[Older care receivers with chronic pain : Cross-sectional study of gender-specific pain intensity and home-care provision in the city environment]. / Ältere Pflegebedürftige mit chronischen Schmerzen : Querschnittsstudie zur geschlechtsspezifischen Schmerzintensität und Versorgung in der großstädtischen Häuslichkeit.

BACKGROUND: Pain prevalence rates of up to 53% are found among older home-care recipients (aged ≥ 60 years). Of people affected by pain in Germany, care recipients comprise a relevant group with prevalence rates of around 70%. The available information on gender-specific pain experience shows a range of differing findings. OBJECTIVE: Our objective was to determine pain parameters of older care receivers in the big city environment who are capable of self-reporting, taking into account gender differences and relevant aspects of medical care and medication. MATERIAL AND METHODS: A cross-sectional study (structured interviews) was carried out among older (≥65 years) home-care recipients (German Social Security Code SGB XI) in Berlin, with chronic pain (n = 225), capable of self-reporting (MMST ≥ 18). Pain parameters were determined using the German version of the brief pain inventory (BPI-NHR). Multiple regression analysis was applied to test and explain how the severest pain was influenced by sociodemographic and medical parameters, mental and physical restrictions, and analgesic provision. RESULTS: Analyses showed an average pain intensity of 5.3 (SD ± 2.0). The severest pain averaged 7.0 (SD ± 2.2). Few indications of significant gender-based differences were found (e.g. pain location, number of medications). The final model identified the number of pain locations (≥14), everyday abilities, and pain medication (as needed, none) as being associated with the severest pain. Treatment achieved pain relief of over 70% in only 24.6% of cases among pain-affected care receivers. CONCLUSION: The findings indicate a significant level of pain experienced by older home-care recipients. Interdisciplinary care concepts are urgently needed.

Interventions to address deficits of pharmacological pain management in nursing home residents--A cluster-randomized trial.

BACKGROUND: To evaluate the effect of interventions for general practitioners and nursing home staff to improve pain severity and appropriateness of pain medication in nursing home residents (NHR). METHODS: This cluster-randomized controlled trial was conducted in six nursing homes in the intervention and control group, respectively. Pain management was analysed before (T0) and after (T1, T2) an educational intervention in 239 NHR, aged ≥65 years, without moderate or severe cognitive impairment. Primary and secondary outcomes were average pain severity and appropriateness of pain medication as determined with the Numeric Rating Scale and Pain Medication Appropriateness Scale (PMASD ), respectively. RESULTS: At T0, 72.2% and 73.7% of NHR (mean age 83 years) reported pain (average pain severity 2.4) in the intervention and control group, respectively. The PMASD at T0 was 53.9 in the intervention group and 60.8 in the control group (p = 0.12), while 20.6% compared to 6.9% (p = 0.009) received no pain medication in the two groups. At T2, non-significant improvements in the average pain severity (1.59) and PMASD (61.07) were observed in the intervention group. Moreover, the mean individual PMASD increased by 8.09 (p = 0.03) and the proportion of NHR without pain medication decreased by 50% (p = 0.03) in the intervention group. No appreciable changes were found in the control group at T2. CONCLUSIONS: NHR exhibited a high prevalence of pain with overall low severity, while a high proportion of individuals received inappropriate pain medications. Both findings were not significantly improved by the intervention, although some aspects of drug treatment were meaningful improved.

[Family Caregivers as a Target Group for Health Promotion and Prevention]. / Pflegende Angehörige als Zielgruppe für Gesundheitsförderung und Prävention.

Family caregivers are a target group for health promotion, due to the various burdens. Against this background an assessment (ARR) was developed, implemented, and validated in the project "Health Promotion for Elderly Family Caregiver". On the basis of the ARR, family caregivers received an individual, need-oriented, and specific offer for health promotion. In order to reach the target group optimally, a national health insurance company was used.

[Arterial hypertension, antihypertensive therapy, and visit-to-visit blood pressure variability of elderly nursing home residents]. / Arterielle Hypertonie, antihypertensive Therapie und Visit-to-visit-Blutdruckvariabilität bei älteren Pflegeheimbewohnern.

