JAGS Abstracts: From the Journal of the American Geriatrics Society
Pain, Dyspnea, and the Quality of Dying in Long-Term Care
Anthony J. Caprio, MD, Laura C. Hanson, MD, MPH, Jean C. Munn, PhD, Christianna S. Williams, PhD, Debra Dobbs, PhD, Philip D. Sloane, MD, MPH, and Sheryl Zimmerman, PhD
OBJECTIVES: To evaluate the relationship between pain, dyspnea, and family perceptions of the quality of dying in long-term care.
DESIGN: After-death interviews.
SETTING: Stratified random sample of 111 nursing homes and residential care and assisted living facilities in four states.
PARTICIPANTS: Paired interviews from facility staff and family caregivers for 325 deceased residents.
MEASUREMENTS: The outcome variable was the Quality of Dying in Long-Term Care (QOD-LTC), a psychometrically sound, retrospective scale representing psychosocial aspects of the quality of dying, obtained from interviews with family caregivers. Facility staff reported the presence, frequency, and severity of pain and dyspnea.
RESULTS: During the last month of life, nearly half of residents experienced pain or dyspnea. QOD-LTC scores did not differ for residents with and without pain (4.15 vs 4.02, P=.16). Overall, residents with dyspnea had better QOD-LTC scores than those without dyspnea (4.20 vs 3.99, P=.006). The association between dyspnea and a better QOD-LTC score was strongest in cognitively impaired residents and for those dying in residential care and assisted living facilities.
CONCLUSION: For residents dying in long-term care, pain and dyspnea were not associated with a poorer quality of dying as perceived by families of deceased residents. Instead, dyspnea may alert staff to the need for care. Initiatives to improve the quality of dying in long-term care should focus not only on physical symptoms, but also on the alleviation of nonphysical sources of suffering at the end of life. J Am Geriatr Soc 2008;56(4):683-688.
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Cognitive, Functional, and Quality-of-Life Outcomes of Patients Aged 80 and Older Who Survived at Least 1 Year After Planned or Unplanned Surgery or Medical Intensive Care Treatment
Sophia E. J. A. de Rooij, MD, PhD, Annerike C. Govers, MD, Johanna C. Korevaar, PhD, Arja W. Giesbers, RN, Marcel Levi, MD, PhD, and Evert de Jonge, MD, PhD
OBJECTIVES: To investigate long-term cognitive, functional, and quality-of-life outcomes in very elderly survivors at least 1 year after planned or unplanned surgery or medical intensive care treatment.
DESIGN: Retrospective cohort study.
SETTING: General, 1,024-bed, tertiary university teaching hospital in the Netherlands.
PARTICIPANTS: Two hundred four survivors of a cohort of 578 patients admitted to the medical–surgical intensive care unit (ICU) between January 1997 and December 2002 and alive in December 2003. The majority of survivors underwent elective surgery.
MEASUREMENTS: From December 2003 until February 2004, data were collected from 190 patients and 169 relatives. The measures were: Informant Questionnaire on Cognitive Decline short form (IQCODE-SF) (cognition), modified Katz index of activities of daily living (ADLs) (functional status), and EuroQol (EQ-5D) (health-related quality of life). The patients themselves completed the modified Katz ADL index and EQ-5D forms; their caregivers completed the ADL caregiver version and IQCODE-SF.
RESULTS: The mean age at admission±standard deviation was 81.7±2.4, and the median time after discharge was 3.7 years (range 1–5.9 years). Of the ICU patients who had planned surgery, 57% survived, compared with 11% of the unplanned surgical admissions and 10% of the medical patients. Three-quarters (74.3%) of the patients who lived at home before ICU admission remained at home at follow-up. Eighty-three percent had no severe cognitive impairment, and 76% had no severe physical limitations (33% had moderate, 40% had mild, and 3% had no limitations). The perceived quality of life was similar to that of an age-matched general population.
CONCLUSION: Long-term survivors of ICU treatment received at the age of 80 and older showed fair-to-good cognitive and physical functioning and quality of life, although few patients who underwent unplanned surgery or who were admitted to the ICU for medical reasons survived. J Am Geriatr Soc 2008;56(5):816-822.
