Jan P.H. Hamers

Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools

BackgroundPain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home people is 40–80%, showing that they are at great risk of experiencing pain. Since assessment of pain is an important step towards the treatment of pain, there is a need for manageable, valid and reliable tools to assess pain in elderly people with dementia.MethodsThis systematic review identifies pain assessment scales for elderly people with severe dementia and evaluates the psychometric properties and clinical utility of these instruments. Relevant publications in English, German, French or Dutch, from 1988 to 2005, were identified by means of an extensive search strategy in Medline, Psychinfo and CINAHL, supplemented by screening citations and references. Quality judgement criteria were formulated and used to evaluate the psychometric aspects of the scales.ResultsTwenty-nine publications reporting on behavioural pain assessment instruments were selected for this review. Twelve observational pain assessment scales (DOLOPLUS2; ECPA; ECS; Observational Pain Behavior Tool; CNPI; PACSLAC; PAINAD; PADE; RaPID; Abbey Pain Scale; NOPPAIN; Pain assessment scale for use with cognitively impaired adults) were identified. Findings indicate that most observational scales are under development and show moderate psychometric qualities.ConclusionBased on the psychometric qualities and criteria regarding sensitivity and clinical utility, we conclude that PACSLAC and DOLOPLUS2 are the most appropriate scales currently available. Further research should focus on improving these scales by further testing their validity, reliability and clinical utility.

The efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates: A systematic literature review

Background: Neonates in a neonatal intensive care unit are exposed to a high number of painful procedures. Since repeated and sustained pain can have consequences for the neurological and behaviour‐oriented development of the newborn, the greatest attention needs to be paid to systematic pain management in neonatology. Non‐pharmacological treatment methods are being increasingly discussed with regard to pain prevention and relief either alone or in combination with pharmacological treatment.

The psychometric quality and clinical usefulness of three pain assessment tools for elderly people with dementia

&NA; In view of the need for valid, reliable, and clinically useful scales to assess pain in elderly people with dementia, this study evaluated the psychometric properties of translated versions of the PAINAD, PACSLAC, and DOLOPLUS‐2 scales. In an observational study design, two raters simultaneously assessed the nursing home residents (n = 128) for pain during influenza vaccination and care situations. The PACSLAC was valued as the most useful scale by nurses. Cronbachs alpha was high (>.80) for the total scale at T2 and T3 and adequate for the ‘Facial expression’ and ‘Social/personality/mood’ subscales. IC scores for the ‘Activity/body movement’ and ‘Physiological indicators/eating/sleeping changes/vocal behaviors’ subscales were low. It demonstrated good validity and reliability, although the scale should be further refined. This refinement should increase homogeneity. The PAINAD showed good psychometric qualities in terms of reliability, validity, and homogeneity (&agr; ranged .69–.74 at T2 and T3) (except for the ‘Breathing’ item). The PAINAD scale had lower scores for clinical usefulness in this sample. The Dutch version of the DOLOPLUS‐2 was considered more difficult to use but showed acceptable psychometric qualities in terms of the issues assessed, except for the ‘psychosocial reactions’ subscale. IC of the DOLOPLUS were adequate for the total scale (&agr; ranged .74–.75) and almost all subscales (&agr; ranged .58–.80). Findings of this study provide evidence of validity and reliability of the three pain assessment scales. Now that a pain scale is available, future studies also need to focus on its implementation in nursing practice.

