Figures
Abstract
The overall aim was to explore the prevalence and persistent regular prescription of opioids and paracetamol among nursing home (NH) residents with dementia at admission and over time. A total of 996 residents with dementia, mean (SD) age 84.5 (7.6) years and (36.1% men), were included at admission (A1). Yearly assessments were performed for two years (A2 and A3) or until death. Pain was assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale. Information regarding prescription of analgesics, general physical health, personal activities of daily living, severity of dementia, neuropsychiatric symptoms, and prescription of psychotropic drugs was collected. A generalized linear mixed model was used to explore whether pain severity was associated with persistent and persistent prescription of opioids and/or paracetamol across timepoints. At A1, 495 of 996 (49.7%) NH residents were prescribed analgesics and prevalence increased at the follow-ups (A2: n = 630, 65.1%; A3: n = 382, 71.2%). Paracetamol was the most frequently prescribed analgesic at all assessments (A1: 45.5%; A2: 59.5%; A3: 67.1%). Opioid prescriptions were quite prevalent (A1: 18.1%; A2: 25.1%; A3: 28.3%), with odds approximately 13 times (OR = 13.3, 95% CI 6.8–26.0) and 9 times (OR = 8.6, 95% CI 3.7–20.3) higher for prescription at follow-up A2 and A3, respectively, relative to prescription at A1. In adjusted analyses, higher pain intensity and poor physical health were associated with prescription and persistent prescription of opioids and paracetamol. In conclusion, prevalence and persistent prescription of analgesics were high in NH residents with dementia. The odds for the prescription of opioids at follow-up were high if prescribed at baseline. Interdisciplinary collaboration, routine assessment of pain at admission and regularly thereafter, and systematic drug reviews are essential to adequately assess and treat pain in NH residents with dementia.
Citation: Helvik A-S, Bergh S, Kabukcuoğlu K, Šaltytė Benth J, Lichtwarck B, Husebø B, et al. (2022) Prevalence and persistent prescription of analgesic drugs in persons admitted with dementia to a nursing home – A longitudinal study. PLoS ONE 17(12): e0279909. https://doi.org/10.1371/journal.pone.0279909
Editor: Muhammad Shahzad Aslam, Xiamen University - Malaysia Campus: Xiamen University - Malaysia, MALAYSIA
Received: September 13, 2022; Accepted: December 18, 2022; Published: December 30, 2022
Copyright: © 2022 Helvik et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The datasets generated and/or analyzed for this study are available for researchers in cooperation with the data owners, the Research Centre for Age-Related Functional Decline and Disease, Innlandet Hospital Trust. Information is available at the following web page: https.//www.sykehuset-innlandet/avdelinger/alderspsykiatrisk-forskningssenter.
Funding: The study was initiated by and was administered and funded by the Public Hospital Research Centre for Age-Related Functional Decline and Disease, Innlandet Hospital Trust, Norway. The Research Centre is public funded, and not relying on funding from industry or commercial interests. The Research centre took part in the design and data collection from the municipality nursing homes, and preparation of the manuscript.
Competing interests: The authors have declared that no competing interest exist.
Introduction
In Europe and the United States, the majority of people with dementia are in a nursing home (NH) at time of death [1, 2], and studies have reported that up to 85% of NH residents have dementia [3–6]. It is further reported that the prevalence and severity of dementia in NH residents have increased over the years, at least in Norway [3, 4], where the jurisdiction to provide NH care lies with local municipalities [7]. To serve the needs of the country’s 5.4 million inhabitants, there are about 40,000 NH places (beds) [8, 9]. The goals of NHs are to limit negative health consequences of diseases and poor functioning, to promote quality of life (QoL) for older adults, and to provide care and treatment around the clock.
Pain is not only an unpleasant experience but also found to be quite prevalent in NH residents with dementia. A prevalence up to 80% has been reported in these NH residents but it is reported to vary considerably [10–20], which may be due to differences in participant characteristics, pain treatment, definition of pain, and methodology used in the studies [15].
Pain may have negative health consequences, including poorer physical functioning [21–23], depression [14], anxiety [14], agitation [24], and aggression [14], but is also found to limit social interaction [21], and contribute to poor QoL [18, 25, 26]. Pain with an intensity that is considered to affect a person’s function and everyday life is defined as clinically relevant [13] and requires attention and treatment by NH care personnel.
There has been increasing attention directed toward pain in older adults and in NH residents since the first guidelines for the clinical management of chronic pain among older adults were published by the American Geriatric Society (AGS) in 1998 [27]. The International Association for the Study of Pain (IASP) in 2007 implementation of projects to reduce pain in older persons by initiating an international year against pain in older adults [28]. Paracetamol is recommended as the first-line analgesic in older adults, whereas prescription of opioids has been recommended for treatment of moderate to severe pain [29]. Preceding the initiation of pain treatment, a systematic and reliable pain assessment is recommended [27, 30]. During pain treatment, the effect and possible side effects must be considered carefully. Anticholinergic side effects may provoke considerable adverse events in people with dementia [31, 32].
The prevalence of prescribed analgesics in NHs has varied from 35% to 79%, with the highest prevalence in the most recently assessed cohorts [33–38]. The prescription of paracetamol and opioids has especially increased [33–35]. To the best of our knowledge, studies exploring clinically relevant pain and the prescription of analgesics at NH admission in residents with dementia are lacking. However, two cross-sectional studies from 2017 and 2019 including NH residents with dementia independent of length of stay prior to the assessment reported the prevalence of the prescription of any analgesic to be 58% [38] and 61.3% [36] in those with clinically relevant pain, respectively. Those with clinically relevant pain were prescribed analgesics more frequently than those without clinically relevant pain [38]. Paracetamol was most frequently prescribed in both groups [36, 38], but opioids were also prescribed among residents without clinically relevant pain [36, 38].
An association between the degree of pain severity and the prescription of analgesics in NH residents has, as expected, been reported in international epidemiological studies [36, 37]. In addition, other factors indicating poor physical health [36, 39], poorer personal activities of daily living (P-ADL) function [37], affective symptoms [36], and being younger [37, 39] have, in some epidemiological cross-sectional studies, been found to be positively associated with prescription of analgesics in NH residents. Furthermore, some of the epidemiological NH studies have found that those with less-severe cognitive limitation or without dementia were more likely to be prescribed analgesics [39–41], but these results are divergent [17, 37]. It has also been reported that female NH residents with dementia were prescribed analgesics more often [42] than male NH residents with dementia, and that the type of care facility [39] may be associated with prescription of analgesics in these NH residents. However, the results are inconsistent with other studies’ findings in regard to prescription among female residents with dementia [36, 39] and with respect to care facility [36].
