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Halpin SN, Alain G, Seaman A, Stevens EE, Zhao H, Fowler ME, Zhang Q, Cadet T, Ye M, Krok-Schoen JL. Comorbid Dementia and Cancer Therapy Decision-Making: A Scoping Review. J Appl Gerontol 2024; 43:1132-1143. [PMID: 38347680 DOI: 10.1177/07334648241233375] [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: 08/09/2024] Open
Abstract
Comorbid dementia complicates cancer therapy decision-making in older adults. We aimed to synthesize the recent literature (<5 years) on the challenges associated with cancer therapy decision-making among older people living with dementia (PLWD) and their caregivers. Of the 20,763 references, 8767 had their title and abstract screened, and eight met the inclusion criteria. Six studies were qualitative, one study employed mixed methods, and one study was quasi-experimental. Most studies were conducted in the UK (89%) and reported homogeneity in race and geography. Breast (56%) and prostate (45%) were the most frequent reported cancers. Five studies (56%) reported multiple types of dementia, with two (22%) indicating stages. The studies indicated that communication between patients, caregivers, and clinical teams might alleviate stress caused by worsening health prospects and potential ethical concerns. Information from this review can lead to better-informed, patient-centered treatment decision processes among older PLWD and cancer, their caregivers, and clinicians.
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Affiliation(s)
- Sean N Halpin
- GenOmics and Translational Research Center RTI International, Research Triangle Park, NC, USA
| | - Gabriel Alain
- School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Aaron Seaman
- Department of General Internal Medicine, The University of Iowa, Iowa City, IA, USA
| | - Erin E Stevens
- Division of Palliative Care, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Hui Zhao
- School of Nursing, James Madison University, Harrisonburg, VA, USA
| | - Mackenzie E Fowler
- School of Public Health, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Qiuyang Zhang
- Department of Structural & Cellular Biology, School of Medicine, Tulane University, New Orleans, LA, USA
| | - Tamara Cadet
- School of Social Policy & Practice, University of Pennsylvania, Boston, MA, USA
| | - Minzhi Ye
- School of Lifespan Development and Educational Science, Kent State University, Kent, OH, USA
| | - Jessica L Krok-Schoen
- School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, OH, USA
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Bonares M, Fisher S, Quinn K, Wentlandt K, Tanuseputro P. Study protocol for the development and validation of a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. Diagn Progn Res 2024; 8:5. [PMID: 38500236 PMCID: PMC10949607 DOI: 10.1186/s41512-024-00168-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/05/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Patients with dementia and their caregivers could benefit from advance care planning though may not be having these discussions in a timely manner or at all. A prognostic tool could serve as a prompt to healthcare providers to initiate advance care planning among patients and their caregivers, which could increase the receipt of care that is concordant with their goals. Existing prognostic tools have limitations. We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. METHODS The derivation cohort will include approximately 235,000 patients with dementia, who were admitted to hospital in Ontario from April 1st, 2009, to December 31st, 2017. Predictor variables will be fully prespecified based on a literature review of etiological studies and existing prognostic tools, and on subject-matter expertise; they will be categorized as follows: sociodemographic factors, comorbidities, previous interventions, functional status, nutritional status, admission information, previous health care utilization. Data-driven selection of predictors will be avoided. Continuous predictors will be modelled as restricted cubic splines. The outcome variable will be mortality within 1 year of admission, which will be modelled as a binary variable, such that a logistic regression model will be estimated. Predictor and outcome variables will be derived from linked population-level healthcare administrative databases. The validation cohort will comprise about 63,000 dementia patients, who were admitted to hospital in Ontario from January 1st, 2018, to March 31st, 2019. Model performance, measured by predictive accuracy, discrimination, and calibration, will be assessed using internal (temporal) validation. Calibration will be evaluated in the total validation cohort and in subgroups of importance to clinicians and policymakers. The final model will be based on the full cohort. DISCUSSION We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. The model would be integrated into the electronic medical records of hospitals to automatically output 1-year mortality risk upon hospitalization. The tool could serve as a trigger for advance care planning and inform access to specialist palliative care services with prognosis-based eligibility criteria. Before implementation, the tool will require external validation and study of its potential impact on clinical decision-making and patient outcomes. TRIAL REGISTRATION NCT05371782.
