Comfort and Satisfaction With Care of Home-Dwelling Dementia Patients at the End of Life.

CONTEXT: Despite the preference to pass away at home, many dementia patients die in institutions, resulting in a paucity of studies examining end-of-life care outcomes in the home setting. OBJECTIVE: The objective of this study was to identify modifiable factors associated with the comfort of dementia patients dying at home and families' satisfaction with care. METHODS: This is a prospective cohort study conducted from October 2014 to April 2019 in Singapore. Dementia patients at Stage 7 on the Functional Assessment Staging Scale, with albumin <35 g/L, enteral feeding, or pneumonia, were recruited from a palliative homecare program. Independent variables included demographics, medical information, and care preferences. The Comfort Assessment in Dying with Dementia scale assessed dying patients' comfort, whereas the Satisfaction with Care at the End-of-Life in Dementia scale evaluated family caregivers' satisfaction two months after bereavement. Gamma regression identified factors independently associated with comfort and satisfaction. RESULTS: The median age of 202 deceased patients whose comfort was assessed was 88 years. Anti-cholinergic prescription (60.4% of patients) [ß (95% CI) = 1.823 (0.660-2.986), P = 0.002] was positively associated with comfort, whereas opioid prescription (89.6%) [ß (95% CI) = -2.179 (-4.107 to -0.251), P = 0.027] and >1 antibiotic courses used in the last two weeks of life (77.2%) [ß (95% CI) = -1.968 (-3.196 to -0.740), P = 0.002] were negatively associated. Independent factors associated with families' satisfaction with care were comfort [ß (95% CI) = 0.149 (0.012-0.286), P = 0.033] and honoring of medical intervention preferences (96.0%) [ß (95% CI) = 3.969 (1.485-6.453), P = 0.002]. CONCLUSION: Achieving comfort and satisfaction with care for dementia patients dying at home involves an interplay of modifiable factors. Honoring medical intervention preferences, such as those with palliative intent associated with patients' comfort, determined families' satisfaction with care.

Factors affecting unplanned readmissions from community hospitals to acute hospitals: a prospective observational study.

INTRODUCTION: While the readmission rate from community hospitals is known, the factors affecting it are not. Our aim was to determine the factors predicting unplanned readmissions from community hospitals (CHs) to acute hospitals (AHs). MATERIALS AND METHODS: This was an observational prospective cohort study, involving 842 patients requiring post-acute rehabilitation in 2 CHs admitted from 3 AHs in Singapore. We studied the role of the Cumulative Illness Rating Scale (CIRS) organ impairment scores, the Mini-mental State Examination (MMSE) score, the Shah modified Barthel Index (BI) score, and the triceps skin fold thickness (TSFT) in predicting the rate of unplanned readmissions (UR), early unplanned readmissions (EUPR) and late unplanned readmissions (LUPR). We developed a clinical prediction rule to determine the risk of UR and EUPR. RESULTS: The rates of EUPR and LUPR were 7.6% and 10.3% respectively. The factors that predicted UR were the CIRS-heart score, the CIRS-haemopoietic score, the CIRS-endocrine / metabolic score and the BI on admission. The MMSE was predictive of EUPR. The TSFT and CIRS-liver score were predictive of LUPR. Upon receiver operator characteristics analysis, the clinical prediction rules for the prediction of EUPR and UR had areas under the curve of 0.745 and 0.733 respectively. The likelihood ratios of the clinical prediction rules for EUPR and UR ranged from 0.42 to 5.69 and 0.34 to 3.16 respectively. CONCLUSIONS: Patients who have UR can be identified by the admission BI, the MMSE, the TSFT and CIRS scores in the cardiac, haemopoietic, liver and endocrine/metabolic systems.

The relationship between medical comorbidity and self-rated pain, mood disturbance, and function in older people with chronic pain.

BACKGROUND: Aging is associated with greater risk for many illnesses and the prospect of multiple, concurrent disease states. Chronic pain is also very common in advanced age, and there is likely to be a relationship with comorbid burden, but few studies have examined this issue. This study tests the hypothesis that comorbid burden is associated with greater levels of self-reported pain and associated disturbance in mood and function. METHODS: Psychometric and medical data were collected from 562 patients (mean age = 76.3 years) attending a geriatric pain clinic. The number of categories endorsed on the Cumulative Illness Rating Scale (CIRS) score was used to measure accumulated comorbid burden. These groups were tested for differences in the severity of self-reported pain. The predictive capacity of comorbid burden for explaining variance in mood disturbance and functional disability was assessed after controlling for any differences in age and severity of pain. RESULTS: Over 50% of the sample had three or more comorbid problems. Groups with greater levels of comorbidity scored higher on the Present Pain Intensity Index, the sensory and affective subscales of the McGill Pain Questionnaire. Multiple regression analysis showed that the CIRS score explained a significant proportion of the variance in scores on the Geriatric Depression Scale (4.1%), Human Activities Profile (4.8%), and the physical domain of the Sickness Impact Profile (5.9%). CONCLUSION: Greater levels of comorbidity are associated with reports of more severe pain, more depressive symptoms, reduced activity levels, and higher physical impact from pain.