Why do we use physical restraints in the elderly

The use of physical restraints in the elderly is a common practice in many countries. This paper summarizes the current knowledge on the use of restraints in home care, hospitals and nursing homes. Between 1999–2004 the reported prevalence numbers range from 41–64% in nursing homes and 33–68% in hospitals; numbers of restraint use in home care are unknown. Bed rails and belts have been reported as the most frequently used restraints in bed; chairs with a table and belts are the most frequently reported restraints in a chair. It is evident that physical restraints in most cases are used as safety measures; the main reason is the prevention of falls. In the hospital setting, the safe use of medical devices is also an important reason for restraint use. Predictors for the use of physical restraints are poor mobility, impaired cognitive status and high dependency of the elderly patient and the risk of falls in the nurses’ opinion. Furthermore, there are indications that restraint use is related to organizational characteristics. Finally, many adverse effects of restraint use have been reported in the literature, like falls, pressure sores, depression, aggression, and death. Because of the adverse effects of restraints and the growing evidence that physical restraints are no adequate measure for the prevention of falls, measures for the reduction of physical restraints are discussed and recommendations are made for future research. Die Anwendung von Fixierung ist in vielen Länder üblich. Dieser Artikel fasst unsere Kenntnis über die Anwendung von Fixierung in der häuslichen Pflege im Krankenhaus und im Pflegeheim zusammen. Zwischen 1999–2004 betrug die gemeldete Prävalenz 41–64% in Pflegeheimen und 33–68% in Krankenhäusern; die Prävalenz in der häuslichen Pflege ist unbekannt. Bettgitter und Fixierungsgurte werden am meisten angewendet im Bett; Stühle mit einem Brett und Fixierungsgurte werden am meisten angewendet im Stuhl. Es ist evident, dass eine Fixierung meistens als Sicherheitsmaßname angewendet wird; der Hauptgrund ist die Prävention von Stürzen. Die sichere Anwendung von medizinischen Interventionen ist ein wichtiger Grund zum Gebrauch der Fixierung im Krankenhaus. Eingeschränkte Mobilität, Verringerung der kognitiven Funktion, große Hilfsbedürftigkeit des älteren Patienten, und das Sturzrisiko nach der Meinung des Plegepersonals, sind Faktoren die die Anwendung von Fixierung voraussagen. Daneben gibt es Hinweise dass die Anwendung von Fixierung zusammenhängt mit organisatorischen Abläufen. Schließlich sind viele negative Konsequenzen von Fixierungsmaßnahmen in der wissenschaftlichen Literatur beschrieben wie Stürze, Dekubitus, Depressionen, Agression und Tod. Wegen dieser negativen Konsequenzen und dem verstärkten Beweis, dass eine Fixierung keine angemesse Intervention ist für die Prävention von Stürzen, werden Maßnamen zur Reduzierung von Fixierung besprochen und Empfehlungen gemacht für zukünftige Forschung.

Prevalence of Urinary Incontinence and Associated Risk Factors in Nursing Home Residents: A Systematic Review

To determine not only prevalence rates of urinary incontinence (UI) in nursing home residents but also factors influencing these prevalence rates, and to provide an overview of risk factors associated with UI in this group.

The prevalence of pain in nursing home residents with dementia measured using an observational pain scale.

Background: Studies on pain and pain prevalence in older people with dementia are limited compared to those on cognitively intact older people. Pain prevalence rates in older people with dementia are estimated to be between 28% and 83%.

Children's pain at home following (adeno)tonsillectomy

The aim of this study was to evaluate the prevalence and severity of childrens pain at home following (adeno)tonsillectomies. The subjects were parents of 161 children (86 boys, 75 girls) undergoing myringotomies, adenoidectomies and (adeno)tonsillectomies. The mean age of the children was 5.5 years (SD = 2.4; range 1–14). Parents were asked to assess the childs average pain on the day of operation and 7 days after the operation, using a 100 mm Visual Analogue Scale (VAS). Parents from (adeno)tonsillectomy patients were also interviewed by phone on day 7.

