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The aim of this study is to describe the last month of life of severely demented elders in long-term care institutions, and the clinical decisions in the management of their end-of-life events.Retrospective exploratory study.Seven Italian long-term care institutions with more than 200 beds.One hundred forty-one patients with advanced (FAST stage = 7c) dementia (Alzheimer disease, vascular, other kinds of dementia, severe cognitive impairment).Diagnosis, Mini-Mental State Examination, cause of death. Data were collected from clinical and nursing records referring to the last 30 days of life: symptoms and signs, intensity and incidence, treatments (antibiotics, analgesics, anxiolytics, antidepressants, artificial nutrition/hydration, and use of restraints); the last 48 hours: cardiopulmonary resuscitation attempts and life-sustaining drugs.Patients were given antibiotics (71.6%), anxiolytics (37.1%), and antidepressants (7.8%). Twenty-nine patients (20.5%) were tube- or percutaneous endoscopic gastrostomy (PEG)-fed. Most patients (66.6%) were also parenterally hydrated (72 intravenously, 15 by hypodermoclysis). Some form of physical restraint was used for 58.2% (bed-rails and other immobilizers). Almost half of the patients had pressure sores. In general, attention to physical suffering was fairly good, but during the last 48 hours a number of interventions could be considered inappropriate for these patients: tube feeding (20.5%), intravenous hydration (66.6%), antibiotics (71.6%), and life-sustaining drugs (34.0%).Some indicators imply a less than optimal quality of care (restraints, pressure sores, psychoactive drugs, and the lack of documentation of shared decision-making) and suggest that far advanced demented patients are not fully perceived as "terminal."

Title. Validation of the Italian version of the Discomfort Scale – Dementia of Alzheimer Type. Aim. This paper is a report of a study to validate the Discomfort Scale – Dementia of Alzheimer Type in Italian. Background. Dementia is a long and highly debilitating illness with a slow course and a steadily rising prevalence. Improving the quality of life of patients with dementia requires instruments to measure their problems and symptoms, because they are unable to communicate and interact with others. In Italy, there are no validated scales to assess discomfort for this population. The Discomfort Scale – Dementia of Alzheimer Type was developed in the USA and has been further tested there as well as in Germany. Methods. The data were collected by 21 nurses during 2006 in five nursing homes with 71 patients with severe dementia. Face and content validity were evaluated in a focus group. Discriminant validity was assessed with the oppositegroup approach and internal consistency and inter-rater reliability were measured. Results. The discriminant validity of the Italian Discomfort Scale – Dementia of Alzheimer Type showed its ability to detect patients with high and low levels of discomfort. Reliability testing gave positive results: the internal consistency level was satisfactory (0AE814) and comparisons of overall discomfort scores across nurses show good reliability. Conclusion. These findings support the use of Discomfort Scale – Dementia of Alzheimer Type in a clinical setting for people with severe dementia for both research and practice. Its ease of use and comprehensibility, and the limited time required to observe patients renders the Discomfort Scale – Dementia of Alzheimer Type a practical instrument for assessment and choosing care interventions.

Aging of registered nurses workforce is already a worrying issue in many countries and therefore attempts to estimate its alarming dimension are on course. Some worrying signals are already evident in Italy but, to date, no data are available on the size and possible evolution of the problem.This study aims to describe the trend of the aging of nurses workforce in three hospitals of Turin in the next 25 years and to explore retention strategies.The percentage of nurses45 years ranges from 19 to 21% but it is bound to steadily increase, ranging from 59 to 71%.The creation of an healthy work place, tailored to the needs of ageing of the workforce and the implementation of retention strategies and incentives centered on this age-group will be one of the immediate future challenges, to govern an highly predictable emergency.

The premises, questions and methodological problems of a multicentre study aimed at describing the epidemiology of patients' problems that require a nursing intervention are described. The main points and methodological challenges are presented and discussed: (a.) the choice of focusing on patients cared for in Nursing homes and districts because a. they are complex, originate very high nursing workload, b. few studies and data from the nursing point of view are produced; c. information on everyday care and problems are lacking, d. they are marginal populations both in research and organization of care; (b.) the need of involving nurses in a surveillance exercise, to increase the attention on problems, their causes and potential avoidability, focusing the attention on problems related to drugs and devices; (c.) the importance-and challenge- of describing what happens in everyday' care, taking in account the variability related to contexts and people. The recognition of a problem is, in fact, related to factors such as the knowledge of the patient and his/her story, the level of knowledge and expertise of the nurse, the attention paid, the context and the organization. The main lessons learned are summarised.

