***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES There is a lack of large-scale , nationwide data describing clinical characteristics and quality of dying of nursing home residents dying with dementia . We set out to investigate quality of end-of-life care and quality of dying of nursing home residents with dementia in Fl and ers , Belgium . DESIGN / SETTING / PARTICIPANTS To obtain representativity , we conducted a postmortem study ( 2010 ) using r and om cluster sampling . In selected nursing homes , all deceased residents with dementia in a period of 3 months were reported . For each case , a structured question naire was filled in by the nurse most involved in care , the family physician , and the nursing home administrator . We used the Cognitive Performance Scale and Global Deterioration Scale to assess dementia . Main outcome measures were health status , clinical complications , symptoms at the end of life , and quality of dying . MEASUREMENTS Health status , clinical complications , symptoms at the end of life , and quality of dying . RESULTS We identified 198 deceased residents with dementia in 69 nursing homes ( 58 % response rate ) . Age distribution was the same as all deceased residents with dementia in Fl and ers , 2010 . Fifty-four percent had advanced dementia . In the last month of life , 95.5 % had 1 or more sentinel events ( eg , eating/drinking problems , febrile episodes , or pneumonia ) ; most frequently reported symptoms were pain , fear , anxiety , agitation , and resistance to care . In the last week , difficulty swallowing and pain were reported most frequently . Pressure sores were present in 26.9 % , incontinence in 89.2 % , and cachexia in 45.8 % .  Physical restraints  were used in 21.4 % of cases , and 10.0 % died outside the home . Comparing stages of dementia revealed few differences between groups regarding clinical complications , symptoms , or quality of dying . CONCLUSION Regardless of the dementia stage , many nursing home residents develop serious clinical complications and symptoms in the last phase of life , posing major challenges to the provision of optimum end-of-life care Background Although dementia at the end of life is increasingly being studied , we lack prospect i ve observational data on dying patients . In this study symptoms were observed in patients with dementia in the last days of life . Methods When the elderly care physicians in two Dutch nursing homes expected death within one week , symptoms of (dis)comfort , pain and suffering were observed twice daily . For this the Pain Assessment in Advanced Dementia ( PAINAD ; range 0–10 ) , Discomfort Scale-Dementia of Alzheimer Type ( DS-DAT ; range 0–27 ) , End-Of-Life in Dementia-Comfort Assessment in Dying ( EOLD-CAD ; range 14–42 ) and an adapted version of the Mini-Suffering State Examination ( MSSE ; range 0–9 ) , were used . Information on care , medical treatment and treatment decisions were also collected . Results Twenty-four participants ( median age 91 years ; 23 females ) , were observed several times ( mean of 4.3 observations ( SD 2.6 ) ) , until they died . Most participants ( n = 15 ) died from dehydration/cachexia and passed away quietly ( n = 22 ) . The mean PAINAD score was 1.0 ( SD 1.7 ) , DS-DAT 7.0 ( SD 2.1 ) , EOLD-CAD 35.1 ( SD 1.7 ) , and MSSE 2.0 ( SD 1.7 ) . All participants received morphine , six received antibiotics , and rehydration was prescribed once . Conclusion In these patients with dementia and expected death , a low symptom burden was observed with vali date d instruments , also in dehydrated patients without aggressive treatment . A good death is possible , but might be enhanced if the symptom burden is regularly assessed with vali date d instruments . The use of observation tools may have influenced the physicians to make treatment decisions Background Nursing home patients have complex mental and physical health problems , disabilities and social needs , combined with widespread prescription of psychotropic drugs  . Preservation of their quality of life is an important goal . This can only be achieved within nursing homes that offer competent clinical conditions of treatment and care . COmmunication , Systematic assessment and treatment of pain , Medication review , Occupational therapy , Safety ( COSMOS ) is an effectiveness-implementation hybrid trial that combines and implements organization of activities evidence -based interventions to improve staff competence and thereby the patients ’ quality of life , mental health and safety . The aim of this paper is to describe the development , content and implementation process of the COSMOS