A cross-sectional analysis of the prevalence of undertreatment of nonpain symptoms and factors associated with undertreatment in older nursing home hospice/palliative care patients

Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.
The American journal of geriatric pharmacotherapy 06/2010; 8(3):225-32. DOI: 10.1016/j.amjopharm.2010.05.002
Source: PubMed


Approximately 25% of all US deaths occur in the long-term care setting, and this figure is projected to rise to 40% by the year 2040. Currently, there is limited information on nonpain symptoms and their appropriate treatment in this setting at the end of life.
This study evaluated the prevalence of undertreatment of nonpain symptoms and factors associated with undertreatment in older nursing home hospice/palliative care patients.
This study used a cross-sectional sample of older (>or=65 years) hospice/palliative care patients to represent all patients from the 2004 National Nursing Home Survey (NNHS) funded by the Centers for Disease Control and Prevention. Nonpain symptoms were determined from facility staff, who used the medical records to answer questions about the residents. Data on medication use were derived from medication administration records. Undertreatment was defined as the omission of a necessary medication for a specific nonpain symptom and was evaluated as a dichotomous variable (yes = the nonpain symptom was not treated with a medication; no = the nonpain symptom was treated with a medication). Cross-sectional bivariate analyses were conducted using chi(2) and regression coefficient tests to determine factors potentially associated with undertreatment of nonpain symptoms.
The cross-sectional sample included 303 older nursing home hospice/palliative care patients from among the 33,413 (weighted) patients from the 2004 NNHS. Overall, most of the patients were white (91.4% [277/303]) and female (71.9% [218/303]), and nearly half were aged >or=85 years (47.9% [145/303]). One or more nonpain symptoms occurred in 82 patients (22.0% weighted). The most common nonpain symptoms (weighted percentages) were constipation/fecal impaction in 35 patients (8.8%), cough in 34 patients (9.2%), nausea/vomiting in 26 patients (7.2%), fever in 11 patients (3.1%), and diarrhea in 9 patients (1.9%). Medication undertreatment of any of the above symptoms was seen in 47 of 82 patients (60.0% weighted), ranging from a low of 26.4% for constipation/ fecal impaction to a high of 88.0% for nausea/vomiting. Undertreated patients had significantly more problems with bed mobility (n [weighted %], 43 [92.3%] vs 21 [67.2%]; P = 0.013), mood (21 [44.7%] vs 7 [19.7%]; P = 0.017), and pressure ulcers (12 [25.7%] vs 2 [6.1%]; P = 0.023) than did treated patients. The undertreated group also had a significantly greater number of secondary diagnoses (weighted mean [SD], 6.5 [0.7] vs 5.2 [0.5]; P = 0.004) but had a shorter length of stay in hospice/ palliative care (120.5 [20.1] vs 219.4 [51.8] days; P < 0.001) or in the nursing home (552.0 [96.5] vs 1285.4 [268.3] days; P = 0.001).
The prevalence of nonpain symptoms was low (22.0% weighted) in older nursing home hospice/palliative care patients. However, medication undertreatment of nonpain symptoms was seen in more than half of these patients. Future quality-improvement initiatives for nursing home hospice/palliative care patients are needed beyond the management of pain symptoms.

Download full-text


Available from: Keri Lyn Rodriguez,
14 Reads
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The treatment of chronic pain, therapeutic opioid use and abuse, and the nonmedical use of prescription drugs have been topics of intense focus and debate. After the liberalization of laws governing opioid prescribing for the treatment of chronic non-cancer pain by state medical boards in the late 1990s, and with the introduction of new pain management standards implemented by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 2000, opioids, in general, and the most potent forms of opioids including Schedule II drugs, in particular, have dramatically increased. Despite the escalating use and abuse of therapeutic opioids, nearly 15 to 20 years later the scientific evidence for the effectiveness of opioids for chronic non-cancer pain remains unclear. Concerns continue regarding efficacy; problematic physiologic effects such as hyperalgesia, hypogonadism and sexual dysfunction; and adverse side effects - especially the potential for misuse and abuse - and the increase in opioid-related deaths. Americans, constituting only 4.6% of the world's population, have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply, as well as two-thirds of the world's illegal drugs. Retail sales of commonly used opioid medications (including methadone, oxycodone, fentanyl base, hydromorphone, hydrocodone, morphine, meperidine, and codeine) have increased from a total of 50.7 million grams in 1997 to 126.5 million grams in 2007. This is an overall increase of 149% with increases ranging from 222% for morphine, 280% for hydrocodone, 319% for hydromorphone, 525% for fentanyl base, 866% for oxycodone, to 1,293% for methadone. Average sales of opioids per person have increased from 74 milligrams in 1997 to 369 milligrams in 2007, a 402% increase. Surveys of nonprescription drug abuse, emergency department visits for prescription controlled drugs, unintentional deaths due to prescription controlled substances, therapeutic use of opioids, and opioid abuse have been steadily rising. This manuscript provides an updated 10-year perspective on therapeutic use, abuse, and non-medical use of opioids and their consequences.
    Pain physician 11/2009; 13(5):401-35. · 3.54 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Silicon nitride films were prepared by plasma-CVD from SiH4-N2and SiF4-N2-H2gas mixtures. These films exhibited lower hydrogen concentration and higher thermal endurance than those of the films deposited from the conventional SiH4-NH3gas mixture. Improved characteristics as encapsulant of MOSFET's and as diffusion and annealing masks suggest usefulness of these films in the field of modern microelectronics processing.
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Opioids have been utilized for thousands of years to treat pain and their use continues to escalate. It is estimated that 90% of the patients who present to pain centers and receive treatment in such facilities are on opioids. However, in contrast to increasing opioid use and the lack of evidence supporting long-term effectiveness in chronic non-cancer pain, is the escalating misuse of prescription opioids, including abuse and diversion. There is also uncertainty about the incidence and clinical salience of multiple, poorly characterized adverse drug events, including endocrine dysfunction, immunosuppression, infectious disease, opioid-induced hyperalgesia, overdoses, deaths, and psychosocial and economic implications. A comprehensive review of the literature. The objective of this comprehensive review is to evaluate the clinical effectiveness and safety of chronic opioid therapy in chronic non-cancer pain. A comprehensive review of the literature relating to chronic opioid therapy in chronic non-cancer pain. The literature was collected from various electronic and other sources. The literature that was evaluated included randomized trials, observational studies, case reports, systematic reviews, and guidelines. Pain relief was the primary outcome measure. The secondary outcome measures were functional improvement and adverse effects. Short-term effectiveness was considered to be less than 6 months; long-term effectiveness was considered to be at least one year. Given the complexity and widespread nature of opioid therapy, there is a paucity of qualitative and/or quantitative literature. The available evidence is weak for pain relief combined with improvement in functional status. Only one drug, tramadol, is effective for pain relief and improvement of functional status. This is a narrative review without application of methodologic quality assessment criteria. Even so, a paucity of literature exists concerning both controlled and observational literature for multiple drugs and multiple conditions of chronic non-cancer pain. This comprehensive review illustrates the lack of literature on long-term opioid therapy; thus, opioid therapy should be provided with great restraint and caution, based on the weak evidence available.
    Pain physician 03/2011; 14(2):E133-56. · 3.54 Impact Factor
Show more