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Kim HD, Duberstein PR, Lin H, Wu B, Zafar A, Jarrín OF. Home Health Care and Hospice Use Among Medicare Beneficiaries With and Without a Diagnosis of Dementia. J Palliat Med 2024; 27:776-783. [PMID: 38359388 DOI: 10.1089/jpm.2023.0583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
Background: Home health care is a core benefit of Medicare and Medicaid insurance programs and includes services to improve health, maintain health, or slow health decline. Objective: To examine the relationship between home health care use during the last three years of life and hospice use in the last six months of life among Medicare beneficiaries with and without dementia. Design: Nationally representative retrospective cohort study. Setting/Subjects: Medicare beneficiaries with at least three years of continuous enrollment who died in 2019 in the United States (n = 2,169,422). Measurements: The primary outcome was hospice use, and the secondary outcome was hospice duration. The independent variable was a composite of the presence and timing of home health care initiation during the last three years of life. Results: Home health care was used by 46.4% of Medicare beneficiaries and hospice care was used by 53.1% of beneficiaries, with 28.3% using both. Compared with beneficiaries who did not use home health care, those who started home health care before the last year of life (odds ratio [OR] = 1.57, 95% confidence interval [CI] = 1.56-1.58) or during the last year of life (OR = 1.75, 95% CI = 1.74-1.77) were more likely to use hospice. The effects were stronger in those without a diagnosis of dementia (OR = 1.92, 95% CI = 1.90-1.94) compared with those without a dementia diagnosis (OR = 1.34, 95% CI = 1.32-1.35) who started home health in the final year of life. Conclusions: Receiving home health care in the final years of life is associated with increased hospice use at the end-of-life in Medicare beneficiaries with and without a dementia diagnosis.
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Affiliation(s)
- Hyosin Dawn Kim
- College of Health, Oregon State University, Corvallis, Oregon, USA
| | - Paul R Duberstein
- School of Public Health, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Haiqun Lin
- School of Nursing, Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - Bei Wu
- Rory Meyers College of Nursing, New York, New York, USA
- NYU Aging Incubator, New York University, New York, New York, USA
| | - Anum Zafar
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Olga F Jarrín
- School of Nursing, Rutgers, The State University of New Jersey, Newark, New Jersey, USA
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
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Morley NE, Ramirez-Urquiola CM, Nakagawa S. Withdrawal of Left Ventricular Assist Device in Dementia: A Case Report. J Palliat Med 2024. [PMID: 38451550 DOI: 10.1089/jpm.2023.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
Left ventricular assistance devices (LVADs) are one type of life support with the unique quality of allowing recipients to live outside the hospital. This case report explores the decision by a patient and their family to withdraw LVAD therapy in the setting of dementia and consultant team recommendations at odds with one another due to the patient's simultaneous alertness and lack of decisional capacity. It then discusses the guiding principles that led to the withdrawal of LVAD therapy and lessons drawn from the experience by the care team.
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Affiliation(s)
- Nicholas E Morley
- Emergency Medicine/Internal Medicine PGY-2, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, New York, New York, USA
| | - Cristina M Ramirez-Urquiola
- Adult Palliative Care Services, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Shunichi Nakagawa
- Adult Palliative Care Services, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
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3
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Dobbs D, Yauk J, Vogel CE, Fanfan D, Buck H, Haley WE, Meng H. Feasibility of the Palliative Care Education in Assisted Living Intervention for Dementia Care Providers: A Cluster Randomized Trial. THE GERONTOLOGIST 2024; 64:gnad018. [PMID: 36842068 DOI: 10.1093/geront/gnad018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Alzheimer's disease and related dementia (ADRD) is a major cause of death in the United States. While effective interventions have been developed to deliver palliative care to nursing home residents with ADRD, little work has identified effective interventions to reach assisted living (AL) residents with dementia. RESEARCH DESIGN AND METHODS One hundred and eighteen AL residents with dementia from 10 different ALs in Florida participated. A pilot study using a cluster randomized trial was conducted, with 6 sites randomized to receive a palliative care educational intervention for staff (N = 23) to deliver care to residents; 4 sites were usual care. The feasibility of the intervention was assessed by examining recruitment, retention, and treatment fidelity at 6 months. Cohen's d statistic was used to calculate facility-level treatment effect sizes on key outcomes (documentation of advance care planning [ACP] discussions, hospice admission, and documentation of pain screening). RESULTS The intervention proved feasible with high ratings of treatment fidelity. The intervention also demonstrated preliminary evidence for efficacy of the intervention, with effect sizes for the treatment group over 0.80 for increases in documentation of ACP discussions compared to the control group. Hospice admissions had a smaller effect size (0.16) and documentation of pain screenings had no effect. DISCUSSION AND IMPLICATIONS The pilot results suggest that the intervention shows promise as a resource for educating and empowering AL staff on implementing person-centered palliative care delivery to persons with dementia in AL. A larger, fully powered randomized trial is needed to test for its efficacy.
