Øyvind Kirkevold

Trends in psychotropic drug prescribing in Norwegian nursing homes from 1997 to 2009: a comparison of six cohorts

Psychotropic drugs are extensively prescribed for the treatment of neuropsychiatric symptoms, despite modest efficacy and severe side effects.

Pain and Quality of Life Among Residents of Norwegian Nursing Homes

Pain is a major problem in the nursing home population, with a prevalence range of 27% to 84%. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain, 2008). It has an impact on many aspects of a persons emotional, social, and physical functioning, and on quality of life (QoL) The purpose of this study was to describe pain and QoL in a nursing home population that could self-report pain and to examine the association between QoL and pain in these patients. Pain was measured by a verbal rating scale from no pain to severe pain. Quality of life was measured by the Dementia Quality of Life Questionnaire (DQoL) consisting of five domains: self-esteem, positive affect/humor, feeling of belonging, and sense of esthetics and negative affect. Totally, 106 patients, with a mean age of 86 years (SD 6.5, range 65-102) with a Mini Mental State Examination (MMSE) score >11 were included, and 87% had mild or moderate reduced cognitive function. In total, 55% reported pain, and out of those, 55% reported mild, 29% moderate, and 16% severe pain. A significant association was found between scores on the negative affect domain and reported pain (t = 3.17; p < .01) and pain intensity (r = 0.40; p < .01). No significant associations were found between the other domains and pain. This study shows that pain has a negative effect on mood. Examining the relationship between pain and negative feelings in persons with reduced cognitive function may suggest new areas of intervention for reducing pain and negative feelings in this patient population.

Pain in patients living in Norwegian nursing homes.

The aims of this study were to describe the pain and use of pain medication in nursing home patients and examine which variables that were associated with pain. Inpatients (n = 307) older than 64 years from nursing homes were included. Pain was measured with a 4-point verbal rating scale in the self-reported group (SRG) and Doloplus-2 in the proxy-rated group (PRG). The mean age was 86 years (SD, 7), and more than two-thirds were female. A total of 128 (60%) patients were able to self-report their pain. Approximately 50% of the SRG reported ‘pain now’, and of these, nearly 50% reported moderate or severe pain intensity. Better cognitive function was associated with higher pain and receiving more potent pain medication in the SRG. The pain prevalence in the PRG was higher than in the SRG (67.5% vs 51%), but no variable was associated with proxy-rated pain. Nearly 30% in the SRG and 40% in the PRG did not receive pain medication in spite of pain. Pain is still a huge problem in the nursing homes, and more research is needed on pain management in nursing home residents.

Psychiatric and behavioural symptoms and the use of psychotropic medication in Special Care Units and Regular Units in Norwegian nursing homes

BACKGROUNDnIn a number of countries Special Care Units (SCUs) have been established to meet the particular needs of patients with dementia. The criteria for SCUs are poorly defined and often not met.nnnAIMnTo assess the frequency distributions of dementia, psychiatric and behavioural symptoms and the use of psychotropic medication in SCUs and Regular Units (RUs) across different regions.nnnMETHODS AND MATERIALnBy means of a structured interview, comprising the Neuropsychiatric Inventory, the Clinical Dementia Rating Scale and Lawtons Physical Self-maintenance scale, a representative sample of 1163 nonselected nursing home patients was assessed. In addition, information was collected from the patients records.nnnRESULTSnOverall SCU patients were significantly more likely to be younger, to have higher level of functioning, to have dementia, to exhibit clinically significant psychiatric and behavioural symptoms and to receive psychotropic medication. There were significant differences across regions in terms of psychiatric and behavioural symptoms and the use of psychotropic medication. The ratio of accommodation in SCUs to that in RUs varied across the regions.nnnCONCLUSIONnPatients in SCUs and patients in RUs are distinct nursing home populations. Regional differences, which might be due to diverse ratios of SCUs, are evident.

