Decision Making About Change of Medication for Comorbid Disease at the End of Life: An Integrative Review

Abstract The main goal of palliative care is to improve quality of life by treating symptoms in patients with lifethreatening illnesses. Most patients suffer from more than five severe comorbidities in the last 6 months of life. However, for patients receiving palliative care, interventions to prevent possible long-term complications of these comorbidities are no longer the primary aim of care. This paper aimed to review the literature regarding decision making about medication for comorbid disease at the end of life, defined as a life expectancy \3 months, and to formulate preliminary recommendations based on the existing literature. An integrative review approach was used. We searched the MEDLINE, EMBASE, and CI-NAHL databases. Papers were included if they had been published in the English language between 1 January 1995 and 31 December 2013, with an abstract. Additional studies were identified by searching bibliographies. Factors to consider when systematically reviewing medications are the goals of care, remaining life expectancy, treatment targets, time until benefit, number needed to treat, number needed to harm, and adverse drug reactions. Existing research focuses particularly on the use of certain drug classes during end-of-life care, including statins, antihypertensive agents, anticoagulants, antihyperglycaemic agents and antibiotics. Based on the results of this review, we made preliminary recommendations for these medication groups. Medication that does not benefit the patient in any way should be avoided. The aim of medication at the end of life should be symptom control. There is a need for prospective trials to give further insight into the decisionmaking process of medication management at the end of life

Allowing Visitors Back in the Nursing Home During the COVID-19 Crisis:A Dutch National Study Into First Experiences and Impact on Well-Being

Objectives: To prevent and control COVID-19 infections, nursing homes across the world have taken very restrictive measures, including a ban for visitors. These restrictive measures have an enormous impact on residents' well-being and pose dilemmas for staff, although primary data are lacking. A Dutch guideline was developed to cautiously open nursing homes for visitors during the COVID-19 pandemic. This study reports the first findings on how the guideline was applied in the local context; the compliance to local protocols; and the impact on well-being of residents, their family caregivers, and staff.Design: A mixed-methods cross-sectional study was conducted.Setting and Participants: In total, 26 nursing homes were permitted to enlarge their possibilities for allowing visitors in their facility. These nursing homes were proportionally representative of the Netherlands as they were selected by their local Area Health Authority for participation. At each nursing home, a contact person was selected for participation in the current study.Methods: A mixed-methods cross-sectional study was conducted, consisting of questionnaire, telephone interviews, analyses of documentation (ie, local visiting protocols), and a WhatsApp group.Results: Variation in local protocols was observed, for example, related to the use of personal protective equipment, location, and supervision of visits. In general, experiences were very positive. All nursing homes recognized the added value of real and personal contact between residents and their loved ones and indicated a positive impact on well-being. Compliance with local guidelines was sufficient to good. No new COVID-19 infections were reported during this time.Conclusions and Implications: These results indicate the value of family visitation in nursing homes and positive impact of visits. Based on these results, the Dutch government has decided to allow all nursing homes in the Netherlands to cautiously open their homes using the guidelines. More research is needed on impact and long-term compliance. (C) 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine.</p

Cost-effectiveness of a multicomponent primary care program targeting frail elderly people

Contains fulltext : 191679.pdf (publisher's version ) (Open Access

Very frequent physical aggression and vocalizations in nursing home residents with dementia

Objectives: We investigated the 2-week prevalence and correlates of very frequent physical aggression (PA) and vocalizations in nursing home (NH)-residents with dementia. Method/Design: This cross-sectional study used combined data of 2074 NH-residents from four studies, collected from 119 dementia special care units in 26 Dutch NH. Very frequent PA was defined as scoring 6 or 7 on the items ‘hitting’, pushing’, ‘biting’ and ‘kicking’ of the Cohen Mansfield Agitation Inventory; very frequent vocalizations as scoring 6 or 7 on ‘screaming’ and ‘making strange noises’. We compared NH-residents with very frequent PA or vocalizations with residents with less frequent PA or vocalizations, assessing correlates using univariate and multivariate multilevel logistic regression analyses. Results: We found a 2-week prevalence of 2.2% (95% confidence interval (CI): 1.63–2.89) of very frequent PA and 11.5% of very frequent vocalizations (95% CI: 10.23–12.98). Very frequent PA was only associated with apathy (odds ratio (OR)=1.93, 95% CI: 1.04–3.61). Correlates of very frequent vocalizations were age (OR = 0.97, 95% CI: 0.951–0.998), dementia severity (overall p-value 0.020), antipsychotic drug use (OR = 1.56, 95% CI: 1.08–2.26), antiepileptic drug use (OR = 2.75, 95% CI: 1.34–5.68) and euphoria (OR = 2.01, 95% CI: 1.22–3.31). Conclusion: Characteristics of NH-residents with very frequent PA or very frequent vocalizations differ from those of NH-residents with less frequent PA or vocalizations. Frontal lobe damage, boredom, pain and/or external factors may explain several of the found associations, but further research is necessary. Our findings may contribute to better care for these residents and thereby to improving their quality of life

