Showing papers by "Michael I. Bennett published in 2013"

Communication skills training in dementia care: a systematic review of effectiveness, training content, and didactic methods in different care settings.

Abstract: Background: Caring for and caring about people with dementia require specific communication skills. Healthcare professionals and family caregivers usually receive little training to enable them to meet the communicative needs of people with dementia. This review identifies existent interventions to enhance communication in dementia care in various care settings.Methods: We searched MEDLINE, AMED, EMBASE, PsychINFO, CINAHL, The Cochrane Library, Gerolit, and Web of Science for scientific articles reporting interventions in both English and German. An intervention was defined as communication skills training by means of face-to-face interaction with the aim of improving basic communicative skills. Both professional and family caregivers were included. The effectiveness of such training was analyzed. Different types of training were defined. Didactic methods, training content, and additional organizational features were qualitatively examined.Results: This review included 12 trials totaling 831 persons with dementia, 519 professional caregivers, and 162 family caregivers. Most studies were carried out in the USA, the UK, and Germany. Eight studies took place in nursing homes; four studies were located in a home-care setting. No studies could be found in an acute-care setting. We provide a list of basic communicative principles for good communication in dementia care. Didactic methods included lectures, hands-on training, group discussions, and role-play.Conclusion: This review shows that communication skills training in dementia care significantly improves the quality of life and wellbeing of people with dementia and increases positive interactions in various care settings. Communication skills training shows significant impact on professional and family caregivers’ communication skills, competencies, and knowledge. Additional organizational features improve the sustainability of communication interventions.

Neuropathic pain in the community: more under-treated than refractory?

Abstract: Best current estimates of neuropathic pain prevalence come from studies using screening tools detecting pain with probable neuropathic features; the proportion experiencing significant, long-term neuropathic pain, and the proportion not responding to standard treatment are unknown. These “refractory” cases are the most clinically important to detect, being the most severe, requiring specialist treatment. The aim of this study was to estimate the proportion of neuropathic pain in the population that is “refractory,” and to quantify associated clinical and demographic features. We posted self-administered questionnaires to 10,000 adult patients randomly selected from 10 general practitioner practices in 5 UK locations. The questionnaire contained chronic pain identification and severity questions, cause of pain, SF-12, EQ-5D, S-LANSS (Self-administered Leeds Assessment of Neuropathic Signs and Symptoms), PSEQ (Pain Self-Efficacy Questionnaire), use of neuropathic pain medications, and health care utilisation. These data were combined to determine the presence and characteristics of “refractory” neuropathic pain according to the defining features identified by a Delphi survey of international experts. Graded categories of chronic pain with and without neuropathic characteristics were generated, incorporating the refractory criteria. Completed questionnaires were returned by 4451 individuals (response rate 47%); 399 had “chronic pain with neuropathic characteristics” (S-LANSS positive, 8.9% of the study sample); 215 (53.9%) also reported a positive relevant history (“Possible neuropathic pain”); and 98 (4.5% of all Chronic Pain) also reported an “adequate” trial of at least one neuropathic pain drug (“Treated possible neuropathic pain”). The most refractory cases were associated with dramatically poorer physical and mental health, lower pain self-efficacy, higher pain intensity and pain-related disability, and greater health care service use.

Animal models of bone cancer pain: systematic review and meta-analyses.

