Pain and delirium: mechanisms, assessment, and management

Purpose: Pain and delirium are common problems for older people. Both conditions are prevalent in acute hospital settings. In people living in the community, delirium often precipitates presentation to the emergency department. Pain and delirium are known to interact in a complex and multidirectional way. This can make it challenging for staff to recognize and treat pain in people with delirium. Methods: This paper aims to explore the complex relationship between pain and delirium and on pain assessment in delirium, drawing together evidence from a range of settings including acute medical, cardiac and orthopaedic post-operative cohorts, as well as from aged care. Results: A limited number of studies suggest there is an association between pain and delirium; however, this is a complex, particularly where analgesics which may-themselves cause delirium are prescribed. Factors acting on the pathway between pain and delirium may include depression, sleep deprivation and disturbance of the cholinergic system. Delirium affects the ability to self-report pain. The fluctuating nature of delirium as well as reduced awareness and attention may challenge practitioners in recognizing, assessing and treating pain. Evidence concerning the reliability and validity of current observational and self-assessment tools in people with delirium is unclear but some show promise in this population. Conclusion: The current evidence base regarding assessing pain in people with delirium is lacking. Tentative recommendations, drawing on current guidelines require robust testing. Guidelines for people with pain and dementia require adaptations regarding the unique characteristics of delirium. The complex interplay between dementia, pain and delirium warrants further investigation across a range of settings

Analgesic prescribing in care home residents: how epidemiological studies may inform clinical practice

Care home residents are often frail with multiple comorbidities and cognitive impairment, most commonly caused by dementia. This population is under-represented in clinical trials, leading to a lack of valid and reliable evidence to inform clinicians’ prescribing practice. This paper summarizes how epidemiological research conducted in similar populations can inform pain management by describing pain prevalence, risk factors, typical features and functional consequences. This evidence can help overcome the numerous barriers to optimal pain management in care home residents

Healthcare decision-making: past present and future, in light of a diagnosis of dementia

End-of-life care policy in the UK states that all people should identify their needs, priorities and preferences for end-of-life care in the form of advance care planning. Advance care planning in dementia is less well developed than in some other disease groups such as cancer and, arguably, may be more complex. A person with dementia may lose the capacity to make decisions associated with advance care planning early in the course of the disease, requiring more involvement of family carers. This study explores the 'lived' context to health care decision-making of dyads (the person with dementia and their carer) in respect of past, present and future healthcare decision-making

New public health approaches to palliative care, a brave new horizon or an impractical ideal? An Integrative literature review with thematic synthesis

Access to palliative care for marginalized communities is frequently problematized as a major challenge facing palliative care services. The traditional response of asking what services can do for the disadvantaged has been invigorated by a new wave of public health measures that embrace death and dying as social processes and ask, what can be done together with such communities as partners working in palliative care. Such work has generated a significant amount of academic, social and political interests over the last 20 years; however, we are yet to see a consistent and sustained change in approach from providers. We argue that this is due to inherent tensions that arise when modelling death, dying and loss as a unified and shared social process. Unresolved tensions destabilize the theoretical foundations and risk misrepresentation of core philosophies. In this integrative review of 75 articles, we present previously undiscussed areas of contention drawing from a pan-disciplinary field of theoretical and empirical evidence. We conclude that new public health approaches lack a consistent and unified theoretical approach. From philosophical, ontological and existential ideas relating to how different stakeholders conceptualize death, to the processes by which communities are motivated and their constituent members empowered through responsibilized notions of duty and reciprocity, there is little acknowledgement of the complex tensions at hand. Increasing academic and political initiative alone is not enough to progress this movement in a manner that achieves its full potential. Instead, we must pay greater attention to the tensions described. This article aims to work with such tensions to better define the landscape of collective moral responsibility in end-of-life care. We believe that this is crucial if palliative care is to avoid becoming a technical speciality with community and communitization reduced to a mere technical solution to more profound questions

Psychiatric liaison service referral patterns during the UK COVID-19 pandemic: An observational study

Background and objectives: COVID-19 has had a profound effect on mental health. Liaison psychiatry teams assess and treat people in mental health crises in emergency departments (EDs) and on hospital wards. During the first pandemic wave, new Mental Health Crisis Assessment Services (MHCAS) were created to divert people away from EDs. Our objective was to describe patterns in referrals to psychiatric liaison services across the North Central London care sector (NCL) and explore the impact of a new MHCAS. / Methods: Retrospective study using routinely collected data (ED and ward referrals) from five liaison psychiatry services across NCL (total population 1.5 million people). We described referrals (per week and month) by individual liaison services and cross-sector, and patterns of activity (January 1st 2020 -September 31st 2020, weeks 1-39) compared with the same period in 2019. We calculated changes in the proportion of ED attendees (all-cause) referred to liaison psychiatry. / Results: From 2019-2020, total referrals decreased by 16.5% (12,265 to 10,247), a 16.4% decrease in ED referrals (9528 to 7965) and 16.6% decrease in ward referrals (2737 to 2282). There was a marked decrease in referrals during the first pandemic wave (March/April 2020), which increased after lockdown ended. The proportion of ED attendees referred to liaison psychiatry services increased compared to 2019. / Conclusions: People in mental health crisis continued to seek help via ED/MHCAS and a higher proportion of people attending ED were referred to liaison psychiatry services just after the first pandemic wave. MHCAS absorbed sector ED activity during the pandemic