To the best of our knowledge, there are few epidemiological longitudinal studies that have assessed prescription of analgesics in NH residents with dementia from admission, with the exception of a relatively small study from the Netherlands (information about analgesics from n = 171 residents at baseline) [10]. However, that study did not assess clinically relevant pain, investigate if or how degree of pain was associated with prescribing opioids and paracetamol, or examine factors associated with persistent prescription of analgesics over time [10].
In the present study, the first aim was to assess the prevalence of analgesic drug prescription among NH residents with dementia at admission and after 12 and 24 months and persistent analgesic drug prescription from admission to 12 months and from 12 to 24 months in the entire sample, as well as stratified by clinically relevant pain. The second aim was to assess prescription of analgesic drugs in relation to prescription one or two timepoints earlier (persistent prescription) and to explore factors associated with persistent analgesic drug prescription. The third aim was to explore whether there is an effect of pain on prescription of these analgesics over time.
Materials and methods
Design
This was an observational, longitudinal study of newly admitted NH residents from a convenience sample of 68 NHs in South-Eastern Norway where baseline data were collected from November 2014 to December 2019. The NHs were located in 32 municipalities representing NHs in rural and urban areas of one county and were all non-profit NHs operated and owned by the municipalities. The follow-up data were collected annually or until the participant’s death. Follow-up assessments are ongoing, but the present study includes information from baseline (A1) to two years (A3), with data collection completed by the end of 2021.
Participation and setting
During 2014–2019, a total of 3,318 residents were registered as admitted to one of the 68 participating NHs. For the present study, 1,283 residents with an expected stay longer than four weeks were recruited. All residents 65 years and older, independent of whether they had established dementia or not, and residents younger than 65 with established dementia were asked to participate. The only exclusion criterion was life expectancy less than six weeks. The persons not recruited (2,035), due either to death shortly after admission (238), not accepting the invitation (567), or other unknown reasons (1,230), were more often women, but they did not differ in age from those recruited, i.e., mean (SD) age 84.2 (862) and 84.53 (7.8) years, respectively.
The present study included only residents with dementia at admission. Based on all available information, two physicians independently diagnosed dementia at admission according to the ICD-10 criteria [43]; a third was consulted in situations where the two physicians disagreed. All physicians had extensive experience with research and clinical old-age psychiatry. In total, 1,074 residents had dementia, 201 did not have dementia, and 8 could not be diagnosed. Of those with dementia, 78 residents lacked information about pain severity. Thus, the present study at baseline (A1) included 996 residents with dementia admitted to a NH. At the follow-ups, the numbers of residents available for analyses were 570 at A2 and 342 at A3 (Fig 1). Mean (SD) duration from A1–A2 and from A2–A3 was 341 (82.7) and 356 (66.9) days, respectively. Mean (SD) time of follow-up was 683 (98.2) days.
Measures
The Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale is an observational tool for people with dementia and was used at all assessments [44, 45]. MOBID-2 assesses nociceptive, musculoskeletal pain during active, guided movements and pain that might be related to internal organs, the head, and the skin during the previous week, documented on a body chart to show potential pain location. The pain scale comprises 10 single items scored from 0 (no pain) to 10 (most severe pain), with a maximum sum score of 100.
An additional item evaluates overall pain intensity from 0 to 10 (most-severe pain intensity). An overall pain-intensity score of ≥3 indicates that the resident has clinically relevant pain intensity [44]. Nursing staff who knew each resident best completed the scale. The MOBID-2 Pain Scale’s validity, reliability, and responsiveness have been assessed, and it has been used in several studies of NH residents including in Norway [45–47].
The prescription of regular analgesics was documented from each resident’s medical record at all assessments. Medications were grouped according to the Anatomical Therapeutic Chemical (ATC) classification system [48]. ATC codes beginning with N02 were divided into opioids (N02A) and paracetamol (N02B E01, N02A J06 & N02A J13) [48]. The prescription of each of these analgesics as well as “any type” was dichotomized as yes or no.
Psychotropic drugs were categorized as antipsychotics (N05A except lithium), antidepressants (N06A), anxiolytics (N05B), and hypnotics/sedatives (N05C) [48]. Prescription of each type of these psychotropic drugs as well as “any type” was dichotomized as yes or no. Additionally, the prescription of any type of psychotropic drug was summarized as the prescription of 0, 1, 2 or ≥3 drugs.
The Neuropsychiatric Inventory–Nursing Home version (NPI-NH) was used at all assessments to measure neuropsychiatric symptoms (NPS) [49]. The 12-item inventory assesses the following symptoms: delusion, hallucination, euphoria, agitation/aggression, disinhibition, irritability/lability, depression/dysphoria, anxiety, apathy/indifference, aberrant motor behavior, night-time behavior disturbances, and appetite and eating disorders (yes/no). For each symptom present, severity (score 1–3) and frequency (score 1–4) are measured. Frequency and severity scores are then multiplied, resulting in a score 0–12 for each symptom. Three sub-syndromes of NPS have been established by factor analysis: psychosis (including delusions and hallucinations), agitation (agitation/aggression, disinhibition, and irritability), and affective (depression and anxiety) [50]. The NPI-NH was translated to Norwegian and validated in 2008 [51].
The severity of dementia was measured using the Clinical Dementia Rating (CDR) scale at each assessment, which assesses six domains: memory, orientation, judgment and problem-solving, community affairs, home and hobbies, and personal care [52]. A total score with five response categories (0, 0.5, 1, 2, and 3) is calculated using an algorithm that prioritizes memory [52, 53]. The categories indicate level of dementia ranging from 0 (no dementia) to 3 (severe dementia). A sum score of the six domains (CDR Sum of Boxes, CDR-SoB) ranging from 0 to 18 offers important advantages when analyzing data. A higher score indicates more-severe dementia. The correlation between the categorical CDR and the CDR-SoB is high [54, 55]. The CDR scale has been translated to Norwegian and used in several NH studies [4, 46].
The Physical Self-Maintenance Scale (PSMS) [56] was used at all assessments to assess P-ADL. The PSMS includes six items with a total score ranging from 6 (highest possible level of functioning) to 30 (poorest possible level of functioning) [56]. The nursing personnel knowing the resident best completed the scale, which is used frequently in Norwegian NH studies [57, 58].
