101
|
Theofilou P, Synodinou C, Panagiotaki H. Undergoing Haemodialysis: A Qualitative Study to Investigate the Lived Experiences of Patients. EUROPES JOURNAL OF PSYCHOLOGY 2013. [DOI: 10.5964/ejop.v9i1.338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
|
102
|
Efficacy and ethics of artificial nutrition in patients with neurologic impairments in home care. J Clin Neurosci 2013; 20:220-3. [DOI: 10.1016/j.jocn.2012.01.054] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 01/20/2012] [Indexed: 11/19/2022]
|
103
|
Abstract
Ethics is a fundamental part of geriatric medicine. Ethical questions are important in all fields of medicine but in geriatrics they are of particular importance. This branch of medicine is concerned with the care and health problems of mostly very old people close to the end of life. They are physically, mentally and socially vulnerable, frail individuals with a high risk for progressive deficits in physical and cognitive functions and are thus progressively dependent on help and care. Decisions about medical interventions are easier when the patients concerned have an intact decisional capacity and is more complex and difficult when dealing with multimorbid, frequently cognitively impaired very old individuals. Ethics is about systematically asking the right questions. This process should be logically structured but questions may remain unanswered. It is about questioning prejudices and modes of action, it means explaining terminology, requesting the best facts possible, formulating definitions and helping to logically reflect on a problem. Good ethics begins with good facts, not with groundless assumptions.
Collapse
Affiliation(s)
- T Frühwald
- Abteilung für Akutgeriatrie, Krankenhaus Hietzing mit Neurologischem Zentrum Rosenhügel, Wolkersbergenstr. 1, 1130, Wien, Österreich.
| |
Collapse
|
104
|
End-of-life care for patients with dementia in the United States: institutional realities. HEALTH ECONOMICS POLICY AND LAW 2012; 7:485-98. [DOI: 10.1017/s1744133112000266] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractFew are satisfied with end-of-life care in the United States. For families and friends of people with dementia, end-of-life care is particularly frustrating. Providing better end-of-life care to people with dementia is urgent because the prevalence of the disease is increasing rapidly. Dementia is currently the seventh leading cause of death in the United States and fifth leading cause of death among people aged 65 years and older. By 2050, there will be around 19 million people with Alzheimer's disease. This article reviews ethical and policy challenges associated with providing end-of-life care for people with dementia in the United States. I explain how disagreements about the meaning of futility lead to poor care for people with dementia. Most people agree that we should not provide care that is futile, but there is little agreement about how futility should be defined. US policies and politics clearly tip the balance in the direction of treatment, even in the face of strong evidence that such care does more harm than good. Although we may never reach a consensus, it is important to address these questions and think about how to develop policies that respect the different values.
Collapse
|
105
|
Stayner JL, Bhatnagar A, McGinn AN, Fang JC. Feeding tube placement: errors and complications. Nutr Clin Pract 2012; 27:738-48. [PMID: 23064019 DOI: 10.1177/0884533612462239] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Feeding tube placement for enteral nutrition (EN) support is widely used in both critically ill and stable chronically ill patients who are unable to meet their nutrition needs orally. Nasal or oral feeding tubes can be performed blindly at the bedside or with fluoroscopic or endoscopic guidance into the stomach or small bowel. Percutaneous feeding tubes are used when EN support is required for longer periods (>4-6 weeks) and are most commonly placed endoscopically or radiographically. Although generally safe and effective, there is a wide spectrum of known complications associated with feeding tube placement. Errors made at the time of feeding tube placement can result in a number of these procedural and postprocedural complications. In many cases, a single error at the time of placement can result in numerous complications. A thorough knowledge of these errors and avoiding them in practice will decrease iatrogenic complications in a vulnerable population. In addition, early recognition and management of complications will further minimize morbidity and even mortality in enteral feeding tube placement. This article reviews the common errors leading to complications of enteral feeding tube placement and their prevention and management.
Collapse
Affiliation(s)
- James L Stayner
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah 84132, USA
| | | | | | | |
Collapse
|
106
|
Teno JM, Gozalo PL, Mitchell SL, Kuo S, Rhodes RL, Bynum JPW, Mor V. Does feeding tube insertion and its timing improve survival? J Am Geriatr Soc 2012; 60:1918-21. [PMID: 23002947 DOI: 10.1111/j.1532-5415.2012.04148.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To examine survival with and without a percutaneous endoscopic gastrostomy (PEG) feeding tube using rigorous methods to account for selection bias and to examine whether the timing of feeding tube insertion affected survival. DESIGN Prospective cohort study. SETTING All U.S. nursing homes (NHs). PARTICIPANTS Thirty-six thousand four hundred ninety-two NH residents with advanced cognitive impairment from dementia and new problems eating studied between 1999 and 2007. MEASUREMENTS Survival after development of the need for eating assistance and feeding tube insertion. RESULTS Of the 36,492 NH residents (88.4% white, mean age 84.9, 87.4% with one feeding tube risk factor), 1,957 (5.4%) had a feeding tube inserted within 1 year of developing eating problems. After multivariate analysis correcting for selection bias with propensity score weights, no difference was found in survival between the two groups (adjusted hazard ratio (AHR) = 1.03, 95% confidence interval (CI) = 0.94-1.13). In residents who were tube-fed, the timing of PEG tube insertion relative to the onset of eating problems was not associated with survival after feeding tube insertion (AHR = 1.01, 95% CI = 0.86-1.20, persons with a PEG tube inserted within 1 month of developing an eating problem versus later (4 months) insertion). CONCLUSION Neither insertion of PEG tubes nor timing of insertion affect survival.
