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Bravo G, Rodrigue C, Thériault V, Arcand M, Downie J, Dubois MF, Kaasalainen S, Hertogh CM, Pautex S, Van den Block L. Should Medical Assistance in Dying Be Extended to Incompetent Patients With Dementia? Research Protocol of a Survey Among Four Groups of Stakeholders From Quebec, Canada. JMIR Res Protoc 2017; 6:e208. [PMID: 29133281 PMCID: PMC5703982 DOI: 10.2196/resprot.8118] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 09/01/2017] [Accepted: 09/06/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Alzheimer's disease and related disorders affect a growing number of people worldwide. Quality of life is generally good in the early stages of these diseases. However, many individuals fear living through the advanced stages. Such fears are triggering requests for medical assistance in dying (MAiD) by patients with dementia. Legislation was recently passed in Canada and the province of Quebec allowing MAiD at the explicit request of a patient who meets a set of eligibility criteria, including competence. Some commentators have argued that MAiD should be accessible to incompetent patients as well, provided appropriate safeguards are in place. Governments of both Quebec and Canada are currently considering whether MAiD should be accessible through written requests made in advance of loss of capacity. OBJECTIVE Aimed at informing the societal debate on this sensitive issue, this study will compare stakeholders' attitudes towards expanding MAiD to incompetent patients with dementia, the beliefs underlying stakeholders' attitudes on this issue, and the value they attach to proposed safeguards. This paper describes the study protocol. METHODS Data will be collected via a questionnaire mailed to random samples of community-dwelling seniors, relatives of persons with dementia, physicians, and nurses, all residing in Quebec (targeted sample size of 385 per group). Participants will be recruited through the provincial health insurance database, Alzheimer Societies, and professional associations. Attitudes towards MAiD for incompetent patients with dementia will be elicited through clinical vignettes featuring a patient with Alzheimer's disease for whom MAiD is considered towards the end of the disease trajectory. Vignettes specify the source of the request (from the patient through an advance request or from the patient's substitute decision-maker), manifestations of suffering, and how close the patient is to death. Arguments for or against MAiD are used to elicit the beliefs underlying respondents' attitudes. RESULTS The survey was launched in September 2016 and is still ongoing. At the time of submission, over 850 respondents have returned the questionnaire, mostly via mail. CONCLUSIONS This study will be the first in Canada to directly compare views on MAiD for incompetent patients with dementia across key stakeholder groups. Our findings will contribute valuable data upon which to base further debate about whether MAiD should be accessible to incompetent patients with dementia, and if so, under what conditions.
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Affiliation(s)
- Gina Bravo
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
- Faculty of Medicine and Health Sciences, Community Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Claudie Rodrigue
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
| | - Vincent Thériault
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
| | - Marcel Arcand
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
- Faculty of Medicine and Health Sciences, Family Medicine, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Jocelyn Downie
- Schulich School of Law, Dalhousie University, Halifax, NS, Canada
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Marie-France Dubois
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
- Faculty of Medicine and Health Sciences, Community Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada
| | | | - Cees M Hertogh
- EMGO+ Institute for Health and Care Research, General Practice & Elderly Care Medicine, Vrije Universiteit Medical Center, Amsterdam, Netherlands
| | - Sophie Pautex
- Geneva University Hospital, Community Medicine and Primary Care, Geneva, Switzerland
| | - Lieve Van den Block
- Vrije Universiteit Brussel, UGhent End-of-Life Care Research Group, Brussels, Belgium
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Fleming J, Calloway R, Perrels A, Farquhar M, Barclay S, Brayne C. Dying comfortably in very old age with or without dementia in different care settings - a representative "older old" population study. BMC Geriatr 2017; 17:222. [PMID: 28978301 PMCID: PMC5628473 DOI: 10.1186/s12877-017-0605-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 09/01/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Comfort is frequently ranked important for a good death. Although rising numbers of people are dying in very old age, many with dementia, little is known about symptom control for "older old" people or whether care in different settings enables them to die comfortably. This study aims to examine, in a population-representative sample, associations between factors potentially related to reported comfort during very old people's final illness: physical and cognitive disability, place of care and transitions in their final illness, and place of death. METHODS Retrospective analyses linked three data sources for n = 180 deceased study participants (68% women) aged 79-107 in a representative population-based UK study, the Cambridge City over-75s Cohort (CC75C): i) prospective in-vivo dementia diagnoses and cognitive assessments, ii) certified place of death records, iii) data from interviews with relatives/close carers including symptoms and "How comfortable was he/she in his/her final illness?" RESULTS In the last year of life 83% were disabled in basic activities, 37% had moderate/severe dementia and 45% minimal/mild dementia or cognitive impairment. Regardless of dementia/cognitive status, three-quarters died following a final illness lasting a week or longer. 37%, 44%, 13% and 7% of the deceased were described as having been "very comfortable", "comfortable", "fairly comfortable" or "uncomfortable" respectively during their final illness, but reported symptoms were common: distress, pain, depression and delirium or confusion each affected 40-50%. For only 10% were no symptoms reported. There were ≥4-fold increased odds of dying comfortably associated with being in a care home during the final illness, dying in a care home, and with staying in place (dying at what death certificates record as "usual address"), whether home or care home, compared with hospital, but no significant association with disability or dementia/cognitive status, regardless of adjustment. CONCLUSIONS These findings are consistent with reports that care homes can provide care akin to hospice for the very old and support an approach of supporting residents to stay in their care home or own home if possible. Findings on reported high prevalence of multiple symptoms can inform policy and training to improve older old people's end-of-life care in all settings.
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Affiliation(s)
- Jane Fleming
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
| | - Rowan Calloway
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- North East Thames Foundation School, London, UK
| | - Anouk Perrels
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Faculty of Medicine, Vrije Universiteit, Amsterdam, Netherlands
| | - Morag Farquhar
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Stephen Barclay
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
- Primary Care Unit, Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
| | - Carol Brayne
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
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Robertshaw D, Cross A. Experiences of Integrated Care for Dementia from Family and Carer Perspectives: A Framework Analysis of Massive Open Online Course Discussion Board Posts. DEMENTIA 2017; 18:1492-1506. [DOI: 10.1177/1471301217719991] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Integrated Care for dementia is an increasingly popular approach to supporting people with dementia, bringing services together to form a single cohesive provision for service users. This approach is still in its infancy but has the potential to improve the management of dementia, social care and to enhance the patient experience. Aims To understand views and experiences of integrated health and social care for dementia from the perspective of carers, families, healthcare professionals and researchers. Methods Crowdsourcing views and experiences from ‘Bridging the Dementia Divide’, a massive open online course at the University of Derby, provide a rich source of qualitative data from carers, families and healthcare professionals. We analysed 847 massive open online course discussion board posts using a Framework Analysis approach. Results Participants described how Integrated Care for dementia should be person-centred and holistic, involving a multidisciplinary team of health and social care practitioners, as well as the patient, the family and the wider community. The establishment of Integrated Care for dementia was viewed positively.