The General Medical Health Rating (GMHR), used at all assessments to measure physical health, is a one-item global rating scale with four response alternatives: excellent, good, fair, and poor [59]. The rating was based on all available information of physical health and use of prescribed medication. The scale has previously been used in large NH studies, including in Norway with NH residents with dementia [57]. For analyses, the scale was dichotomized to either poor (including fair and poor) or good (excellent and good) physical health [18].
Demographic information (age, sex, and marital status) was collected from medical records at baseline. Marital status (married or partner) was recorded at all assessments. The type of NH unit was reported at baseline and categorized either as a regular unit (RU) or a special care unit for people with dementia (SCU).
Procedure
Data were collected by healthcare workers, mainly registered nursing staff (74%), at the NHs and supervised by 10 research nurses. Data collectors completed a two-day training program prior to the data collection. All baseline information regarding each resident was collected over the first month of the NH stay, and data came from a standardized interview with the residents, their next of kin, their caregivers in the NH, and from medical records.
The NH staff, including the NH physician, assessed residents’ capacity to consent to participate in the study, and all residents who had the capacity gave their written consent. If a resident’s capacity to consent was reduced, his or her next of kin consented on the resident’s behalf. These procedures have been recommended and approved by the Norwegian Regional Ethics Committee South-East (2014/917).
Statistics
Baseline characteristics were presented as means and standard deviations (SDs) or frequencies and percentages, as appropriate. As data were collected at different NHs, a hierarchical structure is likely present. Residents prescribed and not prescribed analgesics were, therefore, compared by generalized linear mixed model with random intercepts for NHs.
Prevalence and persistent prescription (prescribed at two consecutive timepoints) of analgesics were presented as percentages for the entire sample as well as stratified by dichotomized overall pain-intensity score (MOBID-2 <3 vs. MOBID-2 ≥3) as assessed at baseline. The groups were compared by generalized linear mixed model with random intercepts for NHs.
The odds for the prescription of analgesic drugs (opioids or paracetamol) at one timepoint, adjusted for prescription of the same drug at a previous timepoint (Lag 1) or two timepoints earlier (Lag 2), were assessed by bivariate generalized linear mixed model with random intercepts for residents nested within NHs. In this model, the outcome was the prescription of an analgesic drug at A2 (12 months) or A3 (24 months), while the main factor was the prescription of the same drug at baseline (A1). The models were further adjusted for preselected covariates (age, sex, marital/partner status, MOBID-2 sum score, CDR-SoB, dichotomized GMHR, PSMS score, NPI-NH agitation sub-syndrome score, NPI-NH affective sub-syndrome score, NPI-NH psychosis sub-syndrome score, NPI-NH apathy score, prescription of psychotropic drugs (0, 1, 2, ≥ 3), and type of NH unit) measured at baseline.
Factors associated with persistent prescription of analgesic drugs at two consecutive timepoints were assessed using a generalized linear mixed model with random intercepts for residents nested within NHs. The model included fixed effects for factors assessed at the earlier of the two consecutive timepoints and was adjusted for the same covariates as above measured simultaneously with outcome whenever possible.
To assess whether pain intensity measured by the MOBID-2 sum score was associated with trend in the odds for prescribing analgesic drugs, a generalized linear mixed model with random effects for patients nested within NH was estimated. The model included fixed effects for time (coded as dummies), MOBID-2 sum score assessed simultaneously with prescription of analgesics, and the interaction between the two. A significant interaction would imply that the association between the prescription of analgesics and MOBID-2 sum score varied with time. The model was adjusted for preselected covariates (reported above) measured simultaneously with outcome whenever possible.
Only cases with no missing values for covariates were included in the regression analyses. All tests were two-sided, and results with p-values below 0.05 were considered significant. The statistical analyses were performed in SPSS version 27 and STATA version 17.
Results
Mean (SD) age was 84.5 (7.6) years, and 360 (36.1%) were men. Mean (SD) CDR-SoB was 11.2 (3.5). NH residents with dementia who were prescribed analgesics (paracetamol and/or opioids) were older, more often in poor physical health, had higher mean PSMS scores (poorer P-ADL functioning), and higher mean agitation sub-syndrome NPI-NH scores compared to those not prescribed analgesics (Table 1). Additionally, those prescribed analgesics were more often prescribed psychotropic drugs and were in regular care units than those not prescribed analgesics.
Prevalence and persistent prescription of analgesics
Of 996 participants, 495 (49.7%) were prescribed paracetamol and/or opioids at baseline (Table 2). The prevalence of any of the analgesics being prescribed increased at the follow-ups (A2 (n = 630, 65.1%) and A3 (n = 382, 71.2%)). Paracetamol was prescribed most frequently at all assessments (A1: 45.5%; A2: 59.5%; A3: 67.1%).
The prevalence of clinically relevant pain (MOBID-2 ≥3) at each timepoint varied, i.e., 35.6% (N = 355/996) at A1, 37.7% (N = 215/570) at A2, and 41.5% (N = 142/342) at A3. At all assessments, the prevalence of any analgesics was higher for those with clinically relevant pain (MOBID-2 ≥3) than for those without clinically relevant pain at baseline.
The persistent prescription of any analgesics between two consecutive assessments was high (>40%) throughout the study period. The persistent prescription of paracetamol between two assessments was higher than the proportion of persistent prescription of opioids between the same assessments. The proportion of participants with persistent prescription of any analgesics between two consecutive assessments was higher in those with clinically relevant pain (MOBID-2 ≥3) at baseline than without clinically relevant pain.
Unadjusted and adjusted odds for the prescription of opioids and paracetamol at one timepoint, given prescription of the same type of analgesics at an earlier timepoint, were high (Table 3). The odds for the persistent prescription of analgesics were highest when compared with prescription at the nearest assessment (Lag 1) compared to odds for prescription two timepoints apart (Lag 2). All results were highly significant (p<0.001).
Results of generalized linear mixed model.
Factors associated with prescription of analgesics at two consecutive timepoints
The adjusted odds for the persistent prescription of opioids at two consecutive timepoints were elevated among residents with higher pain-intensity scores (MOBID-2 sum score), poor physical health (GMHR), lower apathy symptom score, having been prescribed one or three or more psychotropic drugs (compared to none), or having been married/partner at the first of the two assessments (Table 4). The adjusted odds for the persistent prescription of paracetamol were elevated among residents with higher pain-intensity scores (MOBID-2 sum score), poor physical health (GMHR), or having been prescribed one psychotropic drug medication regularly (compared to none) at the first of the two assessments.
