Use of the assessment of discomfort in dementia protocol.

The Assessment of Discomfort in Dementia (ADD) Protocol was developed to improve recognition and treatment of physical pain and affective discomfort in people with dementia who are no longer able to clearly or consistently report on their internal states. The purpose of this study was to describe use of each step of the ADD protocol with 143 residents of long-term care facilities. Of the subjects who received nonpharmacological comfort interventions, 37% showed improved symptoms. Of the 91 protocols in which an analgesic was administered, 83.5% showed improved symptoms. People who complained verbally received considerably more analgesics and other comfort interventions. Limitations inherent in this descriptive exploratory study do not permit conclusions regarding the effectiveness of the ADD protocol. Research with a control group, random assignment, and objective measures of discomfort level is planned.

Building an institutional commitment to pain management in long-term care facilities.

This report reviews the development, implementation and findings of an inter-institutional study directed to the goal of making pain management an institutional priority in Wisconsin long-term care facilities. A total of 87 facilities were recruited in two training cohorts. Each facility identified a team of individuals, with responsibility and authority for care policies within their institution, to participate in four structured educational programs. Each team completed an Action Plan, structured around 14 national practice indicators of an institutional commitment to pain management. At baseline, 14% of facilities had > 51% of the indicators in place; at conclusion 74% of facilities had > 51% of indicators in place. This education project was successful across training cohorts at implementing critical pain management target indicators.

Nurses' perceptions of pain assessment and treatment in the cognitively impaired elderly. It's not a guessing game.

The purpose of the study was to describe nurses' perceptions regarding the assessment and treatment of pain in patients with late-stage dementia. Thirty nurses from six long-term care facilities were interviewed using a semistructured format for this qualitative study. Initial results were presented to a second group for validation and refinement of findings. The most commonly cited behaviors used to indicate discomfort were facial grimacing, restless body movement, change in behavior, moaning, and tense muscles. Psychotropic drugs were perceived to be commonly misused because behavior changes were seen as a psychiatric problem rather than a representation of the patient's unmet need. Nurses had positive feelings about using both narcotics and nonnarcotic analgesics with this population but believed both types of analgesics were underused. The most common concerns regarding the administration of narcotic analgesics to this population were falls, sedation, and constipation.

Development of a teaching module for quality-of-life assessment of terminal patients. The AACE Multi-Institutional Palliative Cancer Education Section. American Association for Cancer Education.

To enhance the teaching of students to assess quality of life of patients with serious disease, the AACE Palliative Cancer Education Section has developed a teaching module. The module, which focuses on four desired learning objectives, is to be used in an hour-long small-group session. The authors describe the development of the module, as well as its objectives, teaching method, evaluation, and future challenges.

Recommendations for incorporating palliative care education into the acute care hospital setting.

This article presents recommendations for improving the education of physicians about end-of-life care in the acute care hospital setting. The authors, who have a variety of backgrounds and represent several types of institutions, formulated and reached consensus on these recommendations as members of the Acute Care Hospital Working Group, one of eight working groups convened at the National Consensus Conference on Medical Education for Care Near the End of Life in May 1997. A recently published literature review on the status of palliative care education, a summary of recent research on education about end-of-life care, and expert opinion were helpful in developing the recommendations. The authors emphasize that the acute care setting offers many opportunities for education about care at the end of life. Faculty should support learners' appreciation of the importance of end-of-life care, and convey the meaning and privilege of attending to patients and families at this difficult time. Faculty should teach students and residents to provide care that embodies attention to the control of distressing physical, physiologic, and spiritual symptoms, appropriate awareness of patients' differing cultural backgrounds and their impact upon the experience of dying, excellent communication skills, the application of bioethical principles, timely referral and smooth transition to other care settings that meet patient and family goals, and the role of the interdisciplinary team in meeting the diverse needs of dying patients and their families.

Pain assessment and management in the long-term care setting.

The assessment and management of pain is a significant public health problem in the United States. Long-term care facilities face unique barriers and challenges to pain management due to the large population of cognitively impaired residents, little physician contact and poor pain education for nurses and nurse assistants. In addition, common misconceptions about pain and pain treatment in the elderly along with health professional and resident fears of addiction and drug toxicity, add to the problem of pain management. The basic principles of pain treatment in long-term care are identical to all other health care settings--utilizing a combination of drug and non-drug treatments. Recent efforts to institutionalize improved pain management practices, through assessment procedures and defined pain management policies, standards and education programming, is a promising venue for systemically improving pain treatment in long-term care settings.

Assessment and treatment of discomfort for people with late-stage dementia.

People with dementia have often been excluded from pain studies. However, there is evidence supporting that people with dementia experience frequent pain, often poorly assessed and undertreated, and that the etiology for pain descriptions is poorly documented. The Assessment of Discomfort in Dementia (ADD) Protocol is designed to: a) more accurately assess discomfort in people with dementia who can no longer verbally describe physical pain or affective discomfort; b) more accurately and thoroughly treat physical pain and affective discomfort; and c) decrease inappropriate use of psychotropic medication. The use of the ADD Protocol was studies with a convenience sample of 104 residents of long-term care with end-stage dementia. Use of the ADD Protocol was associated with a significant decrease in discomfort (t = 6.56, p = 0.000). The most frequently seen behavioral symptoms associated with discomfort were tense body language, sad facial expression, fidgeting, perseverant verbalizations, and verbal outburts. The ADD Protocol was also associated with a significant increase in the use of scheduled analgesics and non-pharmacological comfort interventions. The protocol was not associated with an increase in the use of prn analgesics or with prn or scheduled psychotropics. This study has provided some support for the notion that the needs of people with significant dementia can be discerned and treated.