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Affiliation(s)
- Michael Bonares
- Department of Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Stacey Fisher
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- ICES Ottawa, Ottawa, ON, Canada
| | - Kieran Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
- ICES Toronto, Toronto, ON, Canada
| | - Kirsten Wentlandt
- Department of Supportive Care, University Health Network, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- ICES Ottawa, Ottawa, ON, Canada
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Pullen D, Pillay BS, Krüger E. Tube feeding in advanced dementia: Insights from South African speech-language therapists. SOUTH AFRICAN JOURNAL OF COMMUNICATION DISORDERS 2024; 71:e1-e11. [PMID: 38426734 PMCID: PMC10913100 DOI: 10.4102/sajcd.v71i1.970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Speech-language therapists (SLTs) may recommend tube feeding even with minimal research evidence of its effectiveness, and an understanding of SLTs' perceived practices is warranted. OBJECTIVES To qualitatively describe a sample of South African SLTs' perceived practices regarding feeding tube placement in people with advanced dementia. METHOD Semi-structured online interviews were conducted via Microsoft Teams. Eight South African SLTs with a particular interest in advanced dementia, in public and private settings, were recruited. Data were analysed using inductive reflexive thematic analysis. RESULTS Three main themes were identified: (1) factors influencing SLTs' decisions for feeding tube placement in people with advanced dementia; (2) nature of clinical setting and SLTs' decision-making and (3) SLTs' considerations to improve management of people with advanced dementia. Existing local palliative care guidelines were not employed in decisions about tube feeding. Most participants did not recommend tube feeding during end-of-life care. Perceived burden of care influenced participants' decisions about tube feeding. CONCLUSION Speech-language therapists in South Africa likely have an increased reliance on clinical experience rather than recent research and guidelines for decisions about feeding tube placement. Findings accentuate the importance of clinical supervision, mentoring and continuous professional development in the workplace. The findings are an urgent call to action to improve SLTs' overall practices and ethical service delivery for people with advanced dementia and their families.Contribution: Factors and needs regarding SLTs' decision-making about feeding tubes in people with advanced dementia are highlighted.
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Affiliation(s)
- Danette Pullen
- Department of Speech-Language Pathology and Audiology, Faculty of Humanities, University of Pretoria, Pretoria.
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Roca F, Lepiller L, Keroulle C, Lesage D, Rougette K, Chassagne P. Effect of a multimodal training on the ability of medical students to administer the MMSE: a comparative study. BMC MEDICAL EDUCATION 2024; 24:133. [PMID: 38347495 PMCID: PMC10863194 DOI: 10.1186/s12909-024-05044-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/08/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUNDS The Mini-Mental State Examination (MMSE) is the main screening and follow-up test for neurocognitive disorders. In France, it is often administered by medical students. Conditions allowing to administer the MMSE are strict but not well known by students, leading to mistakes in scoring. Our objectives were to assess the effect of a multimodal training on medical students' ability to administer the MMSE and to describe their previous training. METHODS 75 medical students between the 4th and 6th year of study were included. Previous MMSE training was assessed by a standardized questionnaire. The teaching material used for our training was the article validating MMSE in French, a video explaining the steps on how to administer the MMSE test, and MMSE's scoring exercises. The ability to administer the MMSE was assessed by a Standardized practical exam (SPE). Students were self-selected and then assigned in two groups, one benefiting from all the training before SPE, and the other receiving only the article before SPE. RESULTS 41 students were included in the training group and 34 in the control group. There was no difference between groups regarding previous training. 71% of the students had already administered a MMSE test and only 17% had received specific training. Students considered their previous training as insufficient in most cases. The overall score and scores of each subpart of the SPE were significantly higher in the training group than in the control group (overall score: median [IQR]: 71 [62-78] vs. 52 [41-57], p < 0.001). The rate of students able to complete the MMSE was higher in the training group compared to the control (85% vs. 44%, p < 0.001). Quality of the training and its usefulness were judged to be good or very good by all participants. CONCLUSIONS A multimodal training improves the ability of medical students to administer the MMSE.
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Affiliation(s)
- Frédéric Roca
- Department of Geriatric medicine, Rouen University Hospital, 1 rue de Germont Rouen, F 76 000, Normandy, France.