Results of generalized linear mixed model1 (N = 818).
Pain intensity and its association with prescription of analgesics at the same timepoint
In an adjusted analysis of the prescription of opioids and paracetamol, interaction between time and pain-intensity score (MOBID-2 sum score) was not significant, implying that the association between prescription and pain intensity did not vary with time. Overall, a higher pain-intensity score was significantly associated with higher odds for prescription of these analgesics assessed simultaneously (Table 5).
Results of generalized linear mixed model1 (N = 1645).
In addition, poor physical health was associated with increased odds for prescription of opioids. Furthermore, having poor physical health, low P-ADL functioning (higher PSMS score), or having been prescribed one psychotropic drug (compared to none) increased the odds for the prescription of paracetamol. Older age or being female increased the odds for prescribing paracetamol.
Discussion
The prevalence and persistence of the prescription of any analgesics were high from admission to NH and throughout the 24-month study period, with prevalence ranging from 50% (A1) to 71% (A3) and persistence from 42% (A1–A2) to 56% (A2–A3). Paracetamol was most frequently prescribed at all three assessments. NH residents with clinically relevant pain assessed at baseline (MOBID-2 ≥3) were more frequently prescribed opioids and paracetamol and more often had a persistent prescription for these drugs throughout the study period than those without clinically relevant pain at baseline. The odds for the prescription of opioids and paracetamol at 12-month follow-up when prescribed the same category of analgesics at baseline were higher than at 24-month follow-up when prescribed the same analgesics at baseline. Higher pain intensity (MOBID-2 sum score) was associated with the persistent prescription of both categories of analgesics, and pain intensity was associated with prescription of both opioids and paracetamol, also when adjusting for factors assessed simultaneously. In addition, having poor health increased the odds for the prescription of analgesics when assessed simultaneously.
The high prevalence of the prescription of analgesics found in the present study at NH admission is comparable with recent cross-sectional studies in Europe and Australia that included NH residents with dementia independent of length of stay prior to assessment [36–38]. Furthermore, NH residents at baseline were most frequently prescribed paracetamol, as found in previous studies assessing NH residents with dementia [10, 36–38]. Throughout the study and independent of degree of pain intensity, paracetamol was the most frequently prescribed analgesic drug. The prevalence of its prescription varied between 46% and 67%, which is in line with recommendations for prescribing paracetamol as the first-line analgesic for older adults [29, 31, 60] and people with dementia [31]. Paracetamol appears safe to prescribe at recommended doses to older adults [31, 61, 62] and people with dementia [31]; however, we have limited knowledge about adverse events related to its long-term use for people with dementia [32] as well as whether it works at all.
Even so, the prescription of opioids among participants was prevalent throughout the study (A1: 18.1%; A2: 25.1%; A3: 28.3%). The prevalence at admission was in line with the prevalence of opioids found in previous cross-sectional studies of NH residents with dementia independent of length of stay prior to assessment, i.e., in previous Norwegian studies (2019: 19.3%; 2016: 17.9%) [34, 36] and studies from other European countries (Finland, 2011: 13.5%; Ireland, 2015: 14.3%) [63, 64].
When assessing prescription of analgesics among NH residents with clinically relevant pain intensity at baseline (MOBID-2 ≥3), we found that 60% of those with clinically relevant pain were prescribed analgesics at NH admission (A1), while 40% of those without clinically relevant pain were prescribed analgesics. In total, 11% of the residents without clinically relevant pain were prescribed opioids at A1; these findings are in line with two previous cross-sectional studies including NH residents with dementia independent of length of stay when assessed [36, 38]. In the present study, it seems that, at the follow-ups, the proportion of residents with baseline clinically relevant pain being prescribed any analgesics or opioids had increased (80.1% and 44.7% at A2 and 82.8% and 41.2% at A3, respectively). However, for those with no clinically relevant pain at baseline, the proportion being prescribed any analgesics or opioids had increased, i.e., 58% and 16% at A2 and 66% and 22% at A3, respectively. The present study does not have information about the effect of treatment. At admission, we do not know whether those being prescribed analgesics and being without clinically relevant pain did not have clinically pain due to a treatment effect of the given analgesics or not, or whether a clinically relevant pain intensity will occur if the analgesics are terminated. However, we suggest that those with clinically relevant pain at baseline, independent of whether they were prescribed analgesics or not, could profit from a throughout evaluation of their pain treatment.
The present study adds to the limited literature by assessing NH residents with dementia at admission and using a longitudinal, observational design focusing on both the prevalence and persistent prescription of opioids and paracetamol. A relatively small (n = 171) longitudinal NH study from the Netherlands reported the prevalence and persistent prescription of paracetamol beginning at admission in residents with dementia [10] and following them with biannual assessments for 3.5 years. Compared with our study, the Netherlands study found a somewhat lower prevalence (34%–52%) and a higher proportion of the persistent (48%–80%) prescription of paracetamol [10]. However, it did not report the prevalence and persistent prescription of opioids [10]. In our study we found that, even if relatively few residents were prescribed opioids and the proportion with persistent opioid prescription was low (11%–18%), the odds for opioids at follow-ups A2 and A3 were almost 13 times and 9 times higher when these were prescribed at baseline compared to participants without opioids at baseline. Furthermore, a relatively large number of participants were prescribed paracetamol, and the proportion with persistent prescription was prominent (36%–52%), but the odds for persistent prescription were somewhat more moderate although higher when comparing the prescription of paracetamol with the nearest assessment timepoint, i.e., 8 times and 3 times higher. These findings may indicate that, when opioids were prescribed at baseline, NH residents with dementia were more likely to continue taking opioids than when paracetamol was prescribed at baseline. Persistent use of opioids might be a concern for these residents since it may increase the risk of serious adverse events due to anticholinergic side effects, comorbidities, polypharmacy, and changes in pharmacokinetics and pharmacodynamics [31, 32, 61]. Thus, treating residents with dementia with opioids should include a careful assessment of the benefits and the risks for each resident [31] and should be discontinued when possible [65]. Moreover, according to Norwegian guidelines [65], opioid use should be restricted in the treatment of chronic non-malignant pain because of the risk of addiction and serious adverse events.
