Green Tea, Fruit Extracts Touted as Potential Cancer Fighters

By Randy Dotinga, HealthDay Reporter - Fri Dec 7, 8:45 PM PST

THURSDAY, Dec. 6 (HealthDay News) -- A gel derived from black raspberries, a fruit beverage and old-fashioned green tea all hold potential promise as ways to treat or prevent different types of cancer, preliminary research suggests.

"Until now, foods have not been considered good treatments for chronic illness, especially tackling tumors," Greg Jardine, a biochemist at Dr. Red Nutraceuticals in Australia, said at a teleconference Thursday. In fact, "foods can be medicine," added Jardine, co-author of a manufacturer-funded study of a "punch" that appeared to reduce the growth of prostate cancer in mice.

In addition to Jardine's study, two others -- one with people and one with rats -- suggest that a black raspberry gel can reduce oral cancer lesions and green tea can prevent colorectal cancer.

The studies, which are all small and need further confirmation, were presented at the American Association for Cancer Research's Sixth Annual International Conference on Frontiers in Cancer Prevention Research, which runs through Dec. 8 in Philadelphia.

Researchers at Ohio State University and the University of Kentucky are using a gel made of extracts from black raspberries to treat oral lesions, which often begin as growths inside the mouth and threaten to turn into major tumors.

"About 36 percent will progress to oral squamous cell carcinoma, but, at this point, we don't have the molecular tools to determine which ones will go on to malignancy," said Dr. Susan Mallery, a professor in the Department of Oral Maxillofacial Surgery and Pathology at Ohio State University's College of Dentistry.

About 7,500 people in the United States die each year of oral cancer, according to American Cancer Society statistics, and 34,000 new cases are diagnosed annually.

The researchers assigned 30 patients -- 20 with precancerous lesions and 10 healthy patients -- to apply the gel several times a day. After six weeks of treatment, the grade of the lesions decreased in 35 percent of patients, while it stayed steady in 45 percent of patients and grew in 20 percent, Mallery said.

Patients whose tumors had progressed the least seemed to do the best after undergoing the gel treatment, Mallery said. None of the patients reported side effects.

Why does the gel appear to work? According to Mallery, the active agents appear to be "those chemicals that give it a very rich purple color." The study authors suspect that the chemicals may help "re-educate" tumor cells, reversing their march toward cancer.

In another study, Australian researchers -- funded by Dr. Red Nutraceuticals, the maker of an antioxidant-boosted beverage called "Blueberry Punch" -- gave the drink to mice with tumors that were considered equivalent to prostate cancer in humans.

The tumors were 25 percent smaller in eight mice that drank the punch for two weeks, compared to eight mice that did not drink the punch. Jardine said the next step is to figure out if the punch would have a beneficial effect in men. The punch, designed to be a health aid, is sold in Australia and in New Zealand, and is made of fruit concentrates and a variety of extracts, as well as tarragon, turmeric and ginger, he said.

In the third study, researchers from Rutgers University in New Jersey fed chemicals known as polyphenols from green tea to rats that had colorectal cancer. The polyphenols appeared to reduce the size of tumors by 45 percent, the study authors said.

It's not clear if the polyphenols would have a similar benefit in humans, and the equivalent amount of tea consumption in people would be hefty -- four to six cups a day, the researchers said.

Meat raises lung cancer risk, too, study finds

By Maggie Fox, Health and Science Editor - Mon Dec 10, 5:15 PM PST

A hamburger in a file photo. People who eat a lot of red meat and processed meats have a higher risk of several types of cancer, including lung cancer and colorectal cancer, U.S. researchers reported on Monday. (Lucy Nicholson/Reuters)

WASHINGTON (Reuters) - People who eat a lot of red meat and processed meats have a higher risk of several types of cancer, including lung cancer and colorectal cancer, U.S. researchers reported on Monday.

The work is the first big study to show a link between meat and lung cancer. It also shows that people who eat a lot of meat have a higher risk of liver and esophageal cancer and that men raise their risk of pancreatic cancer by eating red meat.

"A decrease in the consumption of red and processed meat could reduce the incidence of cancer at multiple sites," Dr. Amanda Cross and colleagues at the U.S. National Cancer Institute wrote in their report, published in the Public Library of Science journal PLoS Medicine.

The researchers studied 500,000 people aged 50 to 71 who took part in a diet and health study done in conjunction with the AARP, formerly the American Association for Retired Persons.

After eight years, 53,396 cases of cancer were diagnosed.

"Statistically significant elevated risks (ranging from 20 percent to 60 percent) were evident for esophageal, colorectal, liver, and lung cancer, comparing individuals in the highest with those in the lowest quintile of red meat intake," the researchers wrote.

The people in the top 20 percent of eating processed meat had a 20 percent higher risk of colorectal cancer -- mostly rectal cancer -- and a 16 percent higher risk for lung cancer.

"Furthermore, red meat intake was associated with an elevated risk for cancers of the esophagus and liver," the researchers wrote.

These differences held even when smoking was accounted for.

"Red meat intake was not associated with gastric or bladder cancer, leukemia, lymphoma, or melanoma," added the researchers, whose study is freely available on the Internet at http://medicine.plosjournals.org/perlserv/?request=get-document& doi=10.1371/journal.pmed.0040325.

Red meat was defined as all types of beef, pork and lamb. Processed meat included bacon, red meat sausage, poultry sausage, luncheon meats, cold cuts, ham and most types of hot dogs including turkey dogs.

Meats can cause cancer by several routes, the researchers noted. "For example, they are both sources of saturated fat and iron, which have independently been associated with carcinogenesis," the researchers wrote.

Meat is also a source of several chemicals known to cause DNA mutations, including N-nitroso compounds (NOCs), heterocyclic amines (HCAs) and polycyclic aromatic hydrocarbons (PAHs).

Jeanine Genkinger of Georgetown University in Washington, D.C., and Anita Koushik of the University of Montreal said the findings fit in with other research.

"Meat consumption in relation to cancer risk has been reported in over a hundred epidemiological studies from many countries with diverse diets," they wrote in a commentary.

(Reporting by Maggie Fox; Editing by Julie Steenhuysen and Eric Beech)

Mutated Suppressor Gene Leads to a Type of Breast Cancer

By Carolyn Colwell, HealthDay Reporter - Mon Dec 10, 8:43 PM PST

MONDAY, Dec. 10 (HealthDay News) -- Scientists believe they've discovered how mutations in the cancer-susceptibility gene called BRCA1 can cause some breast cancers.

Basal-like breast cancers (BBCs) represent 10 percent to 20 percent of all breast cancers. BBCs generally have a poor prognosis, are difficult to treat, and are almost always associated with hereditary mutations in the BRCA1 gene, the researchers said.

The researchers found that inherited mutations in the BRCA1 gene deactivate another gene known as PTEN, which helps to suppress tumors. This suppressor gene is deactivated by the mutated BRCA1 gene's failure to repair a break in the PTEN gene's DNA, the scientists said.

The loss of the PTEN gene's tumor-suppressing ability allows increased cell activity that increases tumor growth. That action "can convert the cell from being a well-behaving entity to a bad citizen," said study co-author Dr. Ramon Parsons, a professor of medicine and pathology at Columbia University's College of Physicians and Surgeons.

"This is a very important finding, because this type of breast cancer doesn't have a type of therapy targeted at this point," Parsons said. Basal-like or triple negative tumors don't have receptors for the hormones estrogen and progesterone or the protein HER2, which most breast cancer therapies target, he said. Drugs that can target the pathway related to mutated PTEN genes "may be a way we can improve the survival for women with these basal-like tumors," he added.

Parsons said several pharmaceutical companies already are developing drugs to do just that.

"My guess is there's going to be a huge bolus of clinical trials with these drugs in the next couple of years," he said. "Since there's going to be such a large variety of compounds, my hunch is one or more will be effective." By effective, Parson said he doesn't mean one of them will offer a cure, but the drugs in the right combination could lead to a cure.

The development of these drugs also may be important for other types of cancers that can involve deactivating the PTEN gene, Parsons said.

The study results were published online Dec. 9 in the journal Nature Genetics.

