Short-Term Opioid Treatment of Acute Locomotor Pain in Older Adults: Comparison of Effectiveness and Safety between Tramadol and Oxycodone: A Randomized Trial.

INTRODUCTION: We conducted a head-to-head comparison of step 2 (tramadol) and step 3 (oxycodone) of the WHO pain ladder in older adults with moderate to severe acute locomotor pain. MATERIALS AND METHODS: Multi-center prospective randomized study. Patients were 70 years or older, admitted to the acute geriatric ward of three hospitals, suffering from acute moderate to severe locomotor pain, and opioid-naive. Patients were randomized into two treatment groups: tramadol versus oxycodone. The Consort reporting guidelines were used. RESULTS: Forty-nine patients were included. Mean numeric rating scale (NRS) decreased significantly between day 0 and 2 of the inclusion in both groups. A sustained significant decrease in mean NRS was seen at day 7 in both groups. Nausea was significantly more prevalent in the tramadol group, with a trend towards a higher prevalence of delirium and falls and three serious adverse events in the same group. CONCLUSIONS: Opioid therapy may be considered as a short-term effective treatment for moderate to severe acute locomotor pain in older adults. Oxycodone may possibly be preferred for safety reasons. These results can have implications for geriatric practice, showing that opioids for treatment of acute moderate to severe locomotor pain in older patients are effective and safe if carefully monitored for side effects. Opioid therapy may be considered as a short-term treatment for moderate to severe acute locomotor pain in older adults, if carefully monitored for (side) effects, while oxycodone may possibly be preferred for safety reasons. These results can have implications for daily practice in geriatric, orthopedic, and orthogeriatric wards, as well as in terminal care, more precisely for the treatment of moderate to severe acute locomotor pain in older adults.

Opioids in geriatric units in 14 Belgian hospitals: prevalence, dosage and associated factors.

Introduction: Adverse effects of opioids are common among older individuals, and undertreatment as well as overuse can be an issue. Epidemiological data on opioid use in older individuals are available, but scarce in hospitalized patients.Aims: The aim of this study is to examine the one-day prevalence of opioid use among older inpatients and identify the factors associated with both opioid use and dosage.Materials and methods: One-day cross-sectional study with data collected from geriatric units across 14 Belgian hospitals. The primary focus of the study is to assess the prevalence of opioid use and dosage, along with identifying associated factors. To achieve this, a multiple binary logistic regression model was fitted for opioid use, and a multiple linear regression model for opioid dose.Results: Opioids were used in 24.4% of 784 patients, of which 57.9% was treated with tramadol, 13.2% with oxycodone or morphine and 28.9% with transdermal buprenorphine or fentanyl. The odds for opioid use were 4.2 times higher in patients in orthogeriatric units compared to other patients (OR=4.2, 95% CI=2.50-7.05). The prevalence of opioid use was 34% higher in patients without dementia compared to patients with dementia (OR=0.66, 95% CI=0.46-0.95). The overall mean daily dosage was 14.07mg subcutaneous morphine equivalent. After adjustment for age, gender and dementia, dosage was only associated with type of opioid: the estimated mean opioid dose was 70% lower with tramadol (mean ratio=0,30,95% CI=0,23-0,39) and 67% lower with oxycodone and morphine (mean ratio=0,33, 95% CI=0,22-0,48) compared to transdermal buprenorphine and transdermal fentanyl.Conclusions: One in four patients received opioid treatment. It is not clear whether this reflects under- or overtreatment, but these results can serve as a benchmark for geriatric units to guide future pain management practices. The utilization of transdermal fentanyl and buprenorphine, resulting in higher doses of morphine equivalent, poses significant risks for side effects.