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Affiliation(s)
- Debra Dobbs
- School of Aging Studies, Florida Policy Exchange Center on Aging, University of South Florida, Tampa, Florida, USA
| | - Jessica Yauk
- School of Aging Studies, Florida Policy Exchange Center on Aging, University of South Florida, Tampa, Florida, USA
| | - Carlyn E Vogel
- School of Aging Studies, Florida Policy Exchange Center on Aging, University of South Florida, Tampa, Florida, USA
| | - Dany Fanfan
- College of Nursing, University of Florida, Gainesville, Florida, USA
| | - Harleah Buck
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
| | - William E Haley
- School of Aging Studies, Florida Policy Exchange Center on Aging, University of South Florida, Tampa, Florida, USA
| | - Hongdao Meng
- School of Aging Studies, Florida Policy Exchange Center on Aging, University of South Florida, Tampa, Florida, USA
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Lasalvia A, Patuzzo S, Braun E, Henderson C. Advance statements in mental healthcare: time to close the evidence to practice gap. Epidemiol Psychiatr Sci 2023; 32:e68. [PMID: 38053411 PMCID: PMC10803188 DOI: 10.1017/s2045796023000835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/11/2023] [Indexed: 12/07/2023] Open
Abstract
This article discusses advance statements in mental health care, which allow individuals with mental disorders to express their preferences for treatment during mental health crises. Despite the evidence supporting their effectiveness, their implementation in clinical practice remains limited. This article explores variations among advance statements, such as psychiatric advance directives (PADs), joint crisis plans (JCPs) and self-binding directives (SBDs), highlighting their content, development process and legal status. We outline the benefits of advance statements, including empowerment, early intervention, improved therapeutic relationships and reduced compulsory admissions. We then draw attention to the challenges that may contribute to their lack of implementation, including legal complexities, communication issues, cultural factors, potential inequities, healthcare provider knowledge, changing preferences, resource constraints, crisis responses, data privacy, family involvement, and long-term evaluation. In conclusion, advance statements offer significant benefits but require addressing these critical aspects to ensure ethical and effective use. Bridging the evidence-to-practice gap is essential, with a focus on implementation science. Integrating these tools into routine clinical practice can significantly benefit individuals with severe mental disorders and mental health systems.
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Affiliation(s)
- Antonio Lasalvia
- Section of Psychiatry, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Sara Patuzzo
- Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Esther Braun
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
- Department of Philosophy, University of Oxford, Oxford, UK
| | - Claire Henderson
- Health Service and Population Research Department P029, David Goldberg Centre, King’s College London Institute of Psychiatry, London, UK
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Brucki SMD, Aprahamian I, Borelli WV, Silveira VCD, Ferretti CEDL, Smid J, Barbosa BJAP, Schilling LP, Balthazar MLF, Frota NAF, Souza LCD, Vale FAC, Caramelli P, Bertolucci PHF, Chaves MLF, Nitrini R, Schultz RR, Morillo LS. Management in severe dementia: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Dement Neuropsychol 2022. [DOI: 10.1590/1980-5764-dn-2022-s107en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
ABSTRACT Alzheimer’s disease (AD) and other neurodegenerative dementias have a progressive course, impairing cognition, functional capacity, and behavior. Most studies have focused on AD. Severe dementia is associated with increased age, higher morbidity-mortality, and rising costs of care. It is fundamental to recognize that severe dementia is the longest period of progression, with patients living for many years in this stage. It is the most heterogeneous phase in the process, with different abilities and life expectancies. This practice guideline focuses on severe dementia to improve management and care in this stage of dementia. As it is a long period in the continuum of dementia, clinical practice should consider non-pharmacological and pharmacological approaches. Multidisciplinary interventions (physical therapy, speech therapy, nutrition, nursing, and others) are essential, besides educational and support to caregivers.
