Toluwalase Ajayi MD presented on palliative care for patients with dementia. Key points include:
- Dementia prevalence is increasing as the population ages and life expectancy rises.
- Palliative care aims to improve quality of life for patients and families dealing with dementia.
- Management involves a multidisciplinary team and focuses on both pharmacological and non-pharmacological approaches.
- Advance care planning is important to help families navigate challenging end-of-life decisions as the disease progresses.
Susan Mitchell-Care of the Patient with Advanced Dementia: What Physicians Ne...jewishhome
This document discusses care of patients with advanced dementia. It summarizes that dementia is a terminal illness and the most common complications are feeding problems and infections. Aggressive interventions are less likely when families understand the prognosis and expected complications. Tube feeding is not recommended as it does not provide benefits and antibiotics for pneumonia may prolong life but cause more discomfort. Most hospital transfers can be avoided by managing complications in the nursing home based on the goals of comfort care. The document emphasizes making ethical decisions guided by the patient's goals of care rather than feeling compelled to offer all possible interventions.
This document provides information about dementia care at the end of life. It begins by defining common causes of dementia like Alzheimer's disease and vascular dementia. It then discusses the natural progression of dementia and common complications that contribute to death, such as pneumonia, falls, and malnutrition. The document emphasizes that hospice can improve outcomes for dementia patients by providing better care and support at the end of life compared to traditional medical care alone.
This document discusses end-of-life care considerations for patients with advanced dementia. It finds that feeding tubes do not prevent aspiration pneumonia or malnutrition in these patients and may in fact increase the risk of pressure ulcers and restraint use. Instead, oral assisted feeding is recommended to overcome eating difficulties. The benefits of discussing goals of care and treatment options are emphasized over defaulting to invasive interventions like feeding tubes that do not improve quality of life.
Deciding When Hospice Care is Needed | VITAS HealthcareVITAS Healthcare
The goal of this webinar is to help healthcare professionals address the specific challenges of end-of-life care when determining a terminal prognosis, so they can provide the optimum care for the patient and family during the final stages of life.
Respiratory Symptoms in the Terminally Ill PatientVITAS Healthcare
The goal of this webinar was to educate healthcare professionals on interventions for cough, dyspnea, hemoptysis, and the “death rattle” in patients with end-of-life respiratory symptoms.
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
The goal of this webinar was to help hospice and healthcare professionals understand the ethics and application of artificial nutrition and hydration (ANH) for patients near the end of life.
Susan Mitchell-Care of the Patient with Advanced Dementia: What Physicians Ne...jewishhome
This document discusses care of patients with advanced dementia. It summarizes that dementia is a terminal illness and the most common complications are feeding problems and infections. Aggressive interventions are less likely when families understand the prognosis and expected complications. Tube feeding is not recommended as it does not provide benefits and antibiotics for pneumonia may prolong life but cause more discomfort. Most hospital transfers can be avoided by managing complications in the nursing home based on the goals of comfort care. The document emphasizes making ethical decisions guided by the patient's goals of care rather than feeling compelled to offer all possible interventions.
This document provides information about dementia care at the end of life. It begins by defining common causes of dementia like Alzheimer's disease and vascular dementia. It then discusses the natural progression of dementia and common complications that contribute to death, such as pneumonia, falls, and malnutrition. The document emphasizes that hospice can improve outcomes for dementia patients by providing better care and support at the end of life compared to traditional medical care alone.
This document discusses end-of-life care considerations for patients with advanced dementia. It finds that feeding tubes do not prevent aspiration pneumonia or malnutrition in these patients and may in fact increase the risk of pressure ulcers and restraint use. Instead, oral assisted feeding is recommended to overcome eating difficulties. The benefits of discussing goals of care and treatment options are emphasized over defaulting to invasive interventions like feeding tubes that do not improve quality of life.
Deciding When Hospice Care is Needed | VITAS HealthcareVITAS Healthcare
The goal of this webinar is to help healthcare professionals address the specific challenges of end-of-life care when determining a terminal prognosis, so they can provide the optimum care for the patient and family during the final stages of life.
Respiratory Symptoms in the Terminally Ill PatientVITAS Healthcare
The goal of this webinar was to educate healthcare professionals on interventions for cough, dyspnea, hemoptysis, and the “death rattle” in patients with end-of-life respiratory symptoms.
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
The goal of this webinar was to help hospice and healthcare professionals understand the ethics and application of artificial nutrition and hydration (ANH) for patients near the end of life.
This document provides guidance for healthcare professionals on determining a terminal prognosis and accessing hospice care. It discusses the challenges of prognosis, general clinical criteria like functional status and symptom burden, and disease-specific guidelines for predicting prognosis in cancers, end-stage cardiac or pulmonary disease, dementia, cerebrovascular disease, liver disease, HIV/AIDS, and end-stage renal disease without dialysis. Key points are that prognosis involves clinical judgment of multiple factors, physicians tend to overestimate survival, and guidelines provide population-level rather than individual predictions.
Caring for all in the last year of life: making a difference.Bruce Mason
Inaugural presentation by Prof. Scott A. Murray, St Columba's Hospice Chair of Primary Palliative Care, Primary Palliative Care Research Group, Centre for Population Health Sciences: General Practice Section, University of Edinburgh. April 21, 2009
Evaluation and Management of Behaviors in Persons with Cognitive ImpairmentVITAS Healthcare
The goal of this webinar is to enable healthcare clinicians to implement a comprehensive approach to non-pharmacologic and pharmacologic management of dementia-related behaviors for the benefit of patients and their caregivers.
Carle Palliative Care Journal Club 1/15/2020Mike Aref
A journal club review and criticism of J Natl Cancer Inst. 2019 Dec 17. pii: djz233. doi: 10.1093/jnci/djz233 Emergency Department Visits for Opioid Overdoses Among Patients with Cancer by Jairam V, Yang DX, Yu JB, Park HS.
A diagnostic schema is a cognitive tool that allows clinicians to systematically approach a clinical problem by providing an organizing scaffold. A commonly used schema for acute kidney injury (AKI) separates this problem into pre-renal, intrinsic, and post-renal causes. By approaching AKI using these categories, clinicians can systematically access and explore individual illness scripts as potential diagnoses.
Sepsis & Hospice Eligibility: Natural History, Prognosis & Role of HospiceVITAS Healthcare
The goal of this webinar is to educate healthcare clinicians about the history, incidence, impact and identification of sepsis in the acute-care setting. Hospice care is inadequately utilized for patients with sepsis, a serious condition that results in 250,000 US deaths each year and an annual $3.5 billion in hospital readmission costs.
Palliative care is about providing well-being and the highest quality of life to patients with serious, progressive, chronic life-limiting illness, including during the dying process.
The goal of this webinar was to help hospice and healthcare professionals understand the history, philosophy, and practice of hospice and palliative care.
A Change in Behavior: A Pragmatic Clinical Guide to Delirium, Terminal Restle...VITAS Healthcare
The goal of this webinar was to help physicians and healthcare professionals differentiate delirium, terminal restlessness, and dementia-related agitation and aggression in patients near the end of life.
The goal of this webinar was to help hospice and healthcare professionals understand the history, philosophy, and practice of hospice and palliative care.
This document discusses the effects of an ALS diagnosis on individuals and their caregivers over five phases: pre-diagnosis, acute diagnosis, chronic, recovery, and terminal. It outlines the physical, behavioral, spiritual, cognitive and emotional responses individuals may experience during diagnosis. It also examines what matters most to those with moderate to severe disability, such as relationships and everyday life, and how patient suffering impacts caregiver well-being. The document provides guidance on how healthcare professionals can help individuals and caregivers adjust and cope with change and loss, and introduces palliative and hospice care at appropriate times.
This document discusses end-stage COPD and advanced lung disease. It defines advanced lung disease as chronic lung illnesses like emphysema and pulmonary fibrosis that greatly impair patients' ability to do normal activities. Patients with advanced lung disease experience significant distress from symptoms like shortness of breath. The document discusses how hospice services can help alleviate this distress by providing comprehensive symptom management, equipment, counseling and support for patients and their families. It also presents challenges around identifying when a patient's lung disease has reached an end-stage and discusses the advantages hospice can provide for COPD patients.