In adjusted generalized linear mixed model analyses, higher pain intensity (MOBID-2 sum score) was associated with higher odds for persistent prescription of both opioids and paracetamol at two consecutive assessments and being prescribed opioids and paracetamol at the same assessment. These findings are as expected and comparable to cross-sectional studies reporting prescription of opioids according to pain intensity [36]. Additionally, we found that the prescription of psychotropic drugs at one timepoint was associated with increased odds of prescription of opioids and paracetamol when assessed simultaneously and persistent prescription of paracetamol at two consecutive assessments. We do not have a firm explanation for these findings. Even so, typical pain-related behaviors in persons with dementia, such as verbalization/vocalization (e.g., sighing, moaning, calling out, gasping), facial expressions (e.g., grimacing, frowning), and defensive postures (e.g., freezing, tensing, guarding, pushing, crouching) [27, 66–68] may also be related to dementia [67]. Typical pain symptoms may be difficult to interpret [67]; therefore, this group may be prescribed both analgesics and psychotropic drugs. However, these are speculations and require further investigation. It should also be noted that neuropsychiatric sub-syndrome scores were not associated with the prevalence or persistent prescription of analgesics, although cross-sectional studies have found higher affective syndrome scores linked to prescription of analgesics [36].
Strengths and limitations
A major strength of this study is its methodology, mainly the use of a well-known, internationally recognized scale for assessing pain, MOBID-2 [44, 45]; the use of a measure of cognitive functioning; and the experience of the research institution with such studies [4, 46]. The large sample size allowed us to adjust for several factors known to be linked to the prescription of analgesics in NH residents with dementia, including physical health, activities of daily living, neuropsychiatric symptoms, prescription of psychotropic drugs, and demographics, which limited the risk of confounding. Furthermore, the study was conducted at admission to NH, with an annual follow-up for two years. This made it possible to assess whether length of stay in a NH had an impact on the prescription of analgesics or the relationship between pain severity and persistent prescription of analgesics.
Several limitations must also be mentioned. Firstly, the information regarding pain treatment was restricted. We did not have information about the systematic use of non-pharmacological treatment, which could preferably be included in a later observational study of pain treatment in NH residents with dementia. Others have stated that older adults with chronic pain may benefit from non-pharmacological treatment such as cognitive behavioral therapy, exercise, massage, music therapy, and reflexology [31, 60, 69, 70] for pain relief as well as for optimal treatment of diseases. The information regarding the prescription of analgesics (pharmacological treatment) in the present study could have been more detailed and included information about frequency and dosage of opioids and/or paracetamol prescribed, whether analgesics were taken, and information regarding analgesics as required, NSAIDs, polypharmacy, and the timepoint when the analgesics were prescribed at each assessment. As previously noted, information regarding effect and side effects of the analgesics prescribed is missing. Such information would contribute to a more thorough understanding of pain treatment in NH residents with dementia. Furthermore, participants not using analgesics at A1, A2, and/or A3 may have been prescribed these drugs between the assessment intervals. This information was unavailable for this study and may, therefore, limit the validity of the results.
Secondly, cancer and musculoskeletal disorders are diagnoses commonly found in older adults and related to pain [29], but information about diseases was missing in this study. Thus, associations between these diagnoses or other comorbidities related to pain and the outcome, and prescription and persistent prescription of analgesics could not be explored. However, the present study included information about general physical health in the analysis and found that poor general physical health was associated with the prescription of opioids when assessed simultaneously. Thus, we cannot guarantee that a reverse association is present, i.e., that opioids contribute to reduced physical health.
Thirdly, the definition of clinically relevant pain as baseline MOBID-2 ≥3, used in the initial analysis of this study to compare the prescription of analgesics at all three assessments and finding a persistent prescription of analgesics, may be considered a limitation. However, this was done to have a reference for the comparisons and was mandatory when the persistent prescription of analgesics between two consecutive assessments was assessed. Yet pain severity may change over time, and residents with clinically relevant pain at baseline may not experience clinically relevant pain at the follow-ups and vice versa. The degree to which these are the same residents who have clinically relevant pain at two or more consecutive assessments remains to be explored.
Lastly, a large number of NH residents (and thereby, potential participants) were not included for various reasons other than not having dementia and a life expectancy shorter than 6 weeks and furthermore some were excluded due to a significant amount of missing information, which may limit the study’s validity. Furthermore, data collection was performed in some but not all NHs in one of Norway’s counties. Thus, the sample is not necessarily representative for older adults with dementia admitted to NHs in Norway, and caution should be taken in generalizing the study results.
Clinical implications
As demonstrated in this longitudinal, observational study of NH residents with dementia, pain is often present. Its treatment is demanding, and the prescription of opioids is particularly complex in this population [29, 31, 32]. All healthcare professionals involved in the care of such residents need to be aware of the challenges [71]. To improve quality of care and quality of life for NH residents with dementia, healthcare personnel must prioritize and improve the identification, monitoring, and treatment of pain [20] to reduce the prevalence and persistence of clinically relevant pain. Pain assessment at admission and regularly thereafter, with a valid and reliable pain assessment tool, should be performed routinely in NHs [72–75]. A systematic and reliable pain assessment is essential [27, 30]. For residents with dementia, a behavioral pain-assessment inventory like the MOBID-2 can be used to identify and manage pain [45, 76]. Routine pain assessments can reveal both undiagnosed and untreated pain and improve non-pharmacological and pharmacological pain treatment [18]. Systematic drug reviews [38] and interdisciplinary collaboration between nurses, physicians, and pharmacists are essential to effectively assess and treat pain and to evaluate the effect of pain treatment and identify potential side effects [31]. The application of criteria-based screening tools such as the STOPP/START criteria (Screening Tool of Older Person’s Prescriptions/Screening Tools to Alert Doctors to Right Treatment) [77] and the Norwegian General Practice–Nursing Home criteria (NORGEP-NH) [78] may contribute to appropriate prescribing and deprescribing of analgesics to NH residents with dementia. Future studies could explore innovative digital strategies for assessing pain intensity, pain treatment effects, and potential side effects in NH residents with dementia in order to address some of the clinical challenges pointed out.
Conclusion
The prevalence and persistent prescription of analgesics were high among Norwegian NH residents with dementia. Paracetamol was most frequently prescribed at all assessments. The odds of prescribing opioids at follow-up were high if these were prescribed at baseline. More than a third of the studied residents had clinically relevant pain at NH admission. In adjusted analyses, higher pain intensity and poor physical health were associated with prescription and persistent prescription of analgesics. Interdisciplinary collaboration, routine assessment of pain at admission and regularly thereafter, and systematic drug reviews are essential to adequately assess and treat pain in NH residents with dementia.