Collapse
Affiliation(s)
- Joan M Teno
- Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, RI 02912, USA.
| | | | | | | | | | | | | |
Collapse
|
107
|
Teno JM, Gozalo P, Mitchell SL, Kuo S, Fulton AT, Mor V. Feeding tubes and the prevention or healing of pressure ulcers. ACTA ACUST UNITED AC 2012; 172:697-701. [PMID: 22782196 DOI: 10.1001/archinternmed.2012.1200] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The evidence regarding the use of feeding tubes in persons with advanced dementia to prevent or heal pressure ulcers is conflicting. Using national data, we set out to determine whether percutaneous endoscopic gastrostomy (PEG) tubes prevent or help heal pressure ulcers in nursing home (NH) residents with advanced cognitive impairment (ACI). METHODS A propensity-matched cohort study of NH residents with ACI and recent need for assistance in eating was conducted by matching each NH resident who had a feeding tube inserted during a hospitalization to 3 without a PEG tube inserted. Using the Minimum Data Set (MDS), we examined 2 outcomes: first, whether residents without a pressure ulcer developed a stage 2 or higher pressure ulcer (n = 1124 with PEG insertion); and second, whether NH residents with a pressure ulcer (n = 461) experienced improvement of the pressure ulcer by their first posthospitalization MDS assessment (mean [SD] time between evaluations, 24.6 [32.7] days). RESULTS Matched residents with and without a PEG insertion showed comparable sociodemographic characteristic, rates of feeding tube risk factors, and mortality. Adjusted for risk factors, hospitalized NH residents receiving a PEG tube were 2.27 times more likely to develop a new pressure ulcer (95% CI, 1.95-2.65). Conversely, those with a pressure ulcer were less likely to have the ulcer heal when they had a PEG tube inserted (OR 0.70 [95% CI, 0.55-0.89]). CONCLUSIONS Feeding tubes are not associated with prevention or improved healing of a pressure ulcer. Rather, our findings suggest that the use of PEG tube is associated with increased risk of pressure ulcers among NH residents with ACI.
Collapse
Affiliation(s)
- Joan M Teno
- Center for Gerontology and Health Care Research, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | | | | | | | | | | |
Collapse
|
108
|
Aita K. [Survey of Japanese geriatricians on their practices and attitude towards artificial nutrition and hydration for patients with end-stage dementia]. Nihon Ronen Igakkai Zasshi 2012; 49:71-4. [PMID: 22466774 DOI: 10.3143/geriatrics.49.71] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
109
|
Kumagai R, Kubokura M, Sano A, Shinomiya M, Ohta S, Ishibiki Y, Narumi K, Aiba M, Ichimiya Y. Clinical evaluation of percutaneous endoscopic gastrostomy tube feeding in Japanese patients with dementia. Psychiatry Clin Neurosci 2012; 66:418-22. [PMID: 22834660 DOI: 10.1111/j.1440-1819.2012.02378.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
AIM The aim of this study was to clinically evaluate percutaneous endoscopic gastrostomy (PEG) tube feeding of elderly Japanese patients with dementia. METHOD The records of the 155 patients with dementia who underwent PEG in Juntendo Tokyo Koto Geriatric Medical Center were reviewed for pertinent clinical data, including diagnosis of dementia, place of stay before and after hospitalization, as well as survival rate, albumin levels, and incidence of aspiration pneumonia (AP) before and 6 months after PEG feeding. The latter three data of these patients were compared with those of 106 patients with dementia fed through a nasogastric (NG) tube. RESULTS Alzheimer's disease and vascular dementia were predominant. Fifty-three percent of the patients were admitted from their home; the number of discharges to homes decreased to 21.2%. The mean (SD) of the albumin levels was 2.9 (0.4) g/dl before feeding and 2.9 (0.6) g/dl after 6 months. Among the patients with AP before PEG tube feeding, 51.6% had an AP recurrence. Conversely, AP occurred in 9.4% of the patients without AP before feeding. The patient survival rate was higher by 27 months when using PEG tube than when using an NG tube. CONCLUSION PEG tube feeding in patients with dementia leads to preservation of status for a few years. Compared with NG tube feeding, PEG tube feeding did not induce AP due to impairment of intact swallowing function, and was associated with higher survival rate of approximately 2 years. However, PEG tube feeding does not seem to promote home medical care.
Collapse
Affiliation(s)
- Ryo Kumagai
- Department of Psychiatry, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
110
|
Komiya K, Ishii H, Okabe E, Iwashita T, Miyajima H, Tsubone T, Ohama M, Kushima H, Matsumoto B, Kadota JI. Risk factors for unexpected death from suffocation in elderly patients hospitalized for pneumonia. Geriatr Gerontol Int 2012; 13:388-92. [PMID: 22817527 DOI: 10.1111/j.1447-0594.2012.00912.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM Unexpected death from suffocation as a result of ortholaryngeal mucinous secretions or vomitus during recovery from pneumonia is devastating for patients, their families and medical professionals. This study aimed to determine the risk factors for unexpected death from suffocation in elderly patients hospitalized for pneumonia. METHODS This study was carried out with patients aged 65 years and older that were hospitalized for pneumonia and died of any cause. Unexpected death from suffocation was defined as: (i) being in the recovery stage of pneumonia; (ii) presenting stable vital signs a week before death; (iii) dying within 24 h after suffocation; and (iv) aspiration confirmed by transtracheal suction. The clinical features and courses, and methods of feeding were retrospectively analyzed. RESULTS A total of 11 patients that had an unexpected death from suffocation and 62 patients who died of other causes were enrolled. There were significantly more patients that received tube feeding after admission (continuation and introduction) among the patients who had died of suffocation (63.6%) than in those who had died of other causes (12.9%; P < 0.001). A multiple logistic regression analysis showed that tube feeding after admission was strongly associated with unexpected death from suffocation (adjusted odds ratio 9.536, P = 0.047) after adjusting for sex, age, level of serum albumin, PaO2 /FIO2 ratio, the pneumonia severity score and performance status. CONCLUSION A continuation of tube feeding after admission is thus considered to be a significant predictor of unexpected death from suffocation in elderly patients with pneumonia.
Collapse
Affiliation(s)
- Kosaku Komiya
- Internal Medicine 2, Oita University Faculty of Medicine, Oita, Japan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
111
|
Yeaman PA, Ford JL, Kim KY. Providing Quality Palliative Care in End-Stage Alzheimer Disease. Am J Hosp Palliat Care 2012; 30:499-502. [DOI: 10.1177/1049909112453644] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Providing quality palliative care is a daunting task profoundly impacted by diminished patient capacity at the end of life. Alzheimer disease (AD) is a disorder that erases our memories and is projected to increase dramatically for decades to come. By the time the patients with AD reach the end stage of the disease, the ability of patients to provide pertinent subjective complaints of pain and discomfort would have vanished. Historical perspectives of palliative care, exploration of the AD process, ethical issues, and crucial clinical considerations are provided to improve the understanding of disease progression and quality of care for patients with end-stage AD.