Three hour slide deck for basics of palliative care including what is palliative care, symptom management (pain, dyspnea, nausea, constipation), goals-of-care, family meetings, comfort care, and issues around artificial nutrition.
This document discusses high emergency department (ED) utilization and perceptions of opioid addiction in sickle cell disease (SCD). It finds that 20% of SCD patients account for 54% of ED visits, often due to lack of primary care, disease severity, or ages 18-30. While ED physicians and nurses believe over 20% and 30% of SCD patients respectively are addicted to opioids, the actual rate of addiction is under 10%. Behaviors intended to control pain can resemble addiction (pseudoaddiction), leading to undertreatment of pain in SCD patients. The document recommends identifying high utilizers lacking primary care and addressing psychosocial factors contributing to utilization, as well as fully treating SCD pain without fears of
Success Principle 12: End of life care for COPDNHS Improvement
A series of mix and match cards providing practical examples of changes you can make and how to implement them to improve care and quality at every step of the pathway for patients with COPD and asthma.
1) Dual process theory describes two modes of thinking: System 1 thinking is intuitive, quick, and based on pattern recognition. System 2 thinking is slow, analytical, and deliberate.
2) A 59-year-old man presented with chest pain and elevated cardiac troponin. Initial diagnosis was non-ST elevation myocardial infarction (NSTEMI) based on System 1 thinking.
3) Further examination revealed new cardiac murmurs, neurological symptoms, and asymmetric blood pressure, inconsistent with NSTEMI. This triggered a transition to System 2 thinking and a new diagnosis of aortic dissection was made.
An approach to mulitmorbidity in frail older adultsCamilla Wong
Ms. A is a 72-year-old woman with multiple chronic conditions including COPD, CAD, CHF, diabetes, and CKD. She has multimorbidity, with some conditions being concordant due to similar pathophysiology and management plans. Her diabetes may be considered the dominant condition. Over 10 years, her condition progresses with the addition of colon cancer and mild dementia. In her last year of life, she is frail and in the terminal phase of her multimorbidity. Interventions shift to advanced care planning, symptom management, and liaison with palliative care.
1) The document discusses the evolution of problem representation during a clinical encounter as more information is gathered. It provides an example of a case of a young woman initially presenting with fatigue and abdominal pain whose problem representation changes as additional symptoms of rash and facial palsy emerge.
2) Over the course of several visits and with additional testing revealing panuveitis and lung nodules, the problem representation evolves to that of a sexually active young woman with systemic symptoms consistent with acute sarcoidosis.
3) She is ultimately diagnosed with acute sarcoidosis and her symptoms resolve with corticosteroid treatment.
The goal of this webinar is to educate professionals on strategies for recognizing and addressing the unique physical, emotional, and behavioral manifestations of grief and loss among healthcare and other helping professionals.
This document summarizes a workshop on addressing the palliative and end-of-life care needs of people with dementia in hospitals. The workshop covered challenges in caring for people with dementia, communication strategies, recognizing dementia as a life-limiting illness, assessing pain and symptoms, the role of multidisciplinary teams, and available resources from the Irish Hospice Foundation. The presentation emphasized taking a person-centered approach, advance care planning, continuity of care, and the importance of staff training to meet the complex needs of people with dementia at the end of life.
This presentation discusses comfort-focused behavior management for people with dementia. It begins by outlining the session objectives and noting that human behavior and communication are connected. Two common dementia behaviors are identified as resisting care and refusing medication. The presentation then explores what these behaviors may be communicating, such as pain, fear, or not wanting to complete a task. It suggests remedies for addressing the underlying causes, like pain medication, slowing down interactions, or identifying personal routines. Overall, the presentation emphasizes making comfort the primary goal and observing behaviors for clues about an individual's needs and state of mind.
This document provides guidance for healthcare professionals on determining a terminal prognosis and accessing hospice care. It discusses the challenges of prognosis, general clinical criteria like functional status and symptom burden, and disease-specific guidelines for predicting prognosis in cancers, end-stage cardiac or pulmonary disease, dementia, cerebrovascular disease, liver disease, HIV/AIDS, and end-stage renal disease without dialysis. Key points are that prognosis involves clinical judgment of multiple factors, physicians tend to overestimate survival, and guidelines provide population-level rather than individual predictions.
Caring for all in the last year of life: making a difference.Bruce Mason
Inaugural presentation by Prof. Scott A. Murray, St Columba's Hospice Chair of Primary Palliative Care, Primary Palliative Care Research Group, Centre for Population Health Sciences: General Practice Section, University of Edinburgh. April 21, 2009
Evaluation and Management of Behaviors in Persons with Cognitive ImpairmentVITAS Healthcare
The goal of this webinar is to enable healthcare clinicians to implement a comprehensive approach to non-pharmacologic and pharmacologic management of dementia-related behaviors for the benefit of patients and their caregivers.
Carle Palliative Care Journal Club 1/15/2020Mike Aref
A journal club review and criticism of J Natl Cancer Inst. 2019 Dec 17. pii: djz233. doi: 10.1093/jnci/djz233 Emergency Department Visits for Opioid Overdoses Among Patients with Cancer by Jairam V, Yang DX, Yu JB, Park HS.
A diagnostic schema is a cognitive tool that allows clinicians to systematically approach a clinical problem by providing an organizing scaffold. A commonly used schema for acute kidney injury (AKI) separates this problem into pre-renal, intrinsic, and post-renal causes. By approaching AKI using these categories, clinicians can systematically access and explore individual illness scripts as potential diagnoses.
Sepsis & Hospice Eligibility: Natural History, Prognosis & Role of HospiceVITAS Healthcare
The goal of this webinar is to educate healthcare clinicians about the history, incidence, impact and identification of sepsis in the acute-care setting. Hospice care is inadequately utilized for patients with sepsis, a serious condition that results in 250,000 US deaths each year and an annual $3.5 billion in hospital readmission costs.
Palliative care is about providing well-being and the highest quality of life to patients with serious, progressive, chronic life-limiting illness, including during the dying process.
The goal of this webinar was to help hospice and healthcare professionals understand the history, philosophy, and practice of hospice and palliative care.
A Change in Behavior: A Pragmatic Clinical Guide to Delirium, Terminal Restle...VITAS Healthcare
The goal of this webinar was to help physicians and healthcare professionals differentiate delirium, terminal restlessness, and dementia-related agitation and aggression in patients near the end of life.
The goal of this webinar was to help hospice and healthcare professionals understand the history, philosophy, and practice of hospice and palliative care.
This document discusses the effects of an ALS diagnosis on individuals and their caregivers over five phases: pre-diagnosis, acute diagnosis, chronic, recovery, and terminal. It outlines the physical, behavioral, spiritual, cognitive and emotional responses individuals may experience during diagnosis. It also examines what matters most to those with moderate to severe disability, such as relationships and everyday life, and how patient suffering impacts caregiver well-being. The document provides guidance on how healthcare professionals can help individuals and caregivers adjust and cope with change and loss, and introduces palliative and hospice care at appropriate times.
This document discusses end-stage COPD and advanced lung disease. It defines advanced lung disease as chronic lung illnesses like emphysema and pulmonary fibrosis that greatly impair patients' ability to do normal activities. Patients with advanced lung disease experience significant distress from symptoms like shortness of breath. The document discusses how hospice services can help alleviate this distress by providing comprehensive symptom management, equipment, counseling and support for patients and their families. It also presents challenges around identifying when a patient's lung disease has reached an end-stage and discusses the advantages hospice can provide for COPD patients.
Three hour slide deck for basics of palliative care including what is palliative care, symptom management (pain, dyspnea, nausea, constipation), goals-of-care, family meetings, comfort care, and issues around artificial nutrition.
This document discusses high emergency department (ED) utilization and perceptions of opioid addiction in sickle cell disease (SCD). It finds that 20% of SCD patients account for 54% of ED visits, often due to lack of primary care, disease severity, or ages 18-30. While ED physicians and nurses believe over 20% and 30% of SCD patients respectively are addicted to opioids, the actual rate of addiction is under 10%. Behaviors intended to control pain can resemble addiction (pseudoaddiction), leading to undertreatment of pain in SCD patients. The document recommends identifying high utilizers lacking primary care and addressing psychosocial factors contributing to utilization, as well as fully treating SCD pain without fears of
Success Principle 12: End of life care for COPDNHS Improvement
A series of mix and match cards providing practical examples of changes you can make and how to implement them to improve care and quality at every step of the pathway for patients with COPD and asthma.