Off-label prescription is part of routine care in palliative medicine, but no information is available about the situation in Italy. A cross-sectional observational survey was undertaken on all 66 Italian palliative care freestanding inpatient units to describe off-label prescriptions. Data were collected on 507 patients. Each prescribed drug was matched with Italian Marketing Authorization indications: 159 drugs off-label (4.5% of all prescribed drugs) for the stated indication were given to 128 patients (25.2%), and drugs unlicensed for subcutaneous injection were given to 147 patients (85.4% of all subcutaneous prescriptions, excluding insulin and heparin). The off-label prescriptions were subsequently evaluated by referring to the Italian National Pharmaceutical Formulary (INPF) and the British Palliative Care Formulary (PCF2). Although drugs are frequently prescribed off-label in inpatient palliative care units in Italy, this strategy was not always backed by clinical evidence, and in some cases, official/authoritative sources, such as INPF and PCF2 did not support it. Clinical trials and/or agreed international guidelines are needed to support the off-label use of the most widely prescribed drugs in palliation.

We report the case of a 4.6-year-old girl born pre-term with early bilateral occipital damage. It was revealed that the child had non-severely impaired basic visual abilities and ocular motility, a selective perceptual deficit of figure-ground segregation, impaired visual recognition and abnormal navigating through space. Even if the child's visual functioning was not optimal, this was the expression of adaptive anatomic and functional brain modifications that occurred following the early lesion. Anatomic brain structure was studied with anatomic MRI and Diffusor Tensor Imaging (DTI)-MRI. This behavioral study may provide an important contribution to understanding the impact of an early lesion of the visual system on the development of visual functions and on the immature brain's potential for reorganisation related to when the damage occurred.

Since gender-specific mortality differences are known a great deal of research has been conducted on this subject. The resulting hypotheses for explaining male excess mortality can be sub-divided into two basic categories: the biological approach (focusing on biological and genetic factors) and the non-biological approach (focusing on behavioral and environmental factors). It has been proven impossible to explain the observed trends in mortality differences between women and men by relying solely on one of the two groups of theories. Recent studies indicate that the majority of the female survival advantage can be attributed to gender behaviors while the impact of biological factors seems to be limited to 1-2 years in life expectancy at birth. The main goal of this paper is to analyze the impact of gender-specific health behaviors and gender differences in life quality using micro level data for Western Germany.

Since gender-specific mortality differences are known a great deal of research has been conducted on this subject. The resulting hypotheses for explaining male excess mortality can be sub-divided into two basic categories: the biological approach (focusing on biological and genetic factors) and the non-biological approach (focusing on behavioral and environmental factors). It has been proven impossible to explain the observed trends in mortality differences between women and men by relying solely on one of the two groups of theories. Recent studies indicate that the majority of the female survival advantage can be attributed to gender behaviors while the impact of biological factors seems to be limited to 1-2 years in life expectancy at birth. The main goal of this paper is to analyze the impact of gender-specific health behaviors and gender differences in life quality using micro level data for Western Germany.

An experience of a tentative contribution of the nurses to the health policy planning is described.Fifty one focus groups were organized, with nurses from different contexts (hospital, district, free lance nurses; caring for paediatric, geriatric surgical and medical patients) and nurses were asked to identify problems encountered in patients care, select one, discuss contributing causes assign a weight (from 1 to 100) and define the nurses' contribution to the resolution/improvement of each cause. The problems were discussed in groups and possible solutions identified, with specific attention to the potential implications of regional health policies.The main difficulties identified were the lack of continuity in patients care (for geriatric and paediatrics patients), 12 groups, and the management of chronic patients (7 groups); the lack of information to patients, 6 groups; the appropriateness of care, from hospital admissions to waiting lists, 5 groups; the management of surgical patients, 5 groups; the lack of nursing personnel, 5 groups; the safety of patients and health personnel, 4 groups; and other problems reported by less than 3 groups.This experience allowed nurses to reflect on health care problems throughout the trajectory from the specific problem to its general implications, also for the health care policies. The solutions identified in fact, encompass a dimension relevant for health policy planning. It is also an experience of opportunity (and feasibility) of involvement of the "general nurses" and not only nurse managers, to reflect on practice and propose a specific and original contribution to the development of regional and local policies.