- INSERM U1096, Normandy University, UNIROUEN, F-76000, Rouen, France.
| | - Lucie Lepiller
- Department of Geriatric medicine, Rouen University Hospital, 1 rue de Germont Rouen, F 76 000, Normandy, France
| | - Camille Keroulle
- Department of Geriatric medicine, Rouen University Hospital, 1 rue de Germont Rouen, F 76 000, Normandy, France
| | - Doriane Lesage
- Department of Geriatric medicine, Rouen University Hospital, 1 rue de Germont Rouen, F 76 000, Normandy, France
| | - Kevin Rougette
- Department of Geriatric medicine, Rouen University Hospital, 1 rue de Germont Rouen, F 76 000, Normandy, France
| | - Philippe Chassagne
- Department of Geriatric medicine, Rouen University Hospital, 1 rue de Germont Rouen, F 76 000, Normandy, France
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Kuwabara M, Nakai M, Sumita Y, Iwanaga Y, Ae R, Kodama T, Hisatome I, Kamatani N. Xanthine oxidase inhibitors treatment or discontinuation effects on mortality: evidence of xanthine oxidase inhibitors withdrawal syndrome. Front Pharmacol 2024; 14:1289386. [PMID: 38259292 PMCID: PMC10800388 DOI: 10.3389/fphar.2023.1289386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024] Open
Abstract
Objectives: This study investigates the impact of xanthine oxidase inhibitors (XOI) on mortality in patients with cardiovascular diseases. XOI withdrawal has been reported to increased mortality risk due to rapid adenosine triphosphate (ATP) deficiency. This study aims to determine whether XOI treatment reduces mortality and whether XOI withdrawal increases mortality. Methods: This is a real-world database study using the Japanese Registry of All Cardiac and Vascular Diseases (J-ROAD). We analyzed 1,648,891 hospitalized patients aged 20-90 with acute coronary syndrome or heart failure. In the first study, mortality rates were compared between patients without urate-lowering agents (n = 1,292,486) and those with XOI agents (n = 315,388, excluding 41,017 on other urate-lowering agents). In the second study, mortality rates were compared between the XOI continuous medication group (n = 226,261) and the XOI withdrawal group (n = 89,127). Results: After multiple adjustments, XOI treatment group showed significantly lower mortality compared with that without any urate-lowering agent (odds ratio (OR), 0.576, 95% confidence interval (CI), 0.567-0.587, p < .001). In the sub-analysis, the group with allopurinol (OR, 0.578; 95% CI, 0.557-0.600), febuxostat (OR, 0.610; 95% CI, 0.599-0.622), and topiroxostat (HR, 0.545; 95% CI, 0.473-0.628) showed lower OR of mortality compared with that without any urate-lowering agent. XOI withdrawal group led to significantly higher death rates compared to XOI continuous group (19.8% vs. 0.03%; p < .001). Conclusion: XOI treatment for patients with cardiovascular diseases is associated with reduced mortality. Conversely, XOI withdrawal is linked to elevated mortality risk. This emphasizes the importance of both prescribing and discontinuing XOI carefully to optimize patient outcomes.
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Affiliation(s)
- Masanari Kuwabara
- Department of Cardiology, Toranomon Hospital, Tokyo, Japan
- National Cerebral and Cardiovascular Center, Suita, Japan
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Shimotsuke, Japan
| | | | - Yoko Sumita
- National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Shimotsuke, Japan
| | | | - Ichiro Hisatome
- National Hospital Organization, Yonago Medical Center, Yonago, Japan
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Prajjwal P, Inban P, Sai VP, Shiny KS, Lam JR, John J, Sulaimanov M, Tekuru Y, Wasi ul Haq M, Marsool MDM, Sivarajan VV, Amir Hussin O. The effects of the interplay between vitamins, antibiotics, and gut microbiota on the pathogenesis and progression of dementia: A systematic review and meta-analysis. Health Sci Rep 2024; 7:e1808. [PMID: 38196569 PMCID: PMC10774544 DOI: 10.1002/hsr2.1808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/21/2023] [Accepted: 12/22/2023] [Indexed: 01/11/2024] Open
Abstract
Background Given that there is already evidence of a neural network that connects the brain and gut and that the gut microbiota actively modulates gut health, it is crucial to know which foods, supplements, and medications to use or avoid when treating any disease that causes dementia or cognitive impairment. Previous research has examined the relationships between vitamins, antibiotics, and gut microbiota and the correlations between these factors and dementia. The question arises of how these three factors interact together and if evidence suggests one element is more important than the others in the pathogenesis and development of dementia. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standards were followed when conducting this review. The papers' publication dates varied from (2012-2022). Cochrane/EMBASE, PEDro, and PubMed/Medline databases were searched. The precise terms "gut microbiota," vitamins," antibiotics," and "dementia" were included in the search method, along with the conjunctions "OR" and "AND." Results Gut dysbiosis has a significant impact on cognition, brain function, and the development and progression of dementia. The two most popular probiotics used in studies linked to cognition benefits were Lactobacillus and Bifidobacterium. Numerous scales were used to evaluate cognition, but the mini-mental state examination was the most popular, and the most prevalent impairment was Alzheimer's disease. The supplements with the most significant impact on gut microbiota were vitamin B-12 and folic acid. Conclusion This systematic review concluded that vitamins, gut microbiota and antibiotics have a close association with the development of dementia. More research is required to establish causality and elucidate the underlying mechanisms because there is still little evidence connecting the interactions of vitamins, medications, and microbiota with dementia. The complexity of interactions between genetics, lifestyle factors, and comorbidities, as well as the heterogeneity of dementia, may make it more challenging to interpret the findings.