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Affiliation(s)
| | - Ivan Aprahamian
- Faculdade de Medicina de Jundiaí, Brasil; University of Groningen, The Netherlands; Universidade de São Paulo, Brasil
| | | | | | | | | | - Breno José Alencar Pires Barbosa
- Universidade de São Paulo, Brazil; Universidade Federal de Pernambuco, Brasil; Instituto de Medicina Integral Prof. Fernando Figueira, Brasil
| | - Lucas Porcello Schilling
- Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil
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Brucki SMD, Aprahamian I, Borelli WV, Silveira VCD, Ferretti CEDL, Smid J, Barbosa BJAP, Schilling LP, Balthazar MLF, Frota NAF, Souza LCD, Vale FAC, Caramelli P, Bertolucci PHF, Chaves MLF, Nitrini R, Schultz RR, Morillo LS. Manejo das demências em fase avançada: recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Dement Neuropsychol 2022; 16:101-120. [DOI: 10.1590/1980-5764-dn-2022-s107pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/04/2021] [Accepted: 04/27/2022] [Indexed: 11/29/2022] Open
Abstract
RESUMO A doença de Alzheimer (DA) e outras demências neurodegenerativas têm um curso progressivo com comprometimento da cognição, capacidade funcional e comportamento. A maioria dos estudos enfocou a DA. A demência grave está associada ao aumento da idade, maior morbimortalidade e aumento dos custos de cuidados. É fundamental reconhecer que a demência grave é o período mais longo de progressão, com o paciente vivendo muitos anos nesta fase. É a fase mais heterogênea do processo, com diferentes habilidades e expectativa de vida. Esta diretriz de prática concentra-se na demência grave para melhorar o manejo e o cuidado nessa fase da demência. Como um longo período no continuum da demência, as abordagens não farmacológicas e farmacológicas devem ser consideradas. Intervenções multidisciplinares (fisioterapia, fonoaudiologia, nutrição, enfermagem, entre outras) são essenciais, além de educacionais e de apoio aos cuidadores.
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Affiliation(s)
| | - Ivan Aprahamian
- Faculdade de Medicina de Jundiaí, Brasil; University of Groningen, The Netherlands; Universidade de São Paulo, Brasil
| | | | | | | | | | - Breno José Alencar Pires Barbosa
- Universidade de São Paulo, Brazil; Universidade Federal de Pernambuco, Brasil; Instituto de Medicina Integral Prof. Fernando Figueira, Brasil
| | - Lucas Porcello Schilling
- Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil
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Rajkumar RP. Physician-Assisted Suicide in Dementia: Paradoxes, Pitfalls and the Need for Prudence. FRONTIERS IN SOCIOLOGY 2021; 6:815233. [PMID: 35004941 PMCID: PMC8727695 DOI: 10.3389/fsoc.2021.815233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/07/2021] [Indexed: 06/14/2023]
Abstract
There has been an increasing drive towards the legalization of physician-assisted suicide (PAS) in patients with dementia, particularly in patients with advanced disease and severe cognitive impairment. Advocacy for this position is often based on utilitarian philosophical principles, on appeals to the quality of life of the patient and their caregiver(s), or on economic constraints faced by caregivers as well as healthcare systems. In this paper, two lines of evidence against this position are presented. First, data on attitudes towards euthanasia for twenty-eight countries, obtained from the World Values Survey, is analyzed. An examination of this data shows that, paradoxically, positive attitudes towards this procedure are found in more economically advanced countries, and are strongly associated with specific cultural factors. Second, the literature on existing attitudes towards PAS in cases of dementia, along with ethical arguments for and against the practice, is reviewed and specific hazards for patients, caregivers and healthcare professionals are identified. On the basis of these findings, the author suggests that the practice of PAS in dementia is not one that can be widely or safely endorsed, on both cultural and ethical grounds. Instead, the medical field should work in collaboration with governmental, social welfare and patient advocacy services to ensure optimal physical, emotional and financial support to this group of patients and their caregivers.
