Pain and hospice care in nursing home residents with dementia and terminal cancer.

AIM: One condition associated with severe end-of-life pain that can lead to a poor quality of death is cancer. Cancer pain in people with dementia is of particular concern because of communication problems that occur with worsening disease. The aim of the current pilot study was to examine the association between hospice enrolment, dementia severity and pain among nursing home residents who died from advanced cancer. METHODS: Between-groups cross-sectional chart audits of 55 nursing home residents with dementia who died from cancer were carried out. RESULTS: A total of 45% of residents were in hospice at the end-of-life. Residents in hospice were more likely to receive an opioid (80% vs 43%, P = 0.005); but less likely to show severe cognitive impairment (20% vs 50%, P = 0.050). Enrolment in hospice was associated with an increased likelihood of receiving an opioid after controlling for level of cognitive impairment (OR = 3.9, 95% CI = 1.1-14.0, P = 0.037). Lower levels of cognitive functioning were associated with a decreased likelihood of receiving an opioid after controlling for enrolment in hospice (OR = 0.3, 95% CI = 0.1-0.8, P = 0.030). Notably, 40% of nursing home residents with dementia who died from cancer did not receive any opioid during this time. CONCLUSIONS: Preliminary results suggest that hospice enrolment might be influenced by the facility or region of this particular country. Hospice enrolment predicts more opioid pain treatment in residents with dementia and terminal cancer; however, no resident with very severe dementia and terminal cancer was placed in hospice care. Severely cognitively impaired nursing home residents requiring opioids are at great risk of suffering from untreated advanced cancer pain. New methods are urgently required to improve end-of-life palliative care for nursing home residents with terminal cancer and severe dementia.

Washington State Death with Dignity Act: implications for long-term care.

The Washington Death with Dignity Act (DWDA) allows competent, terminally ill adults to request a lethal dose of medication from a physician. The purpose of this study was to explore knowledge of Directors of Nursing (DONs) in long-term care (LTC) and assisted living facilities regarding the DWDA. Findings of the survey provide insight into DONs' understanding of the law and whether they have provided staff education regarding how to respond to resident requests. This survey, although limited by sample size, may provide guidance for policy development in LTC settings regarding similar laws.

The application of facial expressions to the assessment of orofacial pain in cognitively impaired older adults.

BACKGROUND: The anticipated rapid growth in the number of cognitively impaired older adults, declining edentulism and increasing oral health expectations suggest a greater need for comprehensive dental care and effective ways to evaluate orofacial pain in people with compromised mental function and impaired communication skills. The authors conducted a study to evaluate facial expressions as a means of identifying orofacial pain in cognitively impaired and cognitively intact older adults, compared with other available pain assessment tools. METHODS: The authors conducted a prospective comparative study using three alternative pain measurement tools in a sample of 22 older adults. They divided subjects into cognitively impaired and cognitively intact groups on the basis of their mental status examination scores. The pain measurement methods evaluated were facial expressions quantified by the Facial Actions Coding System (FACS); self-reported pain via the Verbal Descriptor Scale; and physiological response to pain via changes in heart rate. The pain stimuli were local anesthetic injections in subjects who required them for routine dental procedures. RESULTS: The average FACS scores during anesthetic injections were significantly higher than those during the preinjection period (prebuccal versus buccal, P = .016; prepalatal versus palatal, P = .0002). The differences between preinjection and injection segments were even higher in cognitively impaired patients than in cognitively intact patients. There were no correlations between the three pain measurements (P > .05). CONCLUSIONS: Changes in facial expression proved to be the most useful measure overall in identifying pain in both cognitively intact and cognitively impaired older patients. This measure appeared to be more sensitive in cognitively impaired patients because they demonstrated fewer facial movements in anticipation of pain stimuli.

Frail older patient care by interdisciplinary teams: a primer for generalists.

Frail older patients-unlike younger persons in the health care system or even well elders-require complex care. Most frail older patients have multiple chronic illnesses. Optimum care cannot be achieved by following the paradigm of ongoing traditional health care, which emphasizes disease and cure. Because no one health care professional can possibly have all of the specialized skills required to implement such a model of health care delivery, interdisciplinary team care has evolved. This paper describes the roles of the participating team members in the context of interdisciplinary care for frail older adults. In addition, the challenges that occur when Geriatric Interdisciplinary (ID) Teams involved in providing care to frail older patients are identified and discussed.

Treatment of pain for older hip fracture patients across settings.

PURPOSE: To examine the treatment of pain following hip fracture across settings (hospital to nursing home or rehabilitation facility). DESIGN: This was a secondary data analysis of two survey design studies that collected data on hip fracture patients in the hospital and for posthospital days at an institutional setting. SAMPLE: 115 subjects, 65 years or older, who had undergone surgical treatment of a hip fracture. METHODS: Medical records were reviewed to compare the amount of pain medication administered to postoperative hip fracture elders during the last 24 hours in the hospital with that of the first 24 hours in the nursing home (NH). FINDINGS: The mean length of stay following surgery was 4.8 days. Subjects received significantly less medication during the first 24 hours in the NH as compared with the last 24 hours of hospitalization. Over one third (37.4%) of the subjects received no opioid analgesic and 18.3% (n = 21) received no analgesic of any kind during the first 24 hours of NH stay. IMPLICATIONS: Rather than simply listing medications orders, hospital nursing staff should communicate type, amount, frequency and efficacy of pain medication in transfer notes to nursing home staff. Nursing home staff would benefit from postoperative pain management education.

Older adults with hip fractures. Treatment of pain following hospitalization.

This study examined pain experiences and treatment for older adults in long-term care or rehabilitation settings 3 week after surgical repair of a hip fracture. Pain report and pain treatment for cognitively intact residents were compared with cognitively impaired residents. Two thirds of all participants reported pain. Most rated pain as slight or mild in severity. Pain report was similar for cognitively impaired and intact participants. Pain was reported as severe or worse by 17% of the residents. Nursing care plans documented comfort as a goal for fewer than half the participants. Almost 40% (n = 23) of the participants were receiving no pain medication 3 weeks postoperatively, five of these rated their pain as moderate or severe. Pain documentation, including effective non-pharmacological treatments, needs to be improved for cognitively impaired and intact older adults who are recovering from hip fracture surgery.

Gerontologic nurse practitioner preceptor guide.

Geriatric nurse practitioners (GNPs) often serve as clinical preceptors for nurse practitioner students. The Nursing Interest Group of the John A. Hartford Foundation's Geriatric Interdisciplinary Team Training Program recognized a need for a condensed guide that clarifies the role of a GNP preceptor. This guide uses information from the literature to clarify the role of the preceptor, offer suggestions for clinical teaching, provide guidance to determine expectations for student performance, and delineate the progression of a nurse practitioner student. This article reviews the contents of the guide and offers suggestions for its use in clinical practice.