Analgesic Use Patterns Among Patients With Dementia During Transitions From Hospitals to Skilled Nursing Facilities

Gilmore‐Bykovskyi, Andrea; Block, Laura; Hovanes, Melissa; Mirr, Jacquelyn; Kolanowski, Ann

doi:10.3928/19404921-20190122-01

Cited by 10 publications

(8 citation statements)

References 37 publications

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“…The finding of a lower likelihood of opioid use for residents newly admitted to LTC (evident even among those with severe pain) raises concerns regarding possible discontinuity in the assessment, recognition, and/or treatment of pain among older adults during care transitions (e.g., from home to hospital to LTC). Gilmore-Bykovskyi et al [ 41 ] found that 23% of persons with dementia who were prescribed an analgesic in hospital experienced a potentially abrupt discontinuation when discharged to skilled nursing facilities. It is also possible that heightened concern and oversight of opioid prescribing in the community [ 25 ] is contributing to a reduced prevalence of opioid use among those entering LTC more recently [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

Correlates of Opioid Use Among Ontario Long-Term Care Residents and Variation by Pain Frequency and Intensity: A Cross-sectional Analysis

et al. 2022

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Background Chronic non-cancer pain is common among older residents of long-term care (LTC) homes and often poorly recognized and treated. With heightened concerns regarding opioid prescribing in recent years, it is important to examine the current prevalence of opioid use and its association with resident characteristics to help identify those potentially at risk of medication harms as well as suboptimal pain management. Objectives The aims were to estimate the prevalence and correlates of opioid use among non-palliative LTC residents and explore variation in opioid prevalence and correlates across strata defined by pain frequency and intensity. Methods We conducted a population-based cross-sectional study of all older (aged > 65 years) LTC residents (excluding those with cancer or receiving palliative care) in Ontario, Canada during 2018–2019. Health administrative databases were linked with standardized clinical assessment data to ascertain residents’ health and pain characteristics and their opioid and other medication use. Modified Poisson regression models estimated unadjusted and adjusted associations between residents’ characteristics and opioid use, overall and across strata capturing pain frequency and intensity. Results Among 75,020 eligible residents (mean age 85.1 years; 70% female), the prevalence of opioid use was 18.5% and pain was 29.4%. Opioid use ranged from 12.2% for residents with no current pain to 55.7% for those with severe pain. In adjusted models, residents newly admitted to LTC (adjusted risk ratio [aRR] = 0.60, 95% confidence interval [CI] 0.57–0.62) and with moderate to severe cognitive impairment (aRR = 0.69, 95% CI 0.66–0.72) or dementia (aRR = 0.76, 95% CI 0.74–0.79) were significantly less likely to receive an opioid, whereas residents with select conditions (e.g., arthritis, aRR = 1.37, 95% CI 1.32–1.41) and concurrently using gabapentinoids (aRR = 1.80, 95% CI 1.74–1.86), benzodiazepines (aRR = 1.33, 95% CI 1.28–1.38), or antidepressants (aRR = 1.31, 95% CI 1.27–1.35) were significantly more likely to receive an opioid. The associations observed for residents newly admitted, with dementia, and concurrently using gabapentinoids, benzodiazepines, or antidepressants were largely consistent across all pain strata. Conclusions Our findings describe resident sub-groups at potentially higher risk of adverse health outcomes in relation to both opioid use and non-use. LTC clinical and policy changes informed by research are required to ensure the appropriate recognition and management of non-cancer pain in this setting. Supplementary Information The online version contains supplementary material available at 10.1007/s40266-022-00972-9.

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Section: Discussionmentioning

confidence: 99%

Correlates of Opioid Use Among Ontario Long-Term Care Residents and Variation by Pain Frequency and Intensity: A Cross-sectional Analysis

et al. 2022

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“…The finding that HHC patients with ADRD are less likely to use any analgesic for daily interfering pain is consistent with prior studies, which found that pain is undertreated in community-dwelling older adults with ADRD in general, 14 and even more so during post-acute care transitions. 4,5,12,[19][20][21] Multiple factors may have contributed to the undertreatment of pain in older persons with ADRD during post-acute care. 40 First, impaired cognition may limit the patient's ability to self-report pain and changes in pain since administration of analgesics, potentially leading to under-treatment of pain.…”

Section: F I G U R E 1 Mean Of Activity Of Daily Living Score Changes...mentioning

confidence: 99%

“…41,43 Finally, factors specific to post-acute care transitions, such as when one receives HHC after hospital discharge, may also have caused the undertreatment of pain in HHC patients with ADRD. In particular, documentation of pain during hospitalization is often fragmented, one time only, and with insufficient information on pain treatment (e.g., effects of analgesics), 40,41,44 and analgesics are not often prescribed on standing orders in the hospital discharge summary, 20 resulting in gaps in pain management in post-acute care. This is because postacute care providers often rely on the written hospital discharge summary to guide their plan and provision of care, 21 and most post-acute care settings such as skilled nursing facilities and HHC do not have ready access to prescribers even if pain is identified by HHC providers.…”