Acknowledgments
We thank the patients and their next of kin for participating in the study and sharing their information. We also thank the nursing home managers for their cooperation, the staff members who completed the questionnaires, and the research nurses who collected the data. The researchers also thank the Department of Public Health and Nursing at the Norwegian University of Science and Technology, the Norwegian National Centre for Ageing and Health, and the Research Centre for Age-Related Functional Decline and Disease for support during the manuscript preparations.
References
- 1. Houttekier D, Cohen J, Bilsen J, Addington-Hall J, Onwuteaka-Philipsen BD, Deliens L. Place of death of older persons with dementia. A study in five European countries. J Am Geriatr Soc. 2010;58(4):751–6. pmid:20398157
- 2. Mitchell SL, Teno JM, Miller SC, Mor V. A national study of the location of death for older persons with dementia. J Am Geriatr Soc. 2005;53(2):299–305. pmid:15673356
- 3. Sverdrup K, Bergh S, Selbæk G, Røen I, Kirkevold Ø, Tangen GG. Mobility and cognition at admission to the nursing home—a cross-sectional study. BMC Geriatr. 2018;18(1):30. pmid:29378518
- 4. Helvik AS, Engedal K, Benth J, Selbæk G. Prevalence and Severity of Dementia in Nursing Home Residents. Dement Geriatr Cogn Disord. 2015;40(3–4):166–77. pmid:26138271
- 5. Magaziner J, German P, Zimmerman SI, Hebel JR, Burton L, Gruber-Baldini AL, et al. The prevalence of dementia in a statewide sample of new nursing home admissions aged 65 and older: diagnosis by expert panel. Epidemiology of Dementia in Nursing Homes Research Group. Gerontologist. 2000;40(6):663–72. pmid:11131083
- 6. Seitz D, Purandare N, Conn D. Prevalence of psychiatric disorders among older adults in long-term care homes: a systematic review. Int Psychogeriatr. 2010;22(7):1025–39. pmid:20522279
- 7.
omsorgsdepartementet H-o. Prop. 99 L (2015–2016) Endringer i pasient- og brukerrettighetsloven og helse- og omsorgstjenesteloven (rett til opphold i sykehjem eller tilsvarende. In: omsorgsdepartementet H-o, editor. https://www.regjeringen.no/no/dokumenter/prop.-99-l-20152016/id2483443/sec32015.
- 8.
Hoen BT, Abrahamsen DR, Allertsen L. Færre private sykehjemsplasser. https://www.ssb.no/helse/helsetjenester/artikler/faerre-private-sykehjemsplasser: Statistisk sentralbyrå; 2021 November
- 9.
Statsbudsjettet 2013 In: Finansdepartementet, editor. Oslo: http://www.statsbudsjettet.no/Statsbudsjettet-2013/Budsjettsporsmal/Bevilgningssporsmal/Hyre144/?all=true&parti=h%C3%B8yre 2013.
- 10. Hendriks SA, Smalbrugge M, Galindo-Garre F, Hertogh CMPM, van der Steen JT. From Admission to Death: Prevalence and Course of Pain, Agitation, and Shortness of Breath, and Treatment of These Symptoms in Nursing Home Residents With Dementia. Journal of the American Medical Directors Association. 2015;16(6):475–81. pmid:25736822
- 11. Achterberg WP, Gambassi G, Finne-Soveri H, Liperoti R, Noro A, Frijters DH, et al. Pain in European long-term care facilities: cross-national study in Finland, Italy and The Netherlands. Pain. 2010;148(1):70–4. pmid:19910119
- 12. Fox PL, Raina P, Jadad AR. Prevalence and treatment of pain in older adults in nursing homes and other long-term care institutions: a systematic review. Cmaj. 1999;160(3):329–33. pmid:10065074
- 13. Husebo BS, Strand LI, Moe-Nilssen R, Borgehusebo S, Aarsland D, Ljunggren AE. Who suffers most? Dementia and pain in nursing home patients: a cross-sectional study. J Am Med Dir Assoc. 2008;9(6):427–33. pmid:18585645
- 14. Malara A, De Biase GA, Bettarini F, Ceravolo F, Di Cello S, Garo M, et al. Pain Assessment in Elderly with Behavioral and Psychological Symptoms of Dementia. J Alzheimers Dis. 2016;50(4):1217–25. pmid:26757042
- 15. Takai Y, Yamamoto-Mitani N, Okamoto Y, Koyama K, Honda A. Literature review of pain prevalence among older residents of nursing homes. Pain Manag Nurs. 2010;11(4):209–23. pmid:21095596
- 16. Koppitz A, Bosshard G, Schuster DH, Hediger H, Imhof L. Type and course of symptoms demonstrated in the terminal and dying phases by people with dementia in nursing homes. Zeitschrift fur Gerontologie und Geriatrie. 2015;48(2):176–83. pmid:25119700
- 17. Sengupta M, Bercovitz A, Harris-Kojetin LD. Prevalence and management of pain, by race and dementia among nursing home residents: United States, 2004. NCHS data brief. 2010(30):1–8. pmid:20353701
- 18. Helvik AS, Bergh S, Saltyte Benth J, Selbaek G, Husebo BS, Tevik K. Pain in nursing home residents with dementia and its association to quality of life. Aging Ment Health. 2021:1–11. pmid:34251936
- 19. Atee M, Morris T, Macfarlane S, Cunningham C. Pain in Dementia: Prevalence and Association With Neuropsychiatric Behaviors. Journal of Pain & Symptom Management. 2021;61(6):1215–26. pmid:33068708
- 20. Rajkumar AP, Ballard C, Fossey J, Orrell M, Moniz-Cook E, Woods RT, et al. Epidemiology of Pain in People With Dementia Living in Care Homes: Longitudinal Course, Prevalence, and Treatment Implications. Journal of the American Medical Directors Association. 2017;18(5):453.e1-.e6. pmid:28330634
- 21. Corbett A, Husebo B, Malcangio M, Staniland A, Cohen-Mansfield J, Aarsland D, et al. Assessment and treatment of pain in people with dementia. Nat Rev Neurol. 2012;8(5):264–74. pmid:22487749
- 22. Husebø BS, Ballard C, Aarsland D, Selbaek G, Slettebo DD, Gulla C, et al. The Effect of a Multicomponent Intervention on Quality of Life in Residents of Nursing Homes: A Randomized Controlled Trial (COSMOS). J Am Med Dir Assoc. 2019;20(3):330–9. pmid:30630722
- 23. Lin PC, Lin LC, Shyu YI, Hua MS. Predictors of pain in nursing home residents with dementia: a cross-sectional study. J Clin Nurs. 2011;20(13–14):1849–57. pmid:21592246
- 24. Hirsch C. Systematic pain management reduced agitation in nursing home residents with dementia. ACP Journal Club. 2011;155(5):8-.