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Consensus List of Signals to Detect Potential Adverse Drug Reactions in Nursing Homes
Steven M. Handler, MD, MS, Joseph T. Hanlon, PharmD, MS, Subashan Perera, PhD, Yazan F. Roumani, MS, MBA, David A. Nace, MD, MPH, Douglas B. Fridsma, MD, PhD, Melissa I. Saul, MS, Nicholas G. Castle, PhD, and Stephanie A. Studenski, MD, MPH
OBJECTIVES: To develop a consensus list of agreed-upon laboratory, pharmacy, and Minimum Data Set signals that a computer system can use in the nursing home to detect potential adverse drug reactions (ADRs).
DESIGN: Literature search for potential ADR signals, followed by an internet-based, a two-round, modified Delphi survey.
SETTING: A nationally representative survey of experts in geriatrics.
PARTICIPANTS: Panel of 13 physicians, 10 pharmacists, and 13 advanced practitioners.
MEASUREMENTS: Mean score and 95% confidence interval (CI) for each of 80 signals rated on a 5-point Likert scale (5=strong agreement with likelihood of indicating potential ADRs). Consensus agreement indicated by a lower-limit 95% CI of 4.0 or greater.
RESULTS: Panelists reached consensus agreement on 40 signals: 15 laboratory and medication combinations, 12 medication concentrations, 10 antidotes, and three Resident Assessment Protocols (RAPs). Highest consensus scores (4.6, 95% CI=4.4–4.9 or 4.4–4.8) were for naloxone when taking opioid analgesics; phytonadione when taking warfarin; dextrose, glucagon, or liquid glucose when taking hypoglycemic agents; medication-induced hypoglycemia; supratherapeutic international normalized ratio when taking warfarin; and triggering the Falls RAP when taking certain medications.
CONCLUSION: A multidisciplinary expert panel was able to reach consensus agreement on a list of signals to detect potential ADRs in nursing home residents. The results of this study can be used to prioritize an initial list of signals to be included in paper- or computer-based methods for potential ADR detection. J Am Geriatr Soc 2008;56(5):808-815. ________________________________________________________________________________________________________________
MODELS OF GERIATRIC CARE, QUALITY OF IMPROVEMENT, AND PROGRAM DISSEMINATION
Extent of Implementation of Evidence-Based Fall Prevention Practices for Older Patients in Home Health Care
Richard H. Fortinsky, PhD, Dorothy Baker, PhD, RN-CS, Margaret Gottschalk, PT, MS, Mary King, MD, Patricia Trella, MA, and Mary E. Tinetti, MD
This study determined the extent to which fall risk assessment and management practices for older patients were implemented in Medicare-certified home health agencies (HHAs) in a defined geographic area in southern New England that had participated in evidence-based fall prevention training between October 2001 and September 2004. The standardized in-service training sessions taught home health nurses and rehabilitation therapists how to conduct assessments for five evidence-based risk factors for falls in older adults—mobility impairments, balance disturbances, multiple medications, postural hypotension, and home environmental hazards—using techniques shown to be efficacious in clinical trials. Twenty-six HHAs participated in these in-service training sessions; 19 of these participated in a survey of nurses and rehabilitation therapists between October 2004 and September 2005. Self-reported assessment and management practices implemented with older patients during home healthcare visits were measured in this survey, and HHA-level measures for each fall risk factor were constructed based on proportions of clinicians reporting assessment and management practices that were recommended in the fall prevention training sessions. For all fall risk factors except postural hypotension, 80% or more of clinicians in all HHAs reported implementing recommended fall risk management practices. Greater variation was found regarding fall risk assessment practices, with fewer than 70% of clinicians in one or more HHAs reporting recommended assessment practices for all risk factors. Results suggest that evidence-based training for home healthcare clinicians can stimulate fall risk assessment and management practices during home health visits. HHA-level comparisons hold the potential to illustrate the extent of diffusion of evidence-based fall prevention practices within and between agencies. J Am Geriatr Soc 2008;56(42):737-743.