Terminal care in oldest old dying from COVID-19 in the acute hospital : A multicenter study describing pharmacological treatment in the last 24 h.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has a high mortality, especially in the oldest old. Dying from COVID-19 is often characterized by symptoms such as breathlessness and agitation but data concerning medical treatment in the dying phase are limited. OBJECTIVE: This study describes the administration of oxygen, opioids and benzodiazepines in the last 24 h before death in patients 80 years or older dying from COVID-19 on acute hospital wards. MATERIAL AND METHODS: In this multi-centric retrospective study, patients, 80 years and older, admitted to the acute hospital in March and April 2020 were recruited from 10 acute Belgian hospitals. They all were diagnosed with COVID-19 and died on non-ICU wards with COVID-19. Administration of oxygen, opioids and benzodiazepines in the last 24 h before death was registered. RESULTS: Eighty-five percent of patients received oxygen, half of them even by means of a mask providing at least 10l oxygen per minute. The majority (84.3%) of patients were treated with opioids (morphine). Mean dosage of SC morphine equivalent was 31.3 mg/24 h (range 2-120 mg; SD 21.6 mg). More than half of patients (52.8%) received benzodiazepines, mostly midazolam. Mean dosage of midazolam was 20.4 mg/24 h (range 1-100 mg; SD 15.4 mg). Dosages of morphine and midazolam did not differ depending on frailty or comorbidities. Older COVID-19 patients dying with respiratory failure had higher midazolam dosage (p 0.002) but not morphine dosage (p 0.11). CONCLUSION: A high proportion of patients 80 years and older and dying with COVID-19 in the hospital, were treated with oxygen, opioids and benzodiazepines in the last 24 h before death. With this descriptive study, we hope to contribute to the discussion and further research on the optimization of symptom control in an older population dying from/with COVID-19.

Pharmacological treatment in the dying geriatric patient: describing use and dosage of opioids in the acute geriatric wards and palliative care units of three hospitals.

PURPOSE: The quality of dying of the older person could be optimized. One of the cornerstones to achieve better symptom control in the dying patient can be the use of opioids. However, little benchmark data concerning the use and dosage of opioids in the terminal phase in older persons are available. METHODS: In this multi-centric retrospective study, we included patients 75 years and older who died on the acute geriatric unit (AGU) and the palliative care unit (PCU) in three hospitals (during a 2-year period). Sudden deaths were excluded. Demographic and clinical variables, and data concerning use and dosage of opioids in the last 72 h before death were collected. RESULTS: Data from 556 patients were collected (38.5% from PCU, 61.5% from AGU). Older patients on the PCU were younger and suffered more frequently from end-stage malignancies. Most older patients on PCU (98.2%) received opioids with a mean dosage of 88.2 mg in 72 h. On the AGU, 75.5% of patients was treated with opioids with a mean dosage of 27.7 mg in 72 h. After adjusting for the variables age, gender and underlying pathology, use of opioids (OR 11.9; 95% CI 2.7-51.7; p = 0.022) and dosage (B 28.8; 95% CI 4.1-53.4; p = 0.001) still differed between the PCU and the AGU. Dosage of opioids was also associated with suffering from cancer or not. CONCLUSIONS: This descriptive benchmark study shows that opioids are given to 75.5% of dying older patients on the AGU at a mean dose of 27.7 mg over the last 72 h versus 98.2% and 88.2 mg, respectively, on the PCU. Further prospective studies including detailed information on symptomatology and more in-depth clinical information on trajectory of dying and cause of death are necessary.

Specialist palliative care services for older people in primary care: A systematic review using narrative synthesis.

BACKGROUND: There is recognition that older people with incurable conditions should have access to specialist palliative care services. However, it remains unclear which activities and outcomes these services entail for older people in primary care and to which patients they are provided. AIM: The aim of this review was to identify the criteria for referral to specialist services; who provides specialist palliative care; through which activities and with which frequency; which outcomes are reported; and which suggestions are made to improve services. DESIGN: Systematic review of the literature and narrative synthesis. Quality appraisal and selection of studies were performed independently by two researchers. Participant characteristics, intervention features, outcome data and suggestions for improvement were retrieved. DATA SOURCES: Embase, Medline, Web of Science, Cochrane, Google Scholar, PsycINFO and CINAHL EBSCO databases (until June 2019). RESULTS: Ten eligible articles, three qualitative, three quantitative, three mixed-method and one narrative review, were identified. Referral criteria were mainly based on patient characteristics such as diagnosis. The specialist services involved a variety of activities and outcomes and descriptions were often lacking. Services could be improved regarding the information flow between healthcare professionals, greater in-depth palliative care knowledge for case managers and social workers, identification of a key worker and support for family carers. CONCLUSION: The limited evidence available shows areas for improvement of the quality of and access to specialist services for older people, such as support for family carers. In addition, this review underscores the need for comprehensive reporting of interventions and the use of consensus-based outcome measures.

Development and Validation of the Symptom Assessment to Improve Symptom Control for Institutionalized Elderly Scale.