- 25. Rostad HM. Characteristics of nursing home residents with late-stage dementia and pain. Norwegian Journal of Clinical Nursing / Sykepleien Forskning. 2020:1–17.
- 26. Wagatsuma S, Yamaguchi T, Berge LI, Husebo B, Habiger TF, Nouchi R, et al. How, Why and Where it Hurts-Breaking Down Pain Syndrome Among Nursing Home Patients With Dementia: A Cross-Sectional Analysis of the COSMOS Trial. Pain Manag Nurs. 2021;22(3):319–26. pmid:33431262
- 27. The management of chronic pain in older persons: AGS Panel on Chronic Pain in Older Persons. American Geriatrics Society. J Am Geriatr Soc. 1998;46(5):635–51.
- 28. Gibson SJ. IASP global year against pain in older persons: highlighting the current status and future perspectives in geriatric pain. Expert Rev Neurother. 2007;7(6):627–35. pmid:17563246
- 29. AGS. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331–46. pmid:19573219
- 30. Schofield P, Abdulla A. Pain assessment in the older population: what the literature says. Age Ageing. 2018;47(3):324–7. pmid:29584807
- 31. Achterberg W, Lautenbacher S, Husebo B, Erdal A, Herr K. Pain in dementia. Pain Rep. 2020;5(1):e803. pmid:32072098
- 32. Erdal A, Flo E, Aarsland D, Selbaek G, Ballard C, Slettebo DD, et al. Tolerability of buprenorphine transdermal system in nursing home patients with advanced dementia: a randomized, placebo-controlled trial (DEP.PAIN.DEM). Clin Interv Aging. 2018;13:935–46. pmid:29805252
- 33. van Dam PH, Caljouw MAA, Slettebø DD, Achterberg WP, Husebo BS. Quality of Life and Pain Medication Use in Persons With Advanced Dementia Living in Long-Term Care Facilities. J Am Med Dir Assoc. 2019;20(11):1432–7. pmid:30982716
- 34. Sandvik R, Selbaek G, Kirkevold O, Aarsland D, Husebo BS. Analgesic prescribing patterns in Norwegian nursing homes from 2000 to 2011: trend analyses of four data samples. Age Ageing. 2016;45(1):54–60. pmid:26764395
- 35. Torvik K, Kaasa S, Kirkevold O, Rustøen T. Pain and quality of life among residents of Norwegian nursing homes. Pain Manag Nurs. 2010;11(1):35–44. pmid:20207326
- 36. Griffioen C, Husebo BS, Flo E, Caljouw MAA, Achterberg WP. Opioid Prescription Use in Nursing Home Residents with Advanced Dementia. Pain Medicine. 2019;20(1):50–7. pmid:29136228
- 37. Tan ECK, Visvanathan R, Hilmer SN, Vitry A, Emery T, Robson L, et al. Analgesic use and pain in residents with and without dementia in aged care facilities: A cross-sectional study. Australasian Journal on Ageing. 2016;35(3):180–7. pmid:27256958
- 38. van Kooten J, Smalbrugge M, van der Wouden JC, Stek ML, Hertogh CMPM. Prevalence of Pain in Nursing Home Residents: The Role of Dementia Stage and Dementia Subtypes. Journal of the American Medical Directors Association. 2017;18(6):522–7. pmid:28236607
- 39. Hunnicutt JN, Ulbricht CM, Tjia J, Lapane KL. Pain and pharmacologic pain management in long-stay nursing home residents. Pain. 2017;158(6):1091–9. pmid:28267065
- 40. Dube CE, Morrison RA, Mack DS, Jesdale BM, Nunes AP, Liu SH, et al. Prevalence of pain on admission by level of cognitive impairment in nursing homes. Journal of Pain Research. 2020;13:2663–72. pmid:33116808
- 41. Holmerova I, Auer SR, Berankova A, Hofler M, Ratajczak P, Steffl M. Cognitive status and use of analgesics and anxiolytics in residents of nursing homes in the Czech republic. Clinical Interventions in Aging. 2018;13:2511–5. pmid:30587943
- 42. Jensen-Dahm C, Gasse C, Astrup A, Mortensen PB, Waldemar G. Frequent use of opioids in patients with dementia and nursing home residents: A study of the entire elderly population of Denmark. Alzheimers Dement. 2015;11(6):691–9. pmid:25239738
- 43.
Organization. WH. The ICD-10 Classification of Mental and Behavioural Disorders—Diagnostic Criteria for Research. In: Organization WH, editor. Geneva 1993.
- 44. Husebo BS, Strand LI, Moe-Nilssen R, Husebo SB, Snow AL, Ljunggren AE. Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale (MOBID): development and validation of a nurse-administered pain assessment tool for use in dementia. J Pain Symptom Manage. 2007;34(1):67–80. pmid:17509814
- 45. Husebo BS, Ostelo R, Strand LI. The MOBID-2 pain scale: reliability and responsiveness to pain in patients with dementia. Eur J Pain. 2014;18(10):1419–30. pmid:24799157
- 46. Røen I, Selbæk G, Kirkevold Ø, Engedal K, Testad I, Bergh S. Resourse Use and Disease Couse in dementia—Nursing Home (REDIC-NH), a longitudinal cohort study; design and patient characteristics at admission to Norwegian nursing homes. BMC Health Serv Res. 2017;17(1):365. pmid:28532443
- 47. Husebo BS, Strand LI, Moe-Nilssen R, Husebo SB, Ljunggren AE. Pain in older persons with severe dementia. Psychometric properties of the Mobilization-Observation-Behaviour-Intensity-Dementia (MOBID-2) Pain Scale in a clinical setting. Scand J Caring Sci. 2010;24(2):380–91. pmid:20210897
- 48.