BACKGROUND AND AIM: Arterial hypertension is a common health problem in older nursing home residents (NHR). The aim of this study was to prospectively analyze blood pressure (BP) patterns, antihypertensive therapy, and visit-to-visit BP variability in NHR. METHODS: BP, visit-to-visit variability (estimated by standard deviation of means) of systolic BP (SBP) were analyzed in 12 nursing homes in Germany. NHR who were at least 65 years old and had no moderate or severe dementia were studied at baseline (T0), after 3 and 6 months, respectively. RESULTS: BP data were available for 177 NHR (mean age 83.8, 69.5% female) at T0.  A total of 90.4% NHR was affected by hypertension. Mean systolic/diastolic blood pressure was 130,1/75,5 mmHg. BP values of ≥ 140/90 mmHg were found in 29.9%, while 33.9% of NHR exhibited SBP values < 120 mmHg. At least one antihypertensive drug was used in 84.2%, and 40.7% of NHR were treated with at least three different drugs. The median of the visit-to-visit SBP variability was 9.05 (Min. 0, Max. 35.78); an influence of age, sex, and type of antihypertensive medication was not found. CONCLUSION: Elderly German NHR showed a high prevalence of hypertension and BP was controlled in 80%. However, a large proportion received intensive BP lowering pharmacotherapy and exhibited SBP values clearly lower than recommend target values between 140 and 150 mmHg particularly for elderly patients over 80 years. Thus, to avoid overtreatment BP should be monitored closely to adapt antihypertensive therapy in this population.

[Interdisciplinary guidance for pain management in nursing home residents]. / Interdisziplinäre Handlungsempfehlung zum Management von Schmerzen bei älteren Menschen in Pflegeheimen.

Pain management in nursing home residents (NHR) is insufficient. Hence, this guidance summarizes latest research results and guidelines of particular requirements on treatment of pain in the elderly. The purpose is to improve health care processes and outcomes on individual and institutional level. To reach this aim a multidisciplinary collaboration is essential. The prerequisite for adequate pain treatment is to conduct a standardized pain assessment. Likewise, the application of all opportunities of non-medical pain treatment strategies contributes to the reduction of occurrence of pain and therefore to the preservation of quality of life in NHR. Age-related changes in physiology may affect tolerance and effects of analgesics. Besides, drug interactions need to be considered. After all, education of NHR and involvement of their relatives in pain management foster successful management and treatment of pain.

[Family caregivers and health promotion. Pilot study to validate a German assessment to survey resources and risks of elderly family caregivers (ARR)]. / Pflegende Angehörige und Gesundheitsförderung. Pilotstudie zur Validität eines deutschsprachigen Assessments zur Erfassung von Ressourcen und Risiken älterer pflegender Angehöriger (ARR).

The ARR is a German assessment instrument to survey physical and psychological resources and risks of elderly family caregivers (50+). Factor structure, reliability, and validity were investigated using a sample of 202 caregivers from a national health insurance company. The factorial validity was confirmed for the physical profile (PHP) and the psychological profile (PSP). Reliability is good (PHP: Cronbach's α=0.73; PSP: Cronbach's α=0.71) for the shortness of the profiles. The correlation with self-efficacy constitutes an indicator for construct validity. The psychometric qualities allow the conclusion that the ARR is a reliable and valid instrument which is of interest for family caregivers. Nevertheless, further testing of validity is required.

Hearing loss in children with brain tumors treated with cisplatin and carboplatin-based high-dose chemotherapy with autologous bone marrow rescue.

Carboplatin is less ototoxic than cisplatin, but ototoxicity may occur with carboplatin at higher doses. We evaluated hearing in children with brain tumors treated with conventional dose cisplatin followed by high-dose carboplatin. Children under 6 years of age, newly diagnosed with brain tumors, were treated after surgery with cisplatin, Etoposide, cyclophosphamide, and vincristine, followed by consolidation with carboplatin, ThioTEPA, Etoposide, and autologous bone marrow rescue. Hearing was assessed before and after consolidation, utilizing standard audiometric techniques. Seven of the 11 evaluable patients developed high-frequency sensorineural hearing loss after induction therapy. Hearing deteriorated after consolidation in five patients, with pure tone threshold shifts of up to 65 dB between 2,000 and 8,000 Hz. Of these five patients, audiological abnormalities were documented in four prior to consolidation, one received cranial irradiation after consolidation, and all five received aminoglycoside antibiotics for at least 2 weeks, with toxic drug levels in four. Three patients have subsequently required hearing aids. Significant ototoxicity is common in these patients. Ototoxicity related to consolidation therapy is likely due to the high dose of carboplatin used, prior cisplatin therapy, aminoglycosides, and, in one patient, cranial irradiation. Audiological assessment is essential in children treated with dose-intensive chemotherapy regimens containing cisplatin and carboplatin for identification and rehabilitation of ototoxicity.