In spite of the progresses of knowledge and care, pressure sores continue to be a clinically relevant problem. A double blind randomised controlled trial was organised to assess the efficacy of triticum vulgaris (Fitostimoline) vs placebo in the re-epithelisation of superficial pressure sores. Patients with stage NPUAP II or superficial pressure sores, with an expected survival of more than 3 months and eligible for a follow-up up to 8 weeks were included, over a period of 2 years in 46 clinical sites. The protocol was approved by local ethical committees and informed consent was obtained before randomisation. Medications were performed by nurses if the patient was hospitalised and by nurses or properly instructed caregivers at home. Weekly follow-up controls were assumed by nurses. Out of the 294 randomised patients 270 were included in the analyses. The two groups are comparable for the main characteristics except for Norton Scale mean values, less severe in the group assigned to active treatment (10.1+/-3.7 vs 8.9+/-3.2). The mean follow-up was of 3.8 and 4.2 weeks with a mean duration of 26+/-18 and 29+/-18 days for the experimental group and controls respectively. Seventy-six patients in the treatment group and controls (58.0 and 54.7) had their lesions re-epithelized. Adjusting results for age, initial Norton and Push scores there are no differences between treated and controls (OR 0.99 95% IC 0.60-1.67). This multicentre study, sponsored by a research group of nurses, failed to support the hypothesis that triticum vulgaris, the active component of the product Fitostimoline, given on top of recommended treatment, provides a specific therapeutic advantage in terms of frequency and timing of re-epithelization in superficial pressure sores.

In spite of the existing guidelines, the strategies and behaviours adopted in the care of the patients admitted to stroke units may vary widely across centres. The aim of this study was to quantify and quality the degree of real variability of the protocols enforced a sample of 13 of such units. There is no uniform behaviour for the monitoring of patients admitted with a stroke: vital signs are collected with different range intervals, i.e. blood pressure 15 for the first 6 hours, from every 15 minutes to 2-3 hours. The assessment of dysphagia can be performed with the swallow test or having the patient drink a spoonful 10 ml of water, or 50 ml without stopping. The variability of behaviours is not, per se, a negative characteristic but it becomes a potential and unacceptable risk when solid evidences of effective practice are available. In the absence of clear cut recommendations the protocols should be defined trying to find a balance between effectiveness of the behaviours recommended and workload for nurses.

Quality of life (QoL) assessment is crucial for the evaluation of palliative care outcome. In this paper, our methodological approach was based on the creation of summary measures. Fifty-eight Palliative Care Units (PCUs) in Italy participated in the study. Each PCU randomly selected patients to be ‘evaluated’ among the consecutively ‘registered’ patients. At baseline (first visit) and each week the patient was asked to fill in a QoL questionnaire, the Therapy Impact Questionnaire (TIQ). Short-survivors (

The report is a descriptive, comparative study of the cognitive processes used by doctors and nurses when deciding whether or not to administer prn drugs to postoperative cancer patients. Simulations, together with the think aloud technique to provide verbal protocols was the method chosen. The theoretical framework chosen for the analysis was the information processing theory. Five doctors and 5 nurses, each with at least 5 years of working experience were interviewed. The interviews were transcribed so that a content analysis could be performed. The main findings were the following: doctors and nurses generated hypotheses early in the interview; the only statistically significant difference between the two groups was the wider use of theory and/or experience as a source of information by doctors. Although differences are not statistically significant, nurses appear to collect more information on and from the patient and more information on vital signs and symptoms other than pain than the doctors. Differences derived from analysis of the statements expressed by the subjects suggested that nurses pay more attention to the patient's psychological problems and that, while doctors' main concern was to make the right diagnosis, the nurses' main concern were patients' reactions and collaboration.