Section: F I G U R E 1 Mean Of Activity Of Daily Living Score Changes...mentioning

confidence: 99%

“…Pain is under-recognized among older persons with ADRD, 14 because they are less likely to self-report pain than people with intact cognition, 15,16 and clinicians find it difficult to assess pain in this population. 17,18 The identification and treatment of pain for older persons with ADRD are particularly challenging during care transitions, such as those from acute to post-acute care, 4,5,[19][20][21] highlighting the need to study the appropriateness of pain assessment and treatment for patients in post-acute care.…”

Section: Introductionmentioning

confidence: 99%

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Pain treatment and functional improvement in home health care: Relationship with dementia

Wang

Cato

Conwell

et al. 2021

J American Geriatrics Society

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Background Pain management is important to post‐acute functional recovery, yet older persons with Alzheimer's disease and related dementias (ADRD) are often undertreated for pain. The main objectives were (1) to examine the relationship between ADRD and analgesic use among Medicare home health care (HHC) recipients with daily interfering pain, and (2) to examine the impact of analgesic use on functional outcome in patients with and without ADRD. Methods We analyzed longitudinal data from the Outcome and Assessment Information Set, Medicare HHC claims, and HHC electronic medical records during a 60‐day HHC episode. The sample included 6048 Medicare beneficiaries ≥65 years receiving care from an HHC agency in New York in 2019 who reported daily interfering pain. Analgesic use was assessed during HHC medication reconciliation and included any analgesic, non‐opioid analgesic, and opioid. ADRD was identified from ICD‐10 codes (HHC claims) and cognitive impairment symptoms (Outcome and Assessment Information Set [OASIS]). Functional outcome was measured as change in the composite Activity of Daily Living (ADL) limitation score in the HHC episode. Results ADRD was related to a lower likelihood of using any analgesic (odds ratio [OR] = 0.66, 95% confidence interval [CI]: 0.49, 0.90, p = 0.008) and opioids (OR = 0.54, 95% CI: 0.47, 0.62, p < 0.001), but not related to non‐opioid analgesic use (OR = 0.94, 95% CI: 0.74, 1.18, p = 0.58). Stratified analyses showed that any analgesic use (β = −0.43, 95% CI: −0.73, −0.13, p = 0.004) and non‐opioid analgesic use (β = −0.31, 95% CI: −0.56, −0.06, p = 0.016) were associated with greater ADL improvement in patients with ADRD, but not in patients without ADRD. Opioid use was not significantly related to ADL improvement regardless of ADRD status. Conclusions HHC patients with ADRD may be undertreated for pain, yet pain treatment is essential for functional improvement in HHC. HHC clinicians and policymakers should ensure adequate pain management for older persons with ADRD for improved functional outcomes.

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“…Abstraction procedures were performed in a standardized manner using abstraction manuals and tools with training and guidance for medical record review based on prior work. 40,41 Guidance on identifying NPS within clinical documentation contained within abstraction manuals and tools was informed by the Neuropsychiatric Inventory. 42 Specific variables included anxiety, agitation/aggression, hallucinations, depression, disinhibition, irritability or lability, and aberrant motor behavior (Supplementary Material 1).…”

Section: Data Collection and Analysismentioning

confidence: 99%

Discharge Communication of Dementia-Related Neuropsychiatric Symptoms and Care Management Strategies During Hospital to Skilled Nursing Facility Transitions

Gilmore‐Bykovskyi

Hovanes

Mirr

et al. 2020

J Geriatr Psychiatry Neurol

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Provided the complexity of managing dementia-related neuropsychiatric symptoms (NPS), accurate communication about these symptoms at hospital discharge is critical to facilitating safe and effective transitions, particularly transitions from hospitals to skilled nursing facilities (SNF), which are often poorly managed. Skilled nursing facilities providers have cited undercommunication regarding NPS as a major challenge that contributes to poor outcomes including rehospitalization. This multisite retrospective cohort study identified omission rates for NPS and associated management strategies in discharge communication as compared to medical record documentation in the 72 hours preceding discharge among hospitalized patients with dementia. High rates of omission were found across NPS and management strategies: anxiety (94%), agitation/aggression (77%), hallucinations (85%), 1:1 supervision (90%), high fall risk (89%), use of restraints (91%). Omission rate for new or modified antipsychotic medication was 12.9%. Findings underscore the need for additional research on cross-setting communication regarding care needs of patients with dementia—who often cannot communicate these needs on their own—in facilitating high-quality transitions.

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Analgesic Use Patterns Among Patients With Dementia During Transitions From Hospitals to Skilled Nursing Facilities

Cited by 10 publications

References 37 publications

Correlates of Opioid Use Among Ontario Long-Term Care Residents and Variation by Pain Frequency and Intensity: A Cross-sectional Analysis

Correlates of Opioid Use Among Ontario Long-Term Care Residents and Variation by Pain Frequency and Intensity: A Cross-sectional Analysis

Pain treatment and functional improvement in home health care: Relationship with dementia

Discharge Communication of Dementia-Related Neuropsychiatric Symptoms and Care Management Strategies During Hospital to Skilled Nursing Facility Transitions

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