Gamle – og pasienter med demens – Omsorg ved livets slutt

I livets siste leveår vil det store flertall gamle og pasienter med demens trenge kompetent omsorg, pleie, vurdering og behandling, med respekt for deres livsprosjekt og verdighet. Alle vil i de siste måneder, uker, dager og timer før de dør trenge kompetent omsorg ved livets slutt (palliative care), uavhengig av diagnose eller oppholdssted – til alle døgnets tider. Artikkelen drøfter utfordringer og muligheter, grunnlaget for nødvendig kompetanse: etikk, forberedende samtaler, organisering og samhandling

Report of the Lancet Commission on the Value of Death: bringing death back into life

The story of dying in the 21st century is a story of paradox. While many people are overtreated in hospitals with families and communities relegated to the margins, still more remain undertreated, dying of preventable conditions and without access to basic pain relief. The unbalanced and contradictory picture of death and dying is the basis for this Commission

Gamle – og pasienter med demens – Omsorg ved livets slutt

I livets siste leveår vil det store flertall gamle og pasienter med demens trenge kompetent omsorg, pleie, vurdering og behandling, med respekt for deres livsprosjekt og verdighet. Alle vil i de siste måneder, uker, dager og timer før de dør trenge kompetent omsorg ved livets slutt (palliative care), uavhengig av diagnose eller oppholdssted – til alle døgnets tider. Artikkelen drøfter utfordringer og muligheter, grunnlaget for nødvendig kompetanse: etikk, forberedende samtaler, organisering og samhandling

The Liverpool Care Pathway: discarded in cancer patients but good enough for dying nursing home patients? A systematic review

Abstract Background The Liverpool Care Pathway (LCP) is an interdisciplinary protocol, aiming to ensure that dying patients receive dignified and individualized treatment and care at the end-of-life. LCP was originally developed in 1997 in the United Kingdom from a model of cancer care successfully established in hospices. It has since been introduced in many countries, including Norway. The method was withdrawn in the UK in 2013. This review investigates whether LCP has been adapted and validated for use in nursing homes and for dying people with dementia. Methods This systematic review is based on a systematic literature search of MEDLINE, CINAHL, EMBASE, and Web of Science. Results The search identified 12 studies, but none describing an evidence-based adaption of LCP to nursing home patients and people with dementia. No studies described the LCP implementation procedure, including strategies for discontinuation of medications, procedures for nutrition and hydration, or the testing of such procedures in nursing homes. No effect studies addressing the assessment and treatment of pain and symptoms that include dying nursing home patients and people with dementia are available. Conclusion LCP has not been adapted to nursing home patients and people with dementia. Current evidence, i.e. studies investigating the validity and reliability in clinically relevant settings, is too limited for the LCP procedure to be recommended for the population at hand. There is a need to develop good practice in palliative medicine, Advance Care Planning, and disease-specific recommendations for people with dementia

The Liverpool Care Pathway: discarded in cancer patients but good enough for dying nursing home patients? A systematic review

Background The Liverpool Care Pathway (LCP) is an interdisciplinary protocol, aiming to ensure that dying patients receive dignified and individualized treatment and care at the end-of-life. LCP was originally developed in 1997 in the United Kingdom from a model of cancer care successfully established in hospices. It has since been introduced in many countries, including Norway. The method was withdrawn in the UK in 2013. This review investigates whether LCP has been adapted and validated for use in nursing homes and for dying people with dementia. Methods This systematic review is based on a systematic literature search of MEDLINE, CINAHL, EMBASE, and Web of Science. Results The search identified 12 studies, but none describing an evidence-based adaption of LCP to nursing home patients and people with dementia. No studies described the LCP implementation procedure, including strategies for discontinuation of medications, procedures for nutrition and hydration, or the testing of such procedures in nursing homes. No effect studies addressing the assessment and treatment of pain and symptoms that include dying nursing home patients and people with dementia are available. Conclusion LCP has not been adapted to nursing home patients and people with dementia. Current evidence, i.e. studies investigating the validity and reliability in clinically relevant settings, is too limited for the LCP procedure to be recommended for the population at hand. There is a need to develop good practice in palliative medicine, Advance Care Planning, and disease-specific recommendations for people with dementia