OBJECTIVES: To validate a newly developed multiple symptom self-assessment tool in nursing homes. DESIGN: Thirty prevalent symptoms identified in the literature were classified by a 2-round Delphi procedure to a top 10 of the most relevant, burdensome symptoms. Because no existing symptom scale fully covered this top 10, we developed a new scale, consisting of a horizontal numerical scale for the top 10 symptoms, with the possibility to add and rate 3 other symptoms. This scale was validated. SETTING AND PARTICIPANTS: Hundred seventy-four participants, mean age 85 (±5.94) years, were recruited from 7 nursing homes (86%) and 3 acute geriatric wards (14%). METHODS: To test the construct validity, participants with and without a palliative status were enrolled. Participants completed the Symptom Assessment to Improve Symptom Control for Institutionalized Elderly (SATISFIE) scale on day 0 and day 1 (intrarater reliability). Nurses completed the scale on day 0 (inter-rater reliability). Descriptive statistics described the characteristics of the study population and symptom scores. Differences in symptom scores between palliative and nonpalliative participants were analyzed with the Mann-Whitney U test. Intrarater and inter-rater reliability were calculated by means of an intraclass correlation coefficient. Factor analysis searched for possible symptom clusters. Feasibility was evaluated by measuring the assessment time and by providing a questionnaire for the nurses. RESULTS: In the nonpalliative group (n = 130), the highest self-rated median scores were pain on day 1 [median 3, interquartile range (IQR) 0-5] and pain on day 2. In the palliative group (n = 44), the highest median self-rated scores were fatigue on day 1 [median 5 (IQR 0-6)], lack of energy on day 1 and 2 [both median 5 (IQR 0-8)]; and depressed feeling on day 2 [median 3 (IQR 0-5)]. Nurse assessments median scores were the highest for depressed feeling [median 5 (IQR 1-7)], fatigue [median 4.5 (IQR 0-6.5)], and lack of energy, [median 3 (IQR 0-6)] in the palliative group. In the nonpalliative group, none of the median scores was 3 or more. Intraclass correlation coefficients for intrarater reliability varied between 0.65 and 0.89 and for inter-rater reliability (patients-nurses) between 0.18 and 0.63. Mean assessment time for nurses was 2.0 minutes [standard deviation (SD) = 1.01]. For participants, it decreased from 10.5 minutes (SD = 5.41) at the first assessment to 7.5 minutes (SD = 3.72) at the second assessment. Nurses determined the SATISFIE instrument to be useful, applicable in daily practice, and sufficiently comprehensible for the patients. CONCLUSIONS: The SATISFIE scale is a valid and feasible instrument for regular, multiple symptom assessment in institutionalized older persons.

A Typology of Interprofessional Teamwork in Acute Geriatric Care: A Study in 55 units in Belgium.

OBJECTIVES: To explore the quality of interprofessional teamwork in acute geriatric care and to build a model of team types. DESIGN: Cross-sectional multicenter study. SETTING: Acute geriatric units in Belgium. PARTICIPANTS: Team members of different professional backgrounds. MEASUREMENTS: Perceptions of interprofessional teamwork among team members of 55 acute geriatric units in Belgium were measured using a survey covering collaborative practice and experience, managerial coaching and open team culture, shared reflection and decision-making, patient files facilitating teamwork, members' belief in the power of teamwork, and members' comfort in reporting incidents. Cluster analysis was used to determine types of interprofessional teamwork. Professions and clusters were compared using analysis of variance. RESULTS: The overall response rate was 60%. Of the 890 respondents, 71% were nursing professionals, 20% other allied health professionals, 5% physicians, and 4% logistic and administrative staff. More than 70% of respondents scored highly on interprofessional teamwork competencies, consultation, experiences, meetings, management, and results. Fewer than 55% scored highly on items about shared reflection and decision-making, reporting incidents from a colleague, and patient files facilitating interprofessional teamwork. Nurses in this study rated shared reflection and decision-making lower than physicians on the same acute geriatric units (P < .001). Using the mean score on each of the six areas, four clusters that differed significantly in all areas were identified using hierarchical cluster analysis and scree plot analysis (P < .001). CONCLUSION: Interprofessional teamwork in acute geriatric units is satisfactory, but shared reflection and decision-making needs improvement. Four types of interprofessional teamwork are identified and can be used to benchmark the teamwork of individual teams.

Priority topics for European multidisciplinary guidelines on the management of chronic kidney disease in older adults.