Parsons said the discovery of the PTEN deactivation "was kind of a real long-term detective story." For 10 years, researchers have been trying to understand how the mutation in the BRCA1 gene can cause breast cancer. Instead of using traditional gene-sequencing techniques, Parsons and his colleagues looked for physical breaks in the PTEN gene. "PTEN is actually physically broken in half, we estimate, in 30 to more than 50 percent of the BRCA1 tumors," he said.

Dr. Jeffrey Weitzel, an associate professor of medical oncology at the City of Hope Comprehensive Cancer Center in Duarte, Calif., said the study by Parsons' team "helps us understand what's under-appreciated in the complex nature of tumor changes."

Andrew Godwin, director of the clinical molecular genetics laboratory at the Fox Chase Cancer Center in Philadelphia, added: "As we move towards personalized health care [and] medicine, identifying the cadre of genetic defects in a given breast tumor will likely influence how that patient is ultimately treated."

Most Medicare Recipients Ignore Colorectal Cancer Screening

By Ed Edelson, HealthDay Reporter - Mon Dec 10, 8:43 PM PST

MONDAY, Dec. 10 (HealthDay News) -- The majority of Americans in Medicare aren't getting screened for colorectal cancer, a major killer, even though the screening is free, a new study finds.

In fact, the percentage of enrollees in Medicare, the federal health insurance program for older Americans, getting screening tests such as colonoscopies has declined since the program began paying for them, the study said.

An assessment of 153,469 Medicare members identified in 1998 found that 29.2 percent of them were screened for colorectal cancer between 1991 and 1997, when Medicare began paying for screening tests. Only 25.4 were screened between 1998 and 2004, after screening was covered by Medicare, the study found.

Failure to get those tests costs lives, said study author Dr. Gregory Cooper, interim chief of gastroenterology at University Hospitals Case Medical Center in Cleveland.

"We know that the survival curve is strongly related to the state at which the cancer is diagnosed," he said. "For the mostly fairly healthy people in this cohort, early detection would bring a benefit."

Colorectal cancer is the third leading cause of cancer deaths in the United States. The American Cancer Society estimates that 147,000 new cases will be diagnosed in this country this year, with 57,000 deaths.

The new study, published online Dec. 10 in the journal Cancer, looked at a variety of screening tests. They included barium enemas, methods of detecting fecal blood, and colonoscopy, which is regarded as the most definitive test. By detecting polyps before they become malignant, a colonoscopy can help prevent cancer. Colonoscopies are recommended every 10 years for adults, starting at age 50.

The public, doctors and the Medicare system itself are all responsible in different ways for failures to screen for colorectal cancer, said Dr. Otis W. Brawley, chief medical officer of the American Cancer Society.

"Many physicians do not have a preventive mindset as yet," Brawley said. "People go to the doctor overwhelmingly because they are hurt and have a medical problem. No one goes to the doctor with a preventive intention."

Medicare does allow for an initial patient visit with a new doctor, "but it is designed to be all discussion, not for physical examinations," Brawley said. "During that discussion, they [patients] may be told that they have this benefit, but it is up to them to ask for it."

And there's something about colorectal cancer that makes people shy away from discussing it, Brawley said.

"Prostate cancer screening has not been shown to save lives, and people ask for it," he said. "Colon cancer screening has been shown to save lives, and people don't ask for it."

The ultimate responsibility lies with the patient, Cooper said. "If the physician doesn't bring it up, often the patient has to remind them," he said.

The new study findings are troubling, in light of research published in the Journal of the American Medical Association last December that found that since Medicare began paying for colon-cancer screenings, more patients' tumors are being diagnosed at an early, more curable stage.

The new findings also don't reflect a federal report released in March that found that national goals for colorectal cancer screenings are on target with the Healthy People 2010 initiative.

Love in the World of Alzheimer's

By E.J. Mundell, HealthDay Reporter - Mon Dec 10, 8:44 PM PST

MONDAY, Dec. 10 (HealthDay News) -- Even when Alzheimer's disease robs them of the life they once knew, some people can still find love among the ruins.

And in most cases -- as highlighted by recent news on retired Supreme Court Judge Sandra Day O'Connor -- the spouse or child of the Alzheimer's patient grows to understand and accept the new relationship, experts say.

O'Connor's Alzheimer's-stricken husband John, 77, has found companionship with a woman in the nursing home where he now resides, according to recent news reports. The two spend time together, holding hands, even when Justice O'Connor is nearby, the reports said.

This type of relationship was also the focus of the recent film Away From Her, starring Julie Christie as a woman with Alzheimer's who gradually forgets her husband and forms a new bond with a fellow nursing home resident. Her husband gradually comes to accept the relationship, understanding that it gives his wife comfort and stability amid the confusion that Alzheimer's can bring.

Such an emotional journey is common for caregivers confronted with such a situation, said Donna Schempp, program director of the national advocacy group Family Caregiver Alliance, based in San Francisco.

Most spouses or children of people with Alzheimer's "have responded very positively" to these newfound relationships, which are not uncommon, she said. "Because if the person does not know who you are anymore, it's not a rejection," Schempp explained.

"And in the end, we want the person that we care about to be happy," she said. "Just behaviorally, and in other ways, they are going to be better if they are feeling cared about and nurtured, loved and appreciated."

Experts in Alzheimer's disease say many people are surprised to learn that patients continue to have rich emotional lives.

"People still have their personhood at the core of who they are," said Dr. Peter Reed, senior director of programs at the Alzheimer's Association. "So the effects [of the disease] do not diminish the individual's need for social interaction, it doesn't diminish their need for dignity and meaning in their life."

Alzheimer's typically causes an individual to forget all but those they see near them regularly, he added. "So, people learn familiarity with the people around them," Reed said, and with that, "they become more comfortable."

The persistence of emotional needs after declines in memory makes some sense on a neurological level, another expert said.

"The Alzheimer's pathology starts in the memory and learning areas of the brain and then spreads," said Dr. Gary Kennedy, director of geriatric psychiatry at the Montefiore Medical Center in New York City. "The direction and extent of the spread varies tremendously from one person to the next. For some, their thinking and memory are largely gone, but their emotional expressiveness may be relatively intact."

Emotions may often be less guarded as Alzheimer's advances, with people showing less reticence to express affection, he added. "In some instances, emotional expressiveness may be augmented by the illness -- in other words, inhibitions may be taken away," Kennedy said.

Sexuality can enter the mix as well, and that's where relationships between Alzheimer's-affected patients get more complicated, Schempp said.

Depending on a person' level of cognition, "there's a kind of moral-ethical issue as to when someone can be consensually involved," she noted. "Some nursing homes just categorically say no, other nursing homes work on it on a case-by-case basis. Some nursing homes say no because the families object, and some nursing homes say yes because the families are OK with it."

Schempp said that, in her experience, the adult children of Alzheimer's patients typically have a tougher time accepting this new love than spouses do.

"It's harder for the children -- it's an abandonment, and they feel committed to both parents. How could my mother or father do this?" she said.

That's where educating yourself about the progression of the disease really becomes valuable, she said.

"In our experience, so many people know so little about dementia and yet they are caring for someone with dementia," Schempp said. "It just goes back to the incredible need that we have for people to get informed. It takes a lot of information to really be able to navigate how you care for someone with dementia."

In the end, allowing a loved one to find his or her own peace amid the ravages of Alzheimer's may be the best course to take, Kennedy said.

"As Sandra Day O'Connor and others say, they are just thankful that there is a moment of happiness that comes into their loved one's life," he said.

Medication Errors

• Unsafe medication-use practice habits place patients in danger of an infection. To protect patients, remember the following:
  • Place a sterile cap on the end of a reusable I.V. administration set that has been removed from a primary administration set, saline lock, or I.V. catheter hub that will be used again.
  • Properly disinfect the port when accessing needle-free valves on I.V. sets.
  • Always follow aseptic technique.
  • Avoid “looping” - attaching the exposed end of the I.V. tubing to a port on the same tubing.
  • Prohibit unlicensed staff from connecting/disconnecting any medical tubing.
  • Establish policies and assess compliance.
• It was recently reported that an order for PRANDIN (repaglinide) was misread as AVANDIA (rosiglitazone). Both are used to treat diabetes, but the drugs act in different ways. As a precaution, encourage prescribers to include generic names with handwritten orders to help staff differentiate these look-alike brand names.