Abstract: Pain can significantly decrease the quality of life of patients with advanced cancer. Current treatment strategies often provide inadequate analgesia and unacceptable side effects. Animal models of bone cancer pain are used in the development of novel pharmacological approaches. Here we conducted a systematic review and meta-analysis of publications describing in vivo modelling of bone cancer pain in which behavioural, general health, macroscopic, histological, biochemical, or electrophysiological outcomes were reported and compared to appropriate controls. In all, 150 publications met our inclusion criteria, describing 38 different models of bone cancer pain. Reported methodological quality was low; only 31% of publications reported blinded assessment of outcome, and 11% reported random allocation to group. No publication reported a sample size calculation. Studies that reported measures to reduce bias reported smaller differences in behavioural outcomes between tumour-bearing and control animals, and studies that presented a statement regarding a conflict of interest reported larger differences in behavioural outcomes. Larger differences in behavioural outcomes were reported in female animals, when cancer cells were injected into either the tibia or femur, and when MatLyLu prostate or Lewis Lung cancer cells were used. Mechanical-evoked pain behaviours were most commonly reported; however, the largest difference was observed in spontaneous pain behaviours. In the spinal cord astrocyte activation and increased levels of Substance P receptor internalisation, c-Fos, dynorphin, tumor necrosis factor-α and interleukin-1β have been reported in bone cancer pain models, suggesting several potential therapeutic targets. However, the translational impact of animal models on clinical pain research could be enhanced by improving methodological quality.

Neuropathic cancer pain: prevalence, severity, analgesics and impact from the European Palliative Care Research Collaborative-Computerised Symptom Assessment study.

Abstract: Background:Neuropathic pain causes greater pain intensity and worse quality of life than nociceptive pain. There are no published data that confirm this in the cancer population.Aim:We hypothesised that patients with neuropathic cancer pain had more intense pain, experienced greater suffering and were treated with more analgesics than those with nociceptive cancer pain, and a neuropathic pain screening tool, painDETECT, would perform as well in those with cancer pain as is reported in those with non-cancer pain.Design:The data were obtained from an international cross-sectional observational study.Setting/Participants:A total of 1051 patients from inpatients and outpatients, with incurable cancer completed a computerised assessment on symptoms, function and quality of life. In all, 17 centres within eight countries participated. Medical data were recorded by physicians. Pain type was a clinical diagnosis recorded on the Edmonton Classification System for Cancer Pain.Results:Of the patients, 670 had pain: ...

Extent of palliative care need in the acute hospital setting: a survey of two acute hospitals in the UK

Abstract: Background:In common with international health policy, The End of Life Care Strategy for England has highlighted the delivery of high quality palliative care in the acute hospital setting as an are...

Comparative efficacy of epidural, subarachnoid, and intracerebroventricular opioids in patients with pain due to cancer

Abstract: Background Since the 1970s, when endogenous opioids and opioid receptors were first isolated in the central nervous system, attempts have been made to optimize opioid therapy by delivering the medication centrally rather than systemically. Although the vast majority of cancer patients obtain satisfactory pain relief from individualized systemic treatment, there remain the few whose pain is refractory to systemic treatments. These patients may obtain relief from neuraxial opioid therapy: intracerebroventricular, epidural or subarachnoid. Objectives To compare intracerebroventricular therapy with other neuraxial treatments and to determine whether intracerebroventricular (ICV) has anything to offer over epidural (EPI) and subarachnoid (SA) catheters in terms of efficacy, adverse effects, and complications. Search methods A number of electronic databases were searched to retrieve information for inclusion in this review up to January 2003. Non-English language reports are awaiting assessment. Unpublished data were not sought. Selection criteria Randomised studies of intracerebroventricular therapy for patients with intractable cancer pain were sought. However, this level of evidence was not available so data from uncontrolled trials, retrospective case series and uncontrolled prospective cohort studies were assessed. Data collection and analysis Our search did not retrieve any controlled trials. We therefore used data from uncontrolled studies to compare incidences of analgesic efficacy, adverse effects, and complications. We found 72 uncontrolled trials assessing ICV (13 trials, 337 participants), EPI (31 trials, 1343 participants), and SA (28 trials, 722 participants) in cancer patients. From these we extracted data on analgesic efficacy, common pharmacologic adverse effects, and complications. Main results Data from uncontrolled studies reported excellent pain relief among 73% of ICV patients compared with 72% EPI and 62% SA. Unsatisfactory pain relief was low in all treatment groups. Persistent nausea, persistent and transient urinary retention, transient pruritus, and constipation occurred more frequently with EPI and SA. Respiratory depression, sedation and confusion were most common with ICV. The incidence of major infection when pumps were used with EPI and SA was zero. There was a lower incidence of other complications with ICV therapy than with EPI or SA. Authors' conclusions Neuraxial opioid therapy is often effective for treating cancer pain that has not been adequately controlled by systemic treatment. However, long-term use of neuraxial therapy can be complicated by problems associated with the catheters. The data from uncontrolled studies suggests that ICV is at least as effective against pain as other neuraxial treatments and may be a successful treatment for patients whose cancer pain is resistant to other treatments.