PURPOSE: To identify and prioritize potential topics to be addressed in the development of European multidisciplinary guidelines on the management of chronic kidney disease stage 3b-5 in older patients. METHODS: We composed a list of 47 potential guideline topics by reviewing the literature, consulting online 461 nephrologists and 107 geriatricians, and obtaining expert input. A multidisciplinary panel of twelve experts then prioritized the topics during a face-to-face consensus meeting, following a nominal group technique structure with two voting rounds. Topics were rated on a 9-point scale ranging from 1 ('not at all important') to 9 ('critically important'). RESULTS: The highest rating (median; range) was assigned to 'Screening and referral' (8.5; 2.0). Eight topics shared the second highest rating with a median priority score of 8.0 (2.0) and included 'Starting dialysis or not' and 'Accurate assessment of renal function.' 'Targets for and treatment of diabetes' received the lowest rating with (3.0; 6.0). CONCLUSIONS: This joint initiative of the European Renal Association-European Dialysis Transplant Association (ERA-EDTA) and the European Union Geriatric Medicine Society (EUGMS) prioritized the development of guidance on interdisciplinary referral of older patients with chronic kidney disease stage 3b-5. Future guidance will therefore focus on identifying prognostic scores to predict death and progression to end-stage renal disease, as well as accurate tests for assessment of renal function in older kidney patients. This will contribute to more informed treatment decision making in this growing patient population.

Prescription and Deprescription of Medication During the Last 48 Hours of Life: Multicenter Study in 23 Acute Geriatric Wards in Flanders, Belgium.

CONTEXT: Palliative care for the older person is often limited, resulting in poor quality of dying. Pharmacological management can be one of the components to achieve better symptom control. OBJECTIVES: To describe the anticipatory prescription of medication for symptomatic treatment and the deprescription of potentially inappropriate medication during the last days of life. METHODS: This was a cross-sectional descriptive study between October 1, 2012 and September 30, 2013 in 23 acute geriatric wards in Flanders, Belgium. Structured after-death questionnaires were filled out by the treating geriatrician for patients hospitalized for more than 48 hours before dying. RESULTS: Anticipatory prescription of medication was present in 65.4% of cases, 45.5% of the cases was prescribed morphine, 15.5% benzodiazepines, and 13.8% scopolamine hydrobromide. A deprescription of potentially inappropriate medication was noted in 67.9% of cases. The likelihood of anticipatory prescription was significantly higher in cases where death was expected (odds ratio [OR] 19; 95% CI 9-40; P < 0.0001) and significantly lower where dementia was present (OR 0.35; 95% CI 0.16-0.74; P < 0.006). The likelihood of deprescription was higher in cases where death was expected (OR 20; 95% CI 10-43; P < 0.0001) and in cases of patients dying from an oncological disease compared with those dying from frailty or dementia (OR 7.0; 95% CI 1.1-45.6, P = 0.042). CONCLUSION: Anticipatory prescription of medication and deprescription of medication at the end of life in acute geriatric wards could be further optimized. A well-developed intervention to guide health care staff in patient-centered pharmacological management in the last days of life seems to be needed.

Caring for Family Members Older Than 50 Years of Turkish and Northwest African Descent: The Meaning of Caregiving.

BACKGROUND: The first generation of immigrants to Belgium from Turkey and Northwest Africa are aging and at risk for developing cancer. Family members play an important role in both illness and old age. OBJECTIVE: The objective of this study was to gain insight into experiences and perceptions of families with Turkish or Northwest African backgrounds who were caring for cancer patients older than 50 years in Flanders, Belgium. METHODS: A qualitative research design with elements of constructivist grounded theory was used. Twenty-eight loosely structured interviews were conducted. Three researchers were involved in data analysis (researcher triangulation), and 6 conversations took place with experts. RESULTS: Cancer appeared to be a family matter. Caregiving had a strong moral meaning for all participants, particularly for children providing care to a parent. Caregiving could be described as "guiding": family members led the patient through, or familiarized the patient with, the healthcare system. There were strong differences in the extent to which family members believed they should provide care, as well as the kind of professional care considered desirable. CONCLUSIONS: Despite shared values of the importance of family and family caregiving, concrete ideas about caregiving differed considerably. The findings imply that shared cultural or religious normative values do not predict day-to-day care practices. IMPLICATIONS FOR PRACTICE: This study provides new insights into the moral and practical meaning of caregiving, which will help professionals understand the roles adopted by family members. Furthermore, individualized approaches to care appear to be essential, because concrete ideas about informal caregiving differ strongly despite shared values.