The Pharmacologic Management of Pain

SUSAN M. HASENAU PhD, RN, CNNP
JANNA C. ROOP PhD, RN, CHPN
APRIL HAZARD VALLERAND PhD, RN, FAAN

A Home Care Requisite:

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Pain management remains as one of the most important issues in healthcare today. Unrelieved pain can affect the healing process, increase stress, and result in general physical and psychological decline in the sufferer ( McCaffery & Pasero, 1999 ). Home care nurses play a critical role in the assessment and management of pain because economically driven changes in healthcare delivery have placed more patients in the home setting than in acute care settings ( Vallerand, Anthony, & Saunders, 2005 ). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2004) has mandated that healthcare organizations provide adequate interventions to assess and treat pain, and many institutions have responded by identifying pain assessment as a “fifth vital sign.” These efforts have aided in the improvement of pain management, yet pain remains underestimated and inadequately treated ( Vallerand, 2003 ).

What is pain? The “gold standard definition of pain” was developed by McCaffery in 1968 : “Pain is whatever the experiencing person says it is, existing whenever he says it does” (p. 65). Although this definition is widely accepted by home care nurses, data suggest that clinicians are inconsistent in their application of this knowledge. In a study by Vallerand, Hasenau, and Templin (2004) , surveyed nurses reported awareness of McCaffery's definition of pain and could state that pain is what the patient says it is, but further investigation revealed some troubling inconsistencies. Nurses were given 2 vignettes of patients who reported pain scores of 8 on a scale of 1 to 10, with 10 being the worst pain ( Vallerand et al., 2004 ). In the first vignette, the patient was quiet and grimacing, and in the second vignette, the patient was smiling and talking. The survey showed that 91% of the nurses believed the patient's report of pain in the first instance, whereas only 81% believed the smiling patient's report of pain, suggesting that nurses still are reluctant to accept the patient's report of pain in some circumstances.

Pain Assessment

Comprehensive assessment is the foundation for successful pain control ( American Pain Society, 2003 ). Although multiple factors may contribute to inadequate pain management, consistency in assessment of pain and the patient's response to interventions and proper documentation of these findings are fundamental in pain management.

A comprehensive pain assessment is an essential first step. Multiple rubrics exist for assessing pain, and multidimensional tools are available ( Table 1 ). We believe that the tool is not as important as the thoroughness of the examiner and the subsequent documentation. Lynch (2001) offers 1 framework, the mnemonic PAINED, as a guide for pain assessment:

Table 1. Resources for Pain Assessment and Treatment

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* P lace: Location of the pain

* A mount of pain: Intensity, duration, and pattern of the pain

* I ntensifiers: What makes the pain worse?

* N ullifiers: What makes the pain better?

* E ffects: Responses to interventions/medications as well as effects of the pain on daily activities and quality of life. This includes the current pain medications the patient is using, how often they are used, and how effective they are in managing the pain.

* D escription: Quality of the pain or type of pain felt (e.g., burning, stabbing, shooting, dull, aching)

The assessment should include not only any pain incurred at the time of the assessment, but also any pain experienced within the recent period or any pain experience that interferes with normal function and activities. This aspect of the assessment is most appropriate for the home care nurse because improving or maintaining adequate function in the home often is the desired goal of care. A simple question such as “What does the pain keep you from doing?” can provide information about the effect of pain on the patient's activities, as well as what activities are meaningful for that individual patient. This information also may direct the type and focus of the interventions for pain management. Assessment of pain should be an ongoing activity to assess changes in the pain experience and new sources of pain.

Several tools are available that assist in the assessment of pain. These tools maintain the patient's place as the primary source of information regarding pain, but they also help quantify the data and afford a measure of consistency among caregivers. The selected tool should be appropriate for the individual patient's age and culture. For the amount or intensity of pain, a numeric scale of 0 to 10 is a common and simple means of consistent assessment that adapts well to home care ( Mercadante, 1999 ). The British Pain Society publishes the numeric pain scale in 17 languages on their Web site ( http://www.britishpainsociety.org/pain_scales.html ). The Outcome and Assessment Information Set (OASIS) from the U.S. Department of Health and Human Services provides a uniform external comparative data set for measuring patient outcomes ( Stadt & Molare, 2005 ).

A thorough assessment will provide a basis for the choice of treatment or treatments of the pain. Home care nurses must be knowledgeable about pain management principles so that they can effectively advocate for adequate pain control ( Vallerand et al., 2004 ).

Pharmacologic Management of Pain

Although home care nurses encounter many different types of pain, the basic pharmacologic management of most pain types is remarkably similar. As an initial guide, many practitioners refer to the World Health Organization (WHO) 3-Step Analgesic Ladder ( WHO, 1996 ) ( Figure 1 ). This guideline was developed originally to guide practitioners caring for patients with cancer pain, but the same principles can be applied to patients with many types of pain.

Figure 1. World Health Organization (WHO) three-step analgesic ladder. Developed by WHO and available at: http://www.whoint/cancer/palliative/painladder/en/ .

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The WHO 3-Step Analgesic Ladder bases the types of medication used primarily on the intensity of pain. The first level addresses the use of nonopioid analgesics (acetaminophen and nonsteroidal antiinflammatory drugs [NSAIDS]) and possibly adjuvant analgesics for the treatment of mild pain (levels 1–4 on the 0-to-10 scale). Level 2 on the ladder suggests adding opioids for moderate pain (levels 5–6 on the 0-to-10 scale) or a combination of opioids and those analgesics already suggested or used for mild pain. At the third level, for severe pain of 7 or greater on the 0-to-10 scale, strong opioids are used, with nonopioids and adjuvant analgesics added as needed. The following section discusses agents to be used at each level of the analgesic ladder ( WHO, 1996 ).

Nonopioid Analgesics

At the first level of the analgesic ladder, pain is mild and usually controlled with nonopioid analgesics. The choices available include acetaminophen and NSAIDs. Acetaminophen often is chosen because it has a good side effect profile. Most patients can take acetaminophen without experiencing side effects. The biggest concern with acetaminophen is the dose limitation. Doses exceeding 4,000 mg/day are not recommended, and for patients with decreased renal or hepatic function and those with harmful alcohol use, doses should be limited to 2,000 mg/day to prevent renal and hepatic effects ( Deglin & Vallerand, 2005 ; Ferrell et al., 2002 ). Because acetaminophen is found in many over-the-counter medications, the patient must be cautioned not to exceed the total amount recommended. Patients often are unaware that there is acetaminophen in the products they may take for colds, heartburn, and other pain problems.

The choice between acetaminophen and a NSAID should be made according to the type of pain and the patient's history. For pain that has an inflammatory component, such as sprains, postoperative pain, and bone pain, NSAIDs tend to be more effective. Acetaminophen has no antiinflammatory properties and is therefore not as effective for pain with inflammation ( Deglin & Vallerand, 2005 ). Although NSAIDs may be more effective than acetaminophen for analgesia, they also have more side effects, primarily involving in the gastrointestinal system. The use of NSAIDs may upset the stomach and cause ulcers and bleeding. This may be minimized by taking the NSAID with food or milk. Patients also should be advised to stay in an upright position for 20 minutes after NSAID administration to minimize regurgitation. Also, NSAIDs may be taken with antacids, or histamine2 receptor antagonists such as cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid), or ranitidine (Zantac). Proton pump inhibitors such as omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium) also may help to prevent adverse effects ( Ferrell et al., 2002 ).

Bleeding is of particular concern with NSAIDs because NSAIDS prolong the patient's bleeding time. The duration of this effect varies with each NSAID, from minimal to 10 days. It is helpful for the nurse to be aware of the duration of this effect because if the patient is planning to have surgery, he or she may need to stop the NSAID before the surgical procedure.

Opioid Analgesics

The second level of the WHO 3-Step Analgesic ladder addresses moderate pain, or pain of 5 or 6 on the 0-to-10 scale. A pain level of 5 or greater has been shown to impair function ( Serlin, Mendoza, Nakamura, Edwards, & Cleeland, 1995 ). Therefore, a stronger analgesic should be considered. Analgesics at the second level of the ladder include opioid analgesics for moderate pain, often in combination with acetaminophen, aspirin, or ibuprofen including propoxyphene (Darvon, Darvocet), codeine, tramadol (Ultram, Ultracet), hydrocodone (Vicodin, Lortab, Lorcet, Norco, Vicoprofen), or oxycodone (Percocet, Percodan, Tylox, Combunox). The dosage of these drugs is limited by the nonopioid analgesic ingredient, such as acetaminophen or ibuprofen. In addition, propoxyphene has a toxic metabolite that accumulates with repeated dosing and may lead to seizures. Propoxyphene is not recommended for elderly patients or those with renal impairment ( American Pain Society, 2003 ).