trial . Methods / Design COSMOS includes a 2-month pilot study with 128 participants distributed among nine Norwegian nursing homes , and a 4-month multicenter , cluster r and omized effectiveness-implementation clinical hybrid trial with follow-up at month 9 , including 571 patients from 67 nursing home units ( one unit defined as one cluster ) . Clusters are r and omized to COSMOS intervention or current best practice ( control group ) . The intervention group will receive a 2-day education program including written guidelines , repeated theoretical and practical training ( credited education of caregivers , physicians and nursing home managers ) , case discussion s and role play . The 1-day midway evaluation , information and interviews of nursing staff and a telephone hotline all support the implementation process . Outcome measures include quality of life in late-stage dementia , neuropsychiatric symptoms , activities of daily living , pain , depression , sleep , medication , cost-utility analysis , hospital admission and mortality . Discussion Despite complex medical and psychosocial challenges , nursing home patients are often treated by staff possessing low level skills , lacking education and in facilities with a high staff turnover . Implementation of a research -based multicomponent intervention may improve staff ’s knowledge and competence and consequently the quality of life of nursing home patients in general and people with dementia in particular . Trial registration Clinical Trials.gov OBJECTIVES Behavioral disturbances and pain are common in nursing home ( NH ) patients with dementia . An association between pain and increased agitation has been suggested , and recently a significant reduction of agitation has been demonstrated by pain treatment in patients with moderate to severe dementia . We now examined which specific agitated behaviors respond to individualized pain treatment . DESIGN Cluster r and omized clinical trial . SETTING 60 clusters ( i.e. , clusters defined as single independent NH units ) in 18 NHs within five municipalities of Western Norway . PARTICIPANTS 352 patients with moderate to severe dementia and clinical ly significant behavioral disturbances . INTERVENTION The control group received usual treatment and care . According to a predefined scheme for 8 weeks , all patients in the intervention group received individual daily pain treatment with acetaminophen , extended release morphine , buprenorphine transdermal patch , and /or pregabaline . MEASUREMENTS Cohen-Mansfield Agitation Inventory subscales and items . RESULTS Analyses demonstrated that Factor 3 ( Verbally agitated behaviors ) showed the largest significant difference ( DF = 1204.0 , t = -4.308 , p < 0.001 ) , followed by Factor 2 ( Physically non-aggressive behaviors ) ( DF = 1198.0 , t = -2.672 , p = 0.008 ) , and Factor 1 ( Aggressive behaviors ) ( DF = 1196.0 , t = -2.093 , p = 0.037 ) after 8 weeks , by a linear r and om intercept mixed model in two-way repeated- measures configuration with adjustment for heteroscedasticity . CONCLUSION We found that verbal agitation behaviors such as complaining , negativism , repetitious sentences and questions , constant request for attention , and cursing or verbal aggression responded to pain treatment . In addition , restlessness and pacing were sensible to analgesics . Such behaviors should therefore lead to an assessment of pain , and pain treatment . Further studies comparing how pain treatment should be balanced against other strategies including psychotropic drugs are needed Background Pain is frequent and distressing in people with dementia , but no r and omized controlled trials have evaluated the effect of analgesic treatment on pain intensity as a key outcome . Methods Three hundred fifty-two people with dementia and significant agitation from 60 nursing home units were included in this study . These units , representing 18 nursing homes in western Norway , were r and omized to a stepwise protocol of treating pain ( SPTP ) or usual care . The SPTP group received acetaminophen , morphine , buprenorphine transdermal patch and pregabalin for 8 weeks , with a 4-week washout period . Medications were governed by the SPTP and each participant 's existing prescriptions . We obtained pain intensity scores from 327 patients ( intervention n = 164 , control n = 163 ) at five time points assessed by the primary outcome measure , Mobilization-Observation-Behaviour-Intensity-Dementia-2 ( MOBID-2 ) Pain Scale . The secondary outcome was activities of daily living ( ADL ) . We used a linear intercept mixed model in a two-way repeated measures