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Affiliation(s)
| | - Pugazhendi Inban
- Internal MedicineGovernment Medical College OmandurarChennaiTamil NaduIndia
| | | | | | | | - Jobby John
- Internal MedicineDr. Somervell Memorial CSI Medical College and HospitalTrivandrumIndia
| | | | - Yogesh Tekuru
- RVM Institute of Medical Sciences and Research CentreSiddipetIndia
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de Miranda AS, Macedo DS, Rocha NP, Teixeira AL. Targeting the Renin-Angiotensin System (RAS) for Neuropsychiatric Disorders. Curr Neuropharmacol 2024; 22:107-122. [PMID: 36173067 PMCID: PMC10716884 DOI: 10.2174/1570159x20666220927093815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 07/03/2022] [Accepted: 08/14/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Neuropsychiatric disorders, such as mood disorders, schizophrenia, and Alzheimer's disease (AD) and related dementias, are associated to significant morbidity and mortality worldwide. The pathophysiological mechanisms of neuropsychiatric disorders remain to be fully elucidated, which has hampered the development of effective therapies. The Renin Angiotensin System (RAS) is classically viewed as a key regulator of cardiovascular and renal homeostasis. The discovery that RAS components are expressed in the brain pointed out a potential role for this system in central nervous system (CNS) pathologies. The understanding of RAS involvement in the pathogenesis of neuropsychiatric disorders may contribute to identifying novel therapeutic targets. AIMS We aim to report current experimental and clinical evidence on the role of RAS in physiology and pathophysiology of mood disorders, schizophrenia, AD and related dementias. We also aim to discuss bottlenecks and future perspectives that can foster the development of new related therapeutic strategies. CONCLUSION The available evidence supports positive therapeutic effects for neuropsychiatric disorders with the inhibition/antagonism of the ACE/Ang II/AT1 receptor axis or the activation of the ACE2/Ang-(1-7)/Mas receptor axis. Most of this evidence comes from pre-clinical studies and clinical studies lag much behind, hampering a potential translation into clinical practice.
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Affiliation(s)
- Aline Silva de Miranda
- Interdisciplinary Laboratory of Medical Investigation (LIIM), Faculty of Medicine, UFMG, Belo Horizonte, MG, Brazil
- Department of Morphology, Laboratory of Neurobiology, Biological Science Institute, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Danielle S Macedo
- Department of Physiology and Pharmacology, Neuropharmacology Laboratory, Drug Research, and Development Center, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Natalia P Rocha
- Department of Neurology, The Mitchell Center for Alzheimer's Disease and Related Brain Disorders, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
| | - Antonio L Teixeira
- Department of Psychiatry and Behavioral Sciences, Neuropsychiatry Program, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
- Faculdade Santa Casa BH, Belo Horizonte, Brasil
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Lopez RP, Wei A, Locke JR, Plys E. Advanced-Comfort: Usability Testing of a Care Planning Intervention for Nursing Home Residents With Advanced Dementia. J Gerontol Nurs 2023; 49:15-23. [PMID: 37906044 DOI: 10.3928/00989134-20231010-04] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Many nursing home (NH) residents with advanced dementia receive burdensome interventions rather than interventions that promote comfort or quality of life. The purpose of the current study was to test the usability of a novel intervention, ADVANCED-Comfort, which aims to enhance the provision of personalized care for residents with advanced dementia. The intervention comprises structured care plan meetings between the NH team and proxies of residents with dementia (e.g., family members). Using the ADVANCED-Comfort workbook, proxies create individualized care plans addressing six domains adapted from the Age-Friendly Health System Framework. The purpose of this article is to describe the intervention and its theoretical underpinnings and report the usability of the intervention evaluated with surveys, observation, and exit interviews. The study demonstrated that proxies and NH staff found the intervention usable (acceptable, appropriate, and feasible). Based on these preliminary findings, additional testing of the ADVANCED-Comfort intervention is warranted. [Journal of Gerontological Nursing, 49(11), 15-23.].
