A study of longitudinal data examining concomitance of pain and cognition in an elderly long-term care population

Allison H Burfield1, Thomas TH Wan2, Mary Lou Sole3, James W Cooper41Gerontology Program, School of Nursing, College of Health and Human Services, University of North Carolina, Charlotte, NC, USA; 2Health Services, Administration, and Medical Education, Director, Doctoral Program in Public Affairs, Associate Dean for Research, College of Health and Public Affairs, 3College of Nursing, University of Central Florida, Orlando, FL, USA; 4College of Pharmacy, University of Georgia, Athens, GA, USAPurpose: To examine if a concomitant relationship exists between cognition and pain in an elderly population residing in long-term care.Background/significance: Prior research has found that cognitive load mediates interpretation of a stimulus. In the presence of decreased cognitive capacity as with dementia, the relationship between cognition and increasing pain is unknown in the elderly.Patients and methods: Longitudinal cohort design. Data collected from the Minimum Data Set-Resident Assessment Instrument (MDS-RAI) from the 2001–2003 annual assessments of nursing home residents. A covariance model was used to evaluate the relationship between cognition and pain at three intervals.Results: The sample included 56,494 subjects from nursing homes across the United States, with an average age of 83 ± 8.2 years. Analysis of variance scores (ANOVAs) indicated a significant effect (P < 0.01) for pain and cognition, with protected t test revealing scores decreasing significantly with these two measures. Relative stability was found for pain and cognition over time. Greater stability was found in the cognitive measure than the pain measure. Cross-legged effects observed between cognition and pain measures were inconsistent. A concomitant relationship was not found between cognition and pain. Even though the relationship was significant at the 0.01 level, the correlations were low (r ≤ 0.08), indicating a weak association between cognition and pain.Conclusion: Understanding the concomitance of pain and cognition aids in defining additional frameworks to extend models to include secondary needs, contextual factors, and resident outcomes. Cognitive decline, as with organic brain diseases, is progressive. Pain is a symptom that can be treated and reduced to improve resident quality of life. However, cognition can be used to determine the most appropriate method to assess pain in the elderly, thereby improving accuracy of pain detection in this population.Keywords: cognitive impairment, Cognitive Performance Scale (CPS), Minimum Data Set 2.

Behavioral cues to expand a pain model of the cognitively impaired elderly in long-term care

Background: The purpose of this study was to determine the relationship between hypothesized pain behaviors in the elderly and a measurement model of pain derived from the Minimum Data Set-Resident Assessment Instrument (MDS-RAI) 2.0 items. Methods: This work included a longitudinal cohort recruited from Medicare-certified long-term care facilities across the United States. MDS data were collected from 52,996 residents (mean age 83.7 years). Structural equation modeling was used to build a measurement model of pain to test correlations between indicators and the fit of the model by cognitive status. The model evaluates the theoretical constructs of pain to improve how pain is assessed and detected within cognitive levels. Results: Using pain frequency and intensity as the only indicators of pain, the overall prevalence of pain was 31.2%; however, analysis by cognitive status showed that 47.7% of the intact group was in pain, while only 18.2% of the severely, 29.4% of the moderately, and 39.6% of the mildly cognitively impaired groups were experiencing pain. This finding supports previous research indicating that pain is potentially under-reported in severely cognitively impaired elderly nursing home residents. With adjustments to the measurement model, a revised format containing affective, behavioral, and inferred pain indicates a better fit of the data to include these domains, as a more complete measure of the pain construct. Conclusion: Pain has a significant effect on quality of life and long-term health outcomes in nursing home residents. Patients most at risk are those with mild to severe cognitive decline, or those unable to report pain verbally. Nursing homes are under great scrutiny to maintain standards of care and provide uniform high-quality care outcomes. Existing data from federally required resident surveys can serve as a valuable tool to identify indicators of pain and trends in care. Great responsibility lies in ensuring pain is included and monitored as a quality measure in long-term care, especially for residents unable to communicate their pain verbally

Overcoming The Barriers: A Concerted Effort To Prevent Ventilator-Associated Pneumonia

Evidence-based strategies to prevent ventilator-associated pneumonia (VAP) and other complications of critical illness have been published during the past few years1-3. Despite the availability of guidelines and practice recommendations, many nurses do not implement known strategies for preventing VAP in the critical care setting. What are some of the reasons for lack of evidence-based practice? © 2005 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd.)