1) Dual process theory describes two modes of thinking: System 1 thinking is intuitive, quick, and based on pattern recognition. System 2 thinking is slow, analytical, and deliberate.
2) A 59-year-old man presented with chest pain and elevated cardiac troponin. Initial diagnosis was non-ST elevation myocardial infarction (NSTEMI) based on System 1 thinking.
3) Further examination revealed new cardiac murmurs, neurological symptoms, and asymmetric blood pressure, inconsistent with NSTEMI. This triggered a transition to System 2 thinking and a new diagnosis of aortic dissection was made.
An approach to mulitmorbidity in frail older adultsCamilla Wong
Ms. A is a 72-year-old woman with multiple chronic conditions including COPD, CAD, CHF, diabetes, and CKD. She has multimorbidity, with some conditions being concordant due to similar pathophysiology and management plans. Her diabetes may be considered the dominant condition. Over 10 years, her condition progresses with the addition of colon cancer and mild dementia. In her last year of life, she is frail and in the terminal phase of her multimorbidity. Interventions shift to advanced care planning, symptom management, and liaison with palliative care.
1) The document discusses the evolution of problem representation during a clinical encounter as more information is gathered. It provides an example of a case of a young woman initially presenting with fatigue and abdominal pain whose problem representation changes as additional symptoms of rash and facial palsy emerge.
2) Over the course of several visits and with additional testing revealing panuveitis and lung nodules, the problem representation evolves to that of a sexually active young woman with systemic symptoms consistent with acute sarcoidosis.
3) She is ultimately diagnosed with acute sarcoidosis and her symptoms resolve with corticosteroid treatment.
The goal of this webinar is to educate professionals on strategies for recognizing and addressing the unique physical, emotional, and behavioral manifestations of grief and loss among healthcare and other helping professionals.
This document summarizes a workshop on addressing the palliative and end-of-life care needs of people with dementia in hospitals. The workshop covered challenges in caring for people with dementia, communication strategies, recognizing dementia as a life-limiting illness, assessing pain and symptoms, the role of multidisciplinary teams, and available resources from the Irish Hospice Foundation. The presentation emphasized taking a person-centered approach, advance care planning, continuity of care, and the importance of staff training to meet the complex needs of people with dementia at the end of life.
This presentation discusses comfort-focused behavior management for people with dementia. It begins by outlining the session objectives and noting that human behavior and communication are connected. Two common dementia behaviors are identified as resisting care and refusing medication. The presentation then explores what these behaviors may be communicating, such as pain, fear, or not wanting to complete a task. It suggests remedies for addressing the underlying causes, like pain medication, slowing down interactions, or identifying personal routines. Overall, the presentation emphasizes making comfort the primary goal and observing behaviors for clues about an individual's needs and state of mind.
The document describes outcomes from the early years of a dementia outreach service. It discusses three cases:
1. An 80-year-old woman with Alzheimer's and mixed dementia whose agitation and hallucinations improved after stopping mirtazapine and starting regular paracetamol.
2. An 83-year-old woman with vascular dementia whose incontinence and signs of pain resolved with treatment but whose condition continued deteriorating with infections and decline.
3. A woman named June who died peacefully at home with her family after increasing support and symptom management during her decline and dying phase.
The document advocates for frequent review of people with advanced dementia to maintain comfort as their conditions and symptoms
This document provides information on various certification programs and courses offered by the Institute for Professional Care Education. It includes summaries of certification programs in advanced dementia care, care core certification, personal care aide certification, dementia care certification and developmental disabilities certification. Each certification includes multiple courses focused on different caregiving topics and skills. The document also provides details on individual courses, including course IDs, names, descriptions and durations.
Geriatric Population. Geriatric Palliative and End-of-Life Care.Michelle Peck
During your journey through this slide deck Geriatric Population. Geriatric Palliative and End-of-Life Care you will experience what it means to die badly.
After practicing as a Geriatric Clinician for over a decade what I know for sure is: Life is a tremendous gift. 100% of us are going to die. If you don't communicate your end-of-life plan, then you should plan on dying badly.
In The Cost of Dying: End-of-Life Care on CBS 60 minutes Steve Kroft interviews Doctor Ira R. Byock. “Families cannot imagine that there could be anything worse than their loved one dying, but in fact there are things worse, generally it’s having someone you love die badly.” ~Doctor Ira Byock
“Dr. Byock what do you mean dying badly?” ~Mr. Kroft
“Dying suffering, dying connected to machines, denial of death at some point becomes a delusion and we start acting in ways that make no sense whatsoever.” ~Doctor Ira Byock
A majority of Americans say they want to die at home. Why is this not happening?
Place of death should be regarded as an essential goal in end-of-life care.
Let’s explore how the end-of-life decision occurs?
For Doctors
Bernacki & Block (2014) found in their review and synthesis of best practices that physician attitudes, training, and perceptions of feeling inadequate in managing the emotional and behavioral reactions of patients all play a role. A majority of trainees were not taught how to communicate and they express strong desires to learn more. Physician barriers also include not addressing psychosocial concerns, placing focus on diagnoses, treatments, and procedures during discussions about the medical care at the end-of-life.
For Patients
Bernacki & Block (2014) found that patients who do bring up dying concerns with their physicians often meet barriers and often are not aware that they are at the end-of-life. Patients that have not set goals based on meaningful conversations about their desires may overuse life-prolonging treatment and underuse services that support quality of life.
Conclusion
Bernacki & Block (2014) found that there is a large body of evidence demonstrating that early discussions of serious illness care goals are associated with:
♛ beneficial outcomes for patients,
♛ no harmful adverse effects, and
♛ potential cost savings.
Apply & Do
To prevent dying badly start early conversations, enhance your knowledge and establish goals. Dreams are only dreams until you write them down. When you write dreams down then they become goals.
Do ♛ The Conversation Project a collaboration with the Institute for Healthcare Improvement. http://theconversationproject.org/starter-kit/intro/
Do your conversation kit now and make your loved ones aware of your wishes.
Wishing you the very best, Michelle
Bernacki RE, Block SD, for the American College of Physicians High Value Care Task Force. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014;174(12):1994-2003.
Palliative care for advanced dementia adopting a culture of comfortossmc
This document discusses adopting a culture of comfort for palliative care of advanced dementia. It outlines the progression of dementia and problems with antipsychotic use. The speaker describes implementing a comfort model at Beatitudes Campus that individualized care, liberalized diets, and used a soft approach. Positive outcomes included no episodes of problem behaviors, less antipsychotic use, more pain medication, and cost reductions. The presentation concludes that focusing on patient comfort can positively impact those with dementia.
This document provides information about discussing goals of care with family members of patients with dementia. It begins with an introduction and outlines the session goals. It then discusses the natural history and progression of Alzheimer's disease using the FAST scale. Data on the clinical course of advanced dementia is presented showing high rates of infections, eating problems, and burdensome interventions in the last months of life. Evidence is discussed regarding treating or not treating pneumonia and tube feeding. The role play provides an example case of a patient with advanced dementia to discuss goals of care.
The document discusses dementia, including some key points:
- Dementia is rapidly increasing in prevalence as the population ages. Scientists are struggling to find effective treatments.
- It affects memory, personality, and cognitive abilities. The most common cause is Alzheimer's disease.
- Risk factors include age, family history, smoking, and medical conditions like diabetes.
- Symptoms include memory loss, personality changes, mood swings, and difficulty with tasks. It gets progressively worse over time.
- There are currently no treatments to stop or reverse dementia, but medications can help manage symptoms. Maintaining physical and mental activity may help prevent or slow dementia.
1. Dementia is defined as a progressive impairment of cognitive functions occurring in clear consciousness. The most common causes are Alzheimer's disease, dementia with Lewy bodies, frontotemporal dementia, and vascular dementia.
2. Neuroimaging and neuropathological findings help characterize different dementias. Alzheimer's disease shows hippocampal and temporal lobe atrophy on MRI and beta-amyloid plaques and neurofibrillary tangles microscopically. Frontotemporal dementia presents with frontal and anterior temporal lobe atrophy.