Pregabalin for the management of neuropathic pain in adults with cancer: a systematic review of the literature.

Abstract: Objective: To systematically identify and appraise the current literature of pregabalin in the treatment of neuropathic pain resulting from cancer or cancer treatment. Design: A systematic review of the literature was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Interventions and Subjects: Studies reporting pregabalin data for adult (>18 years) patients with cancer experiencing neuropathic pain due to cancer or cancer treatment/surgery were considered eligible for inclusion. Methods: A literature search was conducted in PubMed on February 22, 2012 using the following search terms: "neuropath* AND pain AND cancer OR oncology OR tumor OR tumour AND pregabalin." Open access journals were also searched. Abstracts were screened and reviewed for eligibility based on predetermined criteria for inclusion. Data reporting pain intensity, pain interference, quality of life, symptom quality and intensity, global impression of change, treatment satisfaction, and adverse effects were the predefined factors for analysis. Data were summarized descriptively due to variations in study outcome measures. Results: Five articles were eligible for inclusion; one double-blind National Cancer Institute common toxicity criteria controlled trial, one single-arm open-label study, two observational analyses, and one case report. Conclusions: There were limited published data reporting efficacy and safety outcomes for pregabalin in the treatment of neuropathic pain in adult patients with cancer. Due to limitations within the studies included in this review, it is not possible to draw any conclusions on the descriptive summary of pregabalin for the treatment of cancer-related neuropathic pain, and further studies are required.

What is the extent of potentially avoidable admissions amongst hospital inpatients with palliative care needs

Abstract: There is clear evidence that the full range of services required to support people dying at home are far from being implemented, either in England or elsewhere. No studies to date have attempted to identify the proportion of hospital admissions that could have been avoided amongst patients with palliative care needs, given existing and current local services. This study aimed to examine the extent of potentially avoidable admissions amongst hospital patients with palliative care needs. A cross sectional survey of palliative care needs was undertaken in two acute hospitals in England. Appropriateness of admission was assessed by two Palliative Medicine Consultants using the following data collected from case notes: reasons for admission; diagnosis and co-morbidities; age and living arrangements; time and route of admission; medical and nursing plan on admission; specialist palliative care involvement; and evidence of cognitive impairment. A total of 1359 inpatients were present in the two hospitals at the time of the census. Of the 654 consenting patients/consultees, complete case note data were collected for 580 patients; the analysis in this paper relates to these 580 patients. Amongst 208 patients meeting diagnostic and prognostic criteria for palliative care need in two acute settings in England, only 6.7% were identified as ‘potentially avoidable’ hospitalisations. These patients had a median age of 84. Half of the patients lived in residential or nursing homes and it was concluded that most could have received care in this setting in place of hospital. Our findings challenge assumptions that, within the existing configuration of palliative and end of life health and social care services, patients with palliative care needs experience a high level of potentially avoidable hospitalisations.

The effect of policy on end-of-life care practice within nursing care homes: a systematic review.

Abstract: Background:The number of older people in the UK is increasing. A significant proportion of end of life care for this population is currently provided and will increasingly be provided within nursing care homes.Aim:To identify the impact of implementing end of life care policy with regard to the use of the Gold Standards Framework in Care Homes programme, the Liverpool Care Pathway (or an Integrated Care Pathway) and educational/training interventions to support the provision of end of life care within nursing care homes within the UK.Design:Systematic literature review of published literature and reports.Data sources:An electronic search was undertaken of five databases-Medline, CINAHL, EMBASE, Web of Science and the Cochrane library and websites of government and palliative care organisations for papers and reports published between 2000 to June 2010. The reference lists of studies that were retrieved for the detailed evaluation were hand-searched for any additional relevant citations.. Only studies that...