Pain in older persons with severe dementia. Psychometric properties of the Mobilization–Observation–Behaviour–Intensity–Dementia (MOBID‐2) Pain Scale in a clinical setting

Background: To assess pain in older persons with severe dementia is a challenge due to reduced self‐report capacity. Recently, the development and psychometric property testing of the Mobilization–Observation–Behaviour–Intensity–Dementia (MOBID) Pain Scale was described using video‐recording. The purpose of this article was to present the further development of this instrument. In MOBID‐2 Pain Scale, the assessment of inferred pain intensity is based on patient’s pain behaviours in connection with standardized, guided movements of different body parts (Part 1). In addition, MOBID‐2 includes the observation of pain behaviours related to internal organs, head and skin registered on pain drawings and monitored over time (Part 2). Objective: The aim of this study was to examine psychometric properties of the MOBID‐2 Pain Scale, like inter‐rater and test–retest reliability, internal consistency, as well as face‐, construct‐ and concurrent validity. Subjects and Setting: Patients with severe dementia (n = 77) were examined by 28 primary caregivers in clinical practice, who concurrently and independently completed the MOBID‐2 Pain Scale. Characteristics of the patients’ pain were also investigated by their physicians (n = 4). Results: Prevalence of any pain was 81%, with predominance to the musculoskeletal system, highly associated with the MOBID‐2 overall pain score (rho = 0.82). Most frequent and painful were mobilizing legs. Pain in pelvis and/or genital organs was frequently observed. Moderate to excellent agreement was demonstrated for behaviours and pain drawings (κ = 0.41–0.90 and κ = 0.46–0.93). Inter‐rater and test–retest reliability for pain intensity was very good, ICC (1, 1) ranging 0.80–0.94 and 0.60–0.94. Internal consistency was highly satisfactory; Cronbach’s α ranging 0.82–0.84. Face‐, construct‐ and concurrent validity was good. Overall pain intensity by MOBID‐2 was well correlated with physicians’ clinical examination and defined pain variables (rho = 0.41–0.64). Conclusion: On the basis of pain behaviours, standardized movements and pain drawings, MOBID‐2 Pain Scale was shown to be sufficiently reliable, valid and time‐effective for nurses to assess pain in patients with severe dementia

Deprescribing antihypertensive treatment in nursing home patients and the effect on blood pressure

Background: It is debatable whether treating multimorbid nursing home patients with antihypertensive drugs produces beneficial effects. Most cardiovascular guidelines promote treatment; few have advice on how to deprescribe when treatment may no longer be necessary. We investigated the effect of medication review on antihypertensive drug use and the association between cognition, blood pressure, and prescribing. Methods: From August 2014 to December 2015, 765 patients from 72 units (clusters) in 32 Norwegian nursing homes were included in a 4-month, multicentre, cluster-randomized, controlled trial, with 9-month follow-up. Patients ≥ 65 years old with antihypertensive treatment (n = 295, 39%) were randomized to systematic medication review where the physician received support from peers (collegial mentoring) or were given care as usual (control condition). Outcome measures were the number of antihypertensive drugs, systolic blood pressure, and pulse. We used hospitalizations and deaths as criteria to assess harm. Results: At baseline, each patient used 9.2 ± 3.5 regular drugs, and 1.6 ± 0.7 antihypertensives. Mean blood pressure was 128/71 mmHg and 9% had a systolic pressure ≥ 160 mmHg. Between baseline and month four, antihypertensives were deprescribed to a significantly higher extent in the intervention group (n = 43, 32%) compared to control (n = 11, 10%); Incidence Rate Ratio = 0.8, 95% CI = 0.7-0.9. In the intervention group, there was an immediate increase in systolic blood pressure when antihypertensives were reduced, from baseline 128 ± 19.5 mmHg to 143 ± 25.5 mmHg at month four. However, at month nine, the blood pressure had reverted to baseline values (mean 134 mmHg). Deprescription did not affect pulse and systolic pressure. The number of hospitalizations was higher in control patients at month four (P = 0.031) and nine (P = 0.041). Conclusion: A systematic medication review supported by collegial mentoring significantly decreased the use of antihypertensive drugs in nursing home patients without an effect on the systolic blood pressure over time

