settings. The aim of this study was to test the usability and acceptability of a set of heuristics which could be used by practitioners providing EOLC for people with dementia in a variety of clinical and care settings.

Methods

A three phase co-design process was adopted: 1) Synthesis of evidence and outputs from interviews and focus groups with family carers and practitioners, by a co-design group, to develop heuristics; 2) Testing of the heuristics in five clinical or care settings for six months; 3) Evaluation of the heuristics at three and six months using qualitative individual and group interviews.

Results

Four heuristics were developed covering: eating and swallowing difficulties, agitation and restlessness, reviewing treatment and interventions at the end of life, and providing routine care. The five sites reported that the heuristics were simple and easy to use, comprehensive, and made implicit, tacit knowledge explicit. Four themes emerged from the qualitative evaluation: authority and permission; synthesis of best practice; providing a structure and breaking down complexity; and reassurance and instilling confidence.

Conclusion

Use of heuristics is a novel approach to end of life decision making in dementia which can be useful to both experienced and junior members of staff making decisions. Heuristics are a practical tool which could overcome a lack of care pathways and direct guidance in end of life care for people with dementia.

Emotional Distress of Patients at End-of-Life and Their Caregivers: Interrelation and Predictors

Background: Patients at the end of life and their families experience a strong emotional impact. The well-being of these patients and that of their family caregiver are related. Aim: To study the variables related with the emotional well-being of patients with and without cognitive impairment at the end of life and that of their primary family caregivers. Design: Cross- sectional study. Participants: Data was collected from 202 patients at the end of life with different diagnosis (COPD, cancer, and frail elderly) as well as from their respective 202 primary family caregivers. Results: Structural equation models indicated that the emotional state of the patients was best predicted by their functional independence and the burden of their family caregivers. In addition, the emotional state of the primary family caregiver was predicted by their burden and not by the cognitive state or the functional independence of the patient. Nevertheless, the burden of the family caregiver, which is the only variable predicting both the emotional state of the patient and that of the caregiver, was directly related with the functional independence of the patient and indirectly with the patient's cognitive state. Conclusion: The family caregiver's burden is an important factor to take into consideration when aiming to reduce the emotional distress of patients at the end of life with different diagnosis -whether or not they present significant cognitive impairment- and that of their family caregivers.

Pain assessment in individuals with dementia and communication problems in Spain. A systematic review

BACKGROUND AND OBJECTIVE

Pain assessment in individuals with advanced dementia and communication problems continue to be underdiagnosed and undertreated due to the difficulty in performing this assessment. This review explores and synthesises how pain in individuals with advanced dementia and communication problems are being assessed in the context of Spanish healthcare.

MATERIALS AND METHODS

A systematic review of the literature was conducted following the PRISMA criteria. We reviewed the databases of PubMed, Web of Science, Cinahl, Scopus, Dialnet and Cuitatge up to December 2017. Four independent reviewers identified studies that included instruments to assess pain in individuals with dementia and communication problems in the Spanish healthcare context. We performed a narrative synthesis of the included articles.

RESULTS

After applying the inclusion criteria, 10 studies were included. Of these, 4 were methodological studies validating Spanish versions of scales (Abbey, Algoplus, Doloplus and PAINAD-Sp), and 1 was on the development of the original EDAD scale. We also identified 3 studies conducted in Spain that used a translation of the PAINAD, 1 study that used a Spanish translation of Doloplus2 and 1 publication that included the use in Spain of a scale not validated for this patient profile (Pain-VAS).

CONCLUSIONS

There are currently several instruments validated in Spanish to assess pain in individuals with advanced dementia and communication problems (Abbey, Algoplus, Doloplus y PAINAD-Sp). However, these instruments have still not been widely used in research, and their psychometric properties could be improved.

Patients with limited communication in end-of-life situations: Initial psychometric properties of a discomfort observation scale

This work presents an observational scale which takes into account different observable indicators of discomfort of patients in end-of-life situations with difficulties in communicating due to cognitive impairment, fatigue or sedation and provides details of its validation. In all, 71 adults participated. Model fit was adequate (χ²(27) = 43.28, p = .024, comparative fit index = .975, root mean square error of approximation = .092 and confidence interval 90% (.033-.140)). Alpha coefficient was .70 and composite reliability index was .90. Our study provides data regarding the properties of a discomfort assessment scale. Such a scale is needed and could be very useful for the evaluation of such patients and thus to attend to their needs.

The extended palliative phase of dementia – An integrative literature review

This article presents an integrative literature review of the experience of dementia care associated with the extended palliative phase of dementia. The aim was to highlight how dementia is defined in the literature and describe what is known about the symptomatology and management of advanced dementia regarding the needs and preferences of the person with dementia and their family carer/s. There was no consistent definition of advanced dementia. The extended palliative phase was generally synonymous with end-of-life care. Advanced care planning is purported to enable professionals to work together with people with dementia and their families. A lack of understanding of palliative care among frontline practitioners was related to a dearth of educational opportunities in advanced dementia care. There are few robust concepts and theories that embrace living the best life possible during the later stages of dementia. These findings informed our subsequent work around the concept, ‘Dementia Palliare’.