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Hoda W, Bharati SJ. Palliative care in neurology patients. Int Anesthesiol Clin 2023; 61:73-79. [PMID: 37249177 DOI: 10.1097/aia.0000000000000403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Wasimul Hoda
- Department of Superspeciality Anaesthesia, Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India
| | - Sachidanand J Bharati
- Department of Onco-Anaesthesia & Palliative Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, India
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Tjia J, D’Arcangelo N, Carlston D, Bronzi O, Gazarian P, Reich A, Porteny T, Gonzales K, Perez S, Weissman JS, Ladin K. US clinicians' perspectives on advance care planning for persons with dementia: A qualitative study. J Am Geriatr Soc 2023; 71:1473-1484. [PMID: 36547969 PMCID: PMC10175113 DOI: 10.1111/jgs.18197] [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: 09/30/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although advance care planning (ACP) for persons with dementia (PWD) can promote patient-centered care by aligning future healthcare with patient values, few PWD have documented ACPs for reasons incompletely understood. The objective of this paper is to characterize the perceived value of, barriers to, and successful strategies for completing ACP for PWD as reported by frontline clinicians. METHODS Qualitative study using semi-structured interviews (August 2018-December 2019) with clinicians (physicians, nurse practitioners, nurses, social workers) at 11 US health systems. Interviews asked clinicians about their approaches to ACP with PWDs, including how ACP was initiated, what was discussed, how carepartners were involved, how decision-making was approached, and how decision-making capacity was assessed. RESULTS Of 75 participating generalist and specialty clinicians from across the United States, 61% reported conducting ACP with PWD, of whom 19% conducted ACP as early as possible with PWD. Three themes emerged: value of early ACP preserves PWD's autonomy in cases of differing PWD carepartner values, acute medical crises, and clinician paternalism; barriers to ACP with PWD including the dynamic and subjective assessment of patient decision-making capacity, inconsistent awareness of cognitive impairment by clinicians, and the need to balance patient and family carepartner involvement; and strategies to support ACP include clarifying clinicians' roles in ACP, standardizing clinicians' approach to PWD and their carepartners, and making time for ACP and decision-making assessments that allow PWD and carepartner involvement regardless of the patients' capacity. CONCLUSIONS Clinicians found early ACP for PWD valuable in promoting patient-centered care among an at-risk population. In sharing their perspectives on conducting ACP for PWD, clinicians described challenges that are amenable to changes in training, workflow, and material support for clinician time. Clinical practices need sustainable scheduling and financial support models.
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Affiliation(s)
- Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Noah D’Arcangelo
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA
| | - Daniel Carlston
- Columbia Law School, New York, NY
- College of Nursing and Health Sciences, University of Massachusetts Boston, MA
| | - Olivia Bronzi
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA
| | - Priscilla Gazarian
- College of Nursing and Health Sciences, University of Massachusetts Boston, MA
| | - Amanda Reich
- Center for Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Thalia Porteny
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY
| | - Kristina Gonzales
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA
| | - Stephen Perez
- Center for Surgery, Brigham and Women’s Hospital, Boston, MA
| | | | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA
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Kaur P, Kannapiran P, Ng SHX, Chu J, Low ZJ, Ding YY, Tan WS, Hum A. Predicting mortality in patients diagnosed with advanced dementia presenting at an acute care hospital: the PROgnostic Model for Advanced DEmentia (PRO-MADE). BMC Geriatr 2023; 23:255. [PMID: 37118683 PMCID: PMC10148534 DOI: 10.1186/s12877-023-03945-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 03/31/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Challenges in prognosticating patients diagnosed with advanced dementia (AD) hinders timely referrals to palliative care. We aim to develop and validate a prognostic model to predict one-year all-cause mortality (ACM) in patients with AD presenting at an acute care hospital. METHODS This retrospective cohort study utilised administrative and clinical data from Tan Tock Seng Hospital (TTSH). Patients admitted to TTSH between 1st July 2016 and 31st October 2017 and identified to have AD were included. The primary outcome was ACM within one-year of AD