Marker assisted approach for incorporating durable rust resistance in popular Indian wheat cultivars

Item does not contain fulltextParkinson disease (PD) is common in long term care (LTC) facilities. The number of institutionalized patients with PD will rise sharply in the coming decades because of 2 concurrent phenomena: aging of the population leads to an increased PD prevalence and improved quality of care has led to a prolonged survival in advanced disease stages. Only a few studies have investigated the prevalence and clinical characteristics of patients with PD in LTC facilities. Even fewer studies have addressed the treatment strategies used to support these institutionalized patients, who are mostly in advanced stages of the disease. The available evidence suggests that current management of patients with PD in LTC facilities is less than optimal. In the Netherlands, and we suspect in many other countries, there are no formal guidelines for treating patients with PD who have been admitted to a LTC facility. In this review, we describe the epidemiology, clinical characteristics, and clinical management of patients with PD in LTC settings. We also address potentially modifiable elements of care and provide several recommendations to improve the management of PD in these facilities. We conclude by suggesting a possible guide for future research in this area

Effects of Dementia-Care Mapping on Residents and Staff of Care Homes:A Pragmatic Cluster-Randomised Controlled Trial

BACKGROUND: The effectiveness of dementia-care mapping (DCM) for institutionalised people with dementia has been demonstrated in an explanatory cluster-randomised controlled trial (cRCT) with two DCM researchers carrying out the DCM intervention. In order to be able to inform daily practice, we studied DCM effectiveness in a pragmatic cRCT involving a wide range of care homes with trained nursing staff carrying out the intervention. METHODS: Dementia special care units were randomly assigned to DCM or usual care. Nurses from the intervention care homes received DCM training and conducted the 4-months DCM-intervention twice during the study. The primary outcome was agitation, measured with the Cohen-Mansfield agitation inventory (CMAI). The secondary outcomes included residents’ neuropsychiatric symptoms (NPSs) and quality of life, and staff stress and job satisfaction. The nursing staff made all measurements at baseline and two follow-ups at 4-month intervals. We used linear mixed-effect models to test treatment and time effects. RESULTS: 34 units from 11 care homes, including 434 residents and 382 nursing staff members, were randomly assigned. Ten nurses from the intervention units completed the basic and advanced DCM training. Intention-to-treat analysis showed no statistically significant effect on the CMAI (mean difference between groups 2·4, 95% CI −2·7 to 7·6; p = 0·34). More NPSs were reported in the intervention group than in usual care (p = 0·02). Intervention staff reported fewer negative and more positive emotional reactions during work (p = 0·02). There were no other significant effects. CONCLUSIONS: Our pragmatic findings did not confirm the effect on the primary outcome of agitation in the explanatory study. Perhaps the variability of the extent of implementation of DCM may explain the lack of effect. TRIAL REGISTRATION: Dutch Trials Registry NTR2314

Reopening the doors of Dutch nursing homes during the COVID-19 crisis: results of an in-depth monitoring

Objectives: On May 11, the Dutch Government allowed 26 nursing homes to welcome 1 visitor per resident, after 2 months of lockdown. The study aimed to monitor in-depth the feasibility of the regulations and their impact on the well-being of residents, their visitors, and healthcare staff. Design: Mixed-methods study in 5 of the 26 facilities; the facilities were affiliated to an academic network of nursing homes. Participants: Visitors and healthcare professionals. Intervention: Allowing visitors using local regulations based on national guidelines. Measurements: Digital questionnaire, analyzing documentation such as infection prevention control protocols, attending meetings of COVID-19 crisis teams, in-depth telephone or in-person interviews with visitors and healthcare professionals, and on-site observations. Results: National guidelines were translated with great variety into local care practice. Healthcare professionals agreed that reopening would increase the well-being of the residents and their loved ones. However, there were also great worries for increasing workload, increasing the risk of emotional exhaustion, and the risk of COVID-19 infections. Compliance with local regulations was generally satisfactory, but maintaining social distance and correctly wearing face masks appeared to be difficult. Care staff remained ambivalent for fear of infections. In general, allowing visitors was experienced as having a positive impact on the well-being of all stakeholders. Nevertheless, some residents with dementia showed negative effects. Conclusion: The complete lockdown of Dutch nursing homes had a substantial impact on the well-being of the residents. The reopening was welcomed by all stakeholders, but provided a high organizational workload as well as feelings of ambivalence among care staff. In the second wave, a more tailored approach is being implemented. However, facilities are sometimes still struggling to find the right balance between infection control and well-being