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Affiliation(s)
- David Robertshaw
- College of Health and Social Care, University of Derby, Derby, UK
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Morin L, Aubry R, Frova L, MacLeod R, Wilson DM, Loucka M, Csikos A, Ruiz-Ramos M, Cardenas-Turanzas M, Rhee Y, Teno J, Öhlén J, Deliens L, Houttekier D, Cohen J. Estimating the need for palliative care at the population level: A cross-national study in 12 countries. Palliat Med 2017; 31:526-536. [PMID: 27683475 DOI: 10.1177/0269216316671280] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND To implement the appropriate services and develop adequate interventions, detailed estimates of the needs for palliative care in the population are needed. AIM To estimate the proportion of decedents potentially in need of palliative care across 12 European and non-European countries. DESIGN This is a cross-sectional study using death certificate data. SETTING/PARTICIPANTS All adults (⩾18 years) who died in 2008 in Belgium, Czech Republic, France, Hungary, Italy, Spain (Andalusia, 2010), Sweden, Canada, the United States (2007), Korea, Mexico, and New Zealand ( N = 4,908,114). Underlying causes of death were used to apply three estimation methods developed by Rosenwax et al., the French National Observatory on End-of-Life Care, and Murtagh et al., respectively. RESULTS The proportion of individuals who died from diseases that indicate palliative care needs at the end of life ranged from 38% to 74%. We found important cross-country variation: the population potentially in need of palliative care was lower in Mexico (24%-58%) than in the United States (41%-76%) and varied from 31%-83% in Hungary to 42%-79% in Spain. Irrespective of the estimation methods, female sex and higher age were independently associated with the likelihood of being in need of palliative care near the end of life. Home and nursing home were the two places of deaths with the highest prevalence of palliative care needs. CONCLUSION These estimations of the size of the population potentially in need of palliative care provide robust indications of the challenge countries are facing if they want to seriously address palliative care needs at the population level.
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Affiliation(s)
- Lucas Morin
- 1 Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden.,2 French National Observatory on End-of-Life Care, Paris, France
| | - Régis Aubry
- 2 French National Observatory on End-of-Life Care, Paris, France
| | - Luisa Frova
- 3 Italian National Insitute of Statistics, Rome, Italy
| | - Roderick MacLeod
- 4 HammondCare and University of Sydney, Greenwich, NSW, Australia
| | - Donna M Wilson
- 5 Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Martin Loucka
- 6 Center for Palliative Care, Prague, Czech Republic
| | - Agnes Csikos
- 7 University of Pécs Medical School, Pécs, Hungary
| | - Miguel Ruiz-Ramos
- 8 Regional Ministry of Equality, Health and Social Policies in Andalusia, Seville, Spain
| | - Marylou Cardenas-Turanzas
- 9 McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Joan Teno
- 11 Gerontology and Geriatrics, Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - Joakim Öhlén
- 12 Palliative Research Centre, Ersta Sköndal University College, Stockholm, Sweden.,13 Institute of Health and Care Sciences and University of Gothenburg Centre for Person-Centred Care, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Luc Deliens
- 14 Department of Medical Oncology, University Hospital Ghent, Ghent, Belgium.,15 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Dirk Houttekier
- 15 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Joachim Cohen
- 15 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
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Parsons C, van der Steen JT. Antimicrobial Use in Patients with Dementia: Current Concerns and Future Recommendations. CNS Drugs 2017; 31:433-438. [PMID: 28353140 DOI: 10.1007/s40263-017-0427-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Infections are common in people with dementia, and antibiotic use is widespread, albeit highly variable, across healthcare settings and countries. The few studies conducted to date that consider the appropriateness of antibiotic prescribing specifically for people with dementia focus on people with advanced dementia and suggest that much of the prescribing of antibiotics for these patients may be potentially inappropriate. We suggest that clinicians must consider a number of factors to determine appropriateness of antimicrobial prescribing for people with dementia, including the risks and benefits of assessing and treating infections, the uncertainty regarding the effects of antibiotics on patient comfort, goals of care and treatment preferences, hydration status, dementia severity and patient prognosis. Future research should examine antibiotic prescribing and its appropriateness across the spectrum of common infections, dementia severities, care settings and countries, and should consider how antibiotic therapy should be considered in discussions regarding treatment preferences, goals of care and/or advance care planning between clinicians, patients and families.
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Affiliation(s)
- Carole Parsons
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, Belfast, UK.
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Verhofstede R, Smets T, Cohen J, Eecloo K, Costantini M, Van Den Noortgate N, Deliens L. End-of-Life Care and Quality of Dying in 23 Acute Geriatric Hospital Wards in Flanders, Belgium. J Pain Symptom Manage 2017; 53:693-702. [PMID: 28042062 DOI: 10.1016/j.jpainsymman.2016.10.363] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 10/18/2016] [Accepted: 10/30/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe the nursing and medical interventions performed in the last 48 hours of life and the quality of dying of patients dying in acute geriatric hospital wards. METHODS Cross-sectional descriptive study between October 1, 2012 and September 30, 2013. Twenty-three acute geriatric wards in 13 hospitals in Flanders, Belgium. Patients hospitalized for more than 48 hours before dying in the participating wards. Structured after-death questionnaires, filled out by the nurse, the physician, and the family carer most involved in end-of-life care. Main outcome measures were several nursing and medical interventions reported to be performed in the last 48 hours of life and the quality of dying. RESULTS Of 993 patients, we included 338 (mean age 85.7 years; 173 women). Almost 58% had dementia and nearly half were unable to communicate in the last 48 hours of their life. The most frequently continued or started nursing and medical interventions in the last 48 hours of life were measuring temperature (91.6%), repositioning (83.3%), washing (89.5%), oxygen therapy (49.7%), and intravenous fluids and nutrition (30%). Shortness of breath, lack of serenity, lack of peace, and lack of calm were symptoms reported most frequently by nurses and family carers. CONCLUSION Many nursing and medical interventions are continued or started in the last hours of a patient's life, which may not always be in their best interests. Furthermore, patients dying in acute geriatric wards are often affected by several symptoms.
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Affiliation(s)
- Rebecca Verhofstede
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium.
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Kim Eecloo
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Massimo Costantini
- Palliative Care Unit, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium; Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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Penders YWH, Albers G, Deliens L, Miccinesi G, Vega Alonso T, Miralles M, Moreels S, Van den Block L. End-of-life care for people dying with dementia in general practice in Belgium, Italy and Spain: A cross-sectional, retrospective study. Geriatr Gerontol Int 2017; 17:1667-1676. [PMID: 28060462 DOI: 10.1111/ggi.12948] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 09/06/2016] [Accepted: 09/22/2016] [Indexed: 11/28/2022]
Abstract
AIM To describe and compare end-of-life care for people with mild or severe dementia in general practice in Belgium, Italy and Spain, in terms of place of care, place of death, treatment aims, use of specialized palliative care and communication with general practitioners (GPs). METHODS Cross-sectional retrospective survey was carried out of nationwide networks of GPs in Belgium, Italy and Spain, including patients who died aged 65 years or older in 2009-2011 and were judged by the GP to have had dementia (n = 1623). RESULTS GPs reported a higher proportion of older people with severe dementia in Belgium (55%) than in Spain (46 %) and Italy (45 %), and a higher proportion of patients living in care homes (57% vs 18% and 13%, respectively). A palliative treatment aim was common in the last 3 months of life in all three countries. Specialized palliative care services were provided in 14% (Italy, severe dementia) to 38% (Belgium, severe dementia) of cases. Communication between GP and patient about illness-related topics occurred in between 50% (Italy) and 72% (Belgium) of cases of mild dementia, and 10% (Italy) to 32% (Belgium) of cases of severe dementia. Patient preferences for end-of-life care were known in a minority of cases. Few people (13-15 %) were transferred between care settings in the last week of life. CONCLUSIONS Although overall treatment aims at the end of life are often aligned with a palliative care approach and transfer rates are low, there is room for improvement in end-of-life care for people with dementia in all countries studied, especially regarding early patient-GP communication. Geriatr Gerontol Int 2017; 17: 1667-1676.
