Evaluation of the Strengthening a Palliative Approach in Long Term Care (SPA-LTC) programme: a protocol of a cluster randomised control trial.

INTRODUCTION: Despite the high mortality rates in long-term care (LTC) homes, most do not have a formalised palliative programme. Hence, our research team has developed the Strengthening a Palliative Approach in Long Term Care (SPA-LTC) programme. The goal of the proposed study is to examine the implementation and effectiveness of the SPA-LTC programme. METHODS AND ANALYSIS: A cross-jurisdictional, effectiveness-implementation type II hybrid cluster randomised control trial design will be used to assess the SPA-LTC programme for 18 LTC homes (six homes within each of three provinces). Randomisation will occur at the level of the LTC home within each province, using a 1:1 ratio (three homes in the intervention and control groups). Baseline staff surveys will take place over a 3-month period at the beginning for both the intervention and control groups. The intervention group will then receive facilitated training and education for staff, and residents and their family members will participate in the SPA-LTC programme. Postintervention data collection will be conducted in a similar manner as in the baseline period for both groups. The overall target sample size will be 594 (297 per arm, 33 resident/family member participants per home, 18 homes). Data collection and analysis will involve organisational, staff, resident and family measures. The primary outcome will be a binary measure capturing any emergency department use in the last 6 months of life (resident); with secondary outcomes including location of death (resident), satisfaction and decisional conflict (family), knowledge and confidence implementing a palliative approach (staff), along with implementation outcomes (ie, feasibility, reach, fidelity and perceived sustainability of the SPA-LTC programme). The primary outcome will be analysed via multivariable logistic regression using generalised estimating equations. Intention-to-treat principles will be used in the analysis. ETHICS AND DISSEMINATION: The study has received ethical approval. Results will be disseminated at various presentations and feedback sessions; at provincial, national and international conferences, and in a series of manuscripts that will be submitted to peer-reviewed, open access journals. TRIAL REGISTRATION NUMBER: NCT039359.

Correlates of Opioid Use Among Ontario Long-Term Care Residents and Variation by Pain Frequency and Intensity: A Cross-sectional Analysis.

BACKGROUND: Chronic non-cancer pain is common among older residents of long-term care (LTC) homes and often poorly recognized and treated. With heightened concerns regarding opioid prescribing in recent years, it is important to examine the current prevalence of opioid use and its association with resident characteristics to help identify those potentially at risk of medication harms as well as suboptimal pain management. OBJECTIVES: The aims were to estimate the prevalence and correlates of opioid use among non-palliative LTC residents and explore variation in opioid prevalence and correlates across strata defined by pain frequency and intensity. METHODS: We conducted a population-based cross-sectional study of all older (aged > 65 years) LTC residents (excluding those with cancer or receiving palliative care) in Ontario, Canada during 2018-2019. Health administrative databases were linked with standardized clinical assessment data to ascertain residents' health and pain characteristics and their opioid and other medication use. Modified Poisson regression models estimated unadjusted and adjusted associations between residents' characteristics and opioid use, overall and across strata capturing pain frequency and intensity. RESULTS: Among 75,020 eligible residents (mean age 85.1 years; 70% female), the prevalence of opioid use was 18.5% and pain was 29.4%. Opioid use ranged from 12.2% for residents with no current pain to 55.7% for those with severe pain. In adjusted models, residents newly admitted to LTC (adjusted risk ratio [aRR] = 0.60, 95% confidence interval [CI] 0.57-0.62) and with moderate to severe cognitive impairment (aRR = 0.69, 95% CI 0.66-0.72) or dementia (aRR = 0.76, 95% CI 0.74-0.79) were significantly less likely to receive an opioid, whereas residents with select conditions (e.g., arthritis, aRR = 1.37, 95% CI 1.32-1.41) and concurrently using gabapentinoids (aRR = 1.80, 95% CI 1.74-1.86), benzodiazepines (aRR = 1.33, 95% CI 1.28-1.38), or antidepressants (aRR = 1.31, 95% CI 1.27-1.35) were significantly more likely to receive an opioid. The associations observed for residents newly admitted, with dementia, and concurrently using gabapentinoids, benzodiazepines, or antidepressants were largely consistent across all pain strata. CONCLUSIONS: Our findings describe resident sub-groups at potentially higher risk of adverse health outcomes in relation to both opioid use and non-use. LTC clinical and policy changes informed by research are required to ensure the appropriate recognition and management of non-cancer pain in this setting.