At level three of the 3-Step Analgesic Ladder, severe pain of 7 or greater on a 0-to-10 scale is treated with opioid analgesics for severe pain. The analgesics at this level include morphine (MSIR, MS Contin, Oramorph, Kadian, Avinza), hydromorphone (Dilaudid), oxycodone (Roxicodone, OxyIR, OxyFAST, OxyContin), fentanyl (Sublimaze, Duragesic, Actiq), and methadone. These opioid analgesics are available in many forms, which can be administered by different routes. They vary in onset and duration.

Opioid analgesics at both the second and third levels may be given concurrently with nonopioid analgesics. Differences in the mechanism of action between opioids and nonopioids allow pain to be treated simultaneously at different receptor sites. Concurrent administration of nonopioids also may decrease the amount of opioid required to control the pain ( Deglin & Vallerand, 2005 ).

Adjuvant Analgesics

Adjuvants are drugs that may not be considered analgesics based on their mechanism of action, but have analgesic effects in certain pain conditions ( Foley, 2006 ). For example, neuropathic pain characterized by burning or lancinating pain may require the use of tricyclic antidepressants or anticonvulsants. Corticosteroids may be useful for the treatment of inflammatory pain, and benzodiazepines and muscle relaxants can be helpful in treating pain associated with muscle spasm. Adjuvants may be added at any level of the WHO 3-Step Analgesic Ladder based on the type of pain the patient is experiencing. The use of adjuvants illustrates the need for a comprehensive assessment of the quality of pain to determine the need for these drugs.

Key Principles for Use of the WHO 3-Step Analgesic Ladder

Use of the WHO 3-Step Analgesic Ladder can be enhanced by the application of 5 key principles: by mouth, by the clock, by the ladder, for the individual, and attention to detail ( WHO, 1996 ). “By mouth” focuses on the use of the oral route for analgesic administration. The oral route is the preferred route and proves effective, even for strong analgesics such as morphine.

“By the clock” emphasizes that for persistent pain, analgesics should be taken at regular intervals and not “as needed.” Dosing as needed (PRN) requires the patient to make the decision that the pain is severe enough to take the medication, often allowing a higher level of pain to occur before the medication is taken. This delay often results in the need for a higher dose of medication to control the pain. Dosing at regular intervals around the clock prevents the pain from becoming severe and may require lower doses. In addition, doses should be scheduled to allow the patient to sleep through the night without waking up with an increase in pain.

“By the ladder” directs the clinician to use the WHO 3-Step Analgesic Ladder and the pain intensity to guide the prescription of analgesics. Unless the pain is severe, a nonopioid should be prescribed initially and adjusted to the maximum recommended dose before an opioid is used. An opioid, such as morphine, for moderate to severe pain should be added if the nonopioid no longer adequately relieves the pain. However, if the patient initially has severe pain, an analgesic for severe pain rather than a nonopioid from step 1 should be used.

“For the individual” addresses the variability in patient responses to analgesics. Factors such as pain severity, previous opioid exposure, age, and concurrent diseases may affect the patient's response to analgesics. Because individuals vary in their requirements for analgesics, each drug has a wide range of doses that may be effective for relieving pain in different patients. The underlying principle is that “the correct dose of an analgesic is the dose that relieves the pain. There are no standard opioid doses” ( Foley, 2006 , p. 2). In addition, opioid analgesics have no ceiling effect. The dose of an opioid can be increased as needed to control pain, unless there are unmanageable side effects. It is important to remember that doses should be increased by percentages (50–100%) rather than by predetermined milligrams. For example, a morphine dose of 5 mg could be reasonably increased to 7.5 or 10 mg, but a dose of 50 mg would need to be increased to 75 or 100 mg to achieve additional relief.

“Attention to detail” focuses on the importance of monitoring the patient's response to the analgesic regimen. Reassessment of pain at the peak of the analgesic allows the nurse to determine whether the medication is effective, whether a higher dose is needed, or whether side effects are present. The focus is on ensuring that the patient obtains the maximum benefit with as few adverse effects as possible ( Foley, 2006 ).

Studies have demonstrated that the WHO 3-Step Analgesic Ladder can provide relief to between 77% and 100% of advanced cancer patients with pain ( Foley, 2006 ). The principles from the WHO analgesics ladder also can assist the nurse in determining options for managing pain in other populations of patients.

Although successful pain management strategies have been available for decades, many lay people and clinicians alike cling to outdated and inaccurate ideas. Most healthcare curricula devote little or no time to pain management. Therefore, tradition rather than scientific evidence often guides professional practice ( Furrow, 2001 ; McDonald, Thomas, Livingston, & Severson, 2005 ). The home care nurse can be a valuable resource for educating patients, families, and other professionals on the interdisciplinary team. See Table 2 for more information about some of the most common misconceptions regarding pain.

Table 2. Misconceptions About Pain and Corrections

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The Role of Communication in Pain Management

Successful pain relief strategies rely on a partnership between the patient, family, doctor, nurse, and pharmacist. Communication among all members of the partnership is essential if good pain control is to be achieved. Unfortunately, with so many people involved, there are multiple places for breakdown. In the following sections, we offer suggestions for improving the communication among all the partners.

Communicating With the Patient and Family

Successful treatment of pain always starts with the patient and family, and a comprehensive baseline assessment of pain is the essential first step ( American Pain Society, 2003 ; Passik et al., 2004 ). Because pain is a subjective experience, the patient is the expert regarding his or her pain. The nurse must elicit the best possible understanding of the patient's experience to obtain a meaningful assessment, and the nurse must believe the patient's report of pain ( American Pain Society, 2003 ). Objective signs of pain are inadequate and unreliable assessment data. Both families and clinicians may be misled by the absence of objective signs such as changes in vital signs, facial grimacing, or a decrease in activity, yet patients can experience severe pain without showing any outward signs. Many patients, however, may not know how to talk about their pain or may be reluctant to do so. They also may have misguided or outdated ideas about pain and pain medicines, so the nurse should be prepared to educate both patients and families. It is particularly important that the patient and family understand a few key points:

* Pain can be and should be prevented . Patients and families often believe that it is important to “endure” the pain because people should not complain ( Furrow, 2001 ). They also may believe that they need to save the strong medicine (opioids) for “when the pain is really bad,” mistakenly thinking that if they start opioids too early, the medicine will not work “later, when I really need it.” Sometimes it helps to use an analogy. You would not wait until an infection is severe and taking over your whole body to treat it. You would want to treat it in its early stages. In the same way, you should treat pain early, before it gets severe. For sound physiologic reasons, it is much easier to prevent pain than to treat it after it has become severe. We have found it helpful to remind the patient that his or her job is to be a “reporter.” Many patients are reluctant to “complain.” Reframing complaining as “reporting” can help some patients feel easier about communicating their experience of pain.

* Chronic pain requires around-the-clock (ATC) dosing . Chronic pain, by definition, is long lasting. Because it can be expected to be present at all times, the goal is to maintain a steady plasma concentration of the medicine, and this is best achieved through ATC dosing ( American Pain Society, 2003 ). Nothing is gained by waiting for the medicine to wear off before the next dose is taken. In fact, allowing the medication to wear off complicates the treatment of pain and often requires higher doses to get the pain back under control ( American Pain Society, 2003 ).

* ATC dosing should be accompanied by a plan for rescue dosing . Around-the-clock dosing is designed to maintain a steady plasma concentration, but there are times when the pain may “break through” that steady concentration. Activity, fatigue, and painful treatments such as dressing changes are examples of stimuli that cause breakthrough pain. There must be a plan for rescue dosing (i.e., to use a short-acting medicine). A patient receiving a long-acting form of an opioid typically requires 10% to 20% of that opioid's 24-hour total as a rescue dose. For example, the patient takes 30 mg of MS Contin every 12 hours. Her 24-hour dose is 60 mg (30 mg × 2 = 60 mg). An appropriate rescue dose would be 6 to 12 mg of short-acting morphine every 3 hours as needed.