Collapse
Affiliation(s)
- Paul A. Yeaman
- Salem Veterans Affairs Medical Center, Jefferson College of Health Sciences, VA, USA
| | | | - Kye Y. Kim
- Carilion Center for Healthy Aging, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| |
Collapse
|
112
|
Kwok T, Bai X, Chui MYP, Lai CKY, Ho DWH, Ho FKY, Woo J. Effect of physical restraint reduction on older patients' hospital length of stay. J Am Med Dir Assoc 2012; 13:645-50. [PMID: 22763142 DOI: 10.1016/j.jamda.2012.05.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 05/24/2012] [Accepted: 05/29/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Physical restraints are often used to prevent falls and to secure medical devices in older people in hospitals. Restraint reduction has been advocated on the grounds that physical restraints have negative psychological effects and are not effective in preventing falls. The potential effect of restraint reduction on length of hospital stay (LOS) has not been investigated. This study was undertaken to compare the average length of stay of older patients in a convalescent medical ward setting before and after a restraint reduction program. DESIGN This is a retrospective study. SETTING A convalescent hospital in Hong Kong. PARTICIPANTS This study included 2000 patient episodes. MEASUREMENTS The use of physical restraint, LOS, and clinical outcomes of randomly selected patient episodes in the year before and after the implementation of a restraint reduction program were compared. The clinical outcomes included Modified Functional Ambulatory Categories and modified Barthel index. Subgroup analysis was performed on those with confusion as defined by dementia diagnosis, low abbreviated mental test score, or abnormal mental domain of Norton Score. RESULTS A total of 958 and 988 patient episodes admitted to 10 medical wards in a convalescent hospital in 2007 and 2009 were examined. There were no significant differences in the baseline characteristics of patients in the 2 years. With the implementation of the restraint reduction scheme, the rate of physical restraint use declined significantly from 13.3% in 2007 to 4.1% in 2009 for all patients. The average LOS of patients was significantly lower in the year after the implementation of restraint reduction (19.5 ± 20.7 versus 16.8 ± 13.4 days in 2007 and 2009 respectively, P < .001). On subgroup analysis, the reduction in LOS was significant in the cognitively impaired patients (23.0 ± 26.5 to 17.8 ± 15.0 days in 2007 and 2009 respectively, P < .001), but not in the cognitively normal patients. There were no significant differences between the 2 years in the incidence of fall, mobility, and activities of daily living on discharge. CONCLUSION Physical restraint reduction was associated with significant reduction in average length of stay in convalescent medical wards, especially in the cognitively impaired patients.
Collapse
Affiliation(s)
- Timothy Kwok
- Jockey Club Centre for Positive Ageing, Hong Kong; Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.
| | | | | | | | | | | | | |
Collapse
|
113
|
Pivi GAK, Bertolucci PHF, Schultz RR. Nutrition in severe dementia. Curr Gerontol Geriatr Res 2012; 2012:983056. [PMID: 22645608 PMCID: PMC3356862 DOI: 10.1155/2012/983056] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 02/18/2012] [Accepted: 02/21/2012] [Indexed: 11/17/2022] Open
Abstract
An increasing proportion of older adults with Alzheimer's disease or other dementias are now surviving to more advanced stages of the illness. Advanced dementia is associated with feeding problems, including difficulty in swallowing and respiratory diseases. Patients become incompetent to make decisions. As a result, complex situations may arise in which physicians and families decide whether artificial nutrition and hydration (ANH) is likely to be beneficial for the patient. The objective of this paper is to present methods for evaluating the nutritional status of patients with severe dementia as well as measures for the treatment of nutritional disorders, the use of vitamin and mineral supplementation, and indications for ANH and pharmacological therapy.
Collapse
Affiliation(s)
| | | | - Rodrigo Rizek Schultz
- Behavior Neurology Section, Federal University of São Paulo (UNIFESP), 04025-000 São Paulo SP, Brazil
| |
Collapse
|
114
|
Komiya K, Ishii H, Teramoto S, Yasuda T, Sato S, Yamamoto H, Kimura H, Takahashi O, Hiramatsu K, Kadota JI. Medical Professionals' Attitudes Toward Tube Feeding for Themselves or Their Families: A Multicenter Survey in Japan. J Palliat Med 2012; 15:561-6. [DOI: 10.1089/jpm.2011.0496] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kosaku Komiya
- Department of Internal Medicine 2, Oita University Faculty of Medicine, Oita, Japan
- Research center of respiratory medicine, Tenshindo Hetsugi Hospital, Oita, Japan
| | - Hiroshi Ishii
- Department of Internal Medicine 2, Oita University Faculty of Medicine, Oita, Japan
| | - Shinji Teramoto
- Department of Respiratory Medicine, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Hitachinaka Education and Research Center, Ibaragi, Japan
| | - Takaaki Yasuda
- Department of Psychiatry, Saitama Medical Center, Saitama, Japan
| | - Shintaro Sato
- Division of Respiratory Medicine, Saitama Cooperative Hospital, Saitama, Japan
| | - Hidehiko Yamamoto
- Department of Respiratory Medicine7, Aso Iizuka Hospital, Fukuoka, Japan
| | - Hiroki Kimura
- Department of Respiratory Medicine7, Aso Iizuka Hospital, Fukuoka, Japan
| | - Osamu Takahashi
- Center for Clinical Epidemiology, St. Luke's Life Science Institute, Tokyo, Japan
| | - Kazufumi Hiramatsu
- Department of Internal Medicine 2, Oita University Faculty of Medicine, Oita, Japan
| | - Jun-ichi Kadota
- Department of Internal Medicine 2, Oita University Faculty of Medicine, Oita, Japan
| |
Collapse
|
115
|
|
116
|
Ogita M, Utsunomiya H, Akishita M, Arai H. Indications and practice for tube feeding in Japanese geriatricians: Implications of multidisciplinary team approach. Geriatr Gerontol Int 2012; 12:643-51. [DOI: 10.1111/j.1447-0594.2011.00831.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
117
|
Kosaka Y, Nakagawa-Satoh T, Ohrui T, Fujii M, Arai H, Sasaki H. Survival period after tube feeding in bedridden older patients. Geriatr Gerontol Int 2012; 12:317-21. [DOI: 10.1111/j.1447-0594.2011.00805.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
118
|
Mitchell SL, Black BS, Ersek M, Hanson LC, Miller SC, Sachs GA, Teno JM, Morrison RS. Advanced dementia: state of the art and priorities for the next decade. Ann Intern Med 2012. [PMID: 22213494 DOI: 10.1059/0003-4819-156-1-201201030-00008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.
