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

Abstract

Aim 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. Methods Between-groups cross-sectional chart audits of 55 nursing home residents with dementia who died from cancer were carried out. Results A total of 45% of residents were in hospice at the end-of-life. Residents in hospice were more likely to receive an opioid (80% vs 43%, P = 0.005); but less likely to show severe cognitive impairment (20% vs 50%, P = 0.050). Enrolment in hospice was associated with an increased likelihood of receiving an opioid after controlling for level of cognitive impairment (OR = 3.9, 95% CI = 1.1–14.0, P = 0.037). Lower levels of cognitive functioning were associated with a decreased likelihood of receiving an opioid after controlling for enrolment in hospice (OR = 0.3, 95% CI = 0.1–0.8, P = 0.030). Notably, 40% of nursing home residents with dementia who died from cancer did not receive any opioid during this time. Conclusions Preliminary results suggest that hospice enrolment might be influenced by the facility or region of this particular country. Hospice enrolment predicts more opioid pain treatment in residents with dementia and terminal cancer; however, no resident with very severe dementia and terminal cancer was placed in hospice care. Severely cognitively impaired nursing home residents requiring opioids are at great risk of suffering from untreated advanced cancer pain. New methods are urgently required to improve end-of-life palliative care for nursing home residents with terminal cancer and severe dementia.

Using Complementary and Alternative Medicine to Treat Pain and Agitation in Dementia

“…3 Thus, occurrence of pain and dementia will both increase with age, 4–6 presenting challenges for pain assessment in both long-term care and adult critical care. Cognitively impaired individuals report pain less frequently and receive minimal 7 to no pain medication, 8 even when there is a known condition that causes pain, such as cancer. 7 Pain at rest in the intensive care unit (ICU) is common in adult patients and contributes to complications.…”

“…9 Although multiple tools exist to help assess pain in dementia, 6,10,11 pain remains under assessed and inadequately treated. 8,12,13 …”

Underrecognition and Undertreatment of Pain and Behavioral Symptoms in End-Stage Dementia

“…Earlier enrollment in Hospice is associated with an increased likelihood of receiving an opioid (80% vs 43%) and should be considered. 18 Hospital systems should consider applying pain and behavioral management protocols to address this problem in an attempt to standardize care and enhance end-of-life treatment.…”

Specific Physician Orders Improve Pain Detection and Pain Reports in Nursing Home Residents: Preliminary Data

“…The prevalence of pain and painful conditions among NH residents has remained unchanged over the last two decades, with most studies reporting pain prevalence in nursing homes as greater than 50 percent (Leong & Nuo, 2007; Smalbrugge, Jongenelis, Pot, Beekman, & Eefsting, 2007; Weiner, Peterson, Ladd, McConnell, & Keefe, 1999; Won et al, 2004). Although documentation of pain is now required as the 5 th vital sign among NH residents (Fishman, 2005), pain commonly occurring in this population remains undertreated (Monroe & Carter, 2010; Monroe, Carter, Feldt, Dietrich, & Cowan, 2013; Monroe, Herr, Mion, & Cowan, 2013; Monroe & Mion, 2012). For example, despite cancer being a cause of severe pain among NH residents (Monroe, Carter, et al, 2013), a seminal study found that 26 percent of NH residents (N=13,625) with daily cancer pain did not receive any pain medication (Bernabei et al, 1998).…”

“…Although documentation of pain is now required as the 5 th vital sign among NH residents (Fishman, 2005), pain commonly occurring in this population remains undertreated (Monroe & Carter, 2010; Monroe, Carter, Feldt, Dietrich, & Cowan, 2013; Monroe, Herr, Mion, & Cowan, 2013; Monroe & Mion, 2012). For example, despite cancer being a cause of severe pain among NH residents (Monroe, Carter, et al, 2013), a seminal study found that 26 percent of NH residents (N=13,625) with daily cancer pain did not receive any pain medication (Bernabei et al, 1998). Similarly, another study showed that among 411 hospitalized older adults with acute hip fracture, half complained of moderate to severe pain at rest, and four out of five complained of pain during movement, yet 87 percent did not have a standing order for pain medicine (Morrison et al, 2003).…”