* Side effects usually are transient and can be treated . Nausea, vomiting, and oversedation are troubling for patients starting to receive opioids and their families, but they typically last only a few days. For those few days, antiemetics and mild stimulants such as caffeine can be helpful. Some clinicians routinely prescribe an antiemetic for the first 48 hours of opioid therapy, then taper it as tolerated ( American Pain Society, 2003 ). It should be kept in mind that patients who have experienced a long period of unrelieved pain may be exhausted when the pain is finally relieved. Such patients may need to sleep more than usual for a few days to make up for the sleep lost when they were in pain. Continuing the analgesics during this time is essential to maintaining pain management.

* Constipation must be prevented . Unlike nausea, vomiting, and sedation, constipation often continues to be a side effect for as long as the patient is receiving opioids. It must be anticipated and prevented. In addition to all the strategies used to treat constipation (more fiber, more fluids, more activity), a patient receiving opioids will require a stimulant laxative, such as senna. The expected slowing of peristalsis with an opioid must be counteracted with a stimulant.

Communication With Other Members of the Healthcare Team

The healthcare professional who has the most contact with the patient in his or her home environment will most likely be the home care nurse. One of the most important tasks for the nurse is to make the pain visible to other members of the interdisciplinary team ( Wilke et al., 2001 ). The most effective way to achieve this aim is through thorough documentation and efficient oral communication. Passik et al. (2004) developed the Pain Assessment and Documentation Tool. It was designed for physician's to use to document pain assessment, the treatment plan, and outcomes, but it also is appropriate for nursing. Passik et al. (2004) suggested that documentation should include 4 broad categories, the “4 A's” of pain control: analgesia, activities of daily living, adverse events, and aberrant drug-related behaviors.

* Analgesia . What is the patient's pain level now? What is the best it has been in the past 24 hours? What is the worst it has been in the past 24 hours. What percentage of the past 24 hours has the patient spent in pain? How much and what kind of analgesia is the patient taking now? These all are factors that can be easily quantified for objective communication.

* Activities of daily living . How active has the patient been able to be in the past 24 hours? What percentage of the patient's normal activity has he or she achieved in the past 24 hours. And what has the pain kept the patient from doing? This last question will help to identify those activities that are most important to the patient.

* Adverse events . What adverse effects has the patient experienced in the past 24 hours? Sedation, nausea, vomiting, pruritis, and constipation are among the most common side effects of opioids. Confusion, hallucinations, and disturbing dreams are far less common adverse effects. Many clinicians are very concerned about causing respiratory depression, but Pasero, Portenoy, and McCaffery (1999) reported that the fears are exaggerated. Furthermore, respiratory depression is always preceded by sedation. This means that a patient who is awake and in pain is not at risk for respiratory depression if the dose is increased judiciously. A drug guide reference or the American Pain Society (2003) guidelines should be used to adjust the dosage if the analgesic is at its peak but the patient still has pain and has not experienced unmanageable side effects.

* Aberrant drug-related behaviors . Pain medications, like many other classes of medications including steroids, anticonvulsants, beta blockers, and other antihypertensives, can cause physical dependence ( American Pain Society, 2003 ). It is important that this physical dependence not be confused with addiction. Nevertheless, pain is a ubiquitous symptom, and people with addiction also may require pain medications. The home care nurse must assess for and document any aberrant drug-related behaviors. Adequate treatment will require consultation with a specialist for addictions and pain management. Additionally, documentation of the absence of aberrant drug-related behaviors is part of the documentation of a thorough assessment.

When the assessment indicates a change in the plan of care, the nurse should contact the physician. The nurse is well advised to have a planned suggestion in mind when the call is made and to base requests and suggestions on published professional guidelines. An excellent resource is Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (5th edition), available from the American Pain Society ( www.ampainsoc.org ). Clinicians unfamiliar with the most recent advances in pain management may be more willing to prescribe adequate pain medication if they know that their prescriptions are consistent with national interdisciplinary guidelines. It also is appropriate in this situation to ask the primary doctor for a referral to a physician specializing in palliative care because these physicians are experts in pain and symptom management.

Communicating With Pharmacists

Pharmacists also are important partners in the pain management plan of a patient at home, and like other professionals, they may have misconceptions about appropriate pain management. Patients have reported pharmacists chastising them for taking so much opioid because “you don't look like you're in pain.” Other patients have been given inaccurate counsel about pain control (you can't take a long- and short-acting opioid at the same time) or have had difficulties because the pharmacy has resisted stocking enough medication to allow for seamless refills.

In our experience, if a patient will be taking large doses of opioids, it can be very helpful for the home care nurse to call the pharmacist directly to collaborate on the plan of care. Communicating that the treatment plan includes thorough assessment using the 4 A's of pain control and interventions based on national guidelines can help to ease the pharmacist's concerns.

Implications for Home Care Nurses

Home care nurses play a pivotal role in the management of pain for their patients. Their skills in assessment and their promotion of communication between the patient, the caregiver, the prescribing professional, and other professional members of the team are crucial to high-quality patient care. An accurate, consistent, and comprehensive assessment provides the cornerstone of this process. Nurses who accept the patient's report of pain, have knowledge about basic pharmacologic management of pain, and promote communication among all members of the interdisciplinary team are powerful agents in the quest for optimal pain management.

DepoDur® Extended-Release Epidural Morphine What Perioperative Nurses Need to Know

Epidural morphine as a single bolus dose has demonstrated analgesia that lasts up to 24 hours. Recent advances in drug delivery mechanisms have resulted in a formulation of morphine, DepoDur®, which is a lipid-encapsulated extended-release epidural morphine that provides up to 48 hours of analgesia. The efficacy of DepoDur has been established after hip arthroplasty, lower abdominal surgery involving an incision below the umbilicus, and elective cesarean section delivery. The unique characteristics of DepoDur dictate that clinicians must be aware of the benefits and risks, and facilities must have a comprehensive system to allow for the safe administration of DepoDur. This article provides information on this novel drug delivery system, reviews research findings reported in the literature, and describes the relational collaboration system designed and implemented at Duke University Health System for safe patient care of DepoDur recipients.

DRUG UPDATES: Drug News

(from Drug News Weekly)

• The FDA has approved the following new indication:
  • Diovan (valsartan) - for the treatment of high blood pressure in children and adolescents 6 to 16 years of age.
• The FDA has approved Triesence (triamcinolone acetonide) 40 mg/mL injectable suspension, a synthetic corticosteroid for visualization during vitrectomy and treatment of sympathetic ophthalmia, temporal arteritis, uveitis, and ocular inflammatory conditions unresponsive to topical corticosteroids.
• Roche Pharmaceuticals has discontinued the production of Roferon-A (interferon alfa-2a, recombinant). This action is related to the product's life cycle, not to any safety or efficacy concerns.
• Manufacturers have updated the prescribing information for desmopressin acetate (DDAVP, DDAVP Nasal Spray, DDAVP Rhinal Tube, DDVP, Minirin, and Stimate Nasal Spray). Patients taking desmopressin and children treated with intranasal formulations for primary nocturnal enuresis (PNE) are at risk for developing severe hyponatremia, resulting in seizures and death. Thus, desmopressin intranasal formulations are no longer indicated for PNE treatment and should not be used in hyponatremic patients or patients with a history of hyponatremia. All formulations should be used with caution in patients at risk for water intoxication with hyponatremia.

Barriers in Providing Psychosocial Support for Patients With Cancer

Mari Botti RN, RM, BN, PhD, MRCNA
Ruth Endacott RN, DipN, MA, PhD
Rosemary Watts RN, RM, Crit Care Cert, BN, Grad Dip in Adv
Julie Cairns RN, BN, Cert Cancer Nursing, Master of Bioe
Katrina Lewis RN
Amanda Kenny RN, RM, PhD

There is sound evidence to support the notion that the provision of effective psychosocial care improves the outcomes of patients with cancer. Central to the implementation of this care is that health professionals have the necessary communication and assessment skills. This study aimed to identify key issues related to providing effective psychosocial care for adult patients admitted with hematological cancer, as perceived by registered nurses with 3 or more years of clinical experience. An exploratory qualitative design was used for this study. Two focus group interviews were conducted with 15 experienced cancer nurses. The provision of psychosocial care for patients with cancer is a dynamic process that has a professional and personal impact on the nurse. The 5 analytic themes to emerge from the data were as follows: When is it a good time to talk? Building relationships; Being drawn into the emotional world; Providing support throughout the patient's journey; and Breakdown in communication processes. The findings from this study indicate an urgent need to develop a framework to provide nurses with both skill development and ongoing support in order to improve nurses' ability to integrate psychosocial aspects of care and optimize patient outcomes.

