The last week of life of nursing home residents with advanced dementia: a retrospective study.

BACKGROUND: Barriers to palliative care still exist in long-term care settings for older people, which can mean that people with advanced dementia may not receive of adequate palliative care in the last days of their life; instead, they may be exposed to aggressive and/or inappropriate treatments. The aim of this multicentre study was to assess the clinical interventions and care at end of life in a cohort of nursing home (NH) residents with advanced dementia in a large Italian region. METHODS: This retrospective study included a convenience sample of 29 NHs in the Lombardy Region. Data were collected from the clinical records of 482 residents with advanced dementia, who had resided in the NH for at least 6 months before death, mainly focusing on the 7 days before death. RESULTS: Most residents (97.1%) died in the NH. In the 7 days before death, 20% were fed and hydrated by mouth, and 13.4% were tube fed. A median of five, often inappropriate, drugs were prescribed. Fifty-seven percent of residents had an acknowledgement of worsening condition recorded in their clinical records, a median of 4 days before death. CONCLUSIONS: Full implementation of palliative care was not achieved in our study, possibly due to insufficient acknowledgement of the appropriateness of some drugs and interventions, and health professionals' lack of implementation of palliative interventions. Future studies should focus on how to improve care for NH residents.

The Impact of Nursing Homes Staff Education on End-of-Life Care in Residents With Advanced Dementia: A Quality Improvement Study.

CONTEXT: End-of-life care in nursing homes (NHs) needs improvement. We carried out a study in 29 NHs in the Lombardy Region (Italy). OBJECTIVES: The objective of this study was to compare end-of-life care in NH residents with advanced dementia before and after an educational intervention aimed to improving palliative care. METHODS: The intervention consisted of a seven-hour lecture, followed by two 3-hour meetings consisting of case discussions. The intervention was held in each NH and well attended by NH staff. This multicenter, comparative, observational study included up to 20 residents with advanced dementia from each NH: the last 10 who died before the intervention (preintervention group, 245 residents) and the first 10 who died at least three months after the intervention (postintervention group, 237 residents). Data for these residents were collected from records for 60 days and seven days before death. RESULTS: The use of "comfort hydration" (<1000 mL/day subcutaneously) tended to increase from 16.9% to 26.8% in the postintervention group. The number of residents receiving a palliative approach for nutrition and hydration increased, though not significantly, from 24% preintervention to 31.5% postintervention. On the other hand, the proportion of tube-fed residents and residents receiving intravenous hydration decreased from 15.5% to 10.5%, and from 52% to 42%, respectively. Cardiopulmonary resuscitations decreased also from 52/245 (21%) to 18/237 (7.6%) cases (P = 0.002). CONCLUSION: The short educational intervention modified some practices relevant to the quality of end-of-life care of advanced dementia patients in NHs, possibly raising and reinforcing beliefs and attitudes already largely present.

EHRA Expert Consensus Statement on the management of cardiovascular implantable electronic devices in patients nearing end of life or requesting withdrawal of therapy.

The purpose of this Consensus Statement is to focus on implantable cardioverter-defibrillator (ICD) deactivation in patients with irreversible or terminal illness. This statement summarizes the opinions of the Task Force members, convened by the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS), based on ethical and legal principles, as well as their own clinical, scientific, and technical experience. It is directed to all healthcare professionals who treat patients with implanted ICDs, nearing end of life, in order to improve the patient dying process. This statement is not intended to recommend or promote device deactivation. Rather, the ultimate judgement regarding this procedure must be made by the patient (or in special conditions by his/her legal representative) after careful communication about the deactivation's consequences, respecting his/her autonomy and clarifying that he/she has a legal and ethical right to refuse it. Obviously, the physician asked to deactivate the ICD and the industry representative asked to assist can conscientiously object to and refuse to perform device deactivation.

Atrial fibrillation is a possible marker of frailty in hospitalized patients: results of the GIFA Study.

BACKGROUND AND AIMS: Atrial fibrillation (AF) is the most common arrhythmia in elderly people, who are particularly exposed to its most severe complications, such as stroke, worsening heart failure and dementia. Some studies demonstrate that AF is associated with increased mortality in home-dwelling subjects, but little is known about the clinical impact of the arrhythmia in hospitalized patients. We studied the clinical associations and effects of AF on the 23,174 hospitalized patients enrolled in the GIFA (Gruppo Italiano di Farmacoepidemiologia nell'Anziano) Study. METHODS: Patients were divided into three groups according to the absence or presence of AF (sinus rhythm, non_AF; AF as main diagnosis, AF_main; AF as comorbid condition, AF_associated) and stratified into four age-groups (< or =60, 61-70, 71-80 and >80 yrs). RESULTS: AF_associated patients were older, more frequently disabled, and characterized by greater comorbidity and longer in-hospital length of stay. Urea nitrogen concentration was higher, and total cholesterol was lower in AF_associated patients, compared with the other two groups. Overall mortality was 6.0%. Mortality was higher in AF_associated patients (non_AF: 6.0% vs AF_associated: 7.1% vs AF_main: 0%, p<0.001). CONCLUSIONS: Our results suggest that, in hospitalized patients, AF as a comorbid condition is associated with worse metabolic profile and clinical outcomes, and thus, may represent a marker of frailty.