Factors associated with quality of life of people with dementia in long-term care facilities: A systematic review

BACKGROUND Quality of life has become an important outcome measure in dementia research. Currently there is no convincing evidence about which factors are associated with quality of life of people with dementia living in long-term care facilities. OBJECTIVE This study aims to investigate which factors are associated with quality of life, including factors associated with change over time, of people with dementia living in long-term care facilities. DESIGN A systematic literature review was performed. DATA SOURCES Cochrane, Pubmed, CINAHL, Web of Science, and PsycINFO were searched. REVIEW METHODS Three researchers independently assessed studies for eligibility. The inclusion criteria were: (1) the primary focus was on factors related to quality of life; (2) the study was performed in long-term care facilities; (3) the study regarded quality of life as multidimensional construct. Methodological quality of studies included in the review was assessed with a quality criteria checklist. RESULTS Ten cross-sectional and three longitudinal articles were included in the review. In cross-sectional studies, depressive symptoms were negatively related to self-rated quality of life of people with dementia. The association between depressive symptoms and proxy-rated quality of life was less clear. Behavioural disturbances, especially agitation, appeared to be negatively related to proxy-rated quality of life. There appeared to be a negative relation between quality of life, activities of daily living and cognition, although this could not be confirmed in all studies. In longitudinal studies, depressive symptoms were negatively related and cognition was positively related to self-rated quality of life, whereas dependency and depressive symptoms were negatively related to proxy-rated quality of life. CONCLUSIONS There are only few high quality studies that investigate associations of (change in) quality of life of people with dementia living in long-term care facilities. Our results suggest that depressive symptoms and agitation are related to lower quality of life. Perspective of quality of life measurement, i.e. self- or proxy rating, may influence its associations. Longitudinal studies are needed to determine which factors are related to change in quality of life over time. This information is essential for the development of interventions that aim to improve quality of life.

Reasons for Institutionalization of People With Dementia: Informal Caregiver Reports From 8 European Countries

OBJECTIVES To explore reasons for institutionalization of people with dementia according to informal caregivers as well as variation in reasons between countries. DESIGN An explorative cross-sectional study was conducted in 8 European countries. SETTING Per country, a minimum of 3 long term care facilities, offering care and accommodation as a package, participated in this study. Participating countries were selected to represent different geographic areas in Europe. PARTICIPANTS Of the 791 informal caregivers involved in the RightTimePlaceCare project of people with dementia who were recently admitted to a long term care facility, 786 were included for this study. MEASUREMENTS As part of a semistructured interview, informal caregivers were asked the main reason for institutionalization in an open-ended question. Answers were categorized according to a conventional coding approach. All reasons were then quantified and tested. RESULTS Mainly patient-related reasons were stated, such as neuropsychiatric symptoms (25%), care dependency (24%), and cognition (19%). Neuropsychiatric symptoms were among the most often mentioned reasons in most countries. Besides patient-related reasons, caregiver burden and the inability of the informal caregiver to care for the patient were stated as reasons (both 15%). Further analyses showed countries differ significantly in reasons according to informal caregivers. Additionally, reasons were analyzed for spouses and child-caregivers, showing that spouses more often stated reasons related to themselves compared with child-caregivers. CONCLUSION Multiple reasons contribute to the institutionalization for people with dementia, with several factors that may influence why there were country differences. Variation in the organization of dementia care and cultural aspects, or the relationship between the informal caregiver and person with dementia may be factors influencing the reasons. Because of a wide variation in reasons between countries, no one-size-fits-all approach can be offered to guide informal caregivers when facing the possibility of institutionalization of the person with dementia.

The more physical inactivity, the more agitation in dementia.

Epidemiological studies show a close relationship between physical activity and cognition. A causal relationship between physical activity and cognition has been observed in children, adolescents, older people without dementia, and in older people in a very early stage of dementia. Considering these positive effects, we argue that a decline in physical activity has a detrimental effect on cognition and behavior in patients with dementia. Merely living in a nursing home reduces the level of physical activity. The level of physical activity may even be reduced to a minimum when physical restraints are applied. The use of physical restraints coincides with stress, further aggravating the already existing neuropathology, which may increase stress and agitation even more. Exercise may reduce stress and agitation.