Collapse
Affiliation(s)
- Susan L Mitchell
- Hebrew SeniorLife, Institute for Aging Research, Boston, Massachusetts 02131, USA
| | | | | | | | | | | | | | | |
Collapse
|
119
|
Mitchell SL, Black BS, Ersek M, Hanson LC, Miller SC, Sachs GA, Teno JM, Morrison RS. Advanced dementia: state of the art and priorities for the next decade. Ann Intern Med 2012; 156:45-51. [PMID: 22213494 PMCID: PMC3261500 DOI: 10.7326/0003-4819-156-1-201201030-00008] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.
Collapse
Affiliation(s)
- Susan L Mitchell
- Hebrew SeniorLife, Institute for Aging Research, Boston, Massachusetts 02131, USA
| | | | | | | | | | | | | | | |
Collapse
|
120
|
Sudo E, Hanabusa H. [86-aged case of Alzheimer disease followed by nursing home after percutaneous endoscopic gastrostomy]. Nihon Ronen Igakkai Zasshi 2012; 49:119-122. [PMID: 22466782 DOI: 10.3143/geriatrics.49.119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
|
121
|
Küpper AL, Hughes JC. The challenges of providing palliative care for older people with dementia. Curr Oncol Rep 2011; 13:295-301. [PMID: 21503596 DOI: 10.1007/s11912-011-0171-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Palliative care seems the right approach to dementia, except that it suggests a dichotomy between cure and care. As in cancer care, supportive care provides a broader framework, viewing dementia from the time of diagnosis until death and bereavement. The challenge is to find the right approach to the individual. This challenge arises in the person's own home, in long-term care homes, and in hospitals. The challenging features of palliative care for older people with dementia are found in connection with the use of antibiotics, antipsychotics, and other medications, as well as in decisions about whether the person is in pain or in distress, or whether artificial feeding should be contemplated or not, as well as about the use of advance care plans. In short, the challenges are essentially ethical as well as clinical. The right approach will be the one that recognizes this facet of clinical care.
Collapse
Affiliation(s)
- Anita-Luise Küpper
- Northumberland, Tyne and Wear NHS Foundation Trust, Older People's Services, St. George's Park, Morpeth, NE61 2NU, UK.
| | | |
Collapse
|
122
|
del Río M, Shand B, Bonati P, Palma A, Maldonado A, Taboada P, Nervi F. Hydration and nutrition at the end of life: a systematic review of emotional impact, perceptions, and decision-making among patients, family, and health care staff. Psychooncology 2011; 21:913-21. [DOI: 10.1002/pon.2099] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 10/13/2011] [Accepted: 10/15/2011] [Indexed: 11/10/2022]
Affiliation(s)
- M. I. del Río
- Programa de Medicina Paliativa y Cuidados Continuos; Departamento de Medicina Interna, Pontificia Universidad Católica de Chile; Santiago Chile
| | - B. Shand
- Departamento de Neurología; Pontificia Universidad Católica de Chile; Santiago Chile
| | - P. Bonati
- Programa de Medicina Paliativa y Cuidados Continuos; Departamento de Medicina Interna, Pontificia Universidad Católica de Chile; Santiago Chile
| | - A. Palma
- Programa de Medicina Paliativa y Cuidados Continuos; Departamento de Medicina Interna, Pontificia Universidad Católica de Chile; Santiago Chile
| | - A. Maldonado
- Programa de Medicina Paliativa y Cuidados Continuos; Departamento de Medicina Interna, Pontificia Universidad Católica de Chile; Santiago Chile
| | - P. Taboada
- Centro de Bioética; Pontificia Universidad Católica de Chile; Santiago Chile
| | - F. Nervi
- Programa de Medicina Paliativa y Cuidados Continuos; Departamento de Medicina Interna, Pontificia Universidad Católica de Chile; Santiago Chile
- División de Medicina, Departamento de Gastroenterología; Pontificia Universidad Católica de Chile; Santiago Chile
| |
Collapse
|
123
|
Monod S, Chiolero R, Büla C, Benaroyo L. Ethical issues in nutrition support of severely disabled elderly persons: a guide for health professionals. JPEN J Parenter Enteral Nutr 2011; 35:295-302. [PMID: 21527592 DOI: 10.1177/0148607111405338] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Providing or withholding nutrition in severely disabled elderly persons is a challenging dilemma for families, health professionals, and institutions. Despite limited evidence that nutrition support improves functional status in vulnerable older persons, especially those suffering from dementia, the issue of nutrition support in this population is strongly debated. Nutrition might be considered a basic need that not only sustains life but provides comfort as well by patients and their families. Consequently, the decision to provide or withhold nutrition support during medical care is often complex and involves clinical, legal, and ethical considerations. This article proposes a guide for health professionals to appraise ethical issues related to nutrition support in severely disabled older persons. This guide is based on an 8-step process to identify the components of a situation, analyze conflicting values that result in the ethical dilemma, and eventually reach a consensus for the most relevant plan of care to implement in a specific clinical situation. A vignette is presented to illustrate the use of this guide when analyzing a clinical situation.