2015 WCCfDSM. WHO Collaborating Centre for Drug Statistics Metodology ATC/DDD Index, 2015, Oslo: Noreweigan Institue of Public Health; 2015 [
- 49. Cummings JL. The Neuropsychiatric Inventory: assessing psychopathology in dementia patients. Neurology. 1997;48(5 Suppl 6):S10–6. pmid:9153155
- 50. Selbaek G, Engedal K. Stability of the factor structure of the Neuropsychiatric Inventory in a 31-month follow-up study of a large sample of nursing-home patients with dementia. Int Psychogeriatr. 2012;24(1):62–73. pmid:21682940
- 51. Selbaek G, Kirkevold O, Sommer OH, Engedal K. The reliability and validity of the Norwegian version of the Neuropsychiatric Inventory, nursing home version (NPI-NH). Int Psychogeriatr. 2008;20(2):375–82. pmid:17559707
- 52. Hughes CP, Berg L, Danziger WL, Coben LA, Martin RL. A new clinical scale for the staging of dementia. Br J Psychiatry. 1982;140:566–72. pmid:7104545
- 53. Morris JC. The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology. 1993;43(11):2412–4. pmid:8232972
- 54. Mjorud M, Kirkevold M, Rosvik J, Selbaek G, Engedal K. Variables associated to quality of life among nursing home patients with dementia. Aging Ment Health. 2014:1–9.
- 55. O’Bryant SE, Waring SC, Cullum CM, Hall J, Lacritz L, Massman PJ, et al. Staging dementia using Clinical Dementia Rating Scale Sum of Boxes scores: a Texas Alzheimer’s research consortium study. Arch Neurol. 2008;65(8):1091–5. pmid:18695059
- 56. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179–86. pmid:5349366
- 57. Helvik AS, Selbæk G, Šaltytė Benth J, Røen I, Bergh S. The course of neuropsychiatric symptoms in nursing home residents from admission to 30-month follow-up. PLoS One. 2018;13(10):e0206147. pmid:30335840
- 58. Goyal AR, Bergh S, Engedal K, Kirkevold M, Kirkevold Ø. Trajectories of quality of life and their association with anxiety in people with dementia in nursing homes: A 12-month follow-up study. PLoS One. 2018;13(9):e0203773. pmid:30204812
- 59. Lyketsos CG, Galik E, Steele C, Steinberg M, Rosenblatt A, Warren A, et al. The General Medical Health Rating: a bedside global rating of medical comorbidity in patients with dementia. J Am Geriatr Soc. 1999;47(4):487–91. pmid:10203127
- 60. Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, et al. Guidance on the management of pain in older people. Age Ageing. 2013;42 Suppl 1:i1–57. pmid:23420266
- 61. Reid MC, Eccleston C, Pillemer K. Management of chronic pain in older adults. Bmj. 2015;350:h532. pmid:25680884
- 62. Girard P, Sourdet S, Cantet C, de Souto Barreto P, Rolland Y. Acetaminophen Safety: Risk of Mortality and Cardiovascular Events in Nursing Home Residents, a Prospective Study. J Am Geriatr Soc. 2019;67(6):1240–7. pmid:30912588
- 63. Pitkala KH, Juola AL, Hosia H, Teramura-Gronblad M, Soini H, Savikko N, et al. Eight-Year Trends in the Use of Opioids, Other Analgesics, and Psychotropic Medications Among Institutionalized Older People in Finland. J Am Med Dir Assoc. 2015;16(11):973–8. pmid:26170037
- 64. Barry HE, Parsons C, Passmore AP, Hughes CM. Pain in care home residents with dementia: an exploration of frequency, prescribing and relatives’ perspectives. Int J Geriatr Psychiatry. 2015;30(1):55–63. pmid:24733695
- 65.
Health TNDo. National Counselor for the Use of Opioids for Long-Term Non-Cancer-Related Pain [In Norwegian]. In: Health Do, editor. https://www. helsedirektoratet.no/veiledere/opioider Available August 2022: The Norwegian Directorate of Health; Oslo: The Norwegian; 2016.
- 66. AGS. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(6 Suppl):S205–24.
- 67. McMinn B, Draper B. Vocally disruptive behaviour in dementia: development of an evidence based practice guideline. Aging Ment Health. 2005;9(1):16–24. pmid:15841828
- 68. Pieper MJ, van Dalen-Kok AH, Francke AL, van der Steen JT, Scherder EJ, Husebø BS, et al. Interventions targeting pain or behaviour in dementia: a systematic review. Ageing Res Rev. 2013;12(4):1042–55. pmid:23727161
- 69. Guerriero F, Reid MC. New opioid prescribing guidelines released in the US: what impact will they have in the care of older patients with persistent pain? Curr Med Res Opin. 2017;33(2):275–8. pmid:27786538
- 70. Ellis JM, Wells Y, Ong JSM. Non-Pharmacological Approaches to Pain Management in Residential Aged Care: a Pre-Post-Test Study. Clin Gerontol. 2019;42(3):286–96. pmid:29240534
- 71. Rekatsina M, Paladini A, Viswanath O, Urits I, Myrcik D, Pergolizzi J, et al. Opioids in the Elderly Patients with Cognitive Impairment: A Narrative Review. Pain Ther. 2022;11(2):381–94. pmid:35380373
- 72. Miu DKY, Chan KC. Under-detection of pain in elderly nursing home residents with moderate to severe dementia. Journal of Clinical Gerontology and Geriatrics. 2014;5(1):23–7.
- 73. Hjaltadóttir I, Ekwall AK, Nyberg P, Hallberg IR. Quality of care in Icelandic nursing homes measured with Minimum Data Set quality indicators: retrospective analysis of nursing home data over 7 years. Int J Nurs Stud. 2012;49(11):1342–53. pmid:22749461
- 74. Rantz MJ, Petroski GF, Madsen RW, Mehr DR, Popejoy L, Hicks LL, et al. Setting thresholds for quality indicators derived from MDS data for nursing home quality improvement reports: an update. Jt Comm J Qual Improv. 2000;26(2):101–10. pmid:10672507
- 75. Estabrooks CA, Knopp-Sihota JA, Norton PG. Practice sensitive quality indicators in RAI-MDS 2.0 nursing home data. BMC Res Notes. 2013;6:460. pmid:24220213
- 76. Morrison R, Jesdale B, Dube C, Forrester S, Nunes A, Bova C, et al. Racial/Ethnic Differences in Staff-Assessed Pain Behaviors Among Newly Admitted Nursing Home Residents. J Pain Symptom Manage. 2021;61(3):438-48.e3. pmid:32882357
- 77. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213–8. pmid:25324330
- 78. Nyborg G, Straand J, Klovning A, Brekke M. The Norwegian General Practice—Nursing Home criteria (NORGEP-NH) for potentially inappropriate medication use: A web-based Delphi study. Scand J Prim Health Care. 2015;33(2):134–41. pmid:26100966