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The Limits of Advance Directives in Maintaining Autonomy in Patients with Advanced Dementia. Am J Med 2021; 134:963-967. [PMID: 33811883 DOI: 10.1016/j.amjmed.2021.02.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 11/23/2022]
Abstract
As dementia becomes more prevalent in the aging population, clinicians increasingly face the challenge of caring for patients who had told family members that they preferred death to life with advanced dementia. Advance directives can guide management, but usually are inadequate in caring for patients with advanced dementia. The "now" patient has very different sensibilities than the "then" patient who had expressed preferences for terminal care before dementia severely impaired cognition and executive function. Clinicians lack clear means of following a patient's directive to die rather than to live with advanced dementia. Withholding life-sustaining oral feeding or fluids is ethically problematic. Controversies remain over precedent autonomy as the justification for advance dementia directives, and the consequent legal, ethical, and practical issues clinicians face, particularly involving feeding.
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Tan LF, Ho Wei Fen S. Comment on: Referral criteria to specialist palliative care for patients with dementia: A systematic review. J Am Geriatr Soc 2021; 69:2037-2038. [PMID: 33939834 DOI: 10.1111/jgs.17197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 01/06/2023]
Affiliation(s)
- Li Feng Tan
- Division of Healthy Ageing, Alexandra Hospital, Singapore
| | - Sara Ho Wei Fen
- Department of Medicine, National University Hospital, Singapore
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Petretto DR, Carrogu GP, Gaviano L, Pili L, Pili R. Dementia and Major Neurocognitive Disorders: Some Lessons Learned One Century after the first Alois Alzheimer's Clinical Notes. Geriatrics (Basel) 2021; 6:5. [PMID: 33440669 PMCID: PMC7838901 DOI: 10.3390/geriatrics6010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 11/30/2022] Open
Abstract
Over 100 years ago, Alois Alzheimer presented the clinical signs and symptoms of what has been later called "Alzheimer Dementia" in a young woman whose name was Augustine Deter [...].
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Affiliation(s)
- Donatella Rita Petretto
- Department of Education, Psychology and Philosophy, University of Cagliari, Via Is Mirrionis 1, 09127 Cagliari, Italy; (G.P.C.); (L.G.); (L.P.)
| | - Gian Pietro Carrogu
- Department of Education, Psychology and Philosophy, University of Cagliari, Via Is Mirrionis 1, 09127 Cagliari, Italy; (G.P.C.); (L.G.); (L.P.)
- Global Community on Longevity, Comunità Mondiale della Longevità, Selargius 09047, Italy; IERFOP Onlus, Cagliari, 09134
| | - Luca Gaviano
- Department of Education, Psychology and Philosophy, University of Cagliari, Via Is Mirrionis 1, 09127 Cagliari, Italy; (G.P.C.); (L.G.); (L.P.)
- Global Community on Longevity, Comunità Mondiale della Longevità, Selargius 09047, Italy; IERFOP Onlus, Cagliari, 09134
| | - Lorenzo Pili
- Department of Education, Psychology and Philosophy, University of Cagliari, Via Is Mirrionis 1, 09127 Cagliari, Italy; (G.P.C.); (L.G.); (L.P.)
- Global Community on Longevity, Comunità Mondiale della Longevità, Selargius 09047, Italy; IERFOP Onlus, Cagliari, 09134
| | - Roberto Pili
- Global Community on Longevity, Comunità Mondiale della Longevità, Selargius 09047, Italy; IERFOP Onlus, Cagliari, 09134
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Di Fazio N, Romano S, Del Fante Z, Santoro P, Fineschi V, Frati P. European Countries' Different Legal Orientation About End-of-Life Issues in Patients Affected With Neurological/Psychiatric Diseases: Does Italian Law n.219/2017 Provide Adequate Options for This Fragile Category of Patients? Front Psychiatry 2021; 12:675706. [PMID: 34630172 PMCID: PMC8497821 DOI: 10.3389/fpsyt.2021.675706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 08/26/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nicola Di Fazio
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia Romano
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Zoe Del Fante
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Paola Santoro
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Neuromed Mediterranean Neurological Istitute, Pozzilli, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Neuromed Mediterranean Neurological Istitute, Pozzilli, Italy
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