How I Learned My Abcs: Action, Back To Basics, Collaboration, Discovery

Background: Research is essential to generate the scientific evidence for critical care nursing practice, but it is challenging to conduct research in the busy critical care environment. The challenges are even greater in a setting with limited resources for research and where nurses have not typically conducted independent clinical studies. Objectives: To detail a successful research trajectory for studying the ABCs of patient care in the critically ill: airway, breathing, and circulation. Methods: After initial studies on circulation were conducted, the research was narrowed to focus on airway management. Airway management may be a key factor in preventing ventilator-associated pneumonia because aspiration of colonized oral, gastric, and tracheal secretions is the primary cause of ventilator-associated pneumonia. Multiple descriptive, pilot, and interventional studies have been conducted; findings from each have contributed to future studies. Results: Other ABCs were critical to this research success: action, back to basics, collaboration, and discovery. It is important for researchers to be self-motivated and to take initiative to develop skills and resources for conducting clinical studies. Several guiding principles help to promote success in research: (1) generate research ideas grounded in observation and clinical practice, (2) collaborate with others, and (3) establish affiliations and partnerships. Discovery occurs in many ways: new findings to guide practice and research, resources to conduct the study, and self-discovery. Conclusions: Nursing research is not easy. However, determination and resources help nursing researchers achieve success. © 2010 American Association of Critical-Care Nurses

Enhancing Traditional, Televised, And Videotaped Courses With Web-Based Technologies: A Comparison Of Student Satisfaction

Background: Varied distance learning strategies can be used to deliver nursing courses, including interactive television, videotape, and Web-based approaches. Purposes: (1) To assess student assess student satisfaction with a critical care elective course offered simultaneously via traditional and distance learning formats in which Web-based strategies were added, and (2) to compare satisfaction of students taking the traditional course versus those taking the class via distance technology. Methods: Students (n = 113) who took the course during the spring 1998 and 1999 semesters completed a teacher-constructed evaluation at the end of the semester. Findings: Mean ratings on the evaluation were positive. Ratings of interaction, communication with instructor, and facilitation of learning were higher from students who took the traditional course. Conclusions: The application of Web-based technologies may be one factor for the overall course satisfaction. However, it is important to continue to evaluate strategies that work best for students taking courses via distance technology

Physiological Responses To Passive Exercise In Adults Receiving Mechanical Ventilation

Background Critical illness may weaken muscles, with long-term consequences. Objective To assess physiological responses to an early standardized passive exercise protocol to prevent muscle weakness in adults receiving mechanical ventilation. Methods A quasi-experimental within-subjects repeatedmeasures design was used. Within 72 hours of intubation, 30 patients had 20 minutes of bilateral passive leg movement delivered by continuous-passive-motion machines at a standardized rate and flexion-extension. Heart rate, mean blood pressure, oxygen saturation, and cytokine levels were measured before, during, and after the intervention. The Behavioral Pain Scale was used to measure patients\u27 comfort. Repeatedmeasures analysis of variance was used to analyze the effect of the exercise on independent variables. Results Patients were mostly white men with a mean age of 56.5 years (SD, 16.9) with moderate mortality risk and illness severity. Heart rate, mean blood pressure, and oxygen saturation did not differ from baseline at any time measured. Pain scores were significantly reduced (F2.43,70.42 = 4.08; P = .02) 5 and 10 minutes after exercise started and remained reduced at the end of exercise and 1 hour later. Interleukin 6 levels were significantly reduced (F1.60,43.1 = 4.35; P = .03) at the end of exercise but not after the final rest period. Interleukin 10 levels did not differ significantly. Ratios of interleukin 6 to interleukin 10 decreased significantly (F1.61,43.38 = 3.42; P = .05) at the end of exercise and again after 60 minutes\u27 rest. Conclusion The exercise was well tolerated, and comfort improved during and after the intervention. Cytokine levels provided physiological rationale for benefits of early exercise. © 2013 American Association of Critical-Care Nurses

Comparison Of Airway Management Practices Between Registered Nurses And Respiratory Care Practitioners

