Nursing Education Intervention Effects on Pain Intensity of Nursing Home Residents with Different Levels of Cognitive Impairment: A Cluster-Randomized Controlled Trial.

PURPOSE: Pain management in nursing homes is challenging and pain prevalence remains high. The objective of this study was to improve the pain situation of nursing home residents following a nursing-related educational intervention within a cluster-randomized controlled trial (2016-2018). PARTICIPANTS: Clusters were nursing homes from one nursing home operator in Bavaria, Germany. Nursing home residents who were permanently registered in the facilities, at least 60 years of age, and who themselves or their legal guardians provided informed consent were included. INTERVENTION: In addition to the implementation of pain nurses and pain care assistants, staff of the intervention group received an educational intervention in pain management, containing classroom (quality circles) and web-based training for nurses. METHODS: Based on the Mini-Mental State Examination (MMSE), residents were either interviewed (MMSE 10-30) using self-report instruments or observed (MMSE 0-9) by proxy assessment. The primary outcome in residents able to self-report was maximum pain intensity according to Brief Pain Inventory (BPI); in those not able to self-report treatment-relevant pain above cut-off (≥2) on the Pain Assessment in Advanced Dementia (PAINAD). RESULTS: Out of 20 randomly selected clusters, 9 nursing homes from the control, and 6 nursing homes from the intervention group participated. Multilevel linear (n=347 residents, MMSE 10-30) and logistic regression (n=222 residents, MMSE 0-9) analyses were conducted. Maximum pain intensity was higher after intervention (B=1.32, p<0.01), decreased with a better quality of life (B=-0.07, p<0.001), and was lower when dementia diagnoses were present (B=-1.12, p<0.01). PAINAD scores before and after intervention did not differ significantly (OR=0.89, p=0.724), but chances to exhibit treatment-related pain were higher with decreasing MMSE (OR=0.94, p<0.05). CONCLUSION: While no significant positive intervention effect was measured, findings suggest nurses' raised awareness towards pain management. Overall results indicate that large-scale educational interventions seem to be less effective in complex nursing home settings without also including specific individual-based intervention measures.

Quality of life in nursing home residents with pain: pain interference, depression and multiple pain-related diseases as important determinants.

AIM: Quality of life is an essential outcome parameter in geriatric research and presents an important indicator for the evaluation of care treatments. The present study analyses potential impact factors on health-related quality of life (HRQOL) of nursing home residents (NHR) who are in pain. METHODS: Data came from the cRCT 'PIASMA'. Statistical analyses of 146 respondents were carried out by multiple linear regressions based on the EQ-5D index (Euroquol Quality of Life) as dependent variable. Potential impact factors were applied and categorised in five blocks: pain intensity and interference (according to the Brief Pain Inventory), intervention effect, sex and age, pain-related diagnoses, and scales regarding depressive symptoms and cognitive impairment (based on the Geriatric Depression Scale and the Mini-Mental State Examination). RESULTS: On average, residents showed a pain intensity of 18.49, a pain interference of 29.61, a MMSE score of 22.84, a GDS score of 5.65 and an EQ-5D index of 0.52. Residents with more diagnoses, more depressive symptoms, and a higher pain interference showed a significantly reduced HRQOL. CONCLUSION: Findings underline the importance of identifying and applying treatment options for both pain (especially interference) and depressive disorders to maintain HRQOL of NHR.

Load transfer and periprosthetic fractures after total hip arthoplasty: Comparison of periprosthetic fractures of femora implanted with cementless distal-load or proximal-load femoral components and measurement of the femoral strain at the time of implantation.

BACKGROUND: Little is known about the causes and mechanisms underlying periprosthetic fractures around femoral components particularly in relation to the stem design. In an in vitro study 20 pairs of fresh cadaveric femora were loaded to fracture axially and transversally. FINDINGS: When proximal femoral strain was measured at the time of impaction of cementless stems the load transfer was determined by the underlying anatomy rather than by the shape of the stem, so that the so-called "load transfer" properties - proximal or distal - ascribed to stem designs are a myth. The axial-load and the transverse-load model were then exposed to loads to failure (fracture) and showed a biphasic pattern throughout independent of the impact direction. In the second phase, the fracture phase proper, the bone behaved like a brittle solid. Failure occurred very rapidly within less than 5 milliseconds. The forces to failure were between 2 and 11 kN. Most of the fractures (82.5%) occurred above the stem tip. INTERPRETATION: Note that the study was confined to early preosteointegration fractures. Neither the stem design nor the impact direction, i.e. on the knee or on the side of the hip, was related to the fracture morphology.