3. Treatment involves pharmacological interventions like cholinesterase inhibitors and memantine for Alzheimer's, as well as non-pharmacological approaches like cognitive stimulation, environmental modifications, and
The document discusses dementia, including that the development of dementia is increasing rapidly as the population ages. It notes that the individual chose to research dementia because it is becoming more common and they want to work in healthcare. The document then provides an overview of dementia that will be discussed in more detail, including causes, symptoms, diagnosis and treatment. It states that dementia is not one disease but a collection of symptoms caused by various disorders.
The document discusses palliative care and end-of-life management for cancer patients in the terminal phase. It covers key topics like prognosis, communication with patients, common symptoms in the terminal phase, palliative care emergencies and their management, preferred places of care, specific issues related to spinal cord compression and superior vena cava obstruction, and therapeutic interventions in the last days of life. The overall aim is to help patients die with dignity while relieving suffering through careful symptom control and support.
The document discusses palliative care and end-of-life management for cancer patients in the terminal phase. It covers key topics like prognosis, communication with patients, common symptoms in the terminal phase, palliative care emergencies and their management, preferred places of care, specific issues related to different cancers, medication management, and transitioning from specialist to generalist care. The overall aim is to help patients die with dignity while alleviating suffering.
This document discusses the assessment and management of geriatric patients in emergency settings. It covers the demographics of the elderly population, the aging process, common medical problems in the elderly, trauma considerations, and approaches to assessing and managing elderly patients. Special attention is needed due to physiological changes, multiple illnesses, sensory impairments, and other age-related factors that can impact care.
This document provides an overview of palliative care, including:
1) Palliative care aims to relieve suffering and improve quality of life for patients facing serious illnesses, and involves addressing physical, emotional, and spiritual needs.
2) As the population ages and chronic diseases increase, more patients will benefit from palliative care services to improve end-of-life experiences and outcomes.
3) Prognostication, or predicting a patient's life expectancy, is an important but challenging skill for physicians, and palliative care aims to improve care based on patient preferences near the end of life.
The goal of this webinar is to help the healthcare professional understand how to identify patients with advanced Dementia/Alzheimer’s who may be eligible for the Medicare hospice benefit, and how the timely use of hospice care can address many of the challenges and complications experienced by these patients as they approach the end of life.
The Grey Tsunami - Regulating Aging ProfessionalsAngela Bates
This document discusses aging professionals and regulatory approaches. It notes that as the general population ages, the professional population does as well. Effects of normal aging include declines in cognition, though effects vary. Mild cognitive impairment and dementia are discussed as being on a cognitive continuum, with assessments and adaptations for professionals. Regulators may consider age-targeted assessments or restrictions like limiting solo practice for those with mild cognitive impairment.
Dr. Colin Depp, Associate Professor of Psychiatry at the University of California, San Diego and CREST.BD member, describes research on the changes, including positive ones, that occur as people grow older with bipolar disorder. He shares evidence and considerations for treatments for bipolar disorder in older adults, as well as an overview of the lifestyle and behavioral determinants of healthy aging. He also presents new research on the importance of these factors in aging well with bipolar disorder.
Colin Depp, Ph.D. is an Associate Professor of Psychiatry at the University of California, San Diego. He is also Associate Director of Research Education and Training Division of the San Diego Clinical Translational Science Institute and psychologist at the Veterans Administration Healthcare System in San Diego. His research focuses on psychosocial interventions for bipolar disorder, use of technology for behavioral change, and the determinants of successful aging in people with mental illnesses. Dr. Depp is a principal investigator or co-investigator on multiple studies and he on the Editorial Board of Bipolar Disorders.
This document discusses end of life care decisions in the emergency department. It presents a case scenario of an 86-year-old lady presenting with shortness of breath, chest pain, and other symptoms who is admitted to the ICU and put on life support against her family's wishes. It then poses questions about the issues, ethical considerations, and medico-legal issues around end of life care decisions in the emergency department. It also provides context on tools and guidelines around identifying patients suitable for palliative versus aggressive care.
This document discusses ALS, including its definition, disease progression, prognosis, and palliative care approaches. ALS is a fatal neurodegenerative disorder that results in the loss of motor neurons in the brain and spinal cord. It leads to progressive muscle weakness, paralysis, and eventual death from respiratory failure. While there is no cure, multidisciplinary palliative care can help manage symptoms, discuss goals of care, and potentially prolong survival and quality of life through interventions like noninvasive ventilation and nutritional support.
Vinay Prassad, hematólogo-oncólogo y profesor de Medicina en la Oregon Health and Sciences University. Ponencia presentada en el marco de la jornada Cómo revertir prácticas clínicas de escaso valor organizada por la Societat Catalana de Gestió Sanitària el 18 de mayo de 2018.
Holly Thacker, Update on: Menopause, Hormone Therapy, Sex, Politics, and the ...Cleveland HeartLab, Inc.
This document provides an overview and summary of a presentation on menopause, hormone therapy, cardiovascular health, and women's health issues. It discusses the aftermath of the Women's Health Initiative study 12 years later, compares risks of hormone therapy to other medications, and examines risk/benefit ratios of hormone therapy for cardiovascular disease. It also addresses politics surrounding women's health issues and "war on women" narratives related to hormone therapy. The presentation aims to provide an updated perspective on these issues based on newer research findings.
This document outlines a presentation about cellular aging and its relationship to depression. It discusses how depression may be linked to accelerated aging at the cellular level, as evidenced by shorter telomeres and lower telomerase activity in depressed individuals. Certain lifestyle factors like exercise, diet and meditation may help lengthen telomeres and increase telomerase activity, potentially preventing or reversing some effects of depression-associated cellular aging. The presentation explores the implications of this research and how conceptualizing depression as a systemic illness could lead to novel treatment targets.
End of life decisions are important issues that often require difficult conversations. While many patients prefer to die at home or avoid aggressive medical care, current practices often result in deaths in hospitals or with intensive interventions. However, research shows that discussing end of life options with physicians does not cause patients emotional harm and may result in care more aligned with patients' preferences. Such discussions can also benefit families by increasing their understanding and satisfaction with end of life care. While medical futility can be a complex issue, avoiding guesswork and ensuring quality end of life care options are available benefits both patients and families.
This document discusses various topics related to end of life care, including palliative care, hospice care, pain management, common symptoms, and more. It provides information on:
1) Palliative care aims to make patients as comfortable as possible, while hospice care focuses on those with a life expectancy of 6 months or less.
2) Common symptoms at end of life include pain, nausea, breathlessness, weight loss, and fatigue. Opioids, antiemetics, oxygen, corticosteroids, and other drugs can help manage these symptoms.
3) Additional issues covered include depression, delirium, anorexia, dyspnea, neuropathics pain, bone
This document discusses various topics related to end of life care, including palliative care, hospice care, end of life in the ICU, common symptoms at end of life, and their management. It addresses pain management, including assessment of pain and the WHO pain ladder. It also discusses management of other common symptoms like nausea/vomiting, dyspnea, fatigue, anorexia/cachexia, depression, delirium, and euthanasia. Important court cases related to passive euthanasia in India and other countries are also summarized.
1. The document discusses sleep, sleep disorders like sleep apnea, and how sleep changes with age. It covers the definition of sleep, sleep stages, consequences of sleep deprivation, and prevalence of sleep disorders.
2. Treatment options for sleep apnea are discussed, including CPAP, oral appliances, and surgery. Diagnosis involves a sleep study.
3. Sleep changes as people age, with less deep sleep and more nighttime awakenings. Medical conditions can also affect older adults' sleep. Seeking help from a sleep specialist is recommended for persistent sleep issues.
This document discusses the need for palliative care in the emergency department setting. It notes that many seniors visit the ED in their last month of life and cancer patients often come in their last two weeks. The ED is not well equipped to address patient goals and priorities at end of life. The document provides guidance on discussing goals of care with patients and families using a roadmap approach. It emphasizes focusing on quality rather than quantity of life. Case examples are presented and outcomes of a palliative care program in one ED are described.