Transitions to palliative care for older people in acute hospitals: a mixed-methods study

Abstract: Background: Improving the provision of palliative and end-of-life care is a priority for the NHS. Ensuring an appropriately managed ‘transition’ to a palliative approach for care when patients are likely to be entering the last year of life is central to current policy. Acute hospitals represent a significant site of palliative care delivery and specific guidance has been published regarding the management of palliative care transitions within this setting. Aims: (1) to explore how transitions to a palliative care approach are managed and experienced in acute hospitals and to identify best practice from the perspective of clinicians and service users; (2) to examine the extent of potentially avoidable hospital admissions amongst hospital inpatients with palliative care needs. Design: A mixed-methods design was adopted in two hospitals in England, serving diverse patient populations. Methods included (1) two systematic reviews; (2) focus groups and interviews with 58 health-care professionals to explore barriers to, and facilitators of, palliative care transitions in hospital; (3) a hospital inpatient survey examining palliative care needs and aspects of management including a self-/proxy-completed questionnaire, a survey of medical and nursing staff and a case note review; (4) in-depth interviews with 15 patients with palliative care needs; (5) a retrospective case note review of all inpatients present in the hospital at the time of the survey who had died within the subsequent 12 months; and (6) focus groups with 83 key decision-makers to explore the implications of the findings for service delivery and policy. Results: Of the 514 patients in the inpatient survey sample, just over one-third (n = 185, 36.0%) met one or more of the Gold Standards Framework (GSF) prognostic indicator criteria for palliative care needs. The most common GSF prognostic indicator was frailty, with almost one-third of patients (27%) meeting this criteria. Agreement between medical and nursing staff and the GSF with respect to identifying patients with palliative care needs was poor. In focus groups, health professionals reported difficulties in recognising that a patient had entered the last 12 months of life. In-depth interviews with patients found that many of those interviewed were unaware of their prognosis and showed little insight into what they could expect from the trajectory of their disease. The retrospective case note review found that 35 (7.2%) admissions were potentially avoidable. The potential annual cost saving across both hospitals of preventing these admissions was approximately £5.3M. However, a 2- or 3-day reduction in length of stay for these admissions would result in an annual cost saving of £21.6M or £32.4M respectively. Conclusions: Patients with palliative care needs represent a significant proportion of the hospital inpatient population. There is a significant gap between NHS policy regarding palliative and end-of-life care management in acute hospitals in England and current practice.

‘Like doing a jigsaw with half the parts missing’: community pharmacists and the management of cancer pain in the community

Abstract: Objectives: The aim was to explore and describe community pharmacists' current and potential place in the cancer pain pathway. Objectives were to describe pharmacists' role in advising patients and their carers on optimum use of opioid drugs for pain relief, identify elements of medicines management that could be modified and identify opportunities for improved communication with patients and other professionals. Methods: Semi-structured interviews were conducted with 25 community pharmacists in three areas of England. Data were analysed using the Framework method. Key findings: Pharmacists had no reliable method to identify patients with cancer and no access to disease stage and treatment plan information. There was little evidence of any routine communication with other professionals about patient care. Contact with patients was limited. Access to palliative care medicines could be problematic for patients and medicines use reviews (MURs) were rarely done. Interview data suggested variable levels of knowledge about optimal opioid use in cancer pain or awareness of patients' priorities. For some pharmacists, proactive involvement appeared to be inhibited by fear of discussing emotional and wider social aspects and accounts showed that a wide range of issues and concerns were raised by family members, indicating considerable unmet need. Pharmacists tended to assume information had already been provided by others and felt isolated from other care team members. Many felt that their potential contribution to cancer pain management was constrained but aspired to do more. Conclusions: There is significant scope for improving access to and interaction with, community pharmacists by people with cancer pain and their families. Finding ways to embed pharmacists within palliative care teams could provide a starting point for a greater contribution to cancer pain management.