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Affiliation(s)
- Yolanda W H Penders
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Gwenda Albers
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Luc Deliens
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Guido Miccinesi
- Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, Florence, Italy
| | - Tomás Vega Alonso
- Public Health Directorate, Regional Ministry of Health (Dirección General de Salud Pública, Consellería de Sanidad), Castile and Leon, Valladolid, Spain
| | - Maite Miralles
- Public Health Directorate, Regional Ministry of Health (Dirección General de Salud Pública, Conselleria de Sanitat), Comunitat Valenciana, Valencia, Spain
| | - Sarah Moreels
- Scientific Institute of Public Health (Wetenschappelijk Instituut Volksgezondheid, Institut Scientifique de Santé Publique), Unit of Health Services Research, Brussels, Belgium
| | - Lieve Van den Block
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
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Parsons C. Polypharmacy and inappropriate medication use in patients with dementia: an underresearched problem. Ther Adv Drug Saf 2017; 8:31-46. [PMID: 28203365 PMCID: PMC5298466 DOI: 10.1177/2042098616670798] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Multimorbidity and polypharmacy are increasingly prevalent across healthcare systems and settings as global demographic trends shift towards increased proportions of older people in populations. Numerous studies have demonstrated an association between polypharmacy and potentially inappropriate prescribing (PIP), and have reported high prevalence of PIP across settings of care in Europe and North America and, as a consequence, increased risk of adverse drug reactions, healthcare utilization, morbidity and mortality. These studies have not focused specifically on people with dementia, despite the high risk of adverse drug reactions and PIP in this patient cohort. This narrative review considers the evidence currently available in the area, including studies examining prevalence of PIP in older people with dementia, how appropriateness of prescribing is assessed, the medications most commonly implicated, the clinical consequences, and research priorities to optimize prescribing for this vulnerable patient group. Although there has been a considerable research effort to develop criteria to assess medication appropriateness in older people in recent years, the majority of tools do not focus on people with dementia. Of the limited number of tools available, most focus on the advanced stages of dementia in which life expectancy is limited. The development of tools to assess medication appropriateness in people with mild to moderate dementia or across the full spectrum of disease severity represents an important gap in the research literature and is beginning to attract research interest, with recent studies considering the medication regimen as a whole, or misprescribing, overprescribing or underprescribing of certain medications/medication classes, including anticholinergics, psychotropics, antibiotics and analgesics. Further work is required in development and validation of criteria to assess prescribing appropriateness in this vulnerable patient population, to determine prevalence of PIP in large cohorts of people with the full spectrum of dementia variants and severities, and to examine the impact of PIP on health outcomes.
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Affiliation(s)
- Carole Parsons
- Queen’s University Belfast, 97 Lisburn Road, Belfast, Northern Ireland BT9 7BL, UK
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Hendriks SA, Smalbrugge M, Hertogh CMPM, van der Steen JT. Changes in Care Goals and Treatment Orders Around the Occurrence of Health Problems and Hospital Transfers in Dementia: A Prospective Study. J Am Geriatr Soc 2016; 65:769-776. [DOI: 10.1111/jgs.14667] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Simone A. Hendriks
- Department of General Practice & Elderly Care Medicine and EMGO+ Institute for Health and Care Research; VU University Medical Center; Amsterdam the Netherlands
| | - Martin Smalbrugge
- Department of General Practice & Elderly Care Medicine and EMGO+ Institute for Health and Care Research; VU University Medical Center; Amsterdam the Netherlands
| | - Cees M. P. M. Hertogh
- Department of General Practice & Elderly Care Medicine and EMGO+ Institute for Health and Care Research; VU University Medical Center; Amsterdam the Netherlands
| | - Jenny T. van der Steen
- Department of Primary Care and Community Care; Radboud University Medical Center; Nijmegen the Netherlands
- Department of Public Health and Primary Care; Leiden University Medical Center; Leiden the Netherlands
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Morley JE. JAMDA: The State of the Journal. J Am Med Dir Assoc 2016; 17:867-71. [DOI: 10.1016/j.jamda.2016.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 07/15/2016] [Indexed: 11/25/2022]
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Eicher S, Theill N, Geschwindner H, Moor C, Wettstein A, Bieri-Brüning G, Hock C, Martin M, Wolf H, Riese F. The last phase of life with dementia in Swiss nursing homes: the study protocol of the longitudinal and prospective ZULIDAD study. BMC Palliat Care 2016; 15:80. [PMID: 27557934 PMCID: PMC4997715 DOI: 10.1186/s12904-016-0151-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 08/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The proportion of older people with advanced dementia who will die in nursing homes is constantly growing. However, little is known about the dying phase, the type of symptoms, the management of symptoms and the quality of life and dying in people with advanced dementia. The ZULIDAD (Zurich Life and Death with Advanced Dementia) study aims at extending the current scientific knowledge by providing first data from Switzerland. METHODS The ZULIDAD study employs a prospective design to study nursing home residents with advanced dementia for three years or until their death in eleven nursing homes in Zurich. Observational data from quarterly questionnaires for relatives and primary nurses is combined with data from the Resident Assessment Instrument - Minimum Data Set (RAI-MDS). Special focus is put on 1) the cross-sectional analysis of baseline and post-mortem data regarding quality of life and quality of dying and how the perceptions of these measures differ between relatives and primary nurses, 2) the longitudinal analyses of established health outcome measures (e.g., EOLD, MSSE, BISAD, QUALID) in order to understand their trajectories and 3) international comparisons of cross-sectional and longitudinal data. DISCUSSION The ZULIDAD study is one of the few existing prospective studies on end-of-life care in dementia and it is the first prospective study to describe the situation in Switzerland. Its multi-perspective approach allows a comprehensive approximation to central health outcome measures at the end of life such as pain, suffering or quality of life. Providing insights into the current provision of care, it can serve as a basis for improving dementia end-of-life care in Switzerland and internationally.
