A longitudinal study exploring the use of analgesic medication in English care home residents with dementia

Background: Analgesic medication is widely used in care homes but little is known about how often this medication is prescribed or administered, or what factors influence its use. // Aim: To describe the prescription and administration of regular and PRN analgesic medication in care homes; to investigate whether individual or care home differences are associated with analgesic use; and to compare analgesic prescribing in English care homes to international prescriptions. // Methods: This study is embedded in a longitudinal study of 86 care homes in England. Data were collected at 0-, 4-, and 12-months. Residents were eligible if they had diagnosed or probable dementia. Analgesic prescriptions are presented by drug and class. Administration of PRN analgesics is described. Individual differences (sociodemographic; agitation [Cohen-Mansfield Agitation Inventory]; dementia severity [Clinical Dementia Rating]; psychotropic drug prescriptions) and care home differences (type; ownership; number of beds; dementia-registered/specialist; CQC rating) are explored using multilevel models. // Results: Data were available for 1483 residents. Around 70% of residents were prescribed analgesics at all study visits, predominantly PRN paracetamol. Overall, PRN analgesics were not administered frequently. There were differences between care homes in administration but these differences were not accounted for by the modelled care home-level variables. Residents with more severe dementia, and males, appear to be more at risk of untreated pain. // Conclusion: This is the largest study to date exploring analgesic administration in care homes. Prescription levels of regular analgesics are lower in England compared to other countries, however it is unclear why. Pain management in care homes is largely reliant on PRN paracetamol that is frequently prescribed but infrequently administered. Care homes differ in how often they administer PRN analgesics and this is likely due to internal factors. Therefore care home residents are likely to have untreated pain, and some groups are more at risk than others

Agitation near the end of life with dementia: An ethnographic study of care

Background and objectivesAgitation is common in people living with dementia especially at the end of life. We examined how staff interpreted agitation behavior in people with dementia nearing end of life, how this may influence their responses and its impact on the quality of care.Research designEthnographic study. Structured and semi-structured non-participant observations (referred to subsequently in this paper as "structured observations") of people living with dementia nearing the end of life in hospital and care homes (south-east England) and in-depth interviews with staff, conducted August 2015-March 2017.MethodsThree data sources: 1) detailed field notes, 2) observations using a structured tool and checklist for behaviors classed as agitation and staff and institutional responses, 3) staff semi-structured qualitative interviews. We calculated the time participants were agitated and described staff responses. Data sources were analyzed separately, developed continuously and relationally during the study and synthesized where appropriate.ResultsWe identified two main 'ideal types' of staff explanatory models for agitation: In the first, staff attribute agitated behaviors to the person's "moral judgement", making them prone to rejecting or punitive responses. In the second staff adopt a more "needs-based" approach in which agitation behaviors are regarded as meaningful and managed with proactive and investigative approaches. These different approaches appear to have significant consequences for the timing, frequency and quality of staff response. While these models may overlap they tend to reflect distinct organizational resources and values.ConclusionsCare worker knowledge about agitation is not enough, and staff need organizational support to care better for people living with dementia towards end of life. Positional theory may help to explain much of the cultural-structural context that produces staff disengagement from people with dementia, offering insights on how agitation behavior is reframed by some staff as dangerous. Such behavior may be associated with low-resource institutions with minimal staff training where the personhood of staff may be neglected

Healthcare resource utilisation and costs of agitation in people with dementia living in care homes in England:The Managing Agitation and Raising QUality of LifE in Dementia (MARQUE) study

<div><p>Background</p><p>People with dementia living in care homes often experience clinically significant agitation; however, little is known about its economic impact.</p><p>Objective</p><p>To calculate the cost of agitation in people with dementia living in care homes.</p><p>Methods</p><p>We used the baseline data from 1,424 residents with dementia living in care homes (part of <b>M</b>anaging <b>A</b>gitation and <b>R</b>aising <b>QU</b>ality of lif<b>E</b> in dementia (MARQUE) study) that had Cohen-Mansfield Agitation Inventory (CMAI) scores recorded. We investigated the relationship between residents’ health and social care costs and severity of agitation based on the CMAI total score. In addition, we assessed resource utilisation and compared costs of residents with and without clinically significant symptoms of agitation using the CMAI over and above the cost of the care home.</p><p>Results</p><p>Agitation defined by the CMAI was a significant predictor of costs. On average, a one-point increase in the CMAI will lead to a 0.5 percentage points (cost ratio 1.005, 95%CI 1.001 to 1.010) increase in the annual costs. The excess annual cost associated with agitation per resident with dementia was £1,125.35. This suggests that, on average, agitation accounts for 44% of the annual health and social care costs of dementia in people living in care homes.</p><p>Conclusion</p><p>Agitation in people with dementia living in care homes contributes significantly to the overall costs increasing as the level of agitation increases. Residents with the highest level of agitation cost nearly twice as much as those with the lowest levels of agitation, suggesting that effective strategies to reduce agitation are likely to be cost-effective in this setting.</p></div