Tools to Assess Pain or Lack of Comfort in Dementia: A Content Analysis.

CONTEXT: There is need for tools to help detect pain or lack of comfort in persons unable to communicate. However, pain and (dis)comfort tools have not been compared, and it is unclear to what extent they discriminate between pain and other possible sources of discomfort, or even if items differ. OBJECTIVES: To map and compare items in tools that assess pain and the broader notion of discomfort or comfort in people with severe dementia or at the end of life. METHODS: Using qualitative content analysis with six classifications, we categorized each item of four thoroughly tested observational pain tools (Pain Assessment in Advanced Dementia [PAINAD], Pain Assessment Checklist for Seniors with Limited Ability to Communicate [PACSLAC], Doloplus-2, and draft Pain Assessment in Impaired Cognition [PAIC]), and four discomfort tools (including distress, comfort, and quality of life in severe dementia or at the end of life; Discomfort Scale-Dementia Alzheimer Type [DS-DAT], Disability Distress Assessment Tool [DisDAT], End-of-Life in Dementia-Comfort Assessment in Dying with Dementia [EOLD-CAD], and Quality of Life in Late-Stage Dementia [QUALID] scale). We calculated median proportions to compare distributions of categories of pain and discomfort tools. RESULTS: We found that, despite variable content across tools, items from pain and discomfort tools overlapped considerably. For example, positive elements such as smiling and spiritual items were more often included in discomfort tools but were not unique to these. Pain tools comprised more "mostly descriptive" (median 0.63 vs. 0.44) and fewer "highly subjective" items (0.06 vs. 0.18); some used time inconsistently, mixing present and past observations. CONCLUSION: This analysis may inform a more rigorous theoretical underpinning and (re)development of pain and discomfort tools and calls for empirical testing of a broad item pool for sensitivity and specificity in detecting and discriminating pain from other sources of discomfort.

Perspectives of family members on planning end-of-life care for terminally ill and frail older people.

CONTEXT: Advance care planning (ACP) is the process by which patients, together with their physician and loved ones, establish preferences for future care. Because previous research has shown that relatives play a considerable role in end-of-life care decisions, it is important to understand how family members are involved in this process. OBJECTIVES: To gain understanding of the involvement of family members in ACP for older people near the end of life by exploring their views and experiences concerning this process. METHODS: This was a qualitative research study, done with semistructured interviews. Twenty-one family members were recruited from three geriatric settings in Flanders, Belgium. The data were analyzed using the constant comparative method as proposed by the grounded theory. RESULTS: Family members took different positions in the ACP process depending on how much responsibility the family member wanted to take and to what extent the family member felt the patient expected him/her to play a part. The position of family members on these two dimensions was influenced by several factors, namely acknowledgment of the imminent death, experiences with death and dying, opinion about the benefits of ACP, burden of initiating conversations about death and dying, and trust in health care providers. Furthermore, the role of family members in ACP was embedded in the existing relationship patterns. CONCLUSION: This study provides insight into the different positions of family members in the end-of-life care planning of older patients with a short life expectancy. It is important for health care providers to understand the position of a family member in the ACP of the patient, take into account that family members may experience an active role in ACP as burdensome, and consider existing relationship patterns.

Aged parents' experiences during a critical illness trajectory and after the death of an adult child: a review of the literature.

BACKGROUND: Given the growing life expectancy, the likelihood increases that health-care providers are confronted with older people having an adult child with a life-limiting disease. AIM: This literature review aimed to (1) explore the experiences of aged parents with regard to their position and role as a parent of an adult child with a life-limiting illness, (2) detect gaps in the existing literature and (3) make recommendations for future research. DESIGN: A literature search of English articles, including both quantitative and qualitative designs. DATA SOURCES: Four electronic databases and the reference lists of included studies. RESULTS: In total, 19 studies (7 quantitative and 12 qualitative) were included. Few studies describe the experiences of older people whose adult child has cancer or has died of cancer. Existing studies are merely descriptive and give no concrete recommendations for health-care providers in daily practice. The studies suggest that aged parents carry deep burdens from the prospect of losing their adult child. Aged parents want to stay involved but need to reconfigure their parent role. As soon as the cancer diagnosis is disclosed, parents are confronted with a re-awakening of parental nurturing, which clashes with the autonomy of the adult child. Even after the adult child is deceased, older parents retain the image of themselves as parents. CONCLUSIONS: There is a need for more in-depth research to understand the lived experience of these parents and what health-care providers can do to assist them.