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Affiliation(s)
- Stefanie Eicher
- University Research Priority Program “Dynamics of Healthy Aging”, University of Zurich, Andreasstrasse 15, 8050 Zurich, Switzerland
- Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland
| | - Nathan Theill
- University Research Priority Program “Dynamics of Healthy Aging”, University of Zurich, Andreasstrasse 15, 8050 Zurich, Switzerland
- Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Lenggstr. 31, 8032 Zurich, Switzerland
| | - Heike Geschwindner
- City of Zurich Nursing Homes, Walchestrasse 31, 8021 Zurich, Switzerland
| | - Caroline Moor
- Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland
| | - Albert Wettstein
- Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland
| | | | - Christoph Hock
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Lenggstr. 31, 8032 Zurich, Switzerland
| | - Mike Martin
- University Research Priority Program “Dynamics of Healthy Aging”, University of Zurich, Andreasstrasse 15, 8050 Zurich, Switzerland
- Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland
- Department of Psychology, University of Zurich, Binzmuehlestrasse 14, 8050 Zurich, Switzerland
| | - Henrike Wolf
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Lenggstr. 31, 8032 Zurich, Switzerland
| | - Florian Riese
- University Research Priority Program “Dynamics of Healthy Aging”, University of Zurich, Andreasstrasse 15, 8050 Zurich, Switzerland
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Lenggstr. 31, 8032 Zurich, Switzerland
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Comparing Palliative Care in Care Homes Across Europe (PACE): Protocol of a Cross-sectional Study of Deceased Residents in 6 EU Countries. J Am Med Dir Assoc 2016; 17:566.e1-7. [DOI: 10.1016/j.jamda.2016.03.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/15/2016] [Indexed: 11/22/2022]
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Van Den Noortgate NJ, Verhofstede R, Cohen J, Piers RD, Deliens L, Smets T. Prescription and Deprescription of Medication During the Last 48 Hours of Life: Multicenter Study in 23 Acute Geriatric Wards in Flanders, Belgium. J Pain Symptom Manage 2016; 51:1020-6. [PMID: 26921490 DOI: 10.1016/j.jpainsymman.2015.12.325] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/21/2015] [Accepted: 12/23/2015] [Indexed: 11/19/2022]
Abstract
CONTEXT Palliative care for the older person is often limited, resulting in poor quality of dying. Pharmacological management can be one of the components to achieve better symptom control. OBJECTIVES To describe the anticipatory prescription of medication for symptomatic treatment and the deprescription of potentially inappropriate medication during the last days of life. METHODS This was a cross-sectional descriptive study between October 1, 2012 and September 30, 2013 in 23 acute geriatric wards in Flanders, Belgium. Structured after-death questionnaires were filled out by the treating geriatrician for patients hospitalized for more than 48 hours before dying. RESULTS Anticipatory prescription of medication was present in 65.4% of cases, 45.5% of the cases was prescribed morphine, 15.5% benzodiazepines, and 13.8% scopolamine hydrobromide. A deprescription of potentially inappropriate medication was noted in 67.9% of cases. The likelihood of anticipatory prescription was significantly higher in cases where death was expected (odds ratio [OR] 19; 95% CI 9-40; P < 0.0001) and significantly lower where dementia was present (OR 0.35; 95% CI 0.16-0.74; P < 0.006). The likelihood of deprescription was higher in cases where death was expected (OR 20; 95% CI 10-43; P < 0.0001) and in cases of patients dying from an oncological disease compared with those dying from frailty or dementia (OR 7.0; 95% CI 1.1-45.6, P = 0.042). CONCLUSION Anticipatory prescription of medication and deprescription of medication at the end of life in acute geriatric wards could be further optimized. A well-developed intervention to guide health care staff in patient-centered pharmacological management in the last days of life seems to be needed.
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Affiliation(s)
| | - Rebecca Verhofstede
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Ruth D Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
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Abstract
Since the Liverpool Care Pathway has been withdrawn in the UK, clinicians supporting the palliative needs of patients have faced further challenges, particularly for patients with dementia who are unable to go to a hospice owing to challenging behaviours. It is becoming more important for different services to provide long-term palliative care for patients with dementia. Mental health trusts should construct end-of-life care policies and train staff members accordingly. Through collaborative working, dying patients may be kept where they are best suited. We present the case study of a patient who received end-of-life care at a psychiatric hospital in the UK. We aim to demonstrate how effective end-of-life care might be provided in a psychiatric hospital, in accordance with recent new palliative care guidelines, and highlight potential barriers.
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Affiliation(s)
| | | | - Ollie Minton
- St George's University Hospitals NHS Foundation Trust
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Abstract
BACKGROUND Infections frequently occur in patients with dementia and antibiotics are often prescribed, but may also be withheld. OBJECTIVES The aim of this systematic review is to provide a systematic overview of the prevalence of antibiotic use, and factors associated with prescribing antibiotics in patients with dementia. DATA SOURCES A systematic search of MEDLINE, EMBASE, PSYCINFO, CINAHL, and the Cochrane library databases until February 13, 2014 was performed, using both controlled terms and free-text terms. RESULTS Thirty-seven articles were included. The point prevalence of antibiotic use in patients with dementia ranged from 3.3 to 16.6%. The period prevalence ranged from 4.4 to 88% overall, and from 23.5 to 94% in variable time frames before death; the median use was 52% (median period 14 days) and 48% (median period 22 days), respectively. Most patients with lower respiratory tract infections or urinary tract infections (77-91%) received antibiotic treatment. Factors associated with antibiotic use related to patients, families, physicians, and the healthcare context. More severe dementia and a poor prognosis were associated with less antibiotic use in various countries. Associations with aspiration and illness severity differed by country. CONCLUSIONS AND IMPLICATIONS Antibiotic use in patients with dementia is substantial, and probably highly associated with the particular healthcare context. Future studies may report antibiotic use by infection type and stage of dementia, and compare cross-nationally.
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Fielding E, Beattie E, O'Reilly M, McMaster M. Achieving a National Sample of Nursing Homes: Balancing Probability Techniques and Practicalities. Res Gerontol Nurs 2016; 9:58-65. [DOI: 10.3928/19404921-20151019-03] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 09/04/2015] [Indexed: 11/20/2022]
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Hoben M, Chamberlain SA, Knopp-Sihota JA, Poss JW, Thompson GN, Estabrooks CA. Impact of Symptoms and Care Practices on Nursing Home Residents at the End of Life: A Rating by Front-line Care Providers. J Am Med Dir Assoc 2016; 17:155-61. [DOI: 10.1016/j.jamda.2015.11.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 11/02/2015] [Indexed: 11/29/2022]
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Husebo BS, Achterberg W, Flo E. Identifying and Managing Pain in People with Alzheimer's Disease and Other Types of Dementia: A Systematic Review. CNS Drugs 2016; 30:481-97. [PMID: 27240869 PMCID: PMC4920848 DOI: 10.1007/s40263-016-0342-7] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Pain in patients with Alzheimer's disease is a complex issue; these patients suffer from the common causes of acute and chronic pain, and some also have neuropathic or nociceptive pain. Whatever the mechanism of pain in these patients, their pain will require careful assessment and management, to insure the correct type and level of analgesia is given. The objective of this systematic review was the identification of studies that have investigated the efficacy of different analgesics on pain intensity or pain-related behavior during nursing home stay and at the end of life. METHODS A search using pain, pain treatment, and dementia MESH terms and keywords was conducted (October 15, 2015) in MEDLINE, EMBASE, PsychINFO, CINAHL, and Cochrane libraries. RESULTS Our search yielded 3138 unique hits, published between 1990 and October 2015. We read titles and abstracts, identified 124 papers for full-text evaluation, and included 12 papers to reflect and synthesize the following questions: (1) Which pain assessment tools for people with dementia are responsive to change in pain intensity scores? (2) Which analgesics are efficacy-tested by controlled trials including people with dementia living in nursing homes, including at the end of life? (3) Which outcome measures have been used to identify pain, pain behavior, and/or treatment efficacy in people with dementia? CONCLUSION Despite increased use of analgesics, pain is still prevalent in people with dementia. Validated pain tools are available but not implemented and not fully tested on responsiveness to treatment. Official guidelines for pain assessment and treatment addressing people with dementia living in a nursing home are lacking. The efficacy of analgesic drug use on pain or neuropsychiatric behavior related to dementia has been hardly investigated.
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Affiliation(s)
- Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.