Validation of Doloplus-2 among nonverbal nursing home patients - an evaluation of Doloplus-2 in a clinical setting

BackgroundPain measurement in nonverbal older adults is best based on behavioural observation, e.g. using an observational measurement tool such as Doloplus-2. The purposes of this study were to examine the use of Doloplus-2 in a nonverbal nursing home population, and to evaluate its reliability and validity by comparing registered nurses estimation of pain with Doloplus-2 scores.MethodIn this cross-sectional study, Doloplus-2 was used to observe the pain behaviour of patients aged above 65 years who were unable to self-report their pain. Nurses also recorded their perceptions of patient pain (yes, no, dont know) before they used Doloplus-2. Data on demographics, medical diagnoses, and prescribed pain treatment were collected from patient records. Daily life functioning was measured and participants were screened using the Mini Mental State Examination.ResultsIn total, 77 nursing home patients were included, 75% were women and the mean age was 86 years (SD 6.6, range 68-100). Over 50% were dependent on nursing care to a high or a medium degree, and all were severely cognitively impaired. The percentage of zero scores on Doloplus-2 ranged from 17% (somatic reactions) to 40% (psychosocial reactions). Cronbachs alpha was 0.71 for the total scale. In total, 52% of the patients were judged by nurses to be experiencing pain, compared with 68% when using Doloplus-2 (p = 0.01). For 29% of the sample, nurses were unable to report if the patients were in pain.ConclusionsIn the present study, more patients were categorized as having pain while using Doloplus-2 compared with nurses estimation of pain without using any tools. The fact that nurses could not report if the patients were in pain in one third of the patients supports the claim that Doloplus-2 is a useful supplement for estimating pain in this population. However, nurses must use their clinical experience in addition to the use of Doloplus-2, as behaviour can have different meaning for different patients. Further research is still needed about the use of Doloplus-2 in patients not able to self-report their pain.

What is person-centred care in dementia? Clinical reviews into practice: the development of the VIPS practice model

The VIPS framework is a four-part definition of person-centred care for people with dementia (PCC), which arose out of an earlier review article for this journal. The definition has assisted in the practical application of person-centred care. It has been operationalized into the VIPS practice model (VPM), which has been subject to a recent randomized controlled trial within Norwegian nursing homes. The VPM provided a vehicle for the VIPS framework to be utilized during reflective practice meetings focusing on understanding care situations from the perspective of residents with moderate to severe dementia. VPM incorporated an education and coaching approach, clearly defined staff roles, and resident-focused outcomes in a cycle to support improvements in quality of care. The use of VPM in practice is discussed. VPM was built utilizing the literature from organizational change. The role of literature reviews in bringing about change in practice is highlighted.

Development of residential care services facilitated for persons with dementia in Norway

Background: In the 1980s, special care units devoted to persons with dementia (SCU) were established, and in the 1990s, a new system of sheltered housing for persons with dementia (SH) was inaugurated. Aim: The aim of this study was to examine the establishment of SCUs and SH units and to explore the effects of varying patient-staff ratios and unit sizes. Method: On five occasions (1996/1997, 2000/2001, 2004/2005, 2008, 2010/2011), a detailed questionnaire was sent by post to all Norwegian municipalities. It contained questions about the provision of services for persons with dementia. Results: In 1996/1997, 70% of the municipalities had SCUs and 13.3% of the beds in Norwegian nursing homes were in SCUs. In 2010/11, 87% of the municipalities had such services, which filled 23.8% of the beds in nursing homes. The number of beds in SH units increased from 856 beds in 1996/1997 to 2181 beds in 2010/11. SCUs have on average three patients per carer on an ordinary weekday day-time shift. These numbers have been quite stable throughout the study period. The ratio is about 3.5 patients per carer in the SH units and is also stable. Conclusions: The rate of increase in the provision of institutional beds facilitated for persons with dementia has been slow in Norway over the last 14 years. Both SCUs and SH units seem to have stable staffing ratios and the number of beds in each unit is also stable.

Practice of Competence Assessment in Dementia: Norway

In the discussion about legislation and dementia in Europe, it seems there exist an agreement that the terms “competence” and “incompetence” should be restricted to a person’s legal status, whereas physicians should use terms like “capacity” and “incapacity” when evaluating a person’s mental status (Post and Whitehouse, 1995). However, some authors prefer to use the terms “capacity” or “incapacity” for legal status (Gove and Georges, 2001; Jones, 2001). Thus, “capacity” and “competence” are used as synonyms in legal terminology. In cases when a person is incompetent, most Western countries have legal provisions that allow for the appointment of a guardian to handle an adult person’s welfare and financial interests (Gove and Georges, 2001; Kapp, 2001). Apart from that, medical treatment, care or admission to an institution without the patient’s consent is usually part of the mental health legislation.