Otitis media with effusion in head and neck cancer patients.

Fifty-two patients who had otitis media with effusion associated with head and neck malignancies were identified and studied retrospectively. Forty-three of the patients underwent myringotomy and tube for treatment of the effusion. Ten (23%) of the 43 patients had either multiple infections or continuous otorrhea necessitating tube removal. The patients identified as having the highest rate of serious complications following myringotomy and tube were those individuals who had nasopharyngeal carcinoma, with 6 (55%) of 11 patients in this group having suffered major infections during the study. Myringotomy and tube is a satisfactory treatment for most patients who have effusions as a result of non-malignant etiologies; however, infections were more common and more severe in the study group than those anticipated in noncancer patients. Expectant management and the use of amplification in selected cases may prove to be a viable alternative in patients with unilateral effusion and/or relatively mild symptoms.

Phase II trial of high-dose cisplatin with sodium thiosulfate nephroprotection in patients with advanced carcinoma of the uterine cervix previously untreated with chemotherapy.

Cisplatin is one of the most active single agents in the treatment of advanced cancer of the cervix. The concurrent administration of the nephroprotective agent, sodium thiosulfate, has enabled exploitation of the therapeutic potential of cisplatin. To explore the role of cisplatin dose intensity in the treatment of patients with cancer of the uterine cervix, patients with persistent/recurrent measurable disease were treated with cisplatin at 200 mg/m2 as a 2-hr infusion with sodium thiosulfate given at 3.3 g/m2 1 hr prior to cisplatin and 6.6 g/m2 during the cisplatin infusion. Treatment was repeated monthly. Due to the known cumulative toxicity of cisplatin, treatment beyond two cycles (400 mg/m2) was given only to those patients who had at least demonstrated a PR. Audiologic evaluation was done prior to each cycle of treatment. Eleven patients were entered with a median age of 43 years (range, 25-57), a median KPS of 80% (range, 60-90%), and nine epidermoid and two adenocarcinoma, and all patients had received previous pelvic irradiation. Twenty-eight cycles of treatment were given: 1, five cycles; 3, three cycles; 7, two cycles. No greater than or equal to 3+ hematologic, neurologic, or renal toxicity was demonstrated. Ototoxicity was demonstrated in the mild to moderate hearing loss range (3000-8000 Hz). The greatest threshold shift occurred after the first course of cisplatin. There were three PRs with a maximum duration of 4 months. Due to the significant toxicities encountered, the low response rate, and the limited duration of responses, this trial was closed early to accrual.

Ototoxicity of high-dose cisplatin by bolus administration in patients with advanced cancers and normal hearing.

Our institution undertook a phase I trial to define the toxicity of high-dose (150 to 225 mg) bolus administration (every 3 to 4 weeks) of cisplatin in patients with advanced cancers. All patients reported had baseline normal hearing. Hearing levels were measured prior to each course of chemotherapy. Audiological monitoring included conventional assessment of pure tone sensitivity at 500 to 8,000 Hz and assessment of ultra high frequencies (9,000 to 20,000 Hz). After one to two doses, 100% of patients failed to respond at 9,000 Hz and above. In the 2,000 to 8,000 Hz range, repeated administration of the drug effected successively lower frequencies with progressive loss, until a maximum threshold shift or plateau was reached at each frequency between 3,000 and 8,000 Hz. The plateau for cisplatin ototoxicity appears to fall within the moderate hearing loss range (40 to 60 dB HL) in the high frequencies. All patients complained of tinnitus and difficulty understanding speech in the presence of background noise. The pattern of pure tone audiometric alteration is consistent in all patients, all dosages, and each method of administration. The ultra high frequency alteration is prompt and dramatic.