- Section for Nursing Home Medicine, Municipality of Bergen, Bergen, Norway.
| | - Wilco Achterberg
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Elisabeth Flo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
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Type and course of symptoms demonstrated in the terminal and dying phases by people with dementia in nursing homes. Z Gerontol Geriatr 2015; 48:176-83. [PMID: 25119700 DOI: 10.1007/s00391-014-0668-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In all, 39 % of people living in Swiss nursing homes suffer from dementia. Detailed data about type and course of symptoms displayed by these patients in their terminal phase are lacking. METHODS This descriptive, retrospective study analysed 65 nursing documents from deceased people with dementia in four nursing homes in the canton of Zurich, Switzerland. RESULTS Difficulties with mobility (81 %), pain (71 %) and sleep disturbance (63 %) were the most frequent of the 10 identified symptoms. Towards the end of life, difficulties with mobility, sleep disturbance, agitation and other neuropsychiatric symptoms, such as episodes of depression, decreased (decrescent pattern), while pain, feeding problems, breathing abnormalities, apathy and anxiety increased (crescent pattern). Courses of pain were documented in 17 % of the nursing records. In addition, 76 % of the residents had been visited on a daily basis by next of kin in their last 7 days, compared with only one third of residents previously. Furthermore, daily communication between healthcare professionals and next of kin tripled during this period. CONCLUSION The documented prevalence of a high and increasing level of pain towards the end of life, combined with the lack of documented courses of pain, shows potential for improvement in pain relief and pain identification for patients with dementia in their terminal phase. The increasing number of visits by next of kin and the increasingly intensive contact between healthcare professionals and next of kin in the last 7 days are a strong indicator that the end of life can be predicted relatively well by the involved participants and appropriate reactions follow.
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van der Steen JT, Sampson EL, Van den Block L, Lord K, Vankova H, Pautex S, Vandervoort A, Radbruch L, Shvartzman P, Sacchi V, de Vet HCW, Van Den Noortgate NJA. Tools to Assess Pain or Lack of Comfort in Dementia: A Content Analysis. J Pain Symptom Manage 2015. [PMID: 26212095 DOI: 10.1016/j.jpainsymman.2015.05.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CONTEXT There is need for tools to help detect pain or lack of comfort in persons unable to communicate. However, pain and (dis)comfort tools have not been compared, and it is unclear to what extent they discriminate between pain and other possible sources of discomfort, or even if items differ. OBJECTIVES To map and compare items in tools that assess pain and the broader notion of discomfort or comfort in people with severe dementia or at the end of life. METHODS Using qualitative content analysis with six classifications, we categorized each item of four thoroughly tested observational pain tools (Pain Assessment in Advanced Dementia [PAINAD], Pain Assessment Checklist for Seniors with Limited Ability to Communicate [PACSLAC], Doloplus-2, and draft Pain Assessment in Impaired Cognition [PAIC]), and four discomfort tools (including distress, comfort, and quality of life in severe dementia or at the end of life; Discomfort Scale-Dementia Alzheimer Type [DS-DAT], Disability Distress Assessment Tool [DisDAT], End-of-Life in Dementia-Comfort Assessment in Dying with Dementia [EOLD-CAD], and Quality of Life in Late-Stage Dementia [QUALID] scale). We calculated median proportions to compare distributions of categories of pain and discomfort tools. RESULTS We found that, despite variable content across tools, items from pain and discomfort tools overlapped considerably. For example, positive elements such as smiling and spiritual items were more often included in discomfort tools but were not unique to these. Pain tools comprised more "mostly descriptive" (median 0.63 vs. 0.44) and fewer "highly subjective" items (0.06 vs. 0.18); some used time inconsistently, mixing present and past observations. CONCLUSION This analysis may inform a more rigorous theoretical underpinning and (re)development of pain and discomfort tools and calls for empirical testing of a broad item pool for sensitivity and specificity in detecting and discriminating pain from other sources of discomfort.
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Affiliation(s)
- Jenny T van der Steen
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of General Practice & Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands.
| | - Elizabeth L Sampson
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom; Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, London, United Kingdom
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Belgium, Brussels, Belgium
| | - Kathryn Lord
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
| | - Hana Vankova
- Faculty of Humanities and Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Sophie Pautex
- Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - An Vandervoort
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Belgium, Brussels, Belgium
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany; Center for Palliative Care, Malteser Hospital Seliger Gerhard Bonn/Rhein-Sieg, Bonn, Germany
| | - Pesach Shvartzman
- Pain and Palliative Medicine Unit, Division of Community Health, Department of Family Medicine, Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Valentina Sacchi
- Lincolnshire Partnership Foundation Trust, Lincoln, Lincolnshire, United Kingdom
| | - Henrica C W de Vet
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
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Candy B, Elliott M, Moore K, Vickerstaff V, Sampson E, Jones L. UK quality statements on end of life care in dementia: a systematic review of research evidence. BMC Palliat Care 2015; 14:51. [PMID: 26481400 PMCID: PMC4617713 DOI: 10.1186/s12904-015-0047-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 10/08/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Globally, the number of people who die with dementia is increasing. The importance of a palliative approach in the care of people with dementia is recognised and there are national polices to enhance current care. In the UK implementation of these polices is promoted by the National Institute for Health and Care Excellence (NICE) Dementia Quality Standards (QS). Since publication of the QS new care interventions have been developed. AIM To explore critically the current international research evidence on effect available to inform NICE Dementia QS relevant to end of life (EOL) care. DESIGN We used systematic review methods to seek the research evidence for three statements within the Dementia QS. These are those that recommend: (1) a case management approach, (2) discussing and consideration of making a statement about future care (SFC) and (3) a palliative care assessment (PCA). We included evaluative studies of relevant interventions that used a comparative design, such as trials and cohort studies, and measured EOL care outcomes for persons dying with moderate to severe dementia. Our primary outcome of interest was whether the intervention led to a measurable impact on wellbeing for the person with dementia and their family. We assessed included studies for quality using a scale by Higginson and colleagues (2002) for assessment of quality of studies in palliative care, and two authors undertook key review processes. Data sources included Cinahl, Embase, and PsychINFO from 2001 to August 2014. Our search strategy included free text and medical subject headings relevant to population and recommended care. RESULTS We found seven studies evaluating a care intervention; four assessed SFC, three PCA. None assessed case management. Studies were of weak design; all used retrospective data and relied on others for precise record keeping and for accurate recall of events. There was limited overlap in outcome measurements. Overall reported benefits were mixed. CONCLUSIONS Quality statements relevant to EOL care are useful to advance practice however they have a limited evidence base. High quality empirical work is needed to establish that the recommendations in these statements are best practice.
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Affiliation(s)
- Bridget Candy
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, 6th Floor, Wing B, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
| | - Margaret Elliott
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, 6th Floor, Wing B, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
| | - Kirsten Moore
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, 6th Floor, Wing B, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, 6th Floor, Wing B, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
| | - Elizabeth Sampson
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, 6th Floor, Wing B, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
| | - Louise Jones
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, 6th Floor, Wing B, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
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What Are Physicians' Reasons for Not Referring People with Life-Limiting Illnesses to Specialist Palliative Care Services? A Nationwide Survey. PLoS One 2015; 10:e0137251. [PMID: 26356477 PMCID: PMC4565578 DOI: 10.1371/journal.pone.0137251] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/13/2015] [Indexed: 11/30/2022] Open
Abstract
Background Many people who might benefit from specialist palliative care services are not using them. Aim We examined the use of these services and the reasons for not using them in a population in potential need of palliative care. Methods We conducted a population-based survey regarding end-of-life care among physicians certifying a large representative sample (n = 6188) of deaths in Flanders, Belgium. Results Palliative care services were not used in 79% of cases of people with organ failure, 64% of dementia and 44% of cancer. The most frequently indicated reasons were that 1) existing care already sufficiently addressed palliative and supportive needs (56%), 2) palliative care was not deemed meaningful (26%) and 3) there was insufficient time to initiate palliative care (24%). The reasons differed according to patient characteristics: in people with dementia the consideration of palliative care as not meaningful was more likely to be a reason for not using it; in older people their care needs already being sufficiently addressed was more likely to be a reason. For those patients who were referred the timing of referral varied from a median of six days before death (organ failure) to 16 days (cancer). Conclusions Specialist palliative care is not initiated in almost half of the people for whom it could be beneficial, most frequently because physicians deem regular caregivers to be sufficiently skilled in addressing palliative care needs. This would imply that the safeguarding of palliative care skills in this regular ‘general’ care is an essential health policy priority.