Critical care involves managing organ system failures while considering the overall clinical picture of the patient. Less invasive interventions are preferred when possible to avoid iatrogenic harm. Prognostication is difficult, and outcomes depend on the individual patient's values and preferences. Family meetings require skilled communication to make difficult end-of-life decisions. The goal is providing humane care that aligns with patient priorities through a team-based approach.
Geriatrics focuses on healthcare for the elderly aged 65 and over. It aims to promote health and prevent/treat diseases in older adults. Key competencies include managing cognitive/behavioral disorders, medications, mobility issues, atypical disease presentation, and palliative care. Geriatric medicine considers age-related decline of organs over a lifetime of habits. Common geriatric conditions include dementia, Alzheimer's, cancer, diabetes, heart disease, osteoporosis, Parkinson's, sleep disorders, and stroke. Most older adults take multiple daily medications which can impact hospital care if not reported. Specialties include rehabilitation, psychiatry, cardiology, and oncology tailored to senior needs. Treating geriatrics involves complex legal and medical
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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2. Objective
The overall objective of this talk is to understand how
dementia is unique and important in our line of work
and how we, as a multidisciplinary palliative care team
can help patients’ and their families navigate through
the challenges of this disease.
4. Epidemiology
Population > 65 expected to increase from 12.6% in
2010 to 19.3% in 2030
> 80 years increase from 3.7% to 5.1%
Life expectancy increase to 79.5 by 2020
US Census Bureau Accessed July 22, 2010.
US Census Bureau. Expectations of life at birth.
5. Epidemiology
Dementia increases
exponentially with age
1% at 60 yrs to more
than 20% at 85 yrs
People with dementia
estimated to reach 81.1
million by 2030
O’Connor DW.
Ferri CP et al.
6. Definition
Dementia: significant
deterioration in
cognitive abilities severe
enough to interfere with
everyday life
Palliative care: Improves
quality of life for patients
and families
O’Connor DW.
7. Definition
Most frequent cause is Alzheimer followed by vascular
dementia and then dementia with Lewy body ( DLB )
Langa KM, et al.
14. Non Pharm Management
Cognitive Dysfunction
Diminish quality of life
Agitation
Conflict of caregiver vs patient
Non pharmacologically first
Koopmans RT et al.
Kverno KS et al.
15. Non Pharm Management
Art Therapy
Music Therapy
Activity Therapy
Aroma Therapy
Douglas, S et al.
Burns, A et al.
16. Non Pharm Management
Cognitive Dysfunction
SPECAL method-Three Golden Rules
Don’t Ask Questions
Listen to the expert
Don’t Contradict
Contented Dementia Trust
17. Non Pharm Management
Cognitive Dysfunction
Snoezelen approach
Van Weert JC et al.
multisensory stimulation
18. Pharmacology Treatment
Cognitive Dysfunction
Rule out medical causes
Pharmacologic interventions concurrently
Risperidone and olazapine
Some antidepressants and neuroleptics
Ballard C et al.
Pollock BG et al.
Lanctot KL et al.
19. Pharmacology Treatment
Cholinesterase inhibitors ( eg. donepezil)
Delays progression for about 6 mo
Memantine for more advanced disease
Mainstay for vascular dementia is risk reduction
Burns A, et al.
Roman G.
20. Pharmacology Treatment
Pharmacologic treatment not curative
Dementia is a progressive terminal illness
Final stages similar for all dementia
Mod to severe dementia (MMSE<18) survive > 4 yrs
Corey-Bloom J et al.
McKeith IG, et al.
Larson EB et al.
21.
22. Gazing into the Crystal Ball
Encourage advanced care planning!
23. Challenging Decisions
Study showed 40.7% with advanced dementia
underwent at least one of following in last 3 months of
life
Hospitalizations
ER visit
Parenteral Therapy
Feeding tube
Mitchell SL, et al.
24. Challenging Decisions
CPR
Unless witnessed in-hospital arrest caused by V-fib;
survival is 0.8%
Chances of being discharged alive following arrest are
almost nil
Herlitz J, et al.
25. Challenging Decisions
Feeding
Knowledge versus emotion
Does not improve survival or functional status
Associated with post op complications
Advocate for comfort feeding
Sampson EL, et al.
Finucane TE, et al.
26. Challenging Decisions
Information to be provided to the resident and
family should include:
• Common causes of eating and
swallowing
• Technical considerations
regarding placement and use
of peg tubes
• Principles of benefits of tube
feeding
• Considerations regarding
future discontinuation of PEG
tube.
Data from Mitchell SL et al.
Steps to Decision Making Include
• Guiding residents and their families through
what they have learned about PEG tubes
• How to apply this knowledge to the resident's
preferences, personal values and clinical
situation
• What is the residents' situation?
• What would the resident want?
• How is the decision affecting the family?
• What questions need answering
• Who should decide about the PEG tube
placement?
• When should the PEG be disbanded?
• What is the resident’s or the family’s overall
thoughts about the decision?
27. Challenging Decisions
Hydration
Differentiate dehydration and thirst
Hydration doesn't improve symptoms associated with
dehydration
Risk of complications
Start based on individual cases
Jenkins CA et al.
Viola RA et al.
28. Challenging Decisions
Acute Care Hospitalizations
Complications
Transfer to acute care hospital for pneumonia might
increase mortality
Mitchell SL, Kiely DK et al.
Thompson RS et al.
29. Challenging Decisions
Acute Illness/Pneumonia
No consensus
No benefit from abx vs better short term survival with
more aggressive abx therapy
Lack of scientific evidence of this area
Congedo M et al.
Volicer L et al.
Van Der Steen JT et al.
Kruse RL et al.
33. Challenging Decisions
Chronic Diseases
Never Appropriate
LipidLowering
Medication
Parsons C et al.
Anti-platelets
excluding
aspirin
Antiestrogens
Sex
Hormone
Cytotoxic
Chemotherapy
Hormone
Antagonist
34. Challenging Decisions
Dementia Medications
Recommended as long as clinic benefit
Stopped in MMSE< 10 for Cholinesterase inhibitors; < 3
for Memantine
80% medical directors recommend stopping at hospice
30% accelerated cognitive and functional decline
Shega et al.
Sengstaken et al.
35. Understanding the Loss
Developmental
milestone of
children
Developmental
regression of
dementia
37. Summary
Prevalence of Dementia is increasing internationally
Management of advanced dementia involves a
multidisciplinary team
Advance care planning is critical
Reframing dementia rather than battling dementia is
vital
38. Work Cited
US Census Bureau. International data base. Available at:
www.census.gov/ipc/www/idb/groups.php. Accessed July 22, 2010.
Statistics Division 2010, Social indicators, Indicators on health, United Nations, New York
NY 10017 USA, viewed 5th
May, 2011, <http://unstats.un.org/unsd/demographic/products/socind/health.htm>.
US Census Bureau. Expectations of life at birth, 1970 to 2006, and projections,2010 to
2020. Available at: www.census.gov/compendia/statab/2010/tables/ 10s0102.pdf.
Accessed July 22, 2010.
O’Connor DW. Epidemiology. In: Burns A, O’Brien J, Ames D, editors. Dementia. 3rd
edition. London: Edward Arnold; 2005. p. 16–23.
Langa KM, Foster NL, Larson EB. Mixed dementia: emerging concepts and therapeutic
implications. J Am Med Assoc 2004;292:2901–8.
Burns A, O’Brien J, Auriacombe S, et al. Clinical practice with anti-dementia drugs: a
consensus statement from British association for psychopharmacology. J
Psychopharmacol 2006;20:732–55.
Roman G. Therapeutic strategies for vascular dementia. In: Burns A, O’Brien J, Ames
D, editors. Dementia. 3rd edition. London: Edward Arnold; 2005. p. 574–600.
Corey-Bloom J, Fleisher AS. The natural history of Alzheimer’s disease. In: Burns
A, O’Brien J, Ames D, editors. Dementia. 3rd edition. London: Edward Arnold; 2005. p.
376–86.
39. Work Cited
McKeith IG, Ince P, Jaros EB, et al. What are the relations between Lewy body disease and
AD J Neural Transm Suppl 1998;54:107–16.
Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J
Med 2009;361:1529–38.
Larson EB, Shadlen MF, Wang L, et al. Survival after initial diagnosis of Alzheimer
disease. Ann Intern Med 2004;140:501–9.