Multiple shocks affect thoracic electrical impedance during external cardioversion of atrial fibrillation.

BACKGROUND: Thoracic impedance (TI) influences the success of external cardioversion (ECV) or defibrillation because current intensity traversing the heart is inversely related to TI. Experimental data suggest that TI decreases after multiple shocks. We undertook a clinical study to determine changes of TI values in patients with atrial fibrillation or flutter requiring ECV. METHODS: We enrolled 222 consecutive patients (age 73 +/- 11 years; males 67%; body weight 75 +/- 13 kg) who underwent ECV between January 2004 and February 2007. Biphasic shocks were delivered through adhesive pads placed in the anteroposterior position. The initial energy was set at 1 J/kg, with progressive increases up to a maximum of 180 J in case of failure. In the last 39 elective patients, plasma concentration of interleukin-6 (IL-6) and tumor necrosis factor (TNF)-alpha were determined before and 6 hours after ECV. RESULTS: Sinus rhythm was restored in 202 patients (91.0%). Of these, 155 (69.8%) required more than one shock (on average, 2.5 +/- 1.5 shocks/patient). Final values of energy and peak current intensity were 136 +/- 47 J and 50 +/- 14 A, respectively. TI decreased significantly by 6.2% from baseline after > or =2 shocks (P < 0.001). The absolute reduction was correlated with baseline TI, number of delivered shocks, and hemoglobin oxygen saturation. IL-6 and TNF-alpha increased with ECV (P < 0.001 and P = 0.014, respectively). CONCLUSIONS: TI decreases significantly after multiple shocks, possibly by activation of acute inflammation.

Determinants of thoracic electrical impedance in external electrical cardioversion of atrial fibrillation.

The success of external cardioversion (ECV) of atrial fibrillation depends on generating sufficient transmyocardial current for defibrillation with minimal myocardial injury. Thoracic electrical impedance plays an important role in the relation between the delivered energy and transmyocardial current. This study assessed the determinants of thoracic electrical impedance in ECV of atrial fibrillation. ECV of atrial fibrillation was performed in 80 consecutive patients (mean age 73 +/- 9 years; men 69%; body mass index 26.0 +/- 3.6 kg/m(2)) within 12 months, using biphasic shocks (Multipulse Biowave) delivered through adhesive pads in an anteroposterior position. Thoracic electrical impedance was measured using the first shock. The mean thoracic electrical impedance was 57.7 +/- 12.3 Omega (energy 71 +/- 43 J, current intensity 33 +/- 12 A). Sinus rhythm was immediately restored in 75 patients (94%). Thoracic electrical impedance was greater (60.9 +/- 11.8 vs 51.7 +/- 11.0 Omega, p = 0.001) in patients requiring >1 shock (65%). At multivariate linear regression analysis (R = 0.761, p <0.001), female gender (+9.7 +/- 2.0 Omega, p <0.001), body mass index (+1.5 +/- 0.3 for a 1 kg/m(2) increase, p <0.001), hemoglobin concentration (+1.9 +/- 0.6 for a 1 g/dl increase, p = 0.004), and the presence of chronic heart failure (-5.3 +/- 2.0 Omega, p = 0.009) were independent predictors of thoracic electrical impedance. In conclusion, to increase ECV efficacy and minimize complications, the delivered energy should be adjusted in accordance with the clinical variables that independently affect thoracic electrical impedance and, hence, transmyocardial current.

Reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit: results from a pilot, randomized trial.