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73
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De Roo ML, Albers G, Deliens L, de Vet HCW, Francke AL, Van Den Noortgate N, Van den Block L. Physical and Psychological Distress Are Related to Dying Peacefully in Residents With Dementia in Long-Term Care Facilities. J Pain Symptom Manage 2015; 50:1-8. [PMID: 25847852 DOI: 10.1016/j.jpainsymman.2015.02.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 01/27/2015] [Accepted: 02/02/2015] [Indexed: 11/28/2022]
Abstract
CONTEXT Although dying peacefully is considered an important outcome of high-quality palliative care, large-scale quantitative research on dying peacefully and the factors associated with a peaceful death is lacking. OBJECTIVES To gain insight into how many residents with dementia in long-term care facilities die peacefully, according to their relatives, and whether that assessment is correlated with observed physical and psychological distress. METHODS This was a retrospective cross-sectional study of deceased nursing home residents in a representative sample of long-term care facilities in Flanders, Belgium (2010). Structured post-mortem questionnaires were completed by relatives of the resident, who were asked to what extent they agreed that the resident "appeared to be at peace" during the dying process. Spearman correlation coefficients gave the correlations between physical and psychological distress (as measured using the Symptom Management at the End of Life with Dementia and Comfort Assessment in Dying at the End of Life with Dementia scales) and dying peacefully (as measured using the Quality of Dying in Long Term Care instrument). RESULTS The sample comprised 92 relatives of deceased residents with dementia. In 54% of cases, relatives indicated that the resident died peacefully. Weak-to-moderate correlations (0.2-0.57) were found between dying peacefully and physical distress in the last week of life. Regarding psychological distress, weak-to-moderate correlations were found for both the last week (0.33-0.44) and last month of life (0.28-0.47). CONCLUSION Only half of the residents with dementia died peacefully as perceived by their relatives. Relatives' assessment of whether death was peaceful is related to both physical and psychological distress. Further qualitative research is recommended to gain more in-depth insights into the aspects on which relatives base their judgment of dying peacefully.
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Affiliation(s)
- Maaike L De Roo
- Department of Public and Occupational Health & Expertise Center of Palliative Care, EMGO Institute for Health and Care Research, Vrije University Medical Center, Amsterdam, The Netherlands.
| | - Gwenda Albers
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Luc Deliens
- Department of Public and Occupational Health & Expertise Center of Palliative Care, EMGO Institute for Health and Care Research, Vrije University Medical Center, Amsterdam, The Netherlands; End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Henrica C W de Vet
- Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Anneke L Francke
- Department of Public and Occupational Health & Expertise Center of Palliative Care, EMGO Institute for Health and Care Research, Vrije University Medical Center, Amsterdam, The Netherlands; NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | | | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
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Fin de vie et démence dans les établissements d’hébergement pour personnes âgées dépendantes. MÉDECINE PALLIATIVE : SOINS DE SUPPORT - ACCOMPAGNEMENT - ÉTHIQUE 2015. [DOI: 10.1016/j.medpal.2015.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Disturbances of serum sodium are one of the most common findings in older persons. They are also a major cause of hospital admissions and delirium and are associated with frailty, falls, and hip fractures. Both hypernatremia and hyponatremia are potentially preventable. Treatment involves treating the underlying cause and restoring sodium and volume status to normal. The arginine vasopressin antagonists, vaptans, have increased the therapeutic armamentarium available to physicians.
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Affiliation(s)
- John E Morley
- Divisions of Geriatric Medicine and Endocrinology, Saint Louis University School of Medicine, 1402 South Grand Boulevard, M238, St Louis, MO 63104, USA.
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76
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Morin L, Johnell K, Aubry R. Variation in the place of death among nursing home residents in France. Age Ageing 2015; 44:415-21. [PMID: 25605581 DOI: 10.1093/ageing/afu197] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 09/24/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES recent studies have reported that hospitals have become a common place of death for nursing home residents. This study aimed to (i) measure variations in the proportion of in-hospital deaths across regions after adjustment for facility-level characteristics and (ii) identify environmental risk factors that might explain these variations in France. DESIGN a cross-sectional retrospective survey was conducted in 2013. SETTING AND PARTICIPANTS coordinating physicians in 3,705 nursing homes in France. MEASUREMENTS a regression model was used to construct risk-adjusted rates of in-hospital deaths considering the facilities' characteristics. At the regional level, the outcome was defined as the difference between the observed rate of in-hospital deaths and the expected risk-adjusted rate. Values exceeding zero indicated rates that exceeded the national predicted rate of in-hospital deaths and thus highlighted regions in which the risk-adjusted probability for nursing home residents to die in a hospital was greater than average. RESULTS among 70,119 nursing home decedents, 25.4% (n = 17,789) died in hospitals. The characteristics of the facilities had a significant influence on the proportion of in-hospital deaths among the nursing home decedents. However, after adjustment for these facility-level risk factors, the proportion of nursing homes that reported worse-than-average outcomes showed significant variation (range 26.0-79.6%). At the regional level, both the rate of acute hospital beds and the rate of general practitioners were found to be strongly correlated with the probability of reporting worse-than-average outcomes (P < 0.001). CONCLUSION our study demonstrates the existence of major differences across regions in France and highlights the need for targeted interventions regarding end-of-life care in nursing home facilities.
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Affiliation(s)
- Lucas Morin
- French National Observatory on End-of-Life Care, Paris, France Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Kristina Johnell
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Régis Aubry
- University Hospital of Besancon, Besançon, France
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Jethwa KD, Onalaja O. Advance care planning and palliative medicine in advanced dementia: a literature review. BJPsych Bull 2015; 39:74-8. [PMID: 26191437 PMCID: PMC4478901 DOI: 10.1192/pb.bp.114.046896] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 04/11/2014] [Accepted: 05/19/2014] [Indexed: 11/23/2022] Open
Abstract
Aims and method To assess the factors that affect the clinical use of advanced care planning and palliative care interventions in patients with dementia. A literature search of Medline, Embase and PsycINFO was performed to identify themes in advanced care planning and palliative care in dementia. Results In total, 64 articles were found, including 12 reviews, and three key areas emerged: barriers to advanced care planning, raising awareness and fostering communication between professionals and patients, and disease-specific interventions. Clinical implications Most of the studies analysed were carried out in the USA or Continental Europe. This narrative review aims to help guide future primary research, systematic reviews and service development in the UK.