Herlitz J, Eek M, Engdahl J, et al. Factors at resuscitation and outcome among patients
suffering from out of hospital cardiac arrest in relation to age. Resuscitation 2003;58:309–
17.
Mitchell SL, Kiely DK, Hamel MB. Dying with advanced dementia in the nursing home.
Arch Intern Med 2004;164:321–6.
Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced
dementia. Cochrane Database Syst Rev 2009;2:CD007209.
Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a
review of the evidence. J Am Med Assoc 1999;282:1365–70.
Jenkins CA, Schulz M, Hanson J, et al. Demographic, symptom, and medication profiles
of cancer patients seen by a palliative care consult team in a tertiary referral hospital. J
Pain Symptom Manage 2000;19:174–84.
40. Work Cited
Central Intelligence Agency 2011, The World Factbook, ISSN 1553-8133, Central
Intelligence Agency, Washington, DC, viewed 5th May, 2011,
<https://www.cia.gov/library/publications/the-world-factbook/fields/2102.html>.
Viola RA, Wells GA, Peterson J. The effects of fluid status and fluid therapy on the dying:
a systematic review. J Palliat Care 1997;13:41–52.
Thompson RS, Hall NK, Szpiech M, et al. Treatments and outcomes of nursinghomeacquired pneumonia. J Am Board Fam Pract 1997;10:82–7.
Congedo M, Causarano RI, Alberti F, et al. Ethical issues in end of life treatments for
patients with dementia. Eur J Neurol 2010;17:774–9.
Volicer L, Rheaume Y, Brown J, et al. Hospice approach to the treatment of patients with
advanced dementia of the Alzheimer type. J Am Med Assoc 1986;256:2210–3.
Van der Steen JT, Kruse RL, Ooms ME, et al. Treatment of nursing home residents with
dementia and lower respiratory tract infection in the United States and The Netherlands:
an ocean apart. J Am Geriatr Soc 2004;52:691–9.
Van der Steen JT, Mehr DR, Kruse RL, et al. Treatment strategy and risk of functional
decline and mortality after nursing-home acquired lower respiratory tract infection: two
prospective studies in residents with dementia. Int J Geriatr Psychiatry 2007;22:1013–9.
41. Work Cited
Shega JW, Ellner L, Lau DT, et al. Cholinesterase inhibitor and N-methyl-D-aspartic acid
receptor antagonist use in older adults with end-stage dementia: a survey of hospice
medical directors. J Palliat Med 2009;12:779–83.
Sengstaken EA, King SA. The problems of pain and its detection among geriatric nursing
home residents. J Am Geriatr Soc 1993;41:541–4.
Morrison RS, Siu AL. A comparison of pain and its treatment in advanced dementia and
cognitively intact patients with hip fracture. J Pain Symptom Manage 2000;19:240–8.
Kverno KS, Black BS, Blass DM, et al. Neuropsychiatric symptom patterns in hospiceeligible nursing home residents with advanced dementia. J Am Med Dir Assoc
2008;9:509–15.
Koopmans RT, van der Molen M, Raats M, et al. Neuropsychiatric symptoms and quality
of life in patients in the final phase of dementia. Int J Geriatr Psychiatry 2009;24:25–32.
Van Weert JC, van Dulmen AM, Spreeuwenberg PM, et al. Behavioral and mood effects of
snoezelen integrated into 24-hour dementia care. J Am Geriatr Soc 2005;53:24–33.
Ballard C, Waite J. The effectiveness of atypical antipsychotics for the treatment of
aggression and psychosis in Alzheimer’s disease. Cochrane Database Syst Rev
2006;1:CD003476.
42. Work Cited
Van der Steen JT, Mehr DR, Kruse RL, et al. Treatment strategy and risk of functional decline
and mortality after nursing-home acquired lower respiratory tract infection: two prospective
studies in residents with dementia. Int J Geriatr Psychiatry 2007;22:1013–9.
Kruse RL, Mehr DR, van der Steen JT, et al. Antibiotic treatment and survival of nursing home
patients with lower respiratory tract infection: a cross-national analysis. Ann Fam Med
2005;3:422–9.
Pollock BG, Mulsant BH, Rosen J, et al. A double-blind comparison of citalopram and
risperidone for the treatment of behavioral and psychotic symptoms associated with dementia.
Am J Geriatr Psychiatry 2007;15:942–52.
Lanctoˆ t KL, Herrmann N, van Reekum R, et al. Gender, aggression and serotonergic function
are associated with response to sertraline for behavioral disturbances in Alzheimer’s disease.
Int J Geriatr Psychiatry 2002;17:531–41.
Ferri CP et al. Global prevalence of dementia: a Delphi consensus study. Lancet, 2005, 366
(9503): 2112–2117.
Takeda et al. (2008), Mild cognitive impairment and subjective cognitive impairment.
Psychogeriatric, 8: 155–160. doi: 10.1111/j.1479-8301.2008.00258
Kruse RL, Mehr DR, van der Steen JT, et al. Antibiotic treatment and survival of nursing home
patients with lower respiratory tract infection: a cross-national analysis. Ann Fam Med
2005;3:422–9.
Editor's Notes
The purpose of this presentation is not to delve into the details of the pathophysiology of dementia and the specific type of medications used to treat it. No, rather the point of this talk is to understand how dementia is unique and important in our line of work and how we can help patient’s and their families navigate through the challenges of this disease. To do this, I will start by reviewing the the epidemiology of dementia, then discuss how the most common type of dementia present. We will then go into the general approach to management of patients with cognitive dysfunction as well as management of the secondary symptoms as a multidisciplinary team. We will then continue by navigating through the challenging decisions that patients and their families have to make and conclude by teaching how we can reframe hope.
The aging of the population is a worldwide phenomenon. Between 1980 and 1998, the world's average life expectancy at birth rose from 61 to 67 years, with the most dramatic increases occurring in the low- and middle-income countries. As of 2011, the world life expectancy at birth is 67.07 years of age. More specifically in males it is 65.21 year and in females 69.05
In the United States, for example, the proportion of the population older than 65 years is expected to increasefrom 12.6% in 2010 to 19.3% in 2030, whereas the proportion older than 80 years is expected to increase from 3.7% to 5.1% in the same period.Life expectancy is currently (75.1 years for men and 80.2 years for women), and is expected to increase to79.5 years by 2020
Although dementia is not exclusive to thegeriatric population, its prevalence increases exponentially with age, going from only 1% at 60 years old to more than 20% at 85 years and older. With the aging of the population, the number of patients with dementia is expected to keep rising.In 2005, Alzheimer’s Disease International (ADI) commissioned a panel of experts to review all available epidemiological data and reach a consensus estimate of prevalence in each of 14 world regions. The panel estimated 24.3 million people age 60 years and over with dementia in 2001, 60% living in Low and middle income countries. Each year, 4.6 million new cases were predicted, with numbers affected nearly doubling every 20 years to reach 81.1 million by 2030.
Dementia is an acquired syndrome characterized by a significant deterioration in an individual’s usual cognitive abilities, which provokes a functional decline severe enough to interfere with his everyday life.We are palliative care givers. We are in the business of improving of quality of life patients and their families. With this growing demographic of patients, understanding this disease and how we can use the palliative approach to provide better for these patients is extremely relevant.
