CLINICAL PRACTICE. Advanced Dementia

A patient's experience in dementia care: Using the "lived experience" to improve care

OBJECTIVE

To give FPs an understanding of the "lived experience" of dementia via the words of a person with dementia (PWD)- Faye Forbes, a 64-year-old Anglican priest with Alzheimer disease who provides her perspectives on living with dementia-and to use these thoughts to improve care and outcomes.

SOURCES OF INFORMATION

Ovid MEDLINE was searched from January 2005 to February 2015 using subject headings for dementia, caregiver, perspectives, and quality of health care. Articles geared toward FPs were selected. Relevant review articles and original research articles were used when appropriate and if they were applicable to PWDs and their caregivers.

MAIN MESSAGE

There are several frameworks that organize the main experiences described by patients and caregivers. We used a review of the qualitative literature to provide the framework to summarize Faye's experience under the following headings: seeking a diagnosis, accessing supports and services, information needs, disease management, and communication and attitudes.

CONCLUSION

Physicians should consider these themes when developing a management plan for PWDs. Trying to understand the experiences and perspectives of PWDs and their caregivers is important in providing optimal care.

Higher FT4 or TSH below the normal range are associated with increased risk of dementia: a meta-analysis of 11 studies

Observational studies of thyroid function and dementia have reported conflicting results. We reviewed cohort and case-control studies from MEDLINE, EMBASE, Web of Science and the Cochrane Library that focused on the association between serum thyroxine, thyrotropin and dementia. A total of 24,952 participants from three case-control and eight cohort studies were included. The relationships between dementia and the per standard deviation (SD) increment of free thyroxine (FT4) (random relative ratio (RR) = 1.08, 95% confidence interval (CI) 1.00–1.17) and thyroid-stimulating hormone (TSH) (fixed RR = 0.91, 95% CI 0.84–0.99) were well established. TSH levels in the low category were associated with an increased risk of dementia (fixed RR = 1.60, 95% CI 1.27–2.00). However, the positive association was confined to TSH levels below the normal range (fixed RR = 1.77, 95% CI 1.31–2.39), not those in the lower tertile of the normal range (fixed RR = 1.39, 95% CI 0.98–1.97). Additionally, dementia was not significantly associated with high TSH levels (fixed RR = 0.99, 95% CI 0.76–1.29). Furthermore, there was no positive association between dementia and the low or high categories of TSH in men. Thus, individuals with higher FT4 levels or those with TSH levels below the normal range have an increased risk of dementia.

Three cases of systemic amyloidosis successfully diagnosed by subcutaneous fat tissue biopsy of the hip

Fine-needle aspiration biopsy of the abdominal fat pad is considered to be a minimally invasive procedure for diagnosing systemic amyloidosis. However, this procedure is sometimes difficult and can be dangerous for elderly patients whose abdominal fat layer is thin because of malnutrition. In such cases, alternative diagnostic methods are required. We report three elderly patients with heart failure complicated by malnutrition. In all cases, electrocardiogram showed low voltage in the limb leads and a pseudoinfarct pattern in the chest leads, and echocardiography showed left ventricular wall thickening with granular sparkling appearance. These patients were suspected of having amyloid cardiomyopathy but could not undergo myocardial biopsies because of their poor conditions. After failed attempts at biopsy of the abdominal fat pad or the other organs, subcutaneous fat tissue biopsy over the hip led to the diagnosis of systemic amyloidosis with cardiomyopathy. The resultant diagnosis guided us to choose the appropriate treatment for the patients. This article illustrates that subcutaneous fat tissue biopsy of the hip could be a useful procedure for diagnosing systemic amyloidosis in elderly patients, particularly when a fat tissue biopsy of the abdomen is associated with a high risk of complications because of malnutrition.

Phase angle as a prognostic marker after percutaneous endoscopic gastrostomy (PEG) in a prospective cohort study

OBJECTIVE

The phase angle identifies changes in tissue's electrical properties assessed by bioelectrical impedance measurement and it can predict prognosis in some conditions. Percutaneous endoscopic gastrostomy (PEG) is commonly used in patients with severe nutritional problems, but there is a need to improve the clinical decision-making for using PEG. We examined if a decreased phase angle predicts complications, short-term mortality (within 60 days of PEG insertion), or inflammatory markers (high C-reactive protein [CRP] levels or low albumin levels) following PEG insertion.

MATERIAL AND METHODS

The phase angle was assessed from body resistance and reactance as measured by bioelectrical impedance in 131 patients admitted for PEG. Anthropometrics and clinical biochemical measures were collected at the time of PEG insertion, while complications and mortality were assessed at clinical follow-ups. Multivariable logistic regression analysis provided odds ratios (ORs) with 95% confidence intervals (CIs) adjusted for sex, age, body mass index, and comorbidity.

RESULTS

A decreased phase angle did not statistically significantly increase the probability of acute complications or short-term mortality, but predicted increased inflammatory markers (CRP ≥10 mg/L [OR 1.63, 95% CI 1.02-2.60], albumin <30 g/L [OR 2.10, 95% CI 1.24-3.57] and a combination of CRP ≥10 mg/L and albumin <30 g/L [OR 3.06, 95% CI 1.51-6.19]).