The Bathing Of Older Adults with Dementia

Joanne Rader MN, RN
Ann Louise Barrick PhD
Beverly Hoeffer DNSc, RN, FAAN
Philip D. Sloane MD, MPH
Darlene McKenzie PhD, RN
Karen Amann Talerico PhD, RN
Johanna Uriri Glover PhD, RN

OVERVIEW: Older adults who need assistance with bathing often find the activity to be both physically and emotionally demanding, as do their caregivers. Research has identified several contributing factors, including pain; fatigue and weakness; confusion; anxiety resulting from being naked in front of strangers, being afraid of falling, and being in a noisy or unfamiliar place; and discomfort from cold or drafty bathing areas or harsh water sprays. The authors of this article make the case for the elimination of forced bathing. Research supports this change in philosophy and practice, whereby bathing is not a task to be performed but rather a human interaction. Inexpensive, practical, and evidence-based alternatives are discussed.

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Bathing independently, one of the most personal and complex of the activities of daily living, requires significant cognitive and physical abilities, including dexterity, flexibility, balance, strength, and coordination. 1 To the person who requires assistance in bathing, the change can represent a decline in well-being and cause emotional and physical discomfort. 2 Indeed, caregivers and recipients alike, in both homes and institutions, often say assisted bathing is difficult and distressing.

A significant number of older adults have difficulty or need assistance with bathing. In one study of 626 community-dwelling older adults ages 73 years and over, 195 (31%) met the criteria for “bathing disability” (those “requiring assistance or having difficulty washing or drying the whole body”). 1 And according to a report issued by the National Center for Health Statistics, Nursing Homes, 1977–1999: What Has Changed, What Has Not? at least 90% of nursing home residents need some assistance with bathing. 3

FIGURE. Older adults resist assisted bathing for a number of reasons: it’s physically painful, it’s embarrassing, or it represents a loss of autonomy. Research has shown that giving older adults a choice about when and how to bathe, as well as the opportunity to bathe themselves, when possible, promotes success. Pictured above, Isaac Donner, age 100, washes his face; on the door is a photograph of him as a young man. Photograph taken from Aging in America: The Years Ahead, by photographer Ed Kashi and writer Julie Winokur.

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Our experience, supported by other research, has shown several factors contributing to bathing difficulties, including 1, 4

* pain from musculoskeletal conditions, such as arthritis in the toes, knees, and neck.

* fatigue and weakness caused by frailty and other medical conditions.

* fear and misunderstanding because of memory loss, cognitive decline, previous negative experience, or a combination of these.

* anxiety and apprehension because of such factors as fear of falling, being transported to a noisy area, being naked in front of strangers, and being hoisted high in the air (as on a Hoyer lift).

* discomfort from cold, drafty air or harsh shower sprays.

In our series of studies we’ve found nurses to be critical in improving the bathing experience for older adults. In fact, our recent clinical trial tested two person-centered bathing methods (methods tailored to the needs and comfort level of the person being bathed) aimed at reducing discomfort, agitation, and aggression in nursing home residents with dementia, and we found nurses to play a central role. 5 And with the growth of the geriatric population, particularly those 85 years old and older, nurses will increasingly need to assist with bathing.

Drawing on more than a dozen years of clinical work and research, we suggest the elimination of forced bathing in homes and institutions, a practice we consider on a par with restraint use. Both practices generally went unchallenged and were once thought to be adequate standards of care—some practitioners may still think so—despite the frequent protests and physical resistance of those being restrained or forced to bathe. But solid evidence now disputes the safety and necessity of both of these practices. Bathing people routinely against their wishes—“for their own good”—should become part of nursing history, as person-centered care becomes the norm.

We believe that to bathe people against their wishes, unless there is an acute, compelling health reason to do so, constitutes abuse. We hope to encourage nurses to think creatively about how to individualize care and inform and support those who provide direct care.

CURRENT BATHING PRACTICES

In the home.

Many community-dwelling older adults adapt their bathing methods as they age or become ill, but those who have dementia and those near the end of life usually require assistance and can be particularly challenging. And trying to bathe a person who is very frail, as people often are at the end of life, in a traditional shower or tub can be physically exhausting or impossible.

In the hospital.

Since hospital stays have decreased in length and patient acuity has increased, bathing has been less of a focus in facilities. Some acute care facilities are using premoistened, individually wrapped, no-rinse, disposable cloths that can be heated in a microwave oven. Bathing is often delegated to bedside caregivers, with very little professional oversight. Nurses, with their many competing priorities, may not be aware of problems when they arise or are poorly prepared to deal with them.

In the long-term care facility.

Most nursing homes in the United States schedule routine showers or tub baths for residents at least twice per week. The bathing method and schedule are usually based on the facility’s routine and not on the residents’ preferences. The vast majority are showered. 6 In our experience, we’ve found that the shower or tub rooms are often cold and noisy, with tubs and shower equipment that may be unfamiliar or look intimidating. Staff have reported to us that they feel rushed to get residents up and showered before breakfast. A high proportion of residents have cognitive impairment and may be easily confused or made anxious by being bathed.

Pain during bathing is also common in people with dementia. One study found that 88% of 17 subjects had a history of arthritis, osteoporosis, or joint pain. 7 The movements required during bathing (such as transferring out of bed into a shower chair and raising and lowering the arms and legs) can cause pain, fear, and discomfort. In our experience it’s not uncommon to hear residents’ screams and profanities from the shower or tub room, and many staff and residents’ families have told us that they believe such behaviors and other signs of discomfort during bathing are inevitable. Caregivers tell us that they worry about ensuring hygiene in a safe and comfortable way. It’s stressful to residents and professional and family caregivers to give care that results in pain, exhaustion, and agitated reactions such as hitting, biting, crying, and screaming.

CLINICAL TRIAL: BATHING PEOPLE WITH DEMENTIA

The good news is that the stressors associated with assisted bathing can be modified. Bathing can be pleasant and without harm to older adults in the home, the hospital, and long-term care facility.

We recently worked with other members of a research team to study two bathing methods in nursing home residents with dementia. 5 We discovered several solutions that benefited both caregivers and residents. (Although we studied people with dementia, most of our ideas and principles are relevant to all older adults who require bathing assistance.) The study was a randomized, controlled trial with two experimental groups and a usual-care control group, conducted in nine nursing homes in Oregon and six in North Carolina. Two interventions were evaluated: person-centered showering and towel bathing in bed. We worked with 73 residents (69 completed the study) and 37 certified nursing assistants (CNAs). To be included in the study, residents had to be age 55 or older, have a diagnosis of Alzheimer disease or other dementia, have moderate or severe cognitive impairment, be able to be showered, and demonstrate agitation or aggression during bathing.

The focus of both bathing methods was the resident’s comfort and preferences. Participating CNAs and nurses were encouraged to view resistance and other behavioral symptoms as expressions of unmet needs. They were taught to employ appropriate communication techniques, apply problem-solving approaches to identify causes of and potential solutions for behavioral symptoms, and adapt the environment to the residents’ comfort and security.

Showering uses a wide variety of person-centered techniques, such as covering the resident with towels as much as possible during the shower, distracting the resident with food and interesting objects, using favorite soaps and no-rinse products, modifying the shower spray, and providing choices (such as whether hair is washed first, last, or not at all).

The towel bath, a person-centered, in-bed method adapted from the Totman technique in which the caregiver uses a large towel, one or two regular-size towels, washcloths, a bath blanket, no-rinse soap, and water. 8 Many nurses remember this procedure from obstetrics and hospital practice 30 years ago. 9

Of the 15 nursing homes participating in our study, five served as control and 10 as experimental homes. Recruited facilities were randomly assigned to three groups of five facilities each. One treatment group received the towel bath during the first intervention period and showering during the second period. The other treatment group received the same interventions in reverse order. In the control group, consent and data collection occurred as in the treatment groups, but no intervention took place. In the 10 treatment facilities, clinicians (a clinical nurse specialist in Oregon and a licensed psychologist in North Carolina) worked with participating CNAs to understand the causes of agitation and aggression and to develop an individualized bathing plan designed to address those causes. The clinician and CNAs worked together one or two days per week for four weeks with each resident in the study during each of the two intervention periods.