configuration to assess change over time and between groups . Results The SPTP conferred significant benefit in MOBID-2 scores compared with the control group [ average treatment effect ( ATE ) −1.388 ; p < 0.001 ] at week 8 , and MOBID-2 scores worsened during the washout period ( ATE = −0.701 ; p = 0.022 ) . Examining different analgesic treatments , benefit was conferred to patients receiving acetaminophen compared with the controls at week 2 ( ATE = −0.663 ; p = 0.010 ) , continuing to increase until week 8 ( ATE = −1.297 ; p < 0.001 ) . Although there were no overall improvements in ADL , an increase was seen in the group receiving acetaminophen ( ATE = + 1.0 ; p = 0.022 ) . Conclusion Pain medication significantly improved pain in the intervention group , with indications that acetaminophen also improved ADL function . What 's already known about this topic ? Many people with dementia experience pain regularly , but are not able to communicate this to their carers or physicians due to the limited self-report capacity inherent in the symptomatology of dementia . Few studies have investigated the direct effect of pain treatment on pain intensity in patients suffering from dementia , with previous studies using proxy measures of behavioural symptoms . What does this study add ? A stepwise protocol to treat pain in nursing home residents with moderate to severe dementia significantly reduced pain intensity . Pain treatment by acetaminophen improved activities of daily living . There is an urgent need for a st and ardized approach to assessment and treatment of pain for nursing home residents with dementia Background Mobilization-Observation-Behavior-Intensity-Dementia-2 ( MOBID-2 ) pain scale is a staff-administered pain tool for patients with dementia . This study explores MOBID-2 's test – retest reliability , measurement error and responsiveness to change . Methods Analyses are based upon data from a cluster r and omized trial including 352 patients with advanced dementia from 18 Norwegian nursing homes . Test – retest reliability between baseline and week 2 ( n = 163 ) , and weeks 2 and 4 ( n = 159 ) was examined in patients not expected to change ( controls ) , using intraclass correlation coefficient ( ICC2.1 ) , st and ard error of measurement ( SEM ) and smallest detectable change ( SDC ) . Responsiveness was examined by testing six priori-formulated hypotheses about the association between change scores on MOBID-2 and other outcome measures . Results ICCs of the total MOBID-2 scores were 0.81 ( 0–2 weeks ) and 0.85 ( 2–4 weeks ) . SEM and SDC were 1.9 and 3.1 ( 0–2 weeks ) and 1.4 and 2.3 ( 2–4 weeks ) , respectively . Five out of six hypotheses were confirmed : MOBID-2 discriminated ( p < 0.001 ) between change in patients with and without a stepwise protocol for treatment of pain ( SPTP ) . Moderate association ( r = 0.35 ) was demonstrated with Cohen-Mansfield Agitation Inventory , and no association with Mini-Mental State Examination , Functional Assessment Staging and Activity of Daily Living . Expected associations between change scores of MOBID-2 and Neuropsychiatric Inventory – Nursing Home version were not confirmed . Conclusion The SEM and SDC in connection with the MOBID-2 pain scale indicate that the instrument is responsive to a decrease in pain after a SPTP . Satisfactory test – retest reliability across test periods was demonstrated . Change scores ≥ 3 on total and subscales are clinical ly relevant and are beyond measurement error Some patients with advanced dementia can not convey the experience of pain verbally and may react to pain with aggressive and agitated behaviors . We hypothesized that unrecognized pain could contribute to agitation and that low dose opioid therapy might reduce agitation by reducing pain . We therefore attempted to determine the effect of opioids on agitation in demented patients Objective To determine whether a systematic approach to the treatment of pain can reduce agitation in people with moderate to severe dementia living in nursing homes . Design Cluster r and omised controlled trial . Setting 60 clusters ( single independent nursing home units ) in 18 nursing homes within five municipalities of western Norway . Participants 352 residents with moderate to severe dementia and clinical ly significant behavioural disturbances r and omised to a stepwise protocol for the treatment of pain for eight weeks with additional follow-up four weeks after the end of treatment ( 33 clusters ; n=175 ) or to usual treatment ( control ,  
    Output:
    
Conclusion Despite increased use of analgesics , pain is still prevalent in people with dementia .