Collapse
Affiliation(s)
- Stéfanie Monod
- Service of Geriatric Medicine and Geriatric Rehabilitation, University of Lausanne Medical Center, Lausanne, Switzerland.
| | | | | | | |
Collapse
|
124
|
Rahman M, Evans KE, Arif N, Gorard DA. Mental incapacity in hospitalised patients undergoing percutaneous endoscopic gastrostomy insertion. Clin Nutr 2011; 31:224-9. [PMID: 22047680 DOI: 10.1016/j.clnu.2011.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 10/03/2011] [Accepted: 10/07/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND & AIMS Decisions to insert percutaneous endoscopic gastrostomy (PEG) tubes may be difficult because patients have serious underlying disease, and the procedure has associated risks. Patients may also lack mental capacity to consent to PEG insertion. This study aimed to prospectively determine the prevalence of mental incapacity in hospitalised patients undergoing PEG insertion. METHODS Mental capacity was assessed using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) in 72 consecutive inpatients referred for PEG insertion. Cognitive function was measured using the Mini-Mental State Examination (MMSE). Sixty eight inpatients and 69 outpatients having diagnostic upper gastrointestinal (UGI) endoscopy were similarly studied. RESULTS Thirty nine of the PEG patients had suffered stroke, and none had a primary diagnosis of dementia. Seventy four % (53/72) of inpatients referred for PEG, 22% (15/68) of inpatients having UGI endoscopy, and 3% (2/69) of outpatients having UGI endoscopy, lacked mental capacity, p < 0.001. MMSE scores were normal in just 18% of inpatients having PEG, in 72% of inpatients having UGI endoscopy, and in 91% of outpatients having UGI endoscopy, p < 0.001. CONCLUSION Amongst inpatients undergoing PEG insertion there is a high prevalence (three-quarters patients) of mental incapacity to consent to this important intervention. Decisions have to be made on behalf of most inpatients referred for PEG insertion.
Collapse
Affiliation(s)
- M Rahman
- Wycombe Hospital, Queen Alexandra Road, High Wycombe, Bucks HP11 2TT, United Kingdom
| | | | | | | |
Collapse
|
125
|
Montes JV, Díez SG, Sinobas PE. [Peg in patients with dementia?]. ENFERMERIA CLINICA 2011; 21:302. [PMID: 21920791 DOI: 10.1016/j.enfcli.2011.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2011] [Accepted: 06/15/2011] [Indexed: 11/30/2022]
|
126
|
|
127
|
Vitale CA, Berkman CS, Monteleoni C, Ahronheim JC. Tube feeding in patients with advanced dementia: knowledge and practice of speech-language pathologists. J Pain Symptom Manage 2011; 42:366-78. [PMID: 21454044 DOI: 10.1016/j.jpainsymman.2010.11.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 11/14/2010] [Accepted: 11/23/2010] [Indexed: 11/29/2022]
Abstract
CONTEXT Speech-language pathologists (SLP) are often called on to evaluate eating difficulties in patients with dementia. OBJECTIVES To assess factors associated with SLPs' knowledge and recommendations about feeding tubes in patients with advanced dementia. METHODS A mail survey was administered to a probability sample of 1500 SLPs from the American Speech-Language-Hearing Association mailing list; 731 usable surveys were received (response rate=53.7%). Self-perceived preparedness, knowledge, and care recommendations were measured. Knowledge items were scored as "evidence based" or not according to the best evidence in the literature. RESULTS Only 42.1% of SLP respondents felt moderately/well prepared to manage dysphagia. Only 22.0% of respondents recognized that tube feeding is unlikely to reduce risk of aspiration pneumonia whereas a slight majority understood that tube feeding would not likely prevent an uncomfortable death (50.2%), improve functional status (54.5%), or enhance quality of life (QOL) (63.2%). A majority (70.0%) was willing to consider recommending oral feeding despite high risk of aspiration. Logistic regression analyses indicated that those willing to consider this recommendation gave the most evidence-based responses to knowledge questions about tube feeding outcomes: aspiration pneumonia (odds ratio [OR]=1.75, 95% confidence interval [CI]=1.07-2.87), functional status (OR=1.43, 95% CI=1.0-2.06), QOL (OR=2.19, 95% CI=1.52-3.17), and prevent uncomfortable death (OR=1.97, 95% CI=1.37-2.88). Logistic regression analyses also indicated that those with more experience evaluating patients with dementia gave the most evidence-based response to two knowledge questions: aspiration pneumonia (OR=2.64, 95% CI=1.48-4.72) and prevent uncomfortable death (OR=2.03, 95% CI=1.35-3.05) whereas those with higher self-perceived preparedness in managing dysphagia in dementia had less knowledge in two areas: aspiration pneumonia (OR=0.57, 95% CI=0.38-0.84) and QOL (OR=0.72, 95% CI=0.51-1.01). CONCLUSION Misperceptions among SLPs about tube feeding in advanced dementia are common, especially in relation to risk of aspiration. Knowledge about tube feeding outcomes was positively associated with experience and inversely associated with self-perceived higher preparedness in evaluating patients with dementia.
Collapse
Affiliation(s)
- Caroline A Vitale
- Division of Geriatric Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| | | | | | | |
Collapse
|
128
|
Brody H, Hermer LD, Scott LD, Grumbles LL, Kutac JE, McCammon SD. Artificial nutrition and hydration: the evolution of ethics, evidence, and policy. J Gen Intern Med 2011; 26:1053-8. [PMID: 21380599 PMCID: PMC3157529 DOI: 10.1007/s11606-011-1659-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 01/24/2011] [Accepted: 02/04/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The debate over use of artificial nutrition and hydration (ANH) in terminal illness, including advanced dementia, remains contentious despite extensive ethical and empirical investigation. METHODS For this narrative review we undertook a focused, selective review of literature reflecting ethical analysis, empirical assessment of outcomes, legal responses, and thinking within the Roman Catholic religious tradition. RESULTS The history of the debate over the past 60 years results from a complex interplay of ethical concerns, a growing empirical database, legal changes, public opinion, and financial as well as institutional concerns. Discussions of ANH today are often conducted without any understanding of this historical context. DISCUSSION Patients' interests could be better protected through remedial action at both the individual and the policy levels.