BACKGROUND: Observational studies suggest that open visiting policies are preferred by most patients and visitors in intensive care units (ICUs), but no randomized trial has compared the safety and health outcomes of unrestrictive (UVP) and restrictive (RVP) visiting policies. The aim of this pilot, randomized trial was to compare the complications associated with UVP (single visitor with frequency and duration chosen by patient) and RVP (single visitor for 30 minutes twice a day). METHODS AND RESULTS: Two-month sequences of the 2 visiting policies were randomly alternated for 2 years in a 6-bed ICU, with 226 patients enrolled (RVP/UVP, n=115/111). Environmental microbial contamination, septic and cardiovascular complications, emotional profile, and stress hormones response were systematically assessed. Patients admitted during the randomly scheduled periods of UVP received more frequent (3.2+/-0.2 versus 2.0+/-0.0 visits per day, mean+/-SEM) and longer (2.6+/-0.2 versus 1.0+/-0.0 h/d) visits (P<0.001 for both comparisons). Despite significantly higher environmental microbial contamination during the UVP periods, septic complications were similar in the 2 periods. The risk of cardiocirculatory complications was 2-fold (odds ratio 2.0; 95% CI, 1.1 to 3.5; P=0.03) in the RVP periods, which were also associated with a nonsignificantly higher mortality rate (5.2% versus 1.8%; P=0.28). The UVP was associated with a greater reduction in anxiety score and a significantly lower increase in thyroid stimulating hormone from admission to discharge. CONCLUSIONS: Despite greater environmental microbial contamination, liberalizing visiting hours in ICUs does not increase septic complications, whereas it might reduce cardiovascular complications, possibly through reduced anxiety and more favorable hormonal profile.

Renal, but not systemic, hemodynamic effects of dopamine are influenced by the severity of congestive heart failure.

OBJECTIVE: To determine whether the short-term systemic and renal hemodynamic response to dopamine is influenced by clinical severity of congestive heart failure. DESIGN: Effects of increasing doses of dopamine were assessed in patients consecutively admitted for acutely decompensated congestive heart failure. SETTING: Intensive care unit. PATIENTS: We enrolled 16 congestive heart failure patients stratified by clinical severity (New York Heart Association [NYHA] class III, n = 8; NYHA class IV, n = 8) and two additional NYHA class III patients as controls. INTERVENTIONS: Measurements were carried out throughout five 20-min experimental periods: baseline, dopamine infusion at 2, 4, and 6 microg x kg(-1) x min(-1), and recovery. Controls received a similar amount of saline. MEASUREMENTS AND MAIN RESULTS: Systemic and renal hemodynamics were determined respectively by right cardiac catheterization and radioisotopes (iodine 131-labeled hippuran and iodine 125-labeled iothalamate clearance). The peak increase in heart rate and cardiac index occurred at a dopamine dose of 4-6 microg x kg(-1) x min(-1). The dose-response relation was similar in NYHA classes III and IV. Improvement in effective renal plasma flow and glomerular filtration rate, peaking at 4 microg x kg(-1) x min(-1), was more rapid and marked in NYHA class III than class IV patients, in whom the renal fraction of cardiac output failed to increase. The systemic and renal effects of dopamine were independent of age. No change occurred in controls. CONCLUSIONS: The dose of dopamine producing an optimal improvement of systemic and renal hemodynamics in congestive heart failure is higher than usually reported. A greater clinical severity of congestive heart failure impairs the renal effects of dopamine, probably through a selective loss in renal vasodilating capacity.

Does advanced age affect the immediate and long-term results of direct-current external cardioversion of atrial fibrillation?

OBJECTIVES: To determine whether advanced age affects the immediate and long-term results of direct-current external cardioversion (ECV) of atrial fibrillation (AF), the sustained arrhythmia most commonly encountered in older patients. DESIGN: Retrospective analysis of medical records. SETTING: Intensive care unit. PARTICIPANTS: Two hundred fifty consecutive patients(age 34-100) with AF who underwent ECV following a standardized protocol in an intensive care unit. MEASUREMENTS: Immediate efficacy of ECV, defined as recovery of sinus rhythm, and maintenance of sinus rhythm over the follow-up were study outcomes. The univariate and multivariate associations of immediate efficacy of ECV and long-term results with clinical variables were analyzed. RESULTS: At univariate analysis, immediate efficacy of ECV (overall, 91.2%) was lower in older patients and in those with chronic obstructive pulmonary disease, higher for a 3- to 90-day pre-ECV duration of AF than for a duration of 2 days or less or more than 90 days, and independent of underlying cardiac disease, hypertension, diabetes mellitus, previous AF, and left atrial dimension. However, pre-ECV duration of AF was the only multivariate predictor of ECV immediate success. Major complications occurred in only three patients. Of 220 patients discharged in sinus rhythm, 211 were followed up for a mean period +/- standard deviation of 34 +/- 25 months. AF relapsed in 45.5% of them. At multivariate analysis, underlying cardiac disease was the only predictor of the relapse rate, and relapse rate was lower in coronary heart disease than in valvular heart disease, congestive heart failure, or lone AF. CONCLUSION: Immediate and long-term results of ECV of AF, an effective and safe procedure, are unaffected by age,at least after adjusting for several covariates.