Multi-disciplinary supportive end of life care in long-term care: an integrative approach to improving end of life.

BACKGROUND: Optimal supportive end of life care for frail, older adults in long term care (LTC) homes involves symptom management, family participation, advance care plans, and organizational support. This 2-phase study aimed to combine multi-disciplinary opinions, build group consensus, and identify the top interventions needed to develop a supportive end of life care strategy for LTC. METHODS: A consensus-building approach was undertaken in 2 Phases. The first phase deployed modified Delphi questionnaires to address and transform diverse opinions into group consensus. The second phase explored and prioritized the interventions needed to develop a supportive end of life care strategy for LTC. Development of the Delphi questionnaire was based on findings from published results of physician perspectives of barriers and facilitators to optimal supportive end of life care in LTC, a literature search of palliative care models in LTC, and published results of patient, family and nursing perspectives of supportive end of life care in long term care. The second phase involved World Café Style workshop discussions. A multi-disciplinary purposive sample of individuals inclusive of physicians; staff, administrators, residents, family members, and content experts in palliative care, and researchers in geriatrics and gerontology participated in round one of the modified Delphi questionnaire. A second purposive sample derived from round one participants completed the second round of the modified Delphi questionnaire. A third purposive sample (including participants from the Delphi panel) then convened to identify the top priorities needed to develop a supportive end-of-life care strategy for LTC. RESULTS: 19 participants rated 75 statements on a 9-point Likert scale during the first round of the modified Delphi questionnaire. 11 participants (participation rate 58 %) completed the second round of the modified Delphi questionnaire and reached consensus on the inclusion of 71candidate statements. 35 multidisciplinary participants discussed the 71 statements remaining and prioritized the top clinical practice, communication, and policy interventions needed to develop a supportive end of life strategy for LTC. CONCLUSIONS: Multi-disciplinary stakeholders identified and prioritized the top interventions needed to develop a 5-point supportive end of life care strategy for LTC.

Efficacy and feasibility of nonpharmacological interventions for neuropsychiatric symptoms of dementia in long term care: a systematic review.

BACKGROUND: Nonpharmacological therapies are often recommended as a first-line treatment for neuropsychiatric symptoms (NPS) of dementia in long term care (LTC); however, little is known about which nonpharmacological interventions are most effective for NPS in LTC or the feasibility of interventions, given the availability of resources in typical LTC environments. METHODS: We searched the electronic databases MEDLINE, EMBASE, PsychINFO (1980-2010), the Cochrane Library, and Google Scholar using keywords and medical subject headings for randomized, controlled trials evaluating nonpharmacological interventions for NPS conducted in LTC settings. Change in severity of NPS symptoms was evaluated through the NPS outcomes measures reported in studies. We assessed study quality and described the feasibility of interventions based on various aspects of study design. RESULTS: A total of 40 studies met inclusion criteria. Sixteen (40%) of 40 included studies reported statistically significant results in favor of nonpharmacological interventions on at least one measure of NPS. These interventions included staff training in NPS management strategies, mental health consultation and treatment planning, exercise, recreational activities, and music therapy or other forms of sensory stimulation. Many of the studies had methodological limitations that placed them at potential risk of bias. Most interventions (n = 30, 75%) required significant resources from services outside of LTC or significant time commitments from LTC nursing staff for implementation. CONCLUSIONS: There are several nonpharmacological interventions that may be effective for NPS in LTC, although there are a limited number of large-scale, high-quality studies in this area. The feasibility of some interventions will be limited in many LTC settings and further research into practical and sustainable interventions for NPS in LTC is required to improve usage of these important treatments.