Development of a generic working definition of 'supportive care'

Abstract: Context The term ‘supportive care’, despite everyday and widespread use, remains an ambiguous concept that lacks clarity. A generic definition would underpin the development of services and provide a basis for disease specific approaches to care. Objectives To develop a generic working definition of supportive care that could be applied to a range of diseases and chronic illnesses. Methods An indepth review of the literature was carried out to identify existing generic and disease specific definitions and descriptions of supportive care. Following the review, a modified two-phase Delphi study was performed. Participants included experts in the area of supportive care identified during the review in addition to charities or their representatives. A draft definition was developed based upon the outcome of the Delphi study. Results The literature review identified one brief generic definition of supportive care with no explanation of its origin. A further 17 disease specific definitions were identified, all relating to cancer. The review led to the development of 100 statements for inclusion in phase I of the modified Delphi study. 26 responses were received to phase I of the Delphi study and 17 responses to phase II. General agreement was received during the second stage and a final draft definition subsequently developed. Conclusions The resulting definition of supportive care might provide a basis for service development and could be further adapted to disease specific contexts. It would benefit from broader consultation to determine acceptability among a wider range of health professionals and service users.

Global Framework for Noncommunicable Diseases: How Can We Monitor Palliative Care?

Abstract: Dear Editor: Noncommunicable diseases (NCDs) are the leading global cause of death worldwide. Of the 57 million deaths that occurred in 2008, 36 million were due to NCDs, mainly cardiovascular diseases, cancers, diabetes, and chronic lung diseases. The World Health Organization (WHO) Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases addresses key components of surveillance, prevention, and care. The proposed monitoring framework includes indicators of outcomes, exposures, and health systems capacity and response. For several years the palliative care community has advocated for systematic monitoring of palliative care at national and global levels. Although several palliative care organizations report on the status of palliative care development, WHO member states have no obligation to monitor or report on palliative care, and available reports have had limited impact on the provision of care. The WHO revised discussion paper on the global monitoring framework includes a palliative care indicator, a step forward that is welcomed by the international palliative care community. The proposed indicator is:

Using haloperidol as an antiemetic in palliative care: informing practice through evidence from cancer treatment and postoperative contexts.

Abstract: Nausea and vomiting are common symptoms in palliative care. Haloperidol is often used as an antiemetic in this context, although direct evidence supporting this practice is limited. To evaluate the efficacy and clinical use of haloperidol as an antiemetic in nonpalliative care contexts to inform practice, the authors conducted a rapid review of (i) published evidence to supplement existing systematic reviews, and (ii) practical aspects affecting the use of haloperidol including formulations and doses that are commonly available internationally. In nausea and vomiting related to cancer treatment, haloperidol was superior to control in two small studies. In postoperative nausea and vomiting (PONV), two randomized controlledtrials found treatment with haloperidol comparable to ondansetron. In palliative care, an observational study found a complete response rate of 24% with haloperidol (one in four patients) which would be consistent with a number needed to treat (NNT) of 3 to 5 derived from PONV. There remains insufficient direct evidence to definitively support the use of haloperidol for the management of nausea and vomiting in palliative care. However, generalizing evidence from other clinical contexts may have some validity.

An investigation into the magnitude of the current window and perception of transcutaneous electrical nerve stimulation (TENS) sensation at various frequencies and body sites in healthy human participants.