CONCLUSIONS

A decreased phase angle did not predict acute complications or short-term mortality after PEG insertion, but predicted increased levels of inflammatory markers.

Survival in older adults with dementia and eating problems: To PEG or not to PEG?

BACKGROUND & AIMS

Despite guidelines, long-term enteral nutrition (EN) through percutaneous endoscopic gastrostomy (PEG) is often prescribed to older individuals with dementia and eating problems (refusal to eat or dysphagia). The aim of this prospective observational non-randomized un-blinded study was to assess the role of this procedure on risk of mortality.

METHODS

184 demented malnourished patients (58 M, age 82.2 ± 7.7) with eating problems, discharged from a hospital ward in Italy, were enrolled. Information on dementia type and staging (FAST and CDR scores), Charlson Comorbidity Score and setting of living (community vs nursing home) was collected. After an 18-month follow-up, a telephonic interview with caregivers was planned to assess mortality. Survival of patients discharged on EN by PEG vs oral nutrition (ON) was analyzed by Kaplan-Meier method. Multivariable Cox proportional regression models were also built to test the effects of EN over mortality.

RESULTS

EN was prescribed in 54 patients (15 M). At follow-up, mortality was higher in EN than in ON group (70% vs 40%, p = 0.0002). Survival was significantly shorter in the EN group (log-rank 17.259, p < 0.0001; average length 0.66 ± 0.09 vs 1.28 ± 0.08 years, p < 0.0001). At multivariate Cox proportional regression model, EN was a significant predictor of death (HR 1.82, 95% CI 1.09-3.02, p = 0.02) independent of age, dementia type, FAST, CDR, Charlson score and setting of living in the whole cohort, but not in those with CDR score ranking 4-5.

CONCLUSIONS

In elderly individuals with dementia and eating problems, long-term PEG feeding increases the risk of mortality and should be discouraged.

Mental Health Issues and Special Care Patients

Mental illness is a major health issue in the world today, yet often remains misunderstood, unrecognized, and undertreated. Patients suffering from severe psychiatric disorders generally display poor oral health, often as a consequence of both lifestyle and avoidant-type behaviors that become exacerbated by their illness. Individuals with severe mental illness display a greater incidence of oral disease compared with a similar demographic not dealing with these particular disorders. Efforts to enhance the oral health of these vulnerable patients will play a significant role in the overall rebuilding of their self-esteem and contribute positively to their journey toward stability and recovery.

The Troubling Trichotomy 10 Years Later: Where Are We Now?

A decade ago, "Nutrition Support and The Troubling Trichotomy: A Call To Action" was published in this journal, identifying existing conflicts among technological, ethical, and legal aspects of nutrition support therapy, particularly in terminal or end-of-life situations. Over the past 10 years, the American Society for Parenteral and Enteral Nutrition and others have responded to the action call. A "state of the trichotomy" reveals that while much has been achieved, differences in all 3 aspects will continue to exist due to their dynamic and ever-changing states. The technology arena has made it possible to increase the delivery of nutrition support in alternative settings with the use of telemedicine and social media. Critical/crucial conversations and earlier declarations of individual wishes for care and treatment while having decision-making capacity have been enhanced with the focus on patient-centered and family-centered care. The definition of death as brain death has been challenged in at least one instance. Conflicts between the state's interests and the individual's interests have added to recent legal controversies. Notwithstanding the progress made over the past 10 years, several challenges remain. The future challenges presented by the Troubling Trichotomy can be best confronted if we ACT-Accountability, Communication, and Teamwork. The focus of teamwork should move from multidisciplinary and interdisciplinary teams to transdisciplinary teams, reflecting the shift to function rather than form presented by the new healthcare environment. The transdisciplinary team will be able address the opportunities of the Troubling Trichotomy in the next decade by incorporating the 12 Cs, as detailed in the article.

Atrial Fibrillation and Risk of Dementia/Cognitive Decline

Emerging evidence suggests a link between atrial fibrillation and subsequent development of dementia. While a majority of risk can be attributed to cardioembolic stroke secondary to atrial fibrillation, additional risk is apparent, and may be driven by vascular inflammation and changes in cerebral perfusion. Medical therapies including anticoagulation, statin therapy, and angiotensin-renin-aldosterone axis antagonists may reduce dementia risk. Procedural therapies such as atrial fibrillation catheter ablation and left atrial appendage closure may also prove to be important mediators of acute and long-term risk. In this paper, we review the data supporting a link between atrial fibrillation and dementia syndromes, pathophysiologic mechanisms and the potential roles of medical and procedural therapies at reducing such risk.

Identifying and Managing Pain in People with Alzheimer's Disease and Other Types of Dementia: A Systematic Review

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.

Advanced Dementia

An 89-year-old male nursing home resident with a 10-year history of Alzheimer’s disease presents with a temperature of 38.3°C, a productive cough, and a respiratory rate of 28 breaths per minute. Nurses report that for the past 6 months he has been coughing at breakfast and having trouble swallowing. He has profound memory deficits, no longer recognizes his daughter (who is his health care proxy), is bedbound, is able to mumble a couple of words, and is unable to perform any activities of daily living. The nurse asks whether he should be hospitalized. How should this patient be evaluated and treated?