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.

Muscled by the System: Informal Caregivers' Experiences of Transitioning an Older Adult into Long-term Care.

ABSTRACTThis study explored informal caregivers' experiences of transitioning an older adult into long-term care (LTC). Qualitative description guided our analysis of semi-structured interviews with 13 informal caregivers of older adults from three LTC homes in southern Ontario. Our findings illustrate that caregivers experience chronic worry and burden before deciding on, or requiring to apply for, LTC. A sense of lack of control was a prominent theme, especially when caregivers were applying for LTC beds. Participants perceived pushing, pressure, and punishment from the health care system and felt relieved and fortunate after they accepted a bed offer. This tumultuous experience stimulated caregivers to anticipate future transitions. It is recommended that caregivers receive preparation and targeted support to manage transition experiences. Improved communication among health professionals is essential. Penalties for declining an offer for a bed in LTC should be re-examined in relation to its negative influence on caregivers' experiences.

Quasi-experimental evaluation of a multifaceted intervention to improve quality of end-of-life care and quality of dying for patients with advanced dementia in long-term care institutions.

BACKGROUND: Improvement in the quality of end-of-life care for advanced dementia is increasingly recognized as a priority in palliative care. AIM: To evaluate the impact of a multidimensional intervention to improve quality of care and quality of dying in advanced dementia in long-term care facilities. DESIGN: Quasi-experimental study with the intervention taking place in two long-term care facilities versus usual care in two others over a 1-year period. The intervention had five components: (1) training program to physicians and nursing staff, (2) clinical monitoring of pain using an observational pain scale, (3) implementation of a regular mouth care routine, (4) early and systematic communication with families about end-of-life care issues with provision of an information booklet, and (5) involvement of a nurse facilitator to implement and monitor the intervention. Quality of care was assessed with the Family Perception of Care Scale. The Symptom Management for End-of-Life Care in Dementia and the Comfort Assessment in Dying scales were used to assess the quality of dying. PARTICIPANTS: A total of 193 residents with advanced dementia and their close family members were included (97 in the intervention group and 96 in the usual care group). RESULTS: The Family Perception of Care score was significantly higher in the intervention group than in the usual care group (157.3 vs 149.1; p = 0.04). The Comfort Assessment and Symptom Management scores were also significantly higher in the intervention group. CONCLUSIONS: Our multidimensional intervention in long-term care facilities for patients with terminal dementia resulted in improved quality of care and quality of dying when compared to usual care.

A qualitative investigation of the roles and perspectives of older patients with advanced cancer and their family caregivers in managing pain in the home.

BACKGROUND: Pain in advanced cancer is complex and multifaceted. In older patients comorbidities and age-related functional decline add to the difficulties in managing cancer pain. The current emphasis on care in the community, and preference by patients with life-limiting disease to receive care in the home, has meant that patients and their family caregivers have become increasingly responsible for the day-to-day management of cancer pain. An appreciation of patients' and caregivers' roles and perspectives managing pain is, therefore, fundamental to addressing cancer pain in this setting. Consequently, we sought to explore and describe their perspectives and roles. METHODS: A qualitative descriptive approach was used. Semi-structured interviews were conducted with a purposeful sample of patient- family caregiver dyads. Participants included 18 patients aged 65 years and over, with advanced cancer, receiving palliative care at home, and 15 family caregivers. The interview data were analysed using thematic analyses. Strategies were used to establish rigour. RESULTS: Two main themes were identified. The first theme, "Communicating the pain", represented pain assessment and incorporated four subthemes in which participants described: their roles in pain assessment, the identification and expression of pain, and the communication of pain between patients and caregivers. The second theme, "Finding a solution", comprised of four subthemes that reflected participants' roles and approaches in controlling pain; as well as their beliefs about cancer pain control, experience with side effects, and perspectives on the goals of treatment. CONCLUSIONS: The findings support other studies in identifying knowledge and attitudinal barriers to pain control; while adding to the literature by highlighting practical and relational barriers faced by older patients and their family caregivers. Health care professionals can do much to address the barriers identified by: correcting misconceptions regarding cancer pain, facilitating the communication of pain within dyads, and ensuring that patients and family caregivers have the knowledge, skills, and ability to assess and implement pain treatment strategies. This support needs to be individually tailored to meet the ongoing needs of both members of the dyad so that the shared goals of pain management are accomplished.