diagnosis. Multivariable logistic regression was used. The PROgnostic Model for Advanced Dementia (PRO-MADE) was internally validated using a bootstrap resampling of 1000 replications and externally validated on a more recent cohort of AD patients. The model was evaluated for overall predictive accuracy (Nagelkerke's R2 and Brier score), discriminative [area-under-the-curve (AUC)], and calibration [calibration slope and calibration-in-the-large (CITL)] properties. RESULTS A total of 1,077 patients with a mean age of 85 (SD: 7.7) years old were included, and 318 (29.5%) patients died within one-year of AD diagnosis. Predictors of one-year ACM were age > 85 years (OR:1.87; 95%CI:1.36 to 2.56), male gender (OR:1.62; 95%CI:1.18 to 2.22), presence of pneumonia (OR:1.75; 95%CI:1.25 to 2.45), pressure ulcers (OR:2.60; 95%CI:1.57 to 4.31), dysphagia (OR:1.53; 95%CI:1.11 to 2.11), Charlson Comorbidity Index ≥ 8 (OR:1.39; 95%CI:1.01 to 1.90), functional dependency in ≥ 4 activities of daily living (OR: 1.82; 95%CI:1.32 to 2.53), abnormal urea (OR:2.16; 95%CI:1.58 to 2.95) and abnormal albumin (OR:3.68; 95%CI:2.07 to 6.54) values. Internal validation results for optimism-adjusted Nagelkerke's R2, Brier score, AUC, calibration slope and CITL were 0.25 (95%CI:0.25 to 0.26), 0.17 (95%CI:0.17 to 0.17), 0.76 (95%CI:0.76 to 0.76), 0.95 (95% CI:0.95 to 0.96) and 0 (95%CI:-0.0001 to 0.001) respectively. When externally validated, the model demonstrated an AUC of 0.70 (95%CI:0.69 to 0.71), calibration slope of 0.64 (95%CI:0.63 to 0.66) and CITL of -0.27 (95%CI:-0.28 to -0.26). CONCLUSION The PRO-MADE attained good discrimination and calibration properties. Used synergistically with a clinician's judgement, this model can identify AD patients who are at high-risk of one-year ACM to facilitate timely referrals to palliative care.
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Affiliation(s)
- Palvinder Kaur
- Health Services and Outcomes Research, National Healthcare Group, 3 Fusionopolis Link, #03-08, Singapore, 138543, Singapore
| | - Palvannan Kannapiran
- Health Services and Outcomes Research, National Healthcare Group, 3 Fusionopolis Link, #03-08, Singapore, 138543, Singapore
| | - Sheryl Hui Xian Ng
- Health Services and Outcomes Research, National Healthcare Group, 3 Fusionopolis Link, #03-08, Singapore, 138543, Singapore
| | - Jermain Chu
- Department of Palliative Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Zhi Jun Low
- Department of Palliative Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yew Yoong Ding
- Geriatric Education and Research Institute, 2 Yishun Central 2, Singapore, 768024, Singapore
| | - Woan Shin Tan
- Health Services and Outcomes Research, National Healthcare Group, 3 Fusionopolis Link, #03-08, Singapore, 138543, Singapore
| | - Allyn Hum
- Palliative Care Centre for Excellence in Research and Education, Tan Tock Seng Hospital, 10 Jalan Tan Tock Seng, Singapore, 308436, Singapore.
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Hall AJ, Manning F, Goodwin V. Key Considerations When Providing Physical Rehabilitation for People with Advanced Dementia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4197. [PMID: 36901207 PMCID: PMC10001442 DOI: 10.3390/ijerph20054197] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/17/2023] [Accepted: 02/18/2023] [Indexed: 06/18/2023]
Abstract
Dementia is a growing global challenge with numbers set to increase rapidly in the coming years. Evidence suggests that exercise can be effective in improving cognitive functioning, but the evidence does not yet support improvements in other key domains such as quality of life or physical ability. The aim of this study was to explore the key components that needed to be considered when providing physical rehabilitation to people with advanced dementia. The study used a qualitative approach involving semi-structured focus groups with health care professionals who are experts in delivering interventions to people with advanced dementia. As a pragmatic study seeking to inform the development of interventions, a thematic coding approach was used to make sense of the data. We collected data from 20 healthcare professionals who reported that key considerations needed to be considered from both an assessment and an intervention perspective. The assessment needed to be person centred and, with the right people engaged and using outcome measures that were meaningful to the patient. The actual intervention also needed to follow the principles of person-centred care, with emphasis placed on the importance of taking time to build a rapport with the person, but also reducing any of the barriers that would prevent effective engagement, such as unsuitable environments. Our study suggests that while there are barriers and challenges to providing interventions and rehabilitation to people with advanced dementia, appropriate person-centred, tailored interventions can be effective and therefore should be offered.
