Here is the structured PICO analysis for the sixtieth article you uploaded:
✅
Full Title (verbatim and exact):
“Improving comfort in people with dementia and pneumonia: a cluster randomized trial”
van der Maaden T, de Vet HCW, Achterberg WP, et al.
BMC Medicine (2016); 14:116
DOI: 10.1186/s12916-016-0663-x
📄
Type of Article:
Cluster randomised controlled trial
🔍
PICO Analysis:
Population:
- 367 residents with dementia across 32 Dutch nursing homes, experiencing 464 episodes of pneumonia
- Mean age: 84.2 years; 58% female
- Diagnoses included Alzheimer’s, vascular, and mixed dementia; 87% treated with antibiotics during pneumonia episodes
Intervention:
A physician practice guideline developed via Delphi consensus for symptom relief in dementia patients with pneumonia, including:
- Symptom checklist for pneumonia
- Observational instruments (e.g. PAINAD, RDOS) for assessing pain and respiratory distress
- Tailored treatment recommendations (supportive, non-pharmacological, and pharmacological)
- Guidance on opioid use, even for non-terminal patients
- Physicians were advised, but not required, to apply the guideline at their discretion
Comparator:
- Usual care provided during the pre-intervention phase, and to the control homes during the intervention phase
- Homes were cluster-randomised after a pre-intervention period into:
- Intervention group (n=16 homes, 109 analysed pneumonia episodes)
- Control group (n=16 homes, 80 analysed pneumonia episodes)
Outcome:
1. Person-centred outcomes:
- Measured using validated observational tools:
- Discomfort: Discomfort Scale–Dementia of Alzheimer Type (DS-DAT)
- (Lack of) Comfort: EOLD-CAD
- Pain: PAINAD
- Respiratory distress: RDOS
- Residents who died within 20 days had significantly worse comfort and symptom scores, especially in the control group
2. Process outcomes:
- The guideline had no significant effect on:
- Discomfort (adjusted DS-DAT ratio: 1.11, 95% CI: 0.93–1.31)
- Comfort (EOLD-CAD), Pain (PAINAD), or Respiratory distress (RDOS)
- However, symptoms decreased over time in both groups, possibly due to:
- Increased awareness (Hawthorne effect)
- Broader trends in palliative practice
- Only 57% of pneumonia episodes received symptom-relieving treatment (e.g. opioids in 16%)
- Implementation challenges:
- Low physician uptake
- Physicians believed their current practice aligned with the guideline
- No structured adherence monitoring or enforcement
3. Health system outcomes:
- No effect on mortality, though discomfort decreased over the study period (3.5 years) across both groups:
- DS-DAT score dropped from 6.5 → 5.4 (intervention phase)
- Observational data collection itself may have improved care through increased attention and vigilance
Summary Conclusion:
This large, well-powered Dutch cluster RCT tested a consensus-derived practice guideline for symptom relief in nursing home residents with dementia and pneumonia. The guideline did not significantly reduce discomfort, pain, or respiratory distress compared to usual care. However, overall symptom levels declined over time, possibly due to increased awareness rather than the intervention itself. The authors suggest that guidelines alone may be insufficient—future strategies may need to focus on culture change, real-time monitoring, and interprofessional engagementto improve comfort-focused care at end of life.
Life In The Slower Lane 
Leave a comment