Advance Care Planning in terminally ill and frail older persons.

OBJECTIVE: Advance Care Planning (ACP) - the communication process by which patients establish goals and preferences for future care - is encouraged to improve the quality of end-of-life care. Gaining insight into the views of elderly on ACP was the aim of this study, as most studies concern younger patients. METHODS: We conducted and analysed 38 semi-structured interviews in elderly patients with limited prognosis. RESULTS: The majority of participants were willing to talk about dying. In some elderly, however, non-acceptance of their nearing death made ACP conversations impossible. Most of the participants wanted to plan those issues of end-of-life care related to personal experiences and fears. They were less interested in planning other end-of-life situations being outside of their power of imagination. Other factors determining if patients proceed to ACP were trust in family and/or physician and the need for control. CONCLUSIONS: ACP is considered important by most elderly. However, there is a risk of pseudo-participation in case of non-acceptance of the nearing death or planning end-of-life situations outside the patient's power of imagination. This may result in end-of-life decisions not reflecting the patient's true wishes. PRACTICE IMPLICATIONS: Before engaging in ACP conversations, physicians should explore if the patient accepts dying as a likely outcome. Also the experiences and fears concerning death and dying, trust and the need for control should be assessed.

End-of-life care of the geriatric patient and nurses' moral distress.

OBJECTIVES: Moral distress (MD) occurs when the health care provider feels certain of the ethical course of action but is constrained from taking that action. The purpose was to examine MD in geriatric nursing care and to identify factors related to MD. DESIGN: Cross-sectional survey. SETTING: Twenty nursing homes and 3 acute geriatric wards in Flanders (Belgium). PARTICIPANTS: Participants were 222 nurses providing geriatric care. MEASUREMENTS: Moral distress was assessed with an 18-item questionnaire, adapted from the Moral Distress Scale. Multivariate linear regression analysis was used to identify key factors (situational, work, and personal factors) related to MD. RESULTS: The response rate was 57%. The frequency score of MD was 1.1 (mean, range 0-4) and the intensity score of MD was 2.3 (mean, range 0-4). Nurses identified situations involving unjustifiable life support (mean product score MPS 4.8), unnecessary tests and treatments (MPS 4.4), and working with incompetent colleagues (MPS 4.3) as causing the most MD. Responding to requests for euthanasia (MPS 0.8) and increasing morphine in an unconscious patient believed to hasten death (MPS 1.2) were least likely to cause MD. The total MD score (sum of the 18 product scores) was significantly higher in nurses with intentional or actual job-leave (mean difference = 15.1, t = -3.5, P = .001). After adjusting for demographic factors, the following factors were independently associated with elevated MD: working in an acute geriatric care setting (as compared with the chronic geriatric care setting), a lack of involvement in end-of-life decisions, a lack of ethical debate, and specific measures of burnout (emotional exhaustion and personal accomplishment). CONCLUSION: Providing futile and inadequate care contributes to moral distress more than euthanasia and believing to hasten an unconscious patient's death by increasing morphine in geriatric end-of-life care. Nurses' moral distress is related to situational and work characteristics as well as to burnout and job-leave.

Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians.