Patient safety culture in Norwegian nursing homes

Background Patient safety culture concerns leader and staff interaction, attitudes, routines, awareness and practices that impinge on the risk of patient-adverse events. Due to their complex multiple diseases, nursing home patients are at particularly high risk of adverse events. Studies have found an association between patient safety culture and the risk of adverse events. This study aimed to investigate safety attitudes among healthcare providers in Norwegian nursing homes, using the Safety Attitudes Questionnaire – Ambulatory Version (SAQ-AV). We studied whether variations in safety attitudes were related to professional background, age, work experience and mother tongue. Methods In February 2016, 463 healthcare providers working in five nursing homes in Tønsberg, Norway, were invited to answer the SAQ-AV, translated and adapted to the Norwegian nursing home setting. Previous validation of the Norwegian SAQ-AV for nursing homes identified five patient safety factors: teamwork climate, safety climate, job satisfaction, working conditions and stress recognition. SPSS v.22 was used for statistical analysis, which included estimations of mean values, standard deviations and multiple linear regressions. P-values <0.05 were considered to be significant. Results Out of the 463 employees invited, 288 (62.2%) answered the questionnaire. Response rates varied between 56.9% and 72.2% across the five nursing homes. In multiple linear regression analysis, we found that increasing age and job position among the healthcare providers were associated with significantly increased mean scores for the patient safety factors teamwork climate, safety climate, job satisfaction and working conditions. Not being a Norwegian native speaker was associated with a significantly higher mean score for job satisfaction and a significantly lower mean score for stress recognition. Neither professional background nor work experience were significantly associated with mean scores for any patient safety factor. Conclusions Patient safety factor scores in nursing homes were poorer than previously found in Norwegian general practices, but similar to findings in out-of-hours primary care clinics. Patient safety culture assessment may help nursing home leaders to initiate targeted quality improvement interventions. Further research should investigate associations between patient safety culture and the occurrence of adverse events in nursing homes

Pain and quality of life in nursing home residents with dementia after admission – a longitudinal study

Abstract Background Pain in nursing home (NH) residents with dementia is commonly reported and may affect Quality of Life (QoL) negatively. Few longitudinal studies have explored how pain and QoL develop in NH residents with dementia starting from their admission to the NH. Aim The aim was to explore pain, QoL, and the association between pain and QoL over time in persons with dementia admitted to a NH. Methods A convenience sample, drawn from 68 non-profit NHs, included a total of 996 Norwegian NH residents with dementia (mean age 84.5 years, SD 7.6, 36.1% men) at NH admission (A1), with annual follow-ups for two years (A2 and A3). Pain and QoL were assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale and the Quality of Life in Late-Stage Dementia (QUALID) scale, respectively, at all assessments. Severity of dementia, personal level of activities of daily living, general medical health, neuropsychiatric symptoms, and the prescription of psychotropic drugs and analgesics (opioids and/or paracetamol) were also assessed at all assessments. Results Mean (SD) MOBID-2 pain intensity scores were 2.1 (2.1), 2.2 (2.2), and 2.4 (2.1) at A1, A2, and A3, respectively. Participants who were prescribed analgesics had higher pain intensity scores at all assessments than participants not prescribed analgesics. The mean (SD) QUALID scores at each assessment were 19.8 (7.1), 20.8 (7.2), and 22.1 (7.5) at A1, A2, and A3, respectively. In the adjusted linear mixed model, higher pain intensity score, prescription of opioids, and prescription of paracetamol were associated with poorer QoL (higher QUALID total score and higher scores in the QoL dimensions of sadness and tension) when assessed simultaneously. No time trend in QoL was found in these adjusted analyses. Conclusion NH residents with dementia who have higher pain intensity scores or are prescribed analgesics are more likely to have poorer QoL. Clinicians, NH administrators, and national healthcare authorities need to look into strategies and actions for pharmacological and non-pharmacological pain treatment to reduce pain intensity while simultaneously avoiding negative side effects of pain treatment that hamper QoL