Background Airway management, an essential component of care for patients receiving mechanical ventilation, is multifaceted and includes oral hygiene and suctioning, endotracheal suctioning, and care of endotracheal tubes. Registered nurses and respiratory care personnel often share responsibilities for airway management. Knowledge of current practices can help facilitate evidence-based practices to optimize care of patients receiving mechanical ventilation. Objectives To describe current practices for airway management of intubated patients and determine if practices differ between registered nurses and respiratory care practitioners. Methods A descriptive, comparative design was used. Registered nurses and respiratory care practitioners who provided direct care to intubated patients receiving mechanical ventilation were recruited to complete an online survey of self-reported practices. Results A total of 85 participants completed the survey. Most were experienced caregivers with a bachelor\u27s degree and certification or registration in their field. Selected practices have improved, including increasing oxygen saturation before endotracheal suctioning, maintaining pressure of endotracheal tube cuffs, and providing oral hygiene and suctioning. The practices of registered nurses and respiratory care practitioners differed in many ways. The nurses assumed responsibility for oral antisepsis, whereas the respiratory care practitioners managed the endotracheal tube. The 2 groups shared responsibility for oral and endotracheal suctioning. Knowledge of current guidelines for endotracheal suctioning was lacking. Conclusions Practices in airway management have improved, but opportunities exist to develop shared policies and procedures based on current evidence. © 2014 American Association of Critical-Care Nurses

Implementing Best Practice Strategies To Prevent Infection In The Icu

Critically ill patients are at high risk for infection because of many factors. Quality and regulatory groups have published guidelines regarding infection prevention in the ICU. A multifaceted, multiprofessional team approach is necessary to develop and implement strategies to prevent infections in the critically ill patient. Bundles of interventions along with daily rounds and assessment are essential program components. Ongoing surveillance and re-education and reinforcement are also part of a strong infection prevention program. © 2006 Elsevier Inc. All rights reserved

Too Much Information: Research Issues Associated With Large Databases

PURPOSE:: The purpose of this article was to discuss common issues associated with large databases and present possible solutions to improve the quality and usefulness of large database research. BACKGROUND:: The volume of electronic healthcare-related data is growing exponentially. Some of these data are being stored in registries and administrative databases. These data repositories are increasingly common and can serve as sources of nurse-driven research and quality improvement activities. Although these large databases have a wealth of useful information, they have limitations that may bias results. These include missing data and cases, data accuracy and validity, and the statistical effect of large samples. DESCRIPTION:: Researchers using large databases to address quality, safety, clinical, or systems issues have a variety of available techniques to deal with data issues. Proper data cleaning activities such as screening, visualization, and outlier/inlier identification are essential for addressing inaccurate values within large data sets. Common methods for addressing missing data include case analyses and various imputation techniques. Statistical approaches such as risk reductions and effect size are also useful when working with large sample sizes. CONCLUSION/IMPLICATIONS:: Registries and administrative databases provide healthcare researchers with increasing opportunities to address a wide variety of important practice and patient care questions. Healthcare researchers are encouraged to explore large data sets as they look for ways to improve patient safety and quality care, develop evidence-based practice guidelines, and fulfill regulatory and accreditation requirements. © 2013 Lippincott Williams & Wilkins

Urinary Catheterization Skills: One Simulated Checkoff Is Not Enough

Background: Skills in aseptic technique are essential competencies for preventing infection; yet, aseptic technique is a difficult concept to master. During urinary catheter insertion, failure to properly adhere to strict aseptic technique has been linked to infections and sepsis. This pilot study used simulation to identify the most common breaches in aseptic technique during urinary catheter insertion. Methods: Baccalaureate nursing students with prior documentation of competency were recruited to demonstrate performance of urinary catheterization on a task trainer. The procedure was recorded, and breaches in technique were identified through review of the digital recordings. Results: Data were available for 13 participants. Participants ranged in age from 21 to 43years (mean, 26.6). Ten participants (77%) were female and three (23%) were male. The participants\u27 mean self-rating of confidence was 3.6 on a 5-point scale (range, 3-5), indicating some confidence in performing the skill. Examination of the video recorded data showed that 10 participants (77%) breached aseptic technique in at least one category and in some instances several categories. The most common breach was cleansing the meatus; seven participants (54%) performed it incorrectly. Conclusions: One-time competency validation using a simulator is not enough to ensure skill mastery or retention. Urinary catheter insertion is a high-risk skill and therefore should be afforded ample time to practice. Innovative approaches to ensure skill mastery, including urinary catheterization and other skills requiring sterile techniques, are needed. © 2014 International Nursing Association for Clinical Simulation and Learning