title: A cross-sectional analysis of the prevalence of undertreatment of nonpain symptoms and factors associated with undertreatment in older nursing home hospice/palliative care patients.
abstract: BACKGROUND
  Approximately 25% of all US deaths occur in the long-term care setting, and this figure is projected to rise to 40% by the year 2040. Currently, there is limited information on nonpain symptoms and their appropriate treatment in this setting at the end of life.
  
  
  OBJECTIVE
  This study evaluated the prevalence of undertreatment of nonpain symptoms and factors associated with undertreatment in older nursing home hospice/palliative care patients.
  
  
  METHODS
  This study used a cross-sectional sample of older (>or=65 years) hospice/palliative care patients to represent all patients from the 2004 National Nursing Home Survey (NNHS) funded by the Centers for Disease Control and Prevention. Nonpain symptoms were determined from facility staff, who used the medical records to answer questions about the residents. Data on medication use were derived from medication administration records. Undertreatment was defined as the omission of a necessary medication for a specific nonpain symptom and was evaluated as a dichotomous variable (yes = the nonpain symptom was not treated with a medication; no = the nonpain symptom was treated with a medication). Cross-sectional bivariate analyses were conducted using chi(2) and regression coefficient tests to determine factors potentially associated with undertreatment of nonpain symptoms.
  
  
  RESULTS
  The cross-sectional sample included 303 older nursing home hospice/palliative care patients from among the 33,413 (weighted) patients from the 2004 NNHS. Overall, most of the patients were white (91.4% [277/303]) and female (71.9% [218/303]), and nearly half were aged >or=85 years (47.9% [145/303]). One or more nonpain symptoms occurred in 82 patients (22.0% weighted). The most common nonpain symptoms (weighted percentages) were constipation/fecal impaction in 35 patients (8.8%), cough in 34 patients (9.2%), nausea/vomiting in 26 patients (7.2%), fever in 11 patients (3.1%), and diarrhea in 9 patients (1.9%). Medication undertreatment of any of the above symptoms was seen in 47 of 82 patients (60.0% weighted), ranging from a low of 26.4% for constipation/ fecal impaction to a high of 88.0% for nausea/vomiting. Undertreated patients had significantly more problems with bed mobility (n [weighted %], 43 [92.3%] vs 21 [67.2%]; P = 0.013), mood (21 [44.7%] vs 7 [19.7%]; P = 0.017), and pressure ulcers (12 [25.7%] vs 2 [6.1%]; P = 0.023) than did treated patients. The undertreated group also had a significantly greater number of secondary diagnoses (weighted mean [SD], 6.5 [0.7] vs 5.2 [0.5]; P = 0.004) but had a shorter length of stay in hospice/ palliative care (120.5 [20.1] vs 219.4 [51.8] days; P < 0.001) or in the nursing home (552.0 [96.5] vs 1285.4 [268.3] days; P = 0.001).
  
  
  CONCLUSIONS
  The prevalence of nonpain symptoms was low (22.0% weighted) in older nursing home hospice/palliative care patients. However, medication undertreatment of nonpain symptoms was seen in more than half of these patients. Future quality-improvement initiatives for nursing home hospice/palliative care patients are needed beyond the management of pain symptoms.
authors.affiliation: Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.
authors.forename: Keri L
authors.initials: KL
authors.lastname: Rodriguez
authors.forename: Joseph T
authors.initials: JT
authors.lastname: Hanlon
authors.forename: Subashan
authors.initials: S
authors.lastname: Perera
authors.forename: Emily J
authors.initials: EJ
authors.lastname: Jaffe
authors.forename: Mary Ann
authors.initials: MA
authors.lastname: Sevick
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D005260:Female; D006707:Homes for the Aged / Q000706:statistics & numerical data; D017051:Hospice Care / Q000379:methods / Q000592:standards*; D006801:Humans; D008297:Male; D009735:Nursing Homes / Q000706:statistics & numerical data*; D010166:Palliative Care / Q000379:methods / Q000592:standards*; D004364:Pharmaceutical Preparations / Q000008:administration & dosage*; D015995:Prevalence; D011787:Quality of Health Care / Q000706:statistics & numerical data; D014481:United States
chemical_list: D004364:Pharmaceutical Preparations