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Affiliation(s)
- Ketan Dipak Jethwa
- University of Warwick and Coventry and Warwickshire Partnership NHS Trust
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Chambaere K, Cohen J, Robijn L, Bailey SK, Deliens L. End-of-Life Decisions in Individuals Dying with Dementia in Belgium. J Am Geriatr Soc 2015; 63:290-6. [DOI: 10.1111/jgs.13255] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Kenneth Chambaere
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) and Ghent University; Brussels Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) and Ghent University; Brussels Belgium
| | - Lenzo Robijn
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) and Ghent University; Brussels Belgium
| | - S. Kathleen Bailey
- Department of Psychology; Lakehead University; Thunder Bay Ontario Canada
| | - Luc Deliens
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) and Ghent University; Brussels Belgium
- Ghent University Hospital; Ghent Belgium
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Penders YWH, Albers G, Deliens L, Vander Stichele R, Van den Block L, De Groote Z, Brearly S, Caraceni A, Cohen J, Francke A, Harding R, Higginson I, Kaasa S, Linden K, Miccenesi G, Onwuteaka-Philipsen B, Pardon K, Pasman R, Pautux S, Payne S, Deliens L. Awareness of dementia by family carers of nursing home residents dying with dementia: a post-death study. Palliat Med 2015; 29:38-47. [PMID: 25037605 DOI: 10.1177/0269216314542261] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND High-quality palliative care for people with dementia should be patient-centered, family-focused, and include well-informed and shared decision-making, as affirmed in a recent white paper on dementia from the European Association for Palliative Care. AIM To describe how often family carers of nursing home residents who died with dementia are aware that their relative has dementia, and study resident, family carer, and care characteristics associated with awareness. DESIGN Post-death study using random cluster sampling. SETTING/PARTICIPANTS Structured questionnaires were completed by family carers, nursing staff, and general practitioners of deceased nursing home residents with dementia in Flanders, Belgium (2010). RESULTS Of 190 residents who died with dementia, 53.2% of family carers responded. In 28% of cases, family carers indicated they were unaware their relative had dementia. Awareness by family carers was related to more advanced stages of dementia 1 month before death (odds ratio = 5.4), with 48% of family carers being unaware when dementia was mild and 20% unaware when dementia was advanced. The longer the onset of dementia after admission to a nursing home, the less likely family carers were aware (odds ratio = 0.94). CONCLUSION Family carers are often unaware that their relative has dementia, that is, in one-fourth of cases of dementia and one-fifth of advanced dementia, posing considerable challenges for optimal care provision and end-of-life decision-making. Considering that family carers of residents who develop dementia later after admission to a nursing home are less likely to be aware, there is room for improving communication strategies toward family carers of nursing home residents.
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Affiliation(s)
- Yolanda W H Penders
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Gwenda Albers
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Robert Vander Stichele
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
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Houttekier D, Vandervoort A, Van den Block L, van der Steen JT, Vander Stichele R, Deliens L. Hospitalizations of nursing home residents with dementia in the last month of life: results from a nationwide survey. Palliat Med 2014; 28:1110-7. [PMID: 24866759 DOI: 10.1177/0269216314535962] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hospitalizations of nursing home residents with dementia may not be uncommon. However, evidence from epidemiological studies outside the United States and knowledge about the circumstances of hospitalizations are lacking. AIM To examine the proportion of nursing home residents with dementia hospitalized in the last month of life and factors associated with hospitalization. DESIGN The design is stratified cluster sampling survey. Nurses retrospectively registered demographic and dementia-related information about deceased residents with dementia. This included information about hospitalizations, persons involved in hospitalization decisions and type and content of information transferred when hospitalized. SETTING/PARTICIPANTS Nursing home residents dying with dementia in Belgium (Flanders) in 2010. RESULTS In the final month of life, 19.5% of nursing home residents dying with dementia (N = 198) were hospitalized, including 4.6% admitted to an intensive care unit. For 12.2% of residents dying with dementia, a do-not-hospitalize advance directive was present, for 57.0%, a do-not-hospitalize general physician-order. Residents without a do-not-hospitalize general physician-order were more likely of being hospitalized (adjusted odds ratio: 3.4; 95% confidence interval: 1.3-8.7). None of the hospitalizations occurred at the request of the resident; 37% were at the request of relatives; curative or life-prolonging treatments were the most frequent reasons given. Information about the resident's nursing care or medical treatment was transferred in almost all hospitalizations, information about wishes and preferences for future care in 19%. CONCLUSION Hospitalization in Belgian nursing home residents with dementia in the last month of life was common. Documentation of do-not-hospitalize physician-orders in the resident's medical files may prevent hospitalizations.
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Affiliation(s)
- Dirk Houttekier
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - An Vandervoort
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium Department of Family Medicine, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jenny T van der Steen
- EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, Department of General Practice & Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Robert Vander Stichele
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
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81
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Klapwijk MS, Caljouw MAA, van Soest-Poortvliet MC, van der Steen JT, Achterberg WP. Symptoms and treatment when death is expected in dementia patients in long-term care facilities. BMC Geriatr 2014; 14:99. [PMID: 25181947 PMCID: PMC4158395 DOI: 10.1186/1471-2318-14-99] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although dementia at the end of life is increasingly being studied, we lack prospective 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 validated 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 validated instruments. The use of observation tools may have influenced the physicians to make treatment decisions.
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Affiliation(s)
- Maartje S Klapwijk
- Department of Public Health and Primary Care, Leiden University Medical Center, P,O, Box 9600, 2300 RC Leiden, The Netherlands.
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Abstract
Increasing life span and lack of medication for prevention or treatment of progressive dementias will significantly increase the number of individuals with advanced dementia worldwide. Providing optimal care for them will stretch health care resources and will require evaluation of different treatment strategies. This paper is presenting measures that may be used in this patient population. Evaluation of global goals of palliative care may include measuring quality of life by QUALID scale, comfort by DS-DAT scale, and engagement by MPES scale. Symptom control may be achieved by measuring pain by PAINAD or PACSLAC scales, by evaluating behavioral symptoms and their management (agitation by SOAPD scale, apathy by AES scale and rejection of care by RTC-DAT scale), and by monitoring patients for dyspnea using RDOS scale. Outcomes of palliative care at the end of life may be evaluated by EOLD-CAD scale and by determining family satisfaction with care (EOLD-SWC). Items included in these scales, psychometric properties, and research use of these scales are described. It is hoped that information in this paper will stimulate research interest in this important area.
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83
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Palliative Sedation in Nursing Homes: A Good Death? J Am Med Dir Assoc 2014; 15:541-3. [DOI: 10.1016/j.jamda.2014.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 06/02/2014] [Indexed: 11/23/2022]
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84
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Messinger-Rapport BJ, Gammack JK, Thomas DR, Morley JE. Clinical update on nursing home medicine: 2013. J Am Med Dir Assoc 2014; 14:860-76. [PMID: 24286710 DOI: 10.1016/j.jamda.2013.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 09/18/2013] [Indexed: 12/18/2022]
Abstract
This is the seventh article in the series of Clinical Updates on Nursing Home Care. The topics covered are antiresorptive drugs, hip fracture, hypertension, orthostatic hypotension, depression, undernutrition, anorexia, cachexia, sarcopenia, exercise, pain, and behavioral and psychological symptoms of dementia.