Collapse
Affiliation(s)
- Howard Brody
- Institute for the Medical Humanities, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-1311, USA.
| | | | | | | | | | | |
Collapse
|
129
|
Outcomes of damage control laparotomy with open abdomen management in the octogenarian population. ACTA ACUST UNITED AC 2011; 70:616-21. [PMID: 21610351 DOI: 10.1097/ta.0b013e31820d19ed] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Controversy surrounds the role of abbreviated laparotomy and open abdomen (OA) in the octogenarian population in the acute care surgery model based on concern that the initial insult, combined with its sequelae, is beyond the physiologic reserve of these patients. As the population ages further, this dilemma will arise more frequently, requiring the analysis of futility or utility of OA in this demographic. METHODS The institutional review board approval was obtained to analyze retrospectively patients aged 80 years or older with OA from 1997 to 2009. Univariate, multivariate, and Kaplan-Meier analyses were used to evaluate the effects that demographics, comorbidities, and clinical factors had on in-hospital mortality and overall survival. RESULTS Sixty-seven patients (32 men and 35 women) were identified. Acute general surgery (including vascular procedures) was the most common indication for laparotomy (94%) with trauma a distant second (6%). Early definitive closure was obtained in 52% of patients with a 34% planned ventral hernia rate. Overall complication rate was 62% and overall in-hospital mortality was 37%. Multivariate analysis revealed congestive heart failure (odds ratio, 11.4; 95% confidence interval, 1.01-128.03) and acute renal failure (odds ratio, 11.8; 95% confidence interval, 2.00-69.12) correlated with in-hospital mortality. Of those surviving to hospital dismissal, 2-year survival was 66% with a 17-month median follow-up (range, 1-125 months). CONCLUSION There is utility in octogenarians undergoing aggressive surgical management that requires OA. These patients have high mortality rates, but long-term survival can be better than their peers with other chronic diseases if they survive the surgical insult. Patient selection should be based on preexisting comorbidities such as congestive heart failure and the development of acute renal failure. Despite the adequate long-term survival, most patients will leave the hospital with a hernia.
Collapse
|
130
|
Multidisciplinary Practical Guidelines for Gastrointestinal Access for Enteral Nutrition and Decompression From the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, With Endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). J Vasc Interv Radiol 2011; 22:1089-106. [DOI: 10.1016/j.jvir.2011.04.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 04/08/2011] [Accepted: 04/08/2011] [Indexed: 12/16/2022] Open
|
131
|
Itkin M, DeLegge MH, Fang JC, McClave SA, Kundu S, d'Othee BJ, Martinez-Salazar GM, Sacks D, Swan TL, Towbin RB, Walker TG, Wojak JC, Zuckerman DA, Cardella JF. Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). Gastroenterology 2011; 141:742-65. [PMID: 21820533 DOI: 10.1053/j.gastro.2011.06.001] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 04/08/2011] [Indexed: 02/06/2023]
Affiliation(s)
- Maxim Itkin
- Department of Radiology, Division of Interventional Radiology, University of Pennsylvania Medical Center, Pennsylvania Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
132
|
Chrash M, Mulich B, Patton CM. The APN role in holistic assessment and integration of spiritual assessment for advance care planning. ACTA ACUST UNITED AC 2011. [DOI: 10.1111/j.1745-7599.2011.00644.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
133
|
Malmgren A, Hede GW, Karlström B, Cederholm T, Lundquist P, Wirén M, Faxén-Irving G. Indications for percutaneous endoscopic gastrostomy and survival in old adults. Food Nutr Res 2011; 55:6037. [PMID: 21799666 PMCID: PMC3144742 DOI: 10.3402/fnr.v55i0.6037] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 06/13/2011] [Accepted: 06/23/2011] [Indexed: 11/30/2022] Open
Abstract
Background Many diseases striking old adults result in eating difficulties. Indications for selecting individuals for percutaneous endoscopic gastrostomy (PEG) are unclear and everybody may not benefit from the procedure. Objective The aim of this study was to evaluate indications for and survival after PEG insertion in patients older than 65 years. Design and Methods A retrospective analysis including age, gender, diagnosis, indication, and date of death was made in 201 consecutive individuals, 94 male, mean age 79±7 years, who received a nutritional gastrostomy. Results Dysphagia was present in 86% of the patients and stroke was the most common diagnosis (49%). Overall median survival was 123 days and 30-day mortality was 22%. Patients with dementia and Mb Parkinson had the longest survival (i.e. 244 and 233 days), while those with other neurological diseases, and head and neck malignancy had the shortest (i.e. 75 and 106 days). There was no difference in mortality in patients older or younger than 80 years, except in patients with dementia. Conclusions Old age should not be a contraindication for PEG. A high 30-day mortality indicates that there is a need of better criteria for selection and timing of PEG insertion in the elderly.
Collapse
Affiliation(s)
- Anna Malmgren
- Department of Surgical and Medical Gastroenterology and Hepatology, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | | | | | | |
Collapse
|
134
|
Abstract
Hospitalists care for elderly patients daily, but few have specialized training in geriatric medicine. Elderly patients, and in particular the very old and the frail elderly, are at high risk of functional decline and iatrogenic complications during hospitalization. Other challenges in caring for this patient population include dosing medications safely, preventing delirium and accidental falls, and providing adequate pain control. Ways to improve the care of the hospitalized elderly patient include the following: screening for geriatric syndromes such as delirium, assessing functional status and maintaining mobility, and implementation of interventions that have been shown to prevent delirium, accidental falls, and acute functional decline in the hospital. This article addresses these issues with 10 evidence-based pearls developed to help hospitalists provide optimal care for this expanding population.
Collapse
Affiliation(s)
- Angelena Maria Labella
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington 98195, USA
| | | | | |
Collapse
|
135
|
Desai AK, Grossberg GT. Palliative and end-of-life care in psychogeriatric patients. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/ahe.11.20] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A rapidly growing number of elderly persons and their families are burdened by one or more terminal illnesses in the later years of their life. How best to support their quality of life is a major challenge for healthcare teams. Palliative and end-of-life (PEOL) care is well positioned to respond to this challenge. While the evidence of PEOL is just beginning, much of the suffering can be relieved by what is already known. PEOL care for the elderly needs to go beyond the focus on the patient and should rest on a broad understanding of the nature of suffering that includes family and professional caregivers in that experience of suffering. The dissemination of PEOL care principles should be a public health priority. This article aims to improve understanding of appropriate PEOL care in the elderly and discuss future perspectives.