There are many medical and neurologic conditions that can manifest as a dementia syndrome. The most frequent causes in the geriatric population are Alzheimer disease, accounting for about 60% of all cases, followed by vascular dementia and dementiawith Lewy bodies. Mixed dementia, usually defined as the coexistence of Alzheimer disease and vascular dementia, is also recognized as a major cause of cognitiveimpairment in older patients
Memory Impairment: Early impairment of episodic memory, later impairment of sematic memoryMain features: Language impairment, progression to mutisim, disorientation; visiospatial and object manipulation difficulties, impaired object recognition Executive dysfunctionNeuropsychiatric symptoms: Present in moderate to advanced diseaseNeurologic signs: May be present in later stages: opposition, rigidity, paratonias, parkinsonism, myoclonus, tonic clonic seizures
Memory Impairment: caused by difficulties in retrieving stored information; more dramatically/rapidly seen than in Alzheimer Main features: Psychomotor slowing; inattention; Dysexcutive syndromeNeuropsychiatric symptoms: Frequent. Depression; apathy, emotional liabilityNeurologic Signs: Soft or subtle: magnetic gait, loss of postural reflexes, urinary incontinence
Memory Impairment: Episodic memory impairment less present in early stages, becomes evident as disease progressMain Features: One year rule: less than 1 year between onset of parkinsonism and dementia (vs dementia related to Parkinson disease, which occurs in late stages). Might progress more rapidly than Alzheimer disease. Early executive and visuo-perceptutal impairment. Fluctuations in attention, cognition or alertness.Neuropsychiatric Symptoms: Detailed and recurrent visual hallucinations REM sleep behavior disorder Neurologic signs: Spontaneous parkinsonism Autonomic dysfunction early in disease with postural hypotension that can cause syncope and falls. Less than 50% of patients with DLB present a severe neuroleptic sensitivity, presenting as a sudden exacerbation of parkinsonism, impaired consciousness, or a neuroleptic malignant syndrome. This reaction is seen both with typical or atypical antipsychotics, and it can be immediate or seen within the first weeks of either first exposure or dose increase. Carefulconsideration before prescribing this type of medication is therefore warranted.
Another way of approaching Dementia especially to make it more relatable to our patients and their family is to think of our experiences in life is recorded as a photograph and stored in our album. With this theory, each photograph has two features: Facts and associated feelings. Photographs are stored in our album a split second after each experience, and this storage requires no effort from us whatsoever. Initially, Dementia introduces an entirely new type of photograph: a photograph in which the facts of what has just occurred are not stored, although the feelings associated with the missing facts are stored.Eventually, feelings become very much more important than facts for the person with dementia. They will turn back to much olderpages in their album, trying to make the most useful match they can between what is happening to them in the present - in the here and now – and other photographs from long ago, before dementia started to disrupt their life.
In a retrospective survey of care givers in England, McCarthy et al(1997) reported a host of secondary symptomsand signs experienced by people with dementia in the last year of life: urinary incontinence (72%), pain (64%), low mood (61%), constipation (59%) and loss of appetite (57%).Please refer to the following modules for detailed information on how to manage these secondary symptoms. I would like to use this talk to spend time the symptom that is the hallmark of this disease. Cognitive dysfunction.
The symptoms related to cognitive dysfunction provide the most problems not only for the person with dementia and the care givers, but also in relation to clinical management. The most obvious related symptoms are agitation, aggression, mood disorders and psychosis, but other important symptoms include sexual disinhibition, eating problems and abnormal vocalisations. It takes the whole team to properly address these issues. Every member of the team has a critical role to play in helping to provide the best care for these patients and managing these symptoms.
Agitation, manifested by repetitive mannerisms and vocalizations or physical aggressiveness, seems to beassociated mostly with restiveness to care. This behavior happens during interaction between the severely demented person and a family member or caregiver, and is caused by a lack of understanding.The patient normally wants to just wander, they have this restless about them, and the caregiver wants them to just sit still. This conflict, and insensitiveness on the part of the caregiver leads to aggressive behavior on the part of the patient because they don’t understand the need to be still.This behavior should first be managed with non pharmacologic and environmental approaches, using a gentle approach and adapting to the patient’s routine or pattern.
Art therapy:Activities such as drawing and painting are thought to provide individuals with the opportunity for self-expression and the chance to exercise some choice in terms of the colors and themes of their creations.Music Therapy: The therapy may involve engagement in a musical activity (e.g. singing or playing an instrument), or merely listening to songs or music. It has been shown that music therapy increases the levels of well-being, better social interaction and improvesautobiographical memory in a group of nursing home residents who regularly had music played to them.Activity Therapy: Activity therapy involves a rather amorphous group of recreations such as dance, sport and drama. It has been shown that physical exercise can have a number of health benefits for people with dementia, for example reducing the number of falls and improving mental health and sleep.Aromatherapy:Aromatherapy is one of the fastest growing of all the complementary therapies. It appears to have several advantages over the pharmacological treatments widely used for dementia. It has a positive image and its use aids interaction while providing a sensory experience. It also seems to be well tolerated in comparison with neuroleptic or sedative medication. The two main essential oils used in aromatherapy for dementia are extracted from lavender and melissa balm. They also have the advantage that there are several routes of administration such as inhalation, bathing, massage and topical application in a cream. This means that the therapy can be targeted at individuals with different behaviors: inhalation may be more effective than massage for a person with restlessness, for instance.
The SPECAL Method which stands for Specialized Early Care for Alzheimer’s focus on three simple rules to help increase the person’s confidence, slow the rate of deterioration and reduce the need the medication. It is the hope that by implementing the following three simple rules, one would enable the person to remain in their own home for longer and minimize the distress during and after a transition into a different care setting. Don’t ask questions-Avoid asking any direct question that requires the person with dementia to search their photograph album for factual information that may not have been stored. Their desperate search for missing facts will only increase their perception of their own disability, causing them unnecessary distress. It is surprising how much information you can gather from the person with dementia without asking directquestions.Listen to the expert- Listen to the questions the person with dementia is asking, and consider very carefully what the best answer might be for them. For people with dementia, feelings are more important than facts, and the information that is given to them from now on must generate good feelings for them. There is a moral imperative not to cause them any more anxiety than they are already experiencing. Once you have found the best answer to a question, it should be used consistently by everyone coming into contact with the person. Then move on to the next most frequent question. Using this method may help reduce the anxious questioning gradually subsides.Don’t Contradict-Do not argue with the person with dementia. They are increasingly likely to seek out old photographs from their pre-dementia past, in order to understand what is happening in thepresent. We need to take careful note of the person’s language when they do this, so that we can adapt to them, rather than expecting them to follow our lead.
Snoezelen, an approach using controlled multisensory stimulation (lighting effects, color, sounds, music, scents) has been shown to reduce agitated and withdrawn behavior in patients with Alzheimer disease during treatment sessions, but without evidence of longer-term benefits.
In cases of end-stage behavioral disturbances or symptoms of cognitive dysfunction that are not related to restiveness to care, an underlying physical or medical cause should always be investigated.These causes include symptoms of pain, thirst, hunger, sleep difficulties, constipation, sensory deprivation or overstimulation, social withdrawal, discomfort caused bybad position, or an or infection (eg, pneumonia). Physicians must also exclude the adverse effects of delirium or medications.The only time the evidence shows to use pharmacologic interventions concurrently with non pharmacology approaches is in the presence of severe depression, psychosis or aggression that puts the patient or others at risk of harm. First-step agents for severe agitation, aggression, and psychosis are risperidone and olanzapine. The potential benefit of all antipsychotics must be weighed against the potential risks, eg (extrapyramidal symptoms)Alternatives to antipsychotic medications are memantine,citalopram, sertraline, trazodone,andcarbamazepine, which have shown some benefits in the treatment of psychosis, agitation, and aggressionassociated with dementia.However, medication should never be an alternative to an insufficient ratio of personnel, staff education about non pharmacological approaches.
Pharmacologic treatments of Alzheimer and Lewy body dementia mostly consist of cholinesterase inhibitors (donepezil, rivastigmine, galantamine), which can slow the deterioration of the cognition in patients with mild to moderate dementia, delaying progression for approximately 6 months when effective.Memantine, an antagonist of the N-methyl-D-aspartate (NMDA) receptor, sometimes reduces symptoms in patients with more advanced disease.Although cholinesterase inhibitors and memantine have also been reported to delay the progression of vascular dementia, mainstay of therapy is prevention of vascular disease by reducing risk factors.
Because pharmacologic treatment is not curative but simply delays the progression, dementia is now recognized as a progressive terminal illness.And although the type of dementia is important to predict its clinical course and select the appropriate pharmacologic treatment, the final stages, which are mostly of interest for palliative care, are similar for all types of dementia. Most epidemiologic studies have reported a median length of survival of approximately 6 years after diagnosis for patients with Alzheimer disease, possibly slightly less and more variable for Lewy body disease, and of 41 to 60 months for vascular dementia.