In conducting the interventions, the team learned the following:

Focusing on the person and the relationship rather than the task greatly reduces discomfort and behavioral symptoms. We found that caregivers assisting with bathing often felt rushed and frustrated, while residents felt a loss of control and even attacked. One of us (Rader) was showered in a nursing home during a preliminary study and found the accepted practice to be cold and distressing. Taking the resident’s point of view, we realized that the behaviors we had previously labeled “aggressive” or “resistive” were often defensive actions residents took when feeling threatened and anxious. (For more information, see “Making Sense of Aggressive/Protective Behaviors in Persons with Dementia” by Talerico and Evans in the October–December 2000 issue of Alzheimer’s Care Quarterly. )

We found that by shifting the focus to getting to know the resident, communicating clearly (by reassuring or apologizing for any discomfort caused, for example), and thinking creatively, behavioral symptoms lessened. There was a marked reduction in all behavioral symptoms (by 32% in the shower group and 38% in the towel-bath group). Aggression declined by 53% in the shower group, 60% in the towel-bath group, and only 7% in the control group.

It doesn’t take a lot of water to get clean. Dry skin is a problem for about three-quarters of people age 65 or older. 10 In planning our study, we knew several of the bathing strategies had the advantage of managing dry skin (for example, reducing the frequency of bathing can prevent scaling or cracking of the skin). First, we reduced the frequency of total-body bathing from twice per week to once per week for most subjects. Second, we switched from standard soaps to a no-rinse cleanser, Septi-Soft, with a soybean-oil base. Third, no rinsing was performed during the towel bath, which further reduced exposure to water.

We were concerned that less frequent bathing and using less water in bathing might compromise hygiene. The study demonstrated that the towel bath doesn’t adversely affect skin condition or lead to the accumulation of pathogenic, odor-causing bacteria. Skin condition was significantly improved, in fact, and less debris and dirt were left on the skin. A person doesn’t have to be doused or dunked to be really clean. A bed bath can safely substitute for a shower.

There are many ways to meet hygiene needs.

Most nurses and CNAs are taught to start a bath at the head and work down because it’s assumed that the head and face are cleaner than other areas. But for people with dementia, water dripping in the face and having the head wet are generally the most upsetting parts of the bath; this causes distress at the beginning of the bath. One alternative is to wash the face and hair at the end of the bath or at another time. Another is to use no-rinse products that can shorten and simplify bathing. Infection-control concerns can be addressed by the caregiver washing her hands and using a fresh, clean cloth after cleansing a part of the body that might cause contamination. Although many have been taught to cover the person during a shower or tub bath, few actually do this, possibly leaving the person cold and feeling exposed, embarrassed, and without dignity. Covering the person with a towel and washing beneath it alleviates this distress. These changes are simple, practical, and do not increase the length of bathing time.

Pain is often the cause of behaviors.

The prevalence of pain or potentially painful conditions among institutionalized older adults has been estimated to be between 43% and 71%, 11-13 with mus-culoskeletal conditions the most common source. Many nursing home residents with dementia can’t describe their pain verbally, leading to behavioral symptoms such as aggression, resisting care, and vocalizations. The movements necessary in routine bathing, such as walking, standing, transferring from bed or wheelchair to tub or shower chair, and moving joints and limbs, can often exacerbate chronic pain or precipitate acute pain. We also found that pain is particularly common when washing between the toes, under the arms, and on sensitive areas such as the genitals and face. In our study, residents’ discomfort declined significantly in both intervention groups, but not in the control group; the largest decline was with the towel-bath intervention (26%).

PRACTICAL APPROACHES

To reduce pain associated with bathing, nursing home staff and other caregivers should explore the need for routine analgesia or nonpharmacologic approaches such as applying hot packs to sore joints before a bath. During the bath or shower, caregivers should move the limbs carefully, warn the person before moving or washing a potentially painful body part, and be aware of signs of discomfort. Letting the person assist in cleansing a painful area can diminish aggravation, as well as instill a sense of control that can diminish distress. And while it’s not always practical in all settings, giving a person time to soak in a tub without being rushed can help reduce chronic pain from muscular tension. Also, caregivers in all settings should be familiar with and use universal precautions with any bathing method, wearing gloves when appropriate for protection and infection control.

Nurses should think about bathing others as they would think about bathing themselves. When you had a particularly pleasant bath or shower, what made it enjoyable?

Conceptualize bathing as a pleasant experience.

Nurses should think about bathing others as they would think about bathing themselves. When you last had a particularly pleasant bath or shower, what sensations made it enjoyable? When asked this question in a workshop setting, nurses have mentioned specific preferences: time of day, shower or tub, water temperature, length of shower or bath, music playing (or not), and scent. It’s rare that anyone mentions the process of washing or the goal of getting clean.

This is in stark contrast to the experience of many frail older adults, who depend on others for bathing and whose distress and discomfort can bring them to the point of resistance and aggression. Nurses and other caregivers have traditionally identified these behaviors as the problem and reducing or eliminating them as the goal. But such behaviors should be thought of as symptoms of the real problem: unpleasant bathing.

Suggestions for the shower or tub.

In the home, if the person is having difficulty getting into and out of the shower or tub, have a physical or occupational therapist perform an assessment. A hand-held showerhead, a bath bench, and properly placed grab bars can be of great help and also foster independence. 4 Some spouses report better results when they shower along with the person, if space permits and doing so is customary. When older adults find getting in and out of bathtubs and showers difficult or frightening, despite environmental adaptations, the next step is often to do sponge baths at the sink. Families and other direct caregivers should be made aware of the wide variety of no-rinse products available, since they often make the process quicker, less complex, and less likely to cause agitation. In our study we found that Septi-Soft, when diluted, was useful in shower or tub.

The typical plastic-pipe shower chair used in institutions often adds to pain and discomfort in the shower. Such chairs usually have an unpadded seat, a rather large opening, and no support for the feet. One of us (Rader) found that when she was showered in this type of chair, she sank in the opening and her feet dangled unsupported and turned blue-purple from impaired circulation. Before this personal experience, she had assumed that the foot discoloration she’d often observed in frail older adults was the result of irreversible physiologic changes.

In a preliminary study we purchased a shower chair with a padded seat and foot support. 14 Staff members reported that residents who weren’t cognitively impaired requested this chair specifically once they’d felt how comfortable it was. Since purchasing new shower chairs isn’t always an option, try these adaptations:

* Use a small plastic stool (6-in. to 9-in. tall) or an overturned plastic washbasin to support the feet.

* Cover the cold, often wet, nylon-mesh chair back with a dry towel.

* Cover the arms with closed-cell foam pipe insulation.

* Pad the seat using small towels or washcloths, or purchase an inexpensive potty-seat insert and place it in the hole in the shower chair to pad the seat and make the hole smaller.

* Disinfect shower chair additions along with the shower chair.

* Check for small tears or cuts in the surface of the foam or seat insert and replace for infection control.

In assisted living facilities and nursing homes, a trusted staff member (and the same staff member) assisting with bathing is very important. Think about how difficult bathing would be if someone different were to bathe you each time. If the facility has consistent assignments, and the same person cares for the same resident over time, the caregiver and resident can develop a relationship and tailor the method, time, and frequency of bathing according to the resident’s needs.

Hospitalized patients, unlike nursing home residents, may wish for more frequent bathing or a soothing bath or shower as a way to feel better. Family members can help with this, which can minimize fear and misunderstandings and also allow the patient to schedule bathing according to his energy level and other preferences.

Suggestions for in-room bathing.

Professional and family caregivers should consider routine bathing options outside the bath or shower. Here again, the use of no-rinse products can make bathing more pleasant and easier. Prepackaged “bath-in-a-bag” products, consisting of up to eight premoist-ened, presoaped, no-rinse, disposable cloths, can be used in all settings. The following is a checklist for using them:

* Heat the package according to instructions.

* Check to ensure that the cloths are not too warm.

