Todd Monroe

Pain reports and pain medication treatment in nursing home residents with and without dementia

The purpose of this pilot study was to determine if a diagnosis of dementia influenced pain self‐reports and pain medication use in a group of verbally communicative nursing home (NH) residents.

Don’t ask don’t tell: substance abuse and addiction among nurses

AIM The purpose of this manuscript is to illustrate the challenges faced by nurses who abuse substances and to promote international dialogue about what practitioners, administrators, health care providers and students can do when they suspect someone in the profession is abusing substances, or they may themselves be suffering from addiction. BACKGROUND Addiction among nurses has been recognised by professionals in the field for over 100 years, and current estimates place rates of substance misuse, abuse and addiction rates as high as 20% among practicing nurses. Unfortunately, fear of punishment and discipline may keep nurses or students from asking for help for themselves or from reporting a colleague or friend who is in need of help. DESIGN Discursive paper. METHOD This paper synthesises the results of three previous papers conducted on substance abuse policies in the nursing profession. In the first paper, the authors reviewed the history of addiction in nursing and compared disciplinary and alternative-to-discipline policies. The second focused on the development of an alternative-to-dismissal policy for substance abuse in a school of nursing and using telephone and email interviews, and the final paper reported findings of what types of policies seem to be working to retain and rehabilitate nurses who suffer from addiction in the USA. Lastly, this paper introduces international policy for nurses with addictions. CONCLUSIONS Poor or ineffective policies that mandate punitive action endanger the public by making it difficult for impaired students or professionals to ask for help. Providing early intervention and assistance is essential in helping colleagues and students recover from an addictive disorder and providing a non-punitive atmosphere of support may well be a life-saving first step for nurses and those in their care. Many territories and countries throughout the world now offer confidential, non-punitive, assistance for nurses suffering from addictions. RELEVANCE TO CLINICAL PRACTICE Recognition of a colleagues need of treatment is the important first step in the rehabilitation process. Early intervention and assistance are essential for helping colleagues and students to recover from an addictive disorder and providing a confidential, non-punitive atmosphere of support may well be a life-saving first step for nurses and those in their care.

Assessing advanced cancer pain in older adults with dementia at the end-of-life.

AIM To assess advanced cancer pain in older adults with dementia at the end-of-life. BACKGROUND Self-report is the gold standard for pain assessment; however, people with Alzheimers disease may lose the ability to report pain. Biochemical and neuropathological changes occur in Alzheimers disease that impairs the affective, sensory, and motor pain processing regions of the brain. Because people with severe Alzheimers disease may lose the ability to report their sensory and emotional response to pain verbally, external motor displays of pain, such as grimacing, have been suggested for use in people with Alzheimers disease. DESIGN Between groups cross sectional study. METHOD Retrospective chart audits of people with Alzheimers disease in nine nursing homes in the US in 2009. Participants were nursing home residents (n = 48) with mild to very severe dementia, pain and cognitive measures were collected during the final 3 months of life. The primary outcome variable was the discomfort behaviour scale score (a measure of observed pain behaviour) and the main predictor variable was the cognitive performance scale score (a measure of Alzheimers disease severity). Medication administration (opioid, non-narcotic, and psychotropic medications) recorded over the final 2 weeks of life was collected as a covariate of interest. RESULTS Alzheimers disease severity was negatively associated with pain behaviours. Post hoc procedures showed that this difference was due to the difference in pain behaviours between individuals with moderate and very severe Alzheimers disease. Total amount of opioid analgesic, total number of doses of non-narcotic medications, and psychotropic medications administered over the last 2 weeks of life were not statistically significantly correlated with pain behaviour. An inverse correlation was found between cognitive ability (Cognitive Performance Scale score) and total amount of opioid medication indicating that individuals with severe Alzheimers disease received less opioid. CONCLUSION Because people with worsening Alzheimers disease have fewer pain behaviours, assessing pain using behavioural indicators can be a challenge. Improving methods to assess for pain in people with Alzheimers disease is of critical public health importance. Moreover, future studies are urgently needed to further examine the sensory, emotional, and behavioural responses to pain in people with Alzheimers disease.

Ethical and legal issues in pain research in cognitively impaired older adults.

Research involving those with dementia is critical to informing best practices and improving the quality of their lives. Pain research in people with dementia is of particular interest because the prevalence of both dementia and painful conditions increases with age. Considerable evidence exists documenting inadequate assessment and treatment of pain in this vulnerable population. Unfortunately, research that supports best practices for assessing and treating pain in the cognitively impaired is limited with obstacles to conducting research. Obstacles to research in older adults, including those with cognitive impairment, have been highlighted along with an urgent call for increased research to promote quality pain care for all older adults. The aims of this paper are to provide an overview of major ethical challenges that can occur in pain research in cognitively impaired populations and to present potential solutions when preparing study protocols.

Pain and hospice care in nursing home residents with dementia and terminal cancer

One condition associated with severe end‐of‐life pain that can lead to a poor quality of death is cancer. Cancer pain in people with dementia is of particular concern because of communication problems that occur with worsening disease. The aim of the current pilot study was to examine the association between hospice enrolment, dementia severity and pain among nursing home residents who died from advanced cancer.

