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Biomedical subjects

Ladislav Volicer

Publications and source records attributed to Ladislav Volicer.

26 records · Page 2Linked to original sources
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Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale.

OBJECTIVES: To develop a clinically relevant and easy to use pain assessment tool for individuals with advanced dementia that has adequate psychometric properties. DESIGN: Instrument development study using expert clinicians and behavioral observation methods. Measurement of sensitivity of the instrument to detect the effects of analgesic medications in a quality improvement activity. SETTING: Inpatient dementia special care units in a Veterans Administration Medical Center. PARTICIPANTS: Nineteen residents with advanced dementia who were aphasic or lacked the ability to report their degree of pain and six professional staff members. Additionally, data from medical records of 25 residents who were receiving pain medications as required (PRN) were collected. MEASUREMENTS: Based on the literature review, related assessment tools and consultation with expert clinicians, a five-item observational tool with a range of 0 to 10 was developed. The tool, Pain Assessment in Advanced Dementia (PAINAD), was compared with the Discomfort Scale and two visual analog scales (discomfort and pain) by trained raters/expert clinicians in the development study, and used for detection of analgesic efficacy in a quality improvement activity. RESULTS: Adequate levels of interrater reliability were achieved between dyads of the principal investigator with each clinical research rater and between two raters. PAINAD had satisfactory reliability by internal consistency with a one factor solution. PAINADthe Discomfort Scale-Dementia of Alzheimer Type (DS-DAT) were significantly correlated, providing evidence of construct validity. PAINAD detected statistically significant difference between scores obtained before and after receiving a pain medication. CONCLUSIONS: The PAINAD is a simple, valid, and reliable instrument for measurement of pain in noncommunicative patients. Since the patient population used for its development and testing was limited to a relatively small number of males, further research is needed before it can be universally recommended.

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Management of constipation in residents with dementia: sorbitol effectiveness and cost.

OBJECTIVE: The objective of this report is to describe a cost-effective strategy for management of constipation in nursing home residents with dementia. DESIGN: We conducted a prospective observational quality improvement study of 41 residents with chronic constipation and receiving an osmotic laxative. Sorbitol was substituted for lactulose. SETTING: The study was conducted at a dementia special care unit at a Veterans Administration hospital. MEASUREMENT: We measured the number and amount of laxative use over a period of 4 weeks that were required to maintain regular bowel function. RESULTS: There was no difference in efficacy of lactulose and sorbitol. Use of additional laxatives was infrequent: Milk of Magnesia on approximately 10% of days/patient, bisacodyl suppository on 2% to 4% of days/patient, and Fleet enema only on 3 occasions. The cost of constipation management using routine administration of sorbitol and as-needed use of other laxatives was 27% to 55% lower than the cost of other constipation management strategies reported in the literature. CONCLUSION: Substitution of sorbitol for lactulose does not change efficacy of the treatment and decreases cost. Regular use of an osmotic laxative avoids the costs and discomforts of rectal laxatives.

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Ten myths about decision-making capacity.

As a matter of practical reality, what role patients will play in decisions about their health care is determined by whether their clinicians judge them to have decision-making capacity. Because so much hinges on assessments of capacity, clinicians who work with patients have an ethical obligation to understand this concept. This article, based on a report prepared by the National Ethics Committee (NEC) of the Veterans Health Administration (VHA), seeks to provide clinicians with practical information about decision-making capacity and how it is assessed. A study of clinicians and ethics committee chairs carried out under the auspices of the NEC identified the following 10 common myths clinicians hold about decision-making capacity: (1) decision-making capacity and competency are the same; (2) lack of decision-making capacity can be presumed when patients go against medical advice; (3) there is no need to assess decision-making capacity unless patients go against medical advice; (4) decision-making capacity is an "all or nothing" phenomenon; (5) cognitive impairment equals lack of decision-making capacity; (6) lack of decision-making capacity is a permanent condition; (7) patients who have not been given relevant and consistent information about their treatment lack decision-making capacity; (8) all patients with certain psychiatric disorders lack decision-making capacity; (9) patients who are involuntarily committed lack decision-making capacity; and (10) only mental health experts can assess decision-making capacity. By describing and debunking these common misconceptions, this article attempts to prevent potential errors in the clinical assessment of decision-making capacity, thereby supporting patients' right to make choices about their own health care.

Attitude of Health Personnel↗
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Pitfalls in assessment of decision-making capacity.

A total of 395 consultation-liaison psychiatrists, geriatricians, and geriatric psychologists responded to a survey that asked them to rate the frequency and importance to clinical care of 23 potential pitfalls and misunderstandings by clinicians who refer patients for assessment of decision-making capacity. Respondents also indicated which pitfalls were the most important to address in educating health care professionals. Overall, 22 of 23 pitfalls were rated as common by more than half of the respondents. Thirty-six percent of the respondents indicated that the most important pitfall to address in educating health care professionals was the tendency for health care practitioners to assume that a patient who lacks capacity for one type of medical decision also lacks capacity for all medical decisions. The results suggest that additional education is needed to improve clinicians' ability to evaluate patients' decision-making capacity.

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Characteristics of dementia end-of-life care across care settings.

End-of-life care for persons with dementia in different care settings was retrospectively surveyed. In this sample, care recipients receiving hospice care and pain control stayed at home longer and were more likely to die at home. Psychiatric symptoms increased caregiver burden and were the most common reason for admission to an institution, and psychiatric care was associated with longer stay at home. Presence of advance directives decreased hospital stay and increased the likelihood of dying in a nursing home. Care recipients dying at home had fewer symptoms and less discomfort than care recipients dying in other settings. These results indicate that quality end-of-life care can be provided at home and is facilitated by hospice programs, effective pain control, and psychiatric care.

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End-of-life care in dementia: a review of problems, prospects, and solutions in practice.

The purpose of this literature review was to assess the current state of affairs in end-of-life care for persons with dementia, to identify barriers to the provision of high-quality care, and to describe exemplary programs that have discovered ways to overcome these barriers. The literature reviewed included English-language articles published since 1990, obtained by searches of Medline, presentations at meetings and conferences, and the Internet. Barriers to quality terminal dementia care identified by this review include: (1) measurement issues regarding quality of care and quality of life, (2) inappropriate interventions stemming from lack or disregard of advance directives, cost considerations, healthcare system factors, and caregiver factors, (3) poor symptom management involving both professional and family caregivers, and (4) current health policy formulated by federal or state governments, insurance companies, and health maintenance organization. High-quality care for persons with dementia at the end of life is possible and is currently being provided in some settings. Further research into areas identified in this review is necessary if the quality of care being provided to this population is to improve.

Journal Article↗