CONTEXT: Clinicians in intensive care units (ICUs) who perceive the care they provide as inappropriate experience moral distress and are at risk for burnout. This situation may jeopardize patient quality of care and increase staff turnover. OBJECTIVE: To determine the prevalence of perceived inappropriateness of care among ICU clinicians and to identify patient-related situations, personal characteristics, and work-related characteristics associated with perceived inappropriateness of care. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional evaluation on May 11, 2010, of 82 adult ICUs in 9 European countries and Israel. Participants were 1953 ICU nurses and physicians providing bedside care. MAIN OUTCOME MEASURE: Perceived inappropriateness of care, defined as a specific patient-care situation in which the clinician acts in a manner contrary to his or her personal and professional beliefs, as assessed using a questionnaire designed for the study. RESULTS: Of 1651 respondents (median response rate, 93% overall; interquartile range, 82%-100% [medians 93% among nurses and 100% among physicians]), perceived inappropriateness of care in at least 1 patient was reported by 439 clinicians overall (27%; 95% CI, 24%-29%), 300 of 1218 were nurses (25%), 132 of 407 were physicians (32%), and 26 had missing answers describing job title. Of these 439 individuals, 397 reported 445 situations associated with perceived inappropriateness of care. The most common reports were perceived disproportionate care (290 situations [65%; 95% CI, 58%-73%], of which "too much care" was reported in 89% of situations, followed by "other patients would benefit more" (168 situations [38%; 95% CI, 32%-43%]). Independently associated with perceived inappropriateness of care rates both among nurses and physicians were symptom control decisions directed by physicians only (odds ratio [OR], 1.73; 95% CI, 1.17-2.56; P = .006); involvement of nurses in end-of-life decision making (OR, 0.76; 95% CI, 0.60-0.96; P = .02); good collaboration between nurses and physicians (OR, 0.72; 95% CI, 0.56-0.92; P = .009); and freedom to decide how to perform work-related tasks (OR, 0.72; 95% CI, 0.59-0.89; P = .002); while a high perceived workload was significantly associated among nurses only (OR, 1.49; 95% CI, 1.07-2.06; P = .02). Perceived inappropriateness of care was independently associated with higher intent to leave a job (OR, 1.65; 95% CI, 1.04-2.63; P = .03). In the subset of 69 ICUs for which patient data could be linked, clinicians reported received inappropriateness of care in 207 patients, representing 23% (95% CI, 20%-27%) of 883 ICU beds. CONCLUSION: Among a group of European and Israeli ICU clinicians, perceptions of inappropriate care were frequently reported and were inversely associated with factors indicating good teamwork.

Serum cystatin C concentration compared with other markers of glomerular filtration rate in the old old.

OBJECTIVES: To assess serum cystatin C, compared with other markers of renal function, as a marker of renal function in the old old (aged 85 and older). DESIGN: A cross-sectional analysis of data obtained in medically stable people aged 70 and older in a geriatric ward at a university hospital. SETTING: University hospital in Belgium. PARTICIPANTS: Forty-eight patients (17 men, 31 women) mean age +/- standard deviation 84.4 +/- 6.3 without acute illness or overt malignancy 7 days after admission were included. Twenty-five patients were aged 85 and older. MEASUREMENTS: Blood samples and 24-hour urine collections were obtained from each patient to determine serum creatinine, serum cystatin C levels, serum albumin, and creatinine clearance. Glomerular filtration rate (GFR) was estimated using the Cockcroft-Gault formula and the Modification of Diet in Renal Study Group (MDRD) formula. On the same day, clearance of 51chromium ethylenediamine tetraacetic acid was performed in all patients as the criterion standard of GFR. RESULTS: Serum creatinine (r=0.68), serum cystatin C (r=0.62), urinary creatinine clearance (r=0.57), the Cockcroft-Gault formula (r=0.82), and the MDRD-formula (r=0.65) correlated significantly with GFR (P <.0001). Regression analysis showed that serum cystatin C and serum creatinine were comparable markers of renal function (Y=0.442 +/- 0.007 x GFR and Y=0.494 +/- 0.01 x GFR respectively). Receiver operating characteristic analysis showed a similar area under the curve for serum cystatin C and serum creatinine (P=.5) in detecting renal impairment (GFR <80 mL/min). The Cockcroft-Gault formula provides a good estimation of GFR when the GFR is less than 60 mL/min (Y=1.11 +/- 1.04 x GFR). When the GFR is greater than 60 mL/min, the Cockcroft-Gault formula underestimates GFR (Y=11.01 +/- 0.66 x GFR). In patients aged 85 and older, a slight decrease in GFR (51.8 +/- 21.3 mL/min vs 65.2 +/- 34.3 mL/min in patients aged 70-84; P=.10) is observed. This is reflected by a nonsignificant increase in serum cystatin C (P=.06), whereas serum creatinine is identical in both groups (P=.88). CONCLUSION: Serum cystatin C, serum creatinine, the Cockcroft-Gault formula, the MDRD formula, and urinary creatinine clearance are comparable markers of renal function in the overall older population. The Cockcroft-Gault formula underestimates renal function in older people with GFR greater than 60 mL/min. In our study, serum cystatin C was not superior to serum creatinine in the detection of renal impairment.