Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life

Purpose of Review: To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL). Recent Findings: We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators. Summary: EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind

A Latent Approach to Understanding Pain in Nursing Home Residents Who are Unable to Self-Report Pain

Context: Pain assessment in people with cognitive impairment is challenging. Objective: The study sought to 1) identify pain subgroups based on staff-assessed pain, agitated and reactive behavior, functional status, and symptoms of depression; and 2) understand if cognitive impairment was associated with transitions between pain subgroups at nursing home admission, 3 months, and 6 months. Methods: Using national Minimum Data Set 3.0 data (2011-2016), we included 26,816 newly admitted residents with staff-assessed pain at admission, 3 months, and 6 months. Pain subgroups were identified by latent class analysis at each time point. Transitions between pain subgroups were described using latent transition analysis. Results: Five latent statuses of pain were identified at admission: Behavioral and Severe Depression (prevalence stable, severe or worsening cognitive impairment: 11%, mild/moderate or improved cognitive impairment: 10%), Functional (21%; 25%), Physical (22%; 23%), Behavioral (23%, 19%), and Low (23%; 24%). Regardless of change in cognitive status, most residents remained in the same pain latent class. Among residents with stable, severe or worsening cognitive impairment, 11% in the Behavioral class transitioned to the Behavioral and Severe Depression class by 3 months. Fewer residents transitioned between latent classes in the 3- to 6-month period ( \u3e 80% remained in their 3-month class). Conclusion: For nursing home residents unable to self-report pain, consideration of additional indicators including functioning, depressive symptoms, and agitation may be useful in identifying pain subgroups. Longitudinal changes in the pain subgroups over 6 months post-admission highlight that residents with severe cognitive impairment may be at risk for worsening pain

Development and psychometric evaluation of the Social Connectedness Index in nursing home residents with Alzheimer\u27s disease and dementia using the Minimum Data Set 3.0

OBJECTIVES: To develop a reliable and valid measure of social connectedness among nursing home residents with Alzheimer\u27s disease and related dementias (ADRD) using items available in the Minimum Dataset 3.0 (MDS). METHODS: We conducted a retrospective scale development study using the 2016 MDS with two populations of nursing home residents with ADRD: (1) new admissions (not post-acute care) (n = 146,694); (2) residents with comprehensive annual assessments (n = 294,704). Twenty-nine items were included for consideration. Psychometric evaluation included content validity, item analysis, internal consistency reliability, criterion-related validity, and exploratory factor analysis. Analyses were stratified by self- or staff-assessed pain. RESULTS: The resulting five item Social Connectedness Index (SCI) has good content (Fleiss Kappa = 0.67), criterion-related and construct validity and adequate internal consistency reliability (Kuder Richardson-20: 0.63-0.74) in persons with ADRD. As anticipated, younger residents, men, and those with severe cognitive impairment, anxiety, and depression were more likely to be categorized in the low social connectedness group. CONCLUSION: The SCI is a promising measure for estimating the amount of social connectedness present for nursing home residents with ADRD. Further work needs to be done to evaluate the usefulness of the SCI for evaluating health and well-being among this population over time

Pain Behaviors and Pharmacological Pain Management Among Newly Admitted Nursing Home Residents

BACKGROUND: Clinicians may place more weight on vocal complaints of pain than the other pain behaviors when making decisions about pain management. OBJECTIVES: We examined the association between documented pain behaviors and pharmacological pain management among nursing home residents. METHODS: We included 447,684 residents unable to self-report pain, with staff-documented pain behaviors (vocal, nonverbal, facial expressions, protective behaviors) and pharmacological pain management documented on the 2010-2016 Minimum Data Set 3.0. The outcome was no pharmacological pain medications, as needed only (pro re nata [PRN]), as scheduled only, or as scheduled with PRN medications. We estimated adjusted odds ratios and 95% confidence intervals from multinomial logistic models. RESULTS: Relative to residents with vocal complaints only, those with one pain behavior documented (i.e., nonverbal, facial, or protective behavior) were more likely to lack pain medication versus scheduled and PRN medications. Residents with multiple pain behaviors documented were least likely to have no treatment relative to scheduled with PRN medications, PRN only, or scheduled only pain medication regimens. DISCUSSION: The type and number of pain behaviors observed are associated with pharmacological pain management regimen. Improving staff recognition of pain among residents unable to self-report is warranted in nursing homes

Prevalence and treatment of neuropathic pain diagnoses among U.S. nursing home residents

ABSTRACT: Neuropathic pain is a common condition experienced by older adults. Prevalence estimates of neuropathic pain and descriptive data of pharmacologic management among nursing home residents are unavailable. We estimated the prevalence of neuropathic pain diagnoses and described the use of pain medications among nursing home residents with possible neuropathic pain. Using the Minimum Data Set 3.0 linked to Medicare claims for residents living in a nursing home on November 30, 2016, we included 473,815 residents. ICD-10 codes were used to identify neuropathic pain diagnoses. Identification of prescription analgesics/adjuvants was based on claims for the supply of medications that overlapped with the index date over a 3-month look-back period. The prevalence of neuropathic pain was 14.6%. Among those with neuropathic pain, 19.7% had diabetic neuropathy, 27.3% had back and neck pain with neuropathic involvement, and 25.1% had hereditary or idiopathic neuropathy. Among residents with neuropathic pain, 49.9% received anticonvulsants, 28.6% received antidepressants, 19.0% received opioids, and 28.2% had no claims for analgesics or adjuvants. Resident characteristics associated with lack of medications included advanced age, dependency in activities of daily living, cognitive impairment, and diagnoses of comorbid conditions. A diagnosis of neuropathic pain is common among nursing home residents, yet many lack pharmacologic treatment for their pain. Future epidemiologic studies can help develop a more standard approach to identifying and managing neuropathic pain among nursing home residents