Attractiveness, diagnostic ambiguity, and disability cues impact perceptions of women with pain.

PURPOSE/OBJECTIVE: This experimental study investigated how physical attractiveness, disability cue, and diagnostic ambiguity stereotypes impact perceptions of a patient's pain/disability and personality. RESEARCH METHOD/DESIGN: After viewing photographs of women pictured with or without a cane, accompanied by descriptions of the women's diagnosis (fibromyalgia or rheumatoid arthritis), 147 university students rated the women's pain/disability and personality. RESULTS: Analyses revealed that more attractive women received lower ratings on pain/disability and higher ratings (more positive) on personality. Moreover, those pictured with a disability cue got higher ratings on both pain/disability and personality, and those with medical evidence of pathology (less ambiguity) got higher ratings on pain/disability and lower ratings on personality. Examination of the 3 stereotypes in a single study enabled an evaluation of their interactions. An Attractiveness × Disability Cue × Diagnostic Ambiguity interaction for ratings of pain/disability revealed that the presence of both medical evidence and a disability cue were needed to override the strong "beautiful is healthy" stereotype. Significant 2-way interactions for ratings of personality indicated that the impact of the disability stereotype tends to be overshadowed by the attractiveness stereotype. CONCLUSION/IMPLICATIONS: The results indicate that these stereotypes have a large effect on perceptions of women with chronic pain and that attractiveness, a contextual variable unrelated to the pain experience, exerts an even stronger effect when there is less objective information available. This could have clinical ramifications for assessment and treatment of patients with chronic pain, which often occurs in the absence of "objective" medical evidence or any external cues of disability.

Improving pain assessment practices and outcomes in long-term care facilities: a mixed methods investigation.

An ongoing concern in long-term care (LTC) is that pain problems are often not identified correctly. There is also evidence that behavioral disturbance due to pain is misattributed to psychiatric conditions and consequently frequently treated with psychotropic rather than analgesic medication. This can result in unnecessary polypharmacy and ineffective pain management. In a previous study, implementation of a pain assessment protocol resulted in changes in administration of pro re nata (PRN) medications and positive outcomes. However, there were no changes in regularly scheduled medications suggesting that assessment results were either not communicated to the prescribing physicians or not taken into account. The goal of this study was to determine whether a pain assessment protocol, augmented with communication of the assessment results to the residents' physicians, affects prescriptions of analgesic and psychotropic medication. Psychotropic medication reduction would help address the problem of polypharmacy frequently seen in LTC facilities. PRN medications were also examined. This investigation involved a two group design (control vs. assessment). A mixed methods analysis included both quantitative and qualitative procedures. At the end of the study, residents in the pain assessment group were administered fewer psychotropic medications than patients in the control group, helping address the problem of polypharmacy. Pain levels were comparable between the groups. Health care staff indicated that the protocol resulted in more careful evaluation of residents' pain and greater appropriateness of prescriptions including reductions in polypharmacy.

Cancer-related pain in older adults receiving palliative care: patient and family caregiver perspectives on the experience of pain.

BACKGROUND: Despite an emphasis on pain management in palliative care, pain continues to be a common problem for individuals with advanced cancer. Many of those affected are older due to the disproportionate incidence of cancer in this age group. There remains little understanding of how older patients and their family caregivers perceive patients' cancer-related pain, despite its significance for pain management in the home setting. OBJECTIVES: To explore and describe the cancer pain perceptions and experiences of older adults with advanced cancer and their family caregivers. METHODS: A qualitative descriptive approach was used to describe and interpret data collected from semistructured interviews with 18 patients (≥65 years of age) with advanced cancer receiving palliative care at home and their family caregivers. RESULTS: The main category 'Experiencing cancer pain' incorporated three themes. The theme 'Feeling cancer pain' included the sensory aspects of the pain, its origin and meanings attributed to the pain. A second theme, 'Reacting to cancer pain', included patients' and family caregivers' behavioural, cognitive (ie, attitudes, beliefs and control) and emotional responses to the pain. A third theme, 'Living with cancer pain' incorporated individual and social-relational changes that resulted from living with cancer pain. CONCLUSIONS: The findings provide an awareness of cancer pain experienced by older patients and their family caregivers within the wider context of ongoing relationships, increased patient morbidity and other losses common in the aged.