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Malhotra C, Chaudhry I, Shafiq M, Malhotra R. Three distinct symptom profiles among older adults with severe dementia: A latent class analysis. Palliat Support Care 2023:1-8. [PMID: 36785870 DOI: 10.1017/s1478951523000068] [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: 02/15/2023]
Abstract
OBJECTIVES Older adults with severe dementia experience multiple symptoms at the end of life. This study aimed to delineate distinct symptom profiles of older adults with severe dementia and to assess their association with older adults' and caregiver characteristics and 1-year mortality among older adults. METHODS We used baseline data from a cohort of 215 primary informal caregivers of older adults with severe dementia in Singapore. We identified 10 indicators representing physical, emotional, and functional symptoms, and responsive behaviors, and conducted latent class analysis. We assessed the association between delineated older adults' symptom profiles and their use of potentially burdensome health-care interventions in the past 4 months; older adults' 1-year mortality; and caregiver outcomes. RESULTS We delineated 3 profiles of older adults - primarily responsive behaviors (Class 1; 33%); physical and emotional symptoms with responsive behaviors (Class 2; 20%); and high functional deficits with loss of speech and eye contact (Class 3; 47%). Classes 2 and 3 older adults were more likely to have received a potentially burdensome intervention for symptoms in the past 4 months and have a greater hazard for 1-year mortality. Compared to Class 1, caregivers of Class 2 older adults were more likely to experience adverse caregiver outcomes, that is, higher distress, impact on schedule and health, anticipatory grief, and coping and lower satisfaction with care received (p<0.01 for all). SIGNIFICANCE OF RESULTS The 3 delineated profiles of older adults can be used to plan or optimize care plans to effectively manage symptoms of older adults and improve their caregivers' outcomes.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
- Health Services and System Research, Duke-NUS Medical School, Singapore, Singapore
| | - Isha Chaudhry
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | - Mahham Shafiq
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | - Rahul Malhotra
- Health Services and System Research, Duke-NUS Medical School, Singapore, Singapore
- Centre for Ageing Research and Education, Duke-NUS Medical School, Singapore, Singapore
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14
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Avnon Sawicki A, Dwolatzky T, Clarfield AM. Medical choices regarding feeding tubes in patients with end-stage dementia in Israel: nasogastric vs. percutaneous endoscopic gastrostomy. Eur Geriatr Med 2023; 14:219-222. [PMID: 36656487 DOI: 10.1007/s41999-022-00725-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/20/2022] [Indexed: 01/20/2023]
Abstract
A previous study conducted more than 15 years ago in Israel found a high overall use of tube-feeding for institutionalized end-stage dementia patients (52%) and a proportionally higher use (2:1) of naso-gastric tube (NG) over Percutaneous Endoscopic Gastrostomy (PEG) tubes for enteral feeding. This rate was markedly higher than that observed in other western countries (4.9-34%), and did not conform with clinical guidelines preferring spoon-feeding over tube-feeding for these patients, and PEG over NG for those in whom tube-feeding was initiated in long-term care. Over the past decade, the Israeli Ministry of Health conducted a policy reform to neutralize the administrative incentives presumed to be responsible for this situation. Further administrative and legislative developments followed suit. Despite these, we found no significant reduction in the prevalence of tube-feeding over spoon-feeding. However, we did observe a reduction in the proportional use of NG over PEG.
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Affiliation(s)
- Amitai Avnon Sawicki
- Sheba Medical Center, Ramat Gan, Israel. .,Medical School for International Health, Ben-Gurion University of the Negev, Beersheba, Israel.
| | - Tzvi Dwolatzky
- Geriatric Unit, Rambam Health Care Campus, and the Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - A Mark Clarfield
- Medical School for International Health, Ben-Gurion University of the Negev, Beersheba, Israel
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15
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Shi S, Largent EA, McCreedy E, Mitchell SL. Design Considerations for Embedded Pragmatic Clinical Trials of Advance Care Planning Interventions for Persons Living With Dementia. J Pain Symptom Manage 2023; 65:e155-e163. [PMID: 36423803 PMCID: PMC9875559 DOI: 10.1016/j.jpainsymman.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/23/2022]
Abstract
Advance care planning (ACP) is an important part of comprehensive care for persons living with dementia (PLWD). While many trials have established the efficacy of ACP in improving end-of-life communication and documentation of care preferences, there remains a gap in clinical usage. Embedded pragmatic clinical trials (ePCTs) may facilitate the uptake of evidence-based care into existing healthcare by deploying efficacious ACP interventions into real-world settings. However rigorous conduct of ePCTs of ACP for PLWD presents several unique methodological considerations. Here we describe a framework for the construction of these research studies, with a focus on distinguishing between the target of study: the PLWD, their care partners, or both. We outline specific considerations at each step of the research study process including 1) participant identification/eligibility, 2) participant recruitment/enrollment, 3) intervention implementation, and 4) outcome selection/ascertainment. These considerations are weighed in further detail by describing the approaches from three published trials. Specifically, we consider how potential challenges were overcome by tradeoffs in study design. Finally, we offer directions for future growth to advance ePCTs for ACP among PLWD and catalyze future research.