Collapse
Affiliation(s)
- Abhilash K Desai
- Department of Neurology & Psychiatry, Saint Louis University School of Medicine, 1438 S. Grand Blvd, St Louis, MO 63104, USA
| | | |
Collapse
|
136
|
|
137
|
Teno JM, Mitchell SL, Kuo SK, Gozalo PL, Rhodes RL, Lima JC, Mor V. Decision-making and outcomes of feeding tube insertion: a five-state study. J Am Geriatr Soc 2011; 59:881-6. [PMID: 21539524 DOI: 10.1111/j.1532-5415.2011.03385.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To examine family member's perceptions of decision-making and outcomes of feeding tubes. DESIGN Mortality follow-back survey. Sample weights were used to account for oversampling and survey design. A multivariate model examined the association between feeding tube use and overall quality of care rating regarding the last week of life. SETTING Nursing homes, hospitals, and assisted living facilities. PARTICIPANTS Respondents whose relative had died from dementia in five states with varying feeding tube use. MEASUREMENTS Respondents were asked about discussions, decision-making, and outcomes related to their loved ones' feeding problems. RESULTS Of 486 family members surveyed, representing 9,652 relatives dying from dementia, 10.8% reported that the decedent had a feeding tube, 17.6% made a decision not to use a feeding tube, and 71.6% reported that there was no decision about feeding tubes. Of respondents for decedents with a feeding tube, 13.7% stated that there was no discussion about feeding tube insertion, and 41.6% reported a discussion that was shorter than 15 minutes. The risks associated with feeding tube insertion were not discussed in one-third of the cases, 51.8% felt that the healthcare provider was strongly in favor of feeding tube insertion, and 12.6% felt pressured by the physician to insert a feeding tube. The decedent was often physically (25.9%) or pharmacologically restrained (29.2%). Respondents whose loved ones died with a feeding tube were less likely to report excellent end-of-life care (adjusted odds ratio=0.42, 95% confidence interval=0.18-0.97) than those who were not. CONCLUSION Based on the perceptions of bereaved family members, important opportunities exist to improve decision-making in feeding tube insertion.
Collapse
Affiliation(s)
- Joan M Teno
- Health Services, Policy, and Practice, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.
| | | | | | | | | | | | | |
Collapse
|
138
|
|
139
|
Modi S, Velde B, Gessert CE. Perspectives of community members regarding tube feeding in patients with end-stage dementia: findings from African-American and Caucasian focus groups. OMEGA-JOURNAL OF DEATH AND DYING 2011; 62:77-91. [PMID: 21138071 DOI: 10.2190/om.62.1.d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Research has demonstrated that placement of permanent feeding tubes to provide artificial nutrition is more common among non-white populations, but there is a scarcity of research regarding why those differences may exist. The purpose of this study is to describe and understand community members' attitudes toward tube feeding and end-of-life decision-making. Four focus groups were convened in Greenville, NC. The 28 focus group participants were 11 African American and 17 Caucasian community members between ages 51 and 81. Two focus groups were held with Caucasian participants and two with African-American participants. Focus groups were recorded and transcribed, and qualitative analysis was performed using NVivo software. Seven themes resulted from the analysis of the transcripts. They included: "A feeding tube is," "Food is important," "They want to do the right thing," "To make a rational decision," "There are worse things than death," "There's a lot of good things," "It's out of my hands." There were more commonalities than differences in the views of African Americans and Caucasians on perspectives on tube feeding and elders with dementia. An unexpected emphasis was placed on the importance of food as a symbol of caring. Families tend to be oriented toward personal fidelity to the elder and the symbolic role of feeding in fulfilling that fidelity.
Collapse
|
140
|
Ethische Entscheidungen am Lebensende. Palliat Care 2011. [DOI: 10.1007/978-3-642-20934-5_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
|
141
|
Hines S, McCrow J, Abbey J, Foottit J, Wilson J, Franklin S, Beattie E. The effectiveness and appropriateness of a palliative approach to care for people with advanced dementia: a systematic review. ACTA ACUST UNITED AC 2011; 9:960-1131. [PMID: 27820410 DOI: 10.11124/01938924-201109260-00001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Dementia is a progressive and incurable disease which presents many challenges to care providers, particularly in terms of end-of-life care. A palliative approach; that is an approach to care which seeks to ease burdensome symptoms without attempting curative treatment, has been suggested as the most appropriate framework for addressing the needs of these people. OBJECTIVES The overall objective was to establish best practice in relation to palliative care for people with advanced dementia in terms of effectiveness and appropriateness. SEARCH STRATEGY The search strategy aimed to find both published and unpublished English language studies, published between 1997 and 2009. A three-step search strategy was utilised in each component of this review. CRITICAL APPRAISAL Quantitative, qualitative and discursive text articles were included in this review. Articles were assessed for congruence to the review criteria and then critically appraised for quality using the appropriate JBI tool. DATA COLLECTION AND ANALYSIS Data were extracted using the appropriate JBI data extraction tool for each methodology. No quantitative meta-analysis was possible due to clinical and statistical heterogeneity. Qualitative synthesis was performed with the JBI QARI tool. Discursive textual synthesis was performed with the JBI NOTARI tool. RESULTS Quantitative studies recommended the use of do not resuscitate, do not hospitalise orders and other forms of advance directives to prevent interventions unwanted by the patient and/or their family. Feeding tubes and the use of intravenous antibiotics were not found to be an effective intervention. Interventions designed to treat the burdensome symptoms of advanced dementia (such as pain and agitation) were found to be of the most benefit to patients.Qualitative analysis found it distressing for families to discuss or plan for, a poor quality of life for their loved one during the process of dying. Decisions concerned with palliative treatment for the person with advanced dementia were found to be complicated by knowledge differences, lack of understanding of the disease trajectory of dementia, the unpredictable nature of dementia itself and religious and socio-economical issues. Textual analysis found that a palliative approach to end of life care in advanced dementia is both appropriate and effective in terms of benefit to patients and their significant others.Despite the large volume of data retrieved and analysed for this review, no studies examining the role of case-conferencing for managing the introduction of palliative care or managing a palliative approach met the inclusion criteria for this systematic review. IMPLICATIONS FOR PRACTICE IMPLICATIONS FOR FUTURE RESEARCH: There is a need for further studies in the area of palliation and advanced dementia, particularly high quality studies investigating palliative care case conferencing and other methods of arranging and planning end of life care for people with dementia. CONCLUSION There is some evidence to suggest that a palliative approach is both effective and appropriate for use with people who have advanced dementia. There is no evidence for or against the use of case-conferencing as a method of arranging care for people with advanced dementia.