* Remove a cloth and wash the person, using a new cloth for each part of the body.

* Wash under the covers if the person is very sensitive to cold.

Drying isn’t usually required because there’s minimal moisture. A “bath in a bag” does not require water, so a person can be washed in a variety of places. People living at home at the end of life can be adequately bathed while resting comfortably in a recliner. Even the toilet can be an appropriate place for this type of cleansing; for example, if the person has limited energy, requires an extended period on the commode, or feels pain when transferred, this method might be useful.

If disposable products are too expensive, create the equivalent using a diluted no-rinse product, a number of clean washcloths, and a small plastic bag. Be sure the person is warm and covered before you prepare your equipment:

* Place the washcloths in the plastic bag.

* Fill a graduate or pitcher with warm water (no hotter than 105°F).

* Add a quarter to half ounce of no-rinse product (such as Septi-Soft) to the water and pour just enough solution into the bag to moisten the washcloths.

* Take the bag to the bedside or wherever the washing will take place.

* Wash each section of the body, keeping the rest covered and warm.

* Place the used washcloths in a second plastic bag.

If a more relaxed way of bathing is desired, the towel-bath method can be very comforting and enjoyable (see The Towel Bath, page 44). This method can be presented to the person as a “nice, warm massage” in bed rather than a “bath.” Avoiding the words “wash” and “bathe” can be helpful to people with dementia, who often associate the words with a cold, frightening, and uncomfortable experience. Once the caregiver is familiar with the procedures, the towel-bath technique is simple, quick, and easy to perform. In facilities that routinely use this technique, it’s useful to have the bags and towels prepackaged by laundry or central supply and place them in the linen closet for staff use.

Suggestions for hair washing.

Going to the beauty parlor or barber is a pleasant experience for many people. Continuing this activity in people with dementia is desirable because it’s familiar, it enhances the person’s physical appearance, and it gives an opportunity to socialize. But a traditional beauty salon may overwhelm a person who has dementia. When a beautician is no longer appropriate or available, separating hair washing from the shower or bath is often useful in preventing agitation.

When hair washing is the most dreaded part of bathing, it’s helpful to wash the hair only when it’s absolutely necessary, using a method that has been found to be the most pleasant and tolerable. For example, if you choose to wash the hair as part of a shower or tub bath, wait until the end, cover the person with dry towels, and then wash the hair, as follows:

* Use very little water, pouring from a pitcher and carefully deflecting the water away from the eyes with either the hand or a washcloth; or dampen the hair with wet wash cloths.

* Use as little shampoo as possible to reduce the need for rinsing.

When washing the hair outside of the shower room, a basin-and-washcloth method allows the person to remain fully clothed. Here is one:

* First place a plastic bag and then a towel around the person’s neck and shoulders.

* Dampen the hair with a wet washcloth.

* Add a small amount of shampoo.

* Massage the head.

* Use the wet washcloth to remove the shampoo from the hair one section at a time, rinsing the cloth in the basin of water frequently.

* Gently dry with a towel.

An in-bed inflatable basin is useful when hair-washing is performed separately from the bath or shower. Other options include a dry or no-rinse shampoo or a no-rinse shampoo cap.

RECOMMENDATIONS AND RESOURCES

An interactive CD-ROM and video package, Bathing Without a Battle, produced by three of us (Barrick, Rader, and Sloane), was sent to all federally funded nursing homes in January 2004. It is available for purchase online at www.bathingwithoutabattle.unc.edu . 4 A book by the same name (and authors) is also available in stores and online.

Also, a streaming-video Internet broadcast from the Center for Medicare and Medicaid Services in September 2002 was shared with federal and state nursing home surveyors. Entitled Innovations in the Quality of Life, the program presented bathing in the context of a caring relationship rather than as a task to be completed, thereby improving the quality of direct care. Video and DVD copies are available for purchase online at www.pioneernetwork.net .

Another film, produced by the Alzheimer’s Association and developed by two of us (Sloane and Barrick), Solving Bathing Problems in Persons with Alzheimer’s Disease and Related Disorders, is available at www.terranova.org/Title.aspx?ProductCode=SBPVHS .

Nurses in all settings should work with families so that they can better understand the many ways that hygiene can be maintained. Family members may think the person should be showered or bathed more often than is actually needed, desirable, or is actually tolerable. Without information, family members may see less-frequent showering as a way for nursing home staff to get out of doing the work, for example, rather than as a method of individualizing care.

Working with, Rather Than Against, Resistance

A caregiver is preparing a nursing home resident for bathing and the resident, an older woman with dementia, is resisting. “You think you know more about my own body,” she says, grabbing at the caregiver’s arms and twisting the collar of her blouse. “You don’t want me to live in my own body.” The caregiver says it isn’t so, and the resident counters with, “Well, why don’t you keep your hands off of me?”

This is a scene from a CD-ROM and video package, Bathing Without a Battle: Creating a Better Bathing Experience for Persons with Alzheimer’s Disease and Related Disorders, created by three of us (Rader, Barrick, and Sloane), which depicts actual scenes of assisted bathing that unfold with varying degrees of success. The familiar forms of resistance, such as hitting, biting, and shouting, are shown, as are strategies that caregivers might use.

In another sequence, a caregiver offers a washcloth to an older woman. The woman takes the washcloth and washes her own face. The caregiver then asks the woman’s permission before removing her hospital gown and lets the woman test the temperature of the water before wetting her skin. These actions help the person feel that she has some control, which helps make for a smoother process.

The Towel Bath

A gentle in-bed bath method.

Equipment

1 or more bath blankets:

1 large plastic bag containing:

* 1 large (5'6' × 3'), lightweight towel (fan folded)

* 1 standard bath towel

* 2 or more washcloths

2-to-3-quart plastic pitcher filled with water (approximately 105°F to 110°F), to which you add:

* 1 to 1½ ounces of no-rinse soap, such as Septi-Soft, manufactured by Calgon–Vestal (use manufacturer’s instructions for dilution)

Preparing the person

Explain the bath to the person. Make the room quiet or play soft music and dim the lights if this calms the person, while ensuring privacy. Wash your hands. If necessary, place one bath blanket under the person to protect the linen and provide warmth. Undress the person, keeping her covered with the bed linen or the second bath blanket. You may also protect the covering linen by folding it at the end of the bed.

Preparing the bath

Pour the soapy water into the plastic bag and work the solution into the towels and washcloths until they are uniformly damp but not soggy. If necessary, wring out excess solution through the open end of the bag into the sink. Twist the top of the bag closed to retain heat. Take the plastic bag containing the warm towels and washcloths to the bedside.

Bathing the person

Expose the person’s feet and lower legs and immediately cover the area with the large warm, moist towel. Then gently and gradually uncover the person while simultaneously unfolding the wet towel to cover the person. Place the covers at the end of the bed. Start washing at whatever part of the body is least distressing to the person. For example, start at the feet and cleanse the body in an upward direction by massaging gently through the towel. You may wish to place a bath blanket over the towel to hold in the warmth. Wash the backs of the legs by bending the person’s knee and going underneath. Bathe the face, neck, and ears with one of the wash-cloths. You may also hand a washcloth to the person and encourage her to wash her own face. Turn her to one side and place the smaller warm towel from the plastic bag on the back, washing in a similar manner, while warming her front with the bath blanket or warm moist towel. No rinsing or drying is required. Use a washcloth from the plastic bag to wash the genital and rectal areas. Gloves should be worn when washing these areas. Remove the damp towel before you wash the back or when done with towel bath, depending on the person’s wishes and tolerance.

After the bath

If desired, have the person remain unclothed and covered with the bath blanket and bed linen, dressing at a later time. A dry cotton bath blanket (warmed if possible) placed next to the skin and tucked close is comforting. Place used linen back into the plastic bag; tie the bag, and place it in a hamper.

Adapted from Towel-bath—Totman technique, St. Louis: Calgon–Vestal Laboratories, 1975. Copyright ER Squibb and Sons, LLC.

Improving the Shower or Tub Experience

* Switch bathing to a different or familiar time of the day.

* Separate hair washing from body washing if either is distressing or overwhelming to the person being bathed.

* Cover the person being bathed with a dry towel when using a hand-held shower to prevent the person from being wet, naked, and cold; simply lift up the towel to wash.