The last week of life of nursing home residents with advanced dementia: a retrospective study

Implementing a transmural model of early palliative care in advanced dementia: the use of a hybrid effectiveness-implementation study design

BACKGROUND

People with dementia receive differential access to palliative care services despite suffering from a significant burden of the disease in the advanced stage. Professional and familial caregivers may not view dementia as a terminal illness and are less likely to engage in end-of-life care discussions. Healthcare providers also face challenges coordinating palliative care in the community for dementia, demonstrating a lack of understanding of the needs of patients living with advanced dementia, and resources available to support them within the community.

AIM

The aim of this study is to implement a transmural model of care in a tertiary care setting where patients living with advanced dementia (PLAD) at risk of deterioration in one year are identified early to receive tailored palliative care interventions using a predictive algorithm.

METHODS/DESIGN

The updated medical research council (MRC) framework for complex interventions is used to guide the development and implementation of the transmural model which incorporates a predictive algorithm in clinical practice, with interventions tailored for at risk PLAD both within, and beyond the tertiary care setting. The PROgnostic Model for Advanced DEmentia (PRO-MADE) developed to predict one-year all-cause mortality in PLAD presenting to an acute care hospital was embedded into the electronic health records of the tertiary care setting as a mathematical equation. Predictive modeling markup language in the digital records platform is used to calculate the risk score for PLAD by inputting the predictors. The clinical team is alerted of at risk PLAD through timed directive prompts, with advice on management given through tailored care bundles. The study will adopt a mixed methods approach in a Type 1 effectiveness-implementation study design to concurrently study the effectiveness of the transmural model in practice, and the barriers and facilitators to its implementation.

CONCLUSION

The implementation of a transmural model of early palliative care for patients with advanced dementia requires the coordination between clinicians in the tertiary care setting and community, together with health information technologists. This study protocol describes its development and implementation, and the study design to evaluate its outcomes.

Impact of the COVID-19 Pandemic on the Perceived Quality of Palliative Care in Nursing Homes

The Nursing Homes End-of-life Programme (NUHELP) was developed in 2017 and is based on quality standards of palliative care, but it was not implemented due to the outbreak of the COVID-19 pandemic.

OBJECTIVES

To describe perceptions among staff at nursing homes and primary health care (PHC) centres regarding the relevance, feasibility, and degree of achievement of quality standards for palliative care in nursing homes and to determine the differences in these perceptions before and after the pandemic.

METHODOLOGY

Cross-sectional descriptive study. Professionals at eight nursing homes and related PHC centres who participated in NUHELP development assessed 42 palliative care standards at two time points (2018 and 2022). The Mann-Whitney U test was applied to analyse differences in the scores between these two times and between perceptions at nursing homes and at PHC centres.

RESULTS

The study population consisted of 58 professionals in 2018 and 50 in 2022. The standard regarding communication with persons affected by the death of a family member was considered less relevant (p = 0.05), and that concerning the culturally sensitive and dignified treatment of the body was less fully achieved (p = 0.03) in 2022 than in 2018. Social support (p = 0.04), sharing information among the care team (p = 0.04), patient participation (p = 0.04) and information about the treatment provided (p = 0.03) were all more poorly achieved in 2022 than in 2018. The perceptions of nursing home and PHC workers differed in several respects.

CONCLUSIONS

Professional intercommunication and social support should be reinforced, and residents should be more actively involved in decision-making.

Mortality risks of body mass index and energy intake trajectories in institutionalized elderly people: a retrospective cohort study

Background

Many factors can identify the mortality risks of institutionalized elderly people; among all such factors, body mass index (BMI) and energy intake (EI) can be employed as independent predictors. The objective of this study was to elucidate about the mortality risks and the trajectory of two parameters obtained from continuously monitored data.

Methods

This retrospective cohort study targeted 218 elderly people who were admitted to a nursing home for at least 6 months between 2007 and 2020 and passed away at the nursing home. BMI and EI (kcal) per body weight (BW) were continuously measured until death.

Results

BMI continued to decrease for 5 years until death. The rate of change of BMI significantly increased for 3 years before death (P = 0.004). In contrast, the rate of change of EI per BW significantly increased after 1 year before death (P < 0.001); in addition, 2 months before death, this rate of change significantly exceeded that of BMI (P = 0.007). In the four risk groups that were examined, a BMI of <18.0 + EI per BW of <29.2 and a BMI of <17.3 + EI per BW of <28.3 were significantly correlated with a high risk of death (log-rank test: P < 0.001, P = 0.002, respectively). There was no significant difference in the hazard ratio based on the age at the time of admission; however, when EI per BW was <23.8, the risk of death was significantly higher [hazard ratio = 4.36; 95% confidence interval: 2.31–8.24].

Conclusions

Elderly people in the current study presented a tendency toward decreasing BMI starting 60 months prior to death even if EI per BW remained constant. In the 1 year before death, EI per BW rapidly decreased. When the rate of change of EI per BW exceeded the rate of decrease of BMI, it was considered to be the point of no return when death was imminent. Our study showed that identifying mortality risks from the relationship between the trajectories of the two parameters that were continuously measured for several months to years is possible.