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85
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Van den Block L. The need for integrating palliative care in ageing and dementia policies. Eur J Public Health 2014; 24:705-6. [DOI: 10.1093/eurpub/cku084] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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86
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Elliott M, Harrington J, Moore K, Davis S, Kupeli N, Vickerstaff V, Gola A, Candy B, Sampson EL, Jones L. A protocol for an exploratory phase I mixed-methods study of enhanced integrated care for care home residents with advanced dementia: the Compassion Intervention. BMJ Open 2014; 4:e005661. [PMID: 24939815 PMCID: PMC4067896 DOI: 10.1136/bmjopen-2014-005661] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION In the UK approximately 700,000 people are living with, and a third of people aged over 65 will die with, dementia. People with dementia may receive poor quality care towards the end of life. We applied a realist approach and used mixed methods to develop a complex intervention to improve care for people with advanced dementia and their family carers. Consensus on intervention content was achieved using the RAND UCLA appropriateness method and mapped to sociological theories of process and impact. Core components are: (1) facilitation of integrated care, (2) education, training and support, (3) investment from commissioners and care providers. We present the protocol for an exploratory phase I study to implement components 1 and 2 in order to understand how the intervention operates in practice and to assess feasibility and acceptability. METHODS AND ANALYSIS An 'Interdisciplinary Care Leader (ICL)' will work within two care homes, alongside staff and associated professionals to facilitate service integration, encourage structured needs assessment, develop the use of personal and advance care plans and support staff training. We will use qualitative and quantitative methods to collect data for a range of outcome and process measures to detect effects on individual residents, family carers, care home staff, the intervention team, the interdisciplinary team and wider systems. Analysis will include descriptive statistics summarising process and care home level data, individual demographic and clinical characteristics and data on symptom burden, clinical events and quality of care. Qualitative data will be explored using thematic analysis. Findings will inform a future phase II trial. ETHICS AND DISSEMINATION Ethical approval was granted (REC reference 14/LO/0370). We shall publish findings at conferences, in peer-reviewed journals, on the Marie Curie Cancer Care website and prepare reports for dissemination by organisations involved with end-of-life care and dementia.
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Affiliation(s)
- Margaret Elliott
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Jane Harrington
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Kirsten Moore
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Sarah Davis
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Anna Gola
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
| | - Louise Jones
- Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College London Medical School, London, UK
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Albers G, Van den Block L, Vander Stichele R. The burden of caring for people with dementia at the end of life in nursing homes: a postdeath study among nursing staff. Int J Older People Nurs 2014; 9:106-17. [DOI: 10.1111/opn.12050] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/31/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Gwenda Albers
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) & Ghent University; Brussels Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) & Ghent University; Brussels Belgium
| | - Robert Vander Stichele
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) & Ghent University; Brussels Belgium
- Heymans Institute of Pharmacology; Ghent University; Ghent Belgium
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88
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Vandervoort A, Houttekier D, Vander Stichele R, van der Steen JT, Van den Block L. Quality of dying in nursing home residents dying with dementia: does advanced care planning matter? A nationwide postmortem study. PLoS One 2014; 9:e91130. [PMID: 24614884 PMCID: PMC3948949 DOI: 10.1371/journal.pone.0091130] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 02/10/2014] [Indexed: 11/29/2022] Open
Abstract
Background Advance care planning is considered a central component of good quality palliative care and especially relevant for people who lose the capacity to make decisions at the end of life, which is the case for many nursing home residents with dementia. We set out to investigate to what extent (1) advance care planning in the form of written advance patient directives and verbal communication with patient and/or relatives about future care and (2) the existence of written advance general practitioner orders are related to the quality of dying of nursing home residents with dementia. Methods Cross-sectional study of deaths (2010) using random cluster-sampling. Representative sample of nursing homes in Flanders, Belgium. Deaths of residents with dementia in a three-month period were reported; for each the nurse most involved in care, GP and closest relative completed structured questionnaires. Findings We identified 101 deaths of residents with dementia in 69 nursing homes (58% response rate). A written advance patient directive was present for 17.5%, GP-orders for 56.7%. Controlling for socio-demographic/clinical characteristics in multivariate regression analyses, chances of having a higher mean rating of emotional well-being (less fear and anxiety) on the Comfort Assessment in Dying with Dementia scale were three times higher with a written advance patient directive and more specifically when having a do-not-resuscitate order (AOR 3.45; CI,1.1–11) than for those without either (AOR 2.99; CI,1.1–8.3). We found no association between verbal communication or having a GP order and quality of dying. Conclusion For nursing home residents with dementia there is a strong association between having a written advance directive and quality of dying. Where wishes are written, relatives report lower levels of emotional distress at the end of life. These results underpin the importance of advance care planning for people with dementia and beginning this process as early as possible.
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Affiliation(s)
- An Vandervoort
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Dirk Houttekier
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Robert Vander Stichele
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Jenny T. van der Steen
- EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, Department of General Practice & Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine, Vrije Universiteit Brussel, Brussels, Belgium
- * E-mail:
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Vandervoort A, Houttekier D, Van den Block L, van der Steen JT, Vander Stichele R, Deliens L. Advance care planning and physician orders in nursing home residents with dementia: a nationwide retrospective study among professional caregivers and relatives. J Pain Symptom Manage 2014; 47:245-56. [PMID: 23796587 DOI: 10.1016/j.jpainsymman.2013.03.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 03/05/2013] [Accepted: 03/19/2013] [Indexed: 11/27/2022]
Abstract
CONTEXT Advance care planning (ACP) is key to good palliative care for nursing home (NH) residents with dementia. OBJECTIVES We examined the extent to which the family physicians (FPs), nurses, and the relative most involved in the resident's care are informed about ACP, written advance directives, and FP treatment orders (FP-orders) for NH residents dying with dementia. We also examined the congruence among FP, nurse, and relative regarding the content of ACP. METHODS This was a representative nationwide post-mortem study (2010) in Flanders, Belgium, using random cluster sampling. In selected NHs, all deaths of residents with dementia in a three month period were reported. A structured questionnaire was completed by the FP, the nurse, and the patient's relative. RESULTS We identified 205 deceased residents with dementia in 69 NHs. Residents expressed their wishes regarding end-of-life care in 11.8% of cases according to the FP. The FP and nurse spoke with the resident in 22.0% and 9.7% of cases, respectively, and with the relative in 70.6% and 59.5%, respectively. An advance directive was present in 9.0%, 13.6%, and 18.4% of the cases according to the FP, nurse, and the relative, respectively. The FP-orders were present in 77.3% according to the FP, and discussed with the resident in 13.0% and with the relative in 79.3%. Congruence was fair (FP-nurse) on the documentation of FP-orders (k=0.26), and poor to slight on the presence of an advance directive (FP-relative, k=0.03; nurse-relative, k=-0.05; FP-nurse k=0.12). CONCLUSION Communication regarding care is rarely patient driven and more often professional caregiver or family driven. The level of congruence between professional caregivers and relatives is low.
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Affiliation(s)
- An Vandervoort
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium.
| | - Dirk Houttekier
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium; Department of Family Medicine, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jenny T van der Steen
- Department of General Practice & Elder Care Medicine, EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Robert Vander Stichele
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium; Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium; Department of Public and Occupational Health, EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
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Sternberg S, Bentur N, Shuldiner J. Quality of Care of Older People Living with Advanced Dementia in the Community in Israel. J Am Geriatr Soc 2014; 62:269-75. [DOI: 10.1111/jgs.12655] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Houttekier D, Cohen J, Pepersack T, Deliens L. Dying in hospital: a study of incidence and factors related to hospital death using death certificate data. Eur J Public Health 2013; 24:751-6. [DOI: 10.1093/eurpub/ckt209] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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