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The Confusion Assessment Method: A Systematic Review of Current Usage
Leslie A. Wei, BA, Michael A. Fearing, PhD, Eliezer J. Sternberg, and Sharon K. Inouye, MD, MPH
OBJECTIVES: To examine the psychometric properties, adaptations, translations, and applications of the Confusion Assessment Method (CAM), a widely used instrument and diagnostic algorithm for identification of delirium.
DESIGN: Systematic literature review.
SETTING: Not applicable.
PARTICIPANTS: Not applicable.
MEASUREMENTS: Electronic searches of PubMED, EMBASE, PsychINFO, CINAHL, Ageline, and Google Scholar, augmented by reviews of reference listings, were conducted to identify original English-language articles using the CAM from January 1, 1991, to December 31, 2006. Two reviewers independently abstracted key information from each article.
RESULTS: Of 239 original articles, 10 (4%) were categorized as validation studies, 16 (7%) as adaptations, 12 (5%) as translations, and 222 (93%) as applications. Validation studies evaluated performance of the CAM against a reference standard. Results were combined across seven high-quality studies (N=1,071), demonstrating an overall sensitivity of 94% (95% confidence interval (CI)=91–97%) and specificity of 89% (95% CI=85–94%). The CAM has been adapted for use in the intensive care unit, emergency, and institutional settings and for scoring severity and subsyndromal delirium. The CAM has been translated into 10 languages where published articles are available. In application studies, CAM-rated delirium is most commonly used as a risk factor or outcome but also as an intervention or reference standard.
CONCLUSION: The CAM has helped to improve identification of delirium in clinical and research settings. To optimize performance, the CAM should be scored based on observations made during formal cognitive testing, and training is recommended. Future action is needed to optimize use of the CAM and to improve the recognition and management of delirium. J Am Geriatr Soc 2008;56(5):823-830.
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Dual Use of Bladder Anticholinergics and Cholinesterase Inhibitors: Long-Term Functional and Cognitive Outcomes
Kaycee M. Sink, MD, MAS, Joseph Thomas, III, PhD, Huiping Xu, PhD, Bruce Craig, PhD, Steven Kritchevsky, PhD, and Laura P. Sands, PhD
OBJECTIVES: To determine the cognitive and functional consequences of dual use of cholinesterase inhibitors (ChIs) and the bladder anticholinergics oxybutynin or tolterodine.
DESIGN: Prospective cohort study.
SETTING: Nursing homes (NHs) in the state of Indiana.
PARTICIPANTS: Three thousand five hundred thirty-six Medicaid-eligible NH residents aged 65 and older taking a ChI between January 1, 2003, and December 31, 2004. Residents were excluded if they were taking an anticholinergic other than oxybutynin or tolterodine.
MEASUREMENTS: Indiana Medicaid claims data were merged with data from the Minimum Data Set (MDS). Repeated-measures analyses were performed to assess the effects of dual therapy on change in cognitive function measured using the MDS Cognition Scale (MDS-COGS; scored 0–10) and change in activity of daily living (ADL) function using the seven ADL items in the MDS (scored 0–28). Potential covariates included age, sex, race, number of medications, and Charlson Comorbidity Index score.
RESULTS: Three hundred seventy-six (10.6%) residents were prescribed oxybutynin or tolterodine concomitantly with a ChI. In residents in the top quartile of ADL function, ADL function declined an average of 1.08 points per quarter when not taking bladder anticholinergics (ChI alone), compared with 1.62 points per quarter when taking dual therapy, a 50% greater rate in quarterly decline in ADL function (P=.01). There was no excess decline attributable to dual therapy in MDS-COGS scores or in ADL function for residents who started out with lower functioning.
CONCLUSION: In higher-functioning NH residents, dual use of ChIs and bladder anticholinergics may result in greater rates of functional decline than use of ChIs alone. The MDS-COGS may not be sensitive enough to detect differences in cognition due to dual use. J Am Geriatr Soc 2008;56(5):847-853.