Pain in People With Alzheimer Disease Potential Applications for Psychophysical and Neurophysiological Research

Pain management in people with dementia is a critical problem. Recently, psychophysical and neuroimaging techniques have been used to extend our understanding of pain processing in the brain as well as to identify structural and functional changes in Alzheimer disease (AD). But interpreting the complex relationship between AD pathology, brain activation, and pain reports is challenging. This review proposes a conceptual framework for designing and interpreting psychophysical and neuroimaging studies of pain processing in people with AD. Previous human studies describe the lateral (sensory) and medial (affective) pain networks. Although the majority of the literature on pain supports the lateral and medial networks, some evidence supports an additional rostral pain network, which is believed to function in the production of pain behaviors. The sensory perception of pain as assessed through verbal report and behavioral display may be altered in AD. In addition, neural circuits mediating pain perception and behavioral expression may be hyperactive or underactive, depending on the brain region involved, stage of the disease, and type of pain (acute experimental stimuli or chronic medical conditions). People with worsening AD may therefore experience pain but be unable to indicate pain through verbal or behavioral reports, leaving them at great risk of experiencing untreated pain. Psychophysical (verbal or behavioral) and neurophysiological (brain activation) approaches can potentially address gaps in our knowledge of pain processing in AD by revealing the relationship between neural processes and verbal and behavioral outcomes in the presence of acute or chronic pain.

The Prevalence of Employed Nurses Identified or Enrolled in Substance Use Monitoring Programs

Background:For over 100 years, nurses’ particular work conditions have been anecdotally associated with increases in substance abuse. Reasons include job-related stress and easy access to medications. Current research has suggested that prevalence of nurses with substance use problems is actually similar to, if not less than, that seen in the general population. However, given nurses’ proximity to critical patient care, the potential threat to public health, as well as the current shortage of practitioners and problems related to retention, the lack of research on the effectiveness of the two existing treatment protocols (disciplinary and alternative-to-discipline [ATD]) is a pressing issue of concern to the nursing profession. Objectives:The aims of this study were to estimate the 1-year prevalence of employed nurses requiring an intervention for substance use problems in the United States and the 1-year prevalence of nurses enrolled in substance abuse monitoring programs and to compare the sum total of nurses identified in disciplinary and alternative programs with the general population. Methods:This was a balanced stratified sampling design study. Measurements included the National Council of State Boards of Nursing 2010 Survey of Regulatory Boards Disciplinary Actions on Nurses, the 2009 annual reports of alternative programs, the 2008 National Sample Survey of Registered Nurses, and the 2009 National Survey on Drug Use and Health. Results:The 2009 1-year prevalence of employed nurses identified with substance use problems in the United States and its territories was 17,085 or 0.51% of the employed nursing population. The 1-year prevalence of nurses newly enrolled in substance abuse monitoring programs in the United States and its territories was 12,060 or 0.36%. Although every National Council of State Boards of Nursing jurisdiction has a disciplinary monitoring program, only 73% (n = 43) of these jurisdictions have alternative programs. Despite this, on average, alternative programs had nearly 75% more new enrollees (9,715) when compared with disciplinary programs (2,345). The prevalence of nurses identified with a substance use problem requiring an intervention (and likely treatment) is lower than the prevalence of those who report receiving substance abuse treatment in the general population (0.51% vs. 1.0%). Conclusions:The ATD programs potentially have a greater impact on protecting the public than disciplinary programs because ATD programs identify and/or enroll more nurses with substance use problems, thereby initially removing more nurses with substance use problems from direct patient care.

Barriers and facilitators to implementing delirium rounds in a clinical trial across three diverse hospital settings.

Delirium occurs in more than half of hospitalized older adults with dementia, substantially worsening outcomes. The use of multiple strategies and a local opinion leader, unit champion, has cumulative and lasting effects compared with single-strategy interventions. The purpose of this article is to describe the early barriers and facilitators to rounding with unit champions in a cluster randomized clinical trial in Year 2 of a 5-year trial (5R01NR011042-02). This is a mixed-method study nested within an ongoing multisite cluster-randomized, controlled clinical trial. Descriptive and comparative statistics were collected on N = 192 nursing rounds. Qualitative data were thematically analyzed. On average, rounds lasted 25.54 min (SD = 13.18) and were conducted with the unit champion 64% of the time. This is one of the first studies to systematically address quantitative and qualitative barriers and facilitators to nurse-led delirium rounds, demonstrating the gradual adoption of an intervention in diverse clinical settings.

The Misuse and Abuse of Propofol

Media attention on the misuse of propofol increased significantly when the drug was implicated in the death of pop music superstar Michael Jackson in 2010. The misuse and abuse of propofol among healthcare providers has been reported worldwide, with some misuse resulting in death. Propofol policies guiding healthcare worker re-entry into the workplace after misusing propofol have received rare attention in the research literature. The paucity of information regarding propofol-specific re-entry policies suggests that little research has addressed this problem and the lack of research and policy guidance can contribute to unsafe re-entry and even death. This paper focuses on healthcare providers because they have an easy access to propofol and therefore are vulnerable to misusing or abusing the drug. To accomplish this, the pharmacology and misuse/abuse potential of propofol and the influence of the 12-step recovery paradigm in the re-entry literature are reviewed. In conclusion, existing research and policy are drawn upon to suggest employment re-entry guidelines for healthcare workers.

Pain Assessment in Hospitalized Older Adults With Dementia and Delirium

Pain can have negative effects leading to prolonged hospital stays. Determining the presence of uncontrolled and untreated pain in patients with cognitive impairments such as delirium, dementia, and delirium superimposed on dementia (DSD) is challenging. One tool commonly suggested for use in assessment of pain in older adults with cognitive impairment is the Pain Assessment In Advanced Dementia (PAINAD) scale. Proper use of the PAINAD scale as part of a comprehensive pain management plan can help reduce the likelihood of a patient experiencing unrecognized and untreated pain. Using an individual example, this article illustrates best practices in pain assessment and management for a woman experiencing DSD during an acute hospitalization.