Abstract: Introduction:Strong nonpainful transcutaneous electrical nerve stimulation (TENS) is prerequisite to a successful analgesic outcome although the ease with which this sensation is achieved is likely to depend on the magnitude of current amplitude (mA) between sensory detection threshold (SDT) and pai

Pain Assessment Tools in Palliative Cancer Care

Abstract: Cancer pain is a frequent and distressing symptom experienced by most patients at some point during the illness trajectory, particularly so in the advanced stages of disease. Systematic pain assessment is necessary to ensure adequate pain management, regardless of the pain origin. Pain assessment should be performed in a standardized manner, with precise and validated pain assessment tools, preferably based on universally accepted definitions. Unfortunately, there is still little consensus on how to categorize or classify cancer pain, but international collaborative efforts have led to new consensus-based suggestions. This chapter presents some of the background and development for the recent suggestions related to standardized methods for cancer pain assessment and classification. Specific focus is devoted to the following domains: pain intensity, cancer breakthrough pain, and neuropathic pain, as these domains have been ranked as the most relevant for pain assessment in palliative cancer patients, by both experts and patients. Furthermore, this chapter points to central aspects related to the development of assessment tools for self-report of pain in advanced cancer patients.

A phase i-ii feasibility trial of cancer carer medicines management: an overview

Abstract: Introduction Seventy-onepercent of people with cancer experience pain at the end of life (Teunissen et al 2007). It is well established that family carers play a significant role in managing pain medication. Our scoping exercise of international literature repeatedly found that family carers lack information and confidence, with some holding beliefs that pain cannot be controlled and concerns about medication becoming addictive. Carers9 roles have been neglected, with few interventions concerning pain management focusing specifically on carers, and a particular lack of UK research. Aims and Methods A Phase I-II feasibility study, funded by Dimbleby Marie Curie, is being conducted (2013–2015) to develop a new Cancer Carer Medicines Management intervention and to test its feasibility, acceptability and efficacy to improve carers9 knowledge, beliefs, skills and self-efficacy for pain medicines management, decrease carer strain and improve mood state. This will be achieved through: a rapid appraisal of research on interventions for carer management of end of life pain medicines; development and refinement of the intervention through user collaboration; and a feasibility trial involving nurses and carers in two sites, to inform a follow-on randomised control trial. Results Phase I will produce an educational intervention for delivery by palliative care nurses with family carers. Phase II will evaluate intervention impact on carer outcomes using validated questionnaires measuring carer pain medication knowledge, beliefs and skills; carer strain, self-efficacy and mood state. Secondary outcomes from validated questionnaires and interviews will include perceptions of patient pain, burden of the intervention, and factors inhibiting or facilitating intervention use.

Review Article Pregabalin for the Management of Neuropathic Pain in Adults with Cancer: A Systematic Review of the Literature

Abstract: Objective. To systematically identify and appraise the current literature of pregabalin in the treatment of neuropathic pain resulting from cancer or cancer treatment. Design. A systematic review of the literature was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Interventions and Subjects. Studies reporting pregabalin data for adult (>18 years) patients with cancer experiencing neuropathic pain due to cancer or cancer treatment/surgery were considered eli- gible for inclusion. Methods. A literature search was conducted in PubMed on February 22, 2012 using the following search terms: "neuropath* AND pain AND cancer OR oncology OR tumor OR tumour AND pregabalin." Open access journals were also searched. Abstracts were screened and reviewed for eligibility based on predetermined criteria for inclusion. Data reporting pain intensity, pain interference, quality of life, symptom quality and intensity, global impression of change, treatment satisfaction, and adverse effects were the predefined factors for analysis. Data were summarized descriptively due to variations in study outcome measures. Results. Five articles were eligible for inclusion; one double-blind National Cancer Institute common toxicity criteria controlled trial, one single-arm open- label study, two observational analyses, and one case report. Conclusions. There were limited published data reporting efficacy and safety outcomes for pregabalin in the treatment of neuropathic pain in adult patients with cancer. Due to limitations within the studies included in this review, it is not possible to draw any conclusions on the descriptive summary of pregabalin for the treatment of cancer- related neuropathic pain, and further studies are required.

Mechanism based treatments for anaemia in advanced cancer.

Abstract: Murphy and colleagues highlight the need to transfuse blood safely and appropriately using a more restrictive approach—transfusing at a lower haemoglobin threshold and using only one unit at a time.1 This approach is associated with less morbidity and mortality, with similar efficacy. However, the decision whether or …