This table allows one to look at the progression of dementia in relation to the prognostic indicators such as the Clinical Dementia Rating Scale and FAST. The CDR breaks down the span between the healthy brain to severe dementia into five stages: 0, normal healthy; 1, mild dementia; 2, moderate dementia; and 3, for severe dementia. Between Stages 0 and 1 on the CDR is the Stage 0.5, ‘questionable dementia’, which is described as mild memory loss with intact orientation, full achievement on the activities of daily living (ADL), with slight impairment in social activity but fully independent activity in daily life. Individuals in CDR Stage 0.5 show only slight forgetfulness, partial memory loss, with little impairment in time recognition and full recognition in space and person.It has been said that the point of death is usually between a MMSE score of 5 and 0.
With these two similar ways of viewing dementia, what is the best way to care for these patients? As with all progressive and noncurable illnesses, advanced care planning should be encouraged for all patients with dementia, and should start when the diagnosis is made, to facilitate decision making at the end of life. Because most patients withadvanced dementia as their photographs go missing or fade away are no longer able to express wishes and preferences for level of care, the presence of a living will should be sought.We might be able to gaze into the crystal ball and help families and their loved one plan ahead.
The difficult decisions we are often called upon to help the families make. In a recent prospective study, 40.7% of nursing home residents with advanced dementia underwent at least 1 burdensome intervention (hospitalization, emergency room visit, parenteral therapy, tube feeding) in their last 3 months of life.22 Patientswhose proxies had a better understanding of the poor prognosis of advanced dementia were less likely to undergo such an intervention.
The likelihood of a successful cardiopulmonary resuscitation in an older patient is extremely low (0.8%), except for specific cases such as a witnessed in-hospital arrest caused by ventricular fibrillation.In a patient with advanced dementia, the chances of being discharged alive from the hospital following a cardiopulmonary arrest are almost nil. In the rare cases that it might happen, the experience would surely be traumatic for the patient and family, associated with unnecessary pain and suffering, andleaving the patient with additional disabilities.
Feeding always becomes a difficult problem in patients with severe dementia, for several reasons. They often develop dysphagia, leading to poor oral intake, malnutrition,and weight loss. Patients also sometimes refuse to open their mouth and to eat.Even though we know that decreased oral intake might be partly related to a lower basal metabolic rate and decreased caloric needs, many family members and health care professionals have difficulties leaving a patient without nutrition, which often triggers the placement of a feeding tube. Several studies have shown that tube feeding does not preventmalnutrition or pressure sores, and does not improve survival or functional status.PEG tube placement can also be associated with postoperative complications (in 32%–70% of cases) and discomfort, either from the procedure, the presence of the tube, or the need for restraints to prevent patients from pulling the tube out.To alleviate the families members fear of abandonment of the patient or the patient suffering or being hungry, advocate for comfort feeding rather than placement of feeding tube. Using hand feeding when the patient agrees to open his/her mouth and shows no signs of distress aiming to maximize comfort rather than oral intake.
Here is a guideline that families can be used for families.
The decision to use or withhold parenteral hydration in patients who are unable to maintain adequate oral hydration is as challenging as the decision on feeding tubes.When making this decision, one should be aware of the difference between dehydration and thirst. Dehydration refers to the loss of normal body water and manifests itself by things like dry skin and mucous membranes, thickened secretions, decreased urine output, postural hypotension, irritability, headaches, drowsiness, constipation, weight loss, and disorientation.Thirst is a symptom that usually does not respond to medical treatments, and is best treated by small amounts of fluid or ice chips, and keeping the resident’s mouth and lips moist.There is currently no evidence that parenteral hydration can improve comfort or reduce symptoms associated with dehydration, such as pressure sores or constipation, in patients with end-stage cancer.39,40 To our knowledge, there hasbeen no study of parenteral hydration in patients with advanced dementia.Parenteral hydration, whether it is intravenous or subcutaneous, is associated with a risk of complications such as cellulitis at the site of catheter insertion, discomfort from catheter placement and presence, fluid overload.Because of the lack of evidence for benefits of parenteral hydration, the decision on its use should be individualized and based on the patient’s or family’s wishes, as well as unique circumstances.For example, temporary hydration might be appropriate in the event of an acute illness such as diarrhea, vomiting, or infection. When decreased hydration is caused by patient’s decreased oral intake, oral hydration can often be increased by using simple interventions and frequently encouraging the patient to drink small amounts of fluids when possible.
Admission to an acute care hospital or an emergency room can be detrimental to older patients, and even more so if demented. They are more likely to suffer from complications like delirium, falls, decreased oral intake, nosocomial infections.One study even showed that rather than improving survival, transfer from a nursing home to an acute care hospital for the treatment of a pneumonia might increase the risk ofmortality and functional deterioration in patients with advanced dementia.For these reasons, risks and benefits shouldalways be weighed when considering admitting a patient with advanced dementia to an acute care hospital, either from the community or a nursing home. The decision should be made in collaboration with a well-informed surrogate decision maker
Before one decides to treat an acute illness such as cardiac events, pulmonary embolisms or infections, you once again want to look at the expected benefits, risks, and discomfort and their overall goals of care.Pneumonia is particularly challenging because of its high prevalence in patients with dementia due to the high incidence of dysphagia in this population and it might be responsible for up to 40% of deaths. Though there is no consensus on the appropriateness of treating pneumonia in a patient with advanced dementia, some studies suggest that antibiotics do not improve survival or comfort. Other do show however, better short term survival in patients with more aggressive antibiotic therapy.There is a clear lack of scientific evidence in thisarea. The decision to treat or not to treat a pneumonia in a patient with advanced dementia should therefore be based on clinical judgment, which has been shown to be adequate in a high proportion of case.s
Because of limited life expectancy and consequent low long term benefits of some therapy, such as treatment of dyslipidemia or osteoporosis; treatment of some chronic diseases might not be appropriate.Even knowing this, we as medical care takers have difficulty stopping some of these medications because of the lack of scientific evidence supporting one option or the other.These next two slides are a recommendations from a modified Delphi consensus panel.
Because of limited life expectancy and consequent low long term benefits of some therapy, such as treatment of dyslipidemia or osteoporosis; treatment of some chronic diseases might not be appropriate.Even knowing this, we as medical care takers have difficulty stopping some of these medications because of the lack of scientific evidence supporting one option or the other.These next two slides are a recommendations from a modified Delphi consensus panel.
Because of limited life expectancy and consequent low long term benefits of some therapy, such as treatment of dyslipidemia or osteoporosis; treatment of some chronic diseases might not be appropriate.Even knowing this, we as medical care takers have difficulty stopping some of these medications because of the lack of scientific evidence supporting one option or the other.These next two slides are a recommendations from a modified Delphi consensus panel.
Because of limited life expectancy and consequent low long term benefits of some therapy, such as treatment of dyslipidemia or osteoporosis; treatment of some chronic diseases might not be appropriate.Even knowing this, we as medical care takers have difficulty stopping some of these medications because of the lack of scientific evidence supporting one option or the other.These next two slides are a recommendations from a modified Delphi consensus panel.
We have already talked about the specific medications used to treat the various causes of dementia, and we are aware of their side effects. So, when do we stop them?In a recently published survey, 80% of hospice medical directors surveyed recommend discontinuing cholinesterase inhibitors and memantine at the time of hospice enrolment.However, approximately 30% have observed accelerated cognitive and functional decline or emergence of challenging behaviors with medication discontinuation. Family members are also frequently reluctant to discontinue these medications.
When we first enter the world, we are bald, have no motor control, and cannot speak. Nonetheless, we are instantly loved and cared for. Those around us learn to adapt to the fact that we have limited ability to express ourselves and need constant care. They adapt to their schedule and wake up every two hours to feed us. As babies grow, each milestone they gain brings new excitement and joy as we watch them develop. There is a certain joy that comes with watching a baby gain a new photograph to add to their album. With dementia, we tend to grief the loss of these missing photographs and our loved one’s regression. We tend to become frustrated and disheartened when we are faced daily with with the loss of the person we once knew.
We need to reframe dementia in such a way that focuses on the person we see before us. Dementia actually gives us a snap shot back to when we were first born. Their end stage is similar to the way we all started; bald, no motor skills and an inability to express ourselves. We need to cherish them as they are, and meet them where they are. Part of our skills set as palliative care and hospice caregivers is to help families reframe dementia in this way. To help family members see their loved one as a new light and to help them enjoy them as they are.