Use of vitamin and mineral supplements in long-term care home residents.

Vitamin-mineral supplementation may offer older adults health and cognition-related benefits but overuse may contribute to polypharmacy. We examined the prevalence of supplement usage in long-term care facility (LTC) residents (≥ 65 years of age). As cognition may be affected by nutrition, we also examined use in those with diagnosis of dementia and those with no dementia diagnosis. The prevalence of supplement usage and overall "pill count" from pharmaceutical use was assessed in 189 LTC residents and a subsample of 56 older adults with dementia diagnosis, respectively. Participants were residing in an LTC facility of a mid-size metropolitan area during 2009. The average use of supplements was 1.0 per day for all residents, with 35% taking vitamin D supplements, 20% multivitamins, and 26% calcium. Supplement use was similar (p ≥ 0.05) for those with dementia diagnosis (53%, average 2.0 per day) and for those without such diagnosis (45%, average 2.2 per day). Usage ranged between 1-6 supplements per day. In both of these groups, ∼73% of users were taking vitamin D. The number of prescribed medications ranged from 4 to 24 (average 10.2) in a subsample of residents whose supplement intake was 0 to 6 (average 2). These findings suggest an overall low rate of supplement use, with no significant differences (p ≥ 0.05) in use between residents with and without dementia diagnosis. However, some residents were at risk for supplement overuse.

Comparing two observational systems in the assessment of knee pain.

OBJECTIVE: Research has demonstrated the utility of the Pain Behavior Measurement (PBM) system as a pain index. PBM involves the recording of sighing, rubbing, grimacing, guarding and bracing. A modification of this system has been proposed, focusing on the occurrence of joint flexing, rubbing, unloading the joint, guarding and rigidity, specifically for patients with knee pain. The aim of the present study was to compare the original PBM to the modified version in a sample of knee replacement patients to assess the utility of the more specialized approach. It was expected that the more discomforting physiotherapy activities (knee bending and quadriceps exercises) would result in more pain behaviours than intermediate activities (walking and standing), which, in turn, would result in more pain behaviours than reclining. The extent to which each system reflected this expected pattern was examined. METHODS: Ninety-three seniors were observed while completing a series of structured post-knee surgery physiotherapy activities (knee bending, standing, walking, reclining and a quadriceps exercise). RESULTS: Analyses of self-reported levels of pain were consistent with the expected pattern of pain levels in relation to the physiotherapy activities. Specific pain behaviours within each system (eg, grimacing, rigidity) occurred in a manner consistent with the expected pattern, while other behaviours (e.g., rubbing the affected area) did not. CONCLUSIONS: Although there was no clear advantage for the modified system over the PBM, an optimal approach may involve combining specific behaviours from each system.

Using facial expressions to assess musculoskeletal pain in older persons.

Past research examined measures of pain among seniors who were experiencing movement-related exacerbations of musculoskeletal pain and obtained clear support for the utility of the behavioural coding of pain-related body movements (e.g., bracing, guarding). Support for the utility of the Facial Action Coding System (FACS), which involves the objective coding of facial reactions, was not as strong. The findings concerning FACS could have been an artifact of the methodology that was used. Specifically, the duration of the facial reactions was not taken into account and the patients suffered from a variety of painful conditions. Thus, the physical activities involved in the study could have been painful for some patients but not for others. The present study corrected these methodological concerns by accounting for the duration of facial reactions and ensuring that all patients suffered from the same painful condition. Participants were 82 post-surgical (knee replacement) inpatients. Cognitive status was assessed using the Modified Mini Mental Status Examination. Under physiotherapist's supervision, the patients performed structured activities (i.e., reclining, standing, knee bends). Facial reactions were coded using FACS. Facial reactions varied as a function of the degree to which the various activities were strenuous. The results support the utility of FACS in the assessment of musculoskeletal pain among seniors undergoing rehabilitation following knee surgery.