Collapse
Affiliation(s)
- Sonia Hines
- 1. Dementia Collaborative Research Centre: Carers and Consumers, Queensland University of Technology School of Nursing, an Evidence Synthesis Group of the Joanna Briggs Institute 2. Nursing Research Centre: Mater Health Services, The Queensland Centre for Evidence-Based Nursing and Midwifery: A Collaborating Centre of the Joanna Briggs Institute 3. Research Officer - Nourish Institute of Health and Biomedical Innovation (IHBI), School of Public Health (SPH)
- Queensland University of Technology (QUT)
| | | | | | | | | | | | | |
Collapse
|
142
|
Demenz und Palliative Care. Palliat Care 2011. [DOI: 10.1007/978-3-642-20934-5_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
143
|
Hines S, McCrow J, Abbey J, Foottit J, Wilson J, Franklin S, Beattie E. The effectiveness and appropriateness of a palliative approach to care for people with advanced dementia: a systematic review. ACTA ACUST UNITED AC 2011. [DOI: 10.11124/jbisrir-2011-151] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
144
|
LEIBOVITZ A. Tube-Enteral Feeding for Frail Elderly Patients with Oropharyngeal Dysphagia—Not Only Yes or No, but When? J Nutr Sci Vitaminol (Tokyo) 2011; 57:311-2. [DOI: 10.3177/jnsv.57.311] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
145
|
Löser C. Malnutrition in hospital: the clinical and economic implications. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:911-7. [PMID: 21249138 DOI: 10.3238/arztebl.2010.0911] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Accepted: 01/19/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Undernutrition and malnutrition are common in hospitalized patients. Their combined prevalence on admission is estimated at 25% and is rising. METHODS Selective literature review with special consideration of current guidelines and meta-analyses. RESULTS The nutritional state of every patient should be assessed on admission with simple, established parameters, and patients suffering from under- or malnutrition should be treated with a targeted nutritional intervention based on the established stepwise treatment algorithm. Under- and malnutrition are an independent risk and cost factor with a significant influence on mortality, morbidity, length of hospital stay, and quality of life. Their direct costs alone amount to some 9 billion Euros in Germany each year. Therapeutic trials and meta-analyses have clearly documented the therapeutic benefit and cost-effectiveness of oral nutritional supplements and tube feeds. Targeted nutritional intervention is an integral part of medical treatment and prevention. CONCLUSION Undernutrition and malnutrition are common in hospitalized patients and are both medically and economically harmful. If they are detected early by targeted assessment and then treated appropriately according to the established stepwise treatment algorithm, better clinical outcomes and lower costs will result.
Collapse
Affiliation(s)
- Christian Löser
- Medizinische Klinik Rotes Kreuz Krankenhaus, Kassel, Germany
| |
Collapse
|
146
|
León-Delgado MX, Flórez-Rojas SP, Torres M, Rengifo-Varona ML, Prada D. The Importance of Evaluating Symptoms and Functional Alterations in Chronic Neurological Diseases: Experiences in Palliative Care and Rehabilitation at a Colombian Institution. AQUICHAN 2010. [DOI: 10.5294/aqui.2010.10.3.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Existe un incremento en la prevalencia de enfermedades neurológicas y su carga de enfermedad. Debido a ello, identificar la frecuencia de síntomas y las alteraciones funcionales es de vital importancia para definir un adecuado plan de tratamiento. Se llevó a cabo un estudio de corte transversal para identificar los síntomas principales y las alteraciones funcionales en pacientes neurológicos de un centro de referencia colombiano para manejo de rehabilitación. Se encontraron como síntomas y alteraciones funcionales más frecuentes: alteraciones de la marcha (65,5%), desórdenes de comunicación (36,98%), alteraciones emocionales y de memoria (38%), dolor (29,45%) y alteraciones en las actividades básicas cotidianas (24,3%). El 50% de los pacientes que reportaron dolor, el 30% de los que manifestaron insomnio y el 80% de los que refirieron estreñimiento no recibieron tratamiento en la primera consulta. Algunos de los síntomas identificados no son características que definen la enfermedad, y no siempre son objeto de intervención. Los resultados de este estudio pueden contribuir a reconocer la carga de los síntomas de las enfermedades neurológicas, sensibilizando a los profesionales de la salud acerca de la importancia del cuidado paliativo en pacientes con enfermedades progresivas no oncológicas.
Collapse
|
147
|
Aparanji KP, Dharmarajan TS. Pause before a PEG: A feeding tube may not be necessary in every candidate! J Am Med Dir Assoc 2010; 11:453-6. [PMID: 20627188 DOI: 10.1016/j.jamda.2009.11.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Revised: 11/29/2009] [Accepted: 11/30/2009] [Indexed: 01/02/2023]
Abstract
Percutaneous endoscopic gastrostomies (PEGs) are a means to provide nutrition in older adults incapable of normal adequate nutrient intake. Often decisions to insert a PEG in patients with illness and dementia are made hastily, before exhausting every means of feeding and full evaluation for the potential to regain capacity to feed normally. Further, ethical aspects often cloud such decisions, with data not supporting meaningful long-term improvement in outcomes or quality of life for the recipient of a PEG. Our case illustrates the story of a nursing home resident in whom an organized approach determined a reversible basis for his inability to feed and the potential to avoid tube insertion.
Collapse
|
148
|
|
149
|
Abstract
Critically ill elderly patients facing crucial decisions about their future medical treatment routinely come under the care of hospital physicians who may have no previous relationship with them or their families. The majority of patients for whom this sort of decision must be made are unable to participate in decision making because of dementia, delirium, or both. They are desperately ill, often with a new medical problem with which they have had little time to come to terms. Hospital physicians must rely on advance directives--either a living will, health care proxy, or both--to make decisions. Translating advance directives into practice is a challenging and complex process that is best approached carefully and systematically.
Collapse
Affiliation(s)
- Muriel R Gillick
- Department of Population Medicine, Harvard Pilgrim Health Care Institute/ Harvard Medical School, Boston, MA 02215, USA.
| |
Collapse
|
150
|
|