Implementing a multidisciplinary psychotropic medication review among nursing home residents with dementia:a process evaluation

OBJECTIVES: Before drawing conclusions on the contribution of an effective intervention to daily practice and initiating dissemination, its quality and implementation in daily practice should be optimal. The aim of this process evaluation was to study these aspects alongside a randomized controlled trial investigating the effects of a multidisciplinary biannual medication review in long-term care organizations (NTR3569). DESIGN: Process evaluation with multiple measurements. SETTING: Thirteen units for people with dementia in six long-term care organizations in the Netherlands. PARTICIPANTS: Physicians, pharmacists, and nursing staff of participating units. INTERVENTION: The PROPER intervention is a structured and biannually repeated multidisciplinary medication review supported by organizational preparation and education, evaluation, and guidance. MEASUREMENTS: Web-based questionnaires, interviews, attendance lists of education sessions, medication reviews and evaluation meetings, minutes, evaluation, and registration forms. RESULTS: Participation rates in education sessions (95%), medication reviews (95%), and evaluation meetings (82%) were high. The intervention's relevance and feasibility and applied implementation strategies were highly rated. However, the education sessions and conversations during medication reviews were too pharmacologically oriented for several nursing staff members. Identified barriers to implementation were required time, investment, planning issues, and high staff turnover; facilitators were the positive attitude of professionals toward the intervention, the support of higher management, and the appointment of a local implementation coordinator. CONCLUSION: Implementation was successful. The commitment of both higher management and professionals was an important factor. This may partly have been due to the subject being topical; Dutch long-term-care organizations are pressed to lower inappropriate psychotropic drug use

Calendar 2015

Item does not contain fulltextBACKGROUND: Children of patients with young onset dementia (YOD) who are confronted with a parent who has a progressive disease, often assist in caregiving tasks, which may have a great impact on their lives. The objective of the present study is to explore the experiences of children living with a young parent with dementia with a specific focus on the children's needs. METHODS: Semi-structured interviews with 14 adolescent children between the ages of 15 and 27 years of patients with YOD were analyzed using inductive content analysis. Themes were identified based on the established codes. RESULTS: The emerging categories were divided into three themes that demonstrated the impact of dementia on daily life, different ways of coping with the disease, and children's need for care and support. The children had difficulties managing all of the responsibilities and showed concerns about their future. To deal with these problems, they demonstrated various coping styles, such as avoidant or adaptive coping. Although most children were initially reluctant to seek professional care, several of them expressed the need for practical guidance to address the changing behavior of their parent. The children felt more comfortable talking to someone who was familiar with their situation and who had specific knowledge of YOD and the available services. CONCLUSION: In addition to practical information, more accessible and specific information about the diagnosis and the course of YOD is needed to provide a better understanding of the disease for the children. These findings underline the need for a personal, family-centered approach

Improving psychotropic drug prescription in nursing home patients with dementia:design of a cluster randomized controlled trial

Background: Neuropsychiatric symptoms are highly prevalent in nursing home patients with dementia. Despite modest effectiveness and considerable side effects, psychotropic drugs are frequently prescribed for these neuropsychiatric symptoms. This raises questions whether psychotropic drugs are appropriately prescribed. The aim of the PROPER (PRescription Optimization of Psychotropic drugs in Elderly nuRsing home patients with dementia) II study is to investigate the efficacy of an intervention for improving the appropriateness of psychotropic drug prescription in nursing home patients with dementia.Methods/design: The PROPER II study is a multi-center cluster randomized controlled, pragmatic trial using parallel groups. It has a duration of eighteen months and four six-monthly assessments. Six nursing homes will participate in the intervention and six will continue care as usual. The nursing homes will be located throughout the Netherlands, each participating with two dementia special care units with an average of fifteen patients per unit, resulting in 360 patients. The intervention consists of a structured and repeated multidisciplinary medication review supported by education and continuous evaluation. It is conducted by pharmacists, physicians, and nurses and consists of three components: 1) preparation and education, 2) conduct, and 3) evaluation/guidance. The primary outcome is the proportion of patients with appropriate psychotropic drug use. Secondary outcomes are the overall frequency of psychotropic drug use, neuropsychiatric symptoms, quality of life, activities of daily living, psychotropic drug side effects and adverse events (including cognition, comorbidity, and mortality). Besides, a process analysis on the intervention will be carried out.Discussion: This study is expected to improve the appropriateness of psychotropic drug prescription for neuropsychiatric symptoms in nursing home patients with dementia by introducing a structured and repeated multidisciplinary medication review supported by education and continuous evaluation.</p