The effectiveness of interventions to improve the care and management of people with dementia in general hospitals: a systematic review

Background: People with dementia are at greater risk of being admitted to hospital where care may not be tailored to their needs. Interventions improving care and management are vital. Aim: Assess the effectiveness of interventions designed to improve the care and management of people with dementia in hospital. Method: Six medical and trial registry, and grey literature databases were searched (1999‐1998/2018). Search terms included “Dementia,” “Hospital,” and “Intervention” and limited to experimental designs. Interventions designed to improve the care and management of people with dementia in the general hospital setting were examined. Outcomes included behavioural and psychological symptoms of dementia (BPSD), psychosocial, clinical, staff knowledge, and length of hospital stay. The CASP tools, Cochrane risk of bias tool, and GRADE system assessed methodological quality and certainty of evidence. Results: 9003 unique citations were identified; 24 studies were included. Studies were limited in study design and their conduct was at a risk of bias. There is very low‐quality evidence that multisensory behaviour therapy reduces BPSD. There is low‐quality evidence that a multidisciplinary programme reduces postoperative complications and that robot‐assisted therapy, music therapy, multimodal‐comprehensive care, person‐centred care, and family‐centred function‐focused care interventions improved staff knowledge, competence, efficacy, and communication. No studies reported reduced length of stay. Conclusions: Whilst we found that these interventions improved the care and management of people with dementia in hospital, it was low‐ to very low‐quality evidence. New clinical recommendations cannot be made based on current evidence, and robust trial designs are necessary to inform evidence‐based care

Social networks, social capital and end-of-life care for people with dementia: a realist review

OBJECTIVES (1) To develop an understanding of how social capital may be conceptualised within the context of endof-life care and how it can influence outcomes for people with dementia and their families with specific reference to the context and mechanisms that explain observed outcomes. (2) To produce guidance for healthcare systems and researchers to better structure and design a public health approach to end-of-life care for people with dementia. DESIGN A realist review. Data sources MEDLINE, EMBASE, CINAHL and grey literature. ANALYSIS We conceptualised social capital as a complex intervention and, in order to understand how change is generated, used realist evaluation methods to create different configurations of context, mechanism and outcomes. We conducted an iterative search focusing on social capital, social networks and end-of-life care in dementia. All study designs and outcomes were screened and analysed to elicit explanations for a range of outcomes identified. Explanations were consolidated into an overarching programme theory that drew on substantive theory from the social sciences and a public health approach to palliative care. RESULTS We identified 118 articles from 16 countries ranging from 1992 to 2018. A total of 40 contextmechanism-outcome configurations help explain how social capital may influence end-of-life care for people with dementia. Such influence was identified within five key areas. These included: (1) socially orientating a person with dementia following diagnosis; (2) transitions in the physical environment of care; (3) how the caregiving experience is viewed by those directly involved with it; (4) transition of a person with dementia into the fourth age; (5) the decision making processes underpinning such processes. CONCLUSION This review contributes to the dispassionate understanding of how complex systems such as community and social capital might be viewed as a tool to improve end-of-life care for people with dementia. PROSPERO REGISTRATION NUMBER CRD42018084524

Mapping and understanding the decision-making process for providing nutrition and hydration to people living with dementia: a systematic review

BACKGROUND: This systematic review aimed to explore the process of decision-making for nutrition and hydration for people living with dementia from the perspectives and experiences of all involved. METHODS: We searched CINAHL, the Cochrane Library, EMBASE, MEDLINE and PsycINFO databases. Search terms were related to dementia, decision-making, nutrition and hydration. Qualitative, quantitative and case studies that focused on decision-making about nutrition and hydration for people living with dementia were included. The CASP and Murad tools were used to appraise the quality of included studies. Data extraction was guided by the Interprofessional Shared Decision Making (IP-SDM) model. We conducted a narrative synthesis using thematic analysis. PROSPERO registration number CRD42019131497. RESULTS: Forty-five studies were included (20 qualitative, 15 quantitative and 10 case studies), comprising data from 17 countries and 6020 patients, family caregivers and practitioners. The studies covered a range of decisions from managing oral feeding to the use of tube feeding. We found that decisions about nutrition and hydration for people living with dementia were generally too complex to be mapped onto the precise linear steps of the existing decision-making model. Decision-making processes around feeding for people living with dementia were largely influenced by medical evidence, personal values, cultures and organizational routine. Although the process involved multiple people, family caregivers and non-physician practitioners were often excluded in making a final decision. Upon disagreement, nutrition interventions were sometimes delivered with conflicting feelings concealed by family caregivers or practitioners. Most conflicts and negative feelings were resolved by good relationship, honest communication, multidisciplinary team meetings and renegotiation. CONCLUSIONS: The decision-making process regarding nutrition and hydration for people living with dementia does not follow a linear process. It needs an informed, value-sensitive, and collaborative process. However, it often characterized by unclear procedures and with a lack of support. Decisional support is needed and should be approached in a shared and stepwise manner