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Affiliation(s)
- Sandra Shi
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research (S.S., S.L.M.), Boston, MA, USA.
| | - Emily A Largent
- University of Pennsylvania Perelman School of Medicine (E.A.L.), Philadelphia, PA, USA
| | - Ellen McCreedy
- Brown University School of Public Health (E.M.), Providence, RI, USA
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research (S.S., S.L.M.), Boston, MA, USA
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16
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Ouellet GM, O’Leary JR, Leggett CG, Skinner J, Tinetti ME, Cohen AB. Benefits and harms of oral anticoagulants for atrial fibrillation in nursing home residents with advanced dementia. J Am Geriatr Soc 2023; 71:561-568. [PMID: 36310367 PMCID: PMC9957933 DOI: 10.1111/jgs.18108] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Approximately 20% of older persons with dementia have atrial fibrillation (AF). Nearly all have stroke risks that exceed the guideline-recommended threshold for anticoagulation. Although individuals with dementia develop profound impairments and die from the disease, little evidence exists to guide anticoagulant discontinuation, and almost one-third of nursing home residents with advanced dementia and AF remain anticoagulated in the last 6 months of life. We aimed to quantify the benefits and harms of anticoagulation in this population. METHODS Using Minimum Data Set and Medicare claims, we conducted a retrospective cohort study with 14,877 long-stay nursing home residents aged ≥66 between 2013 and 2018 who had advanced dementia and AF. We excluded individuals with venous thromboembolism and valvular heart disease. We measured anticoagulant exposure quarterly, using Medicare Part D claims. The primary outcome was all-cause mortality; secondary outcomes were ischemic stroke and serious bleeding. We performed survival analyses with multivariable adjustment and inverse probability of treatment (IPT) weighting. RESULTS In the study sample, 72.0% were female, 82.7% were aged ≥80 years, and 13.5% were nonwhite. Mean CHA2 DS2 VASC score was 6.19 ± 1.58. In multivariable survival analysis, anticoagulation was associated with decreased risk of death (HR 0.71, 95% CI 0.67-0.75) and increased bleeding risk (HR 1.15, 95% CI 1.02-1.29); the association with stroke risk was not significant (HR 1.08, 95% CI 0.80-1.46). Results were similar in models with IPT weighting. While >50% of patients in both groups died within a year, median weighted survival was 76 days longer for anticoagulated individuals. CONCLUSION Persons with advanced dementia and AF derive clinically modest life prolongation from anticoagulation, at the cost of elevated risk of bleeding. The relevance of this benefit is unclear in a group with high dementia-related mortality and for whom the primary goal is often comfort.
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Affiliation(s)
- Gregory M. Ouellet
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - John R. O’Leary
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Christopher G. Leggett
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH
| | - Jonathan Skinner
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH
| | - Mary E. Tinetti
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
| | - Andrew B. Cohen
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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Pita Gutiérrez F, Álvarez Hernández J, Ballesteros-Pomar MD, Botella Romero F, Bretón Lesmes I, Campos Del Portillo R, Hernández Moreno A, Júdez J, De Montalvo Jaaskelainen F. Executive summary of the position paper on the use of enteral nutrition in advanced dementia. ENDOCRINOL DIAB NUTR 2022; 69:878-887. [PMID: 36446711 DOI: 10.1016/j.endien.2022.11.026] [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: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 06/16/2023]
Abstract
Dementia is an increasingly prevalent disease in our environment, with significant health and social repercussions. Despite the available scientific evidence, there is still controversy regarding the use of enteral tube nutrition in people with advanced dementia. This document aims to reflect on the key aspects of advanced dementia, tube nutritional therapy and related ethical considerations, as well as to respond to several frequent questions that arise in our daily clinical practice.
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Affiliation(s)
- Francisco Pita Gutiérrez
- Unidad de Nutrición Clínica y Dietética, Servicio de Endocrinología y Nutrición, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain.
| | - Julia Álvarez Hernández
- Servicio de Endocrinología y Nutrición, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | | | - Francisco Botella Romero
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Irene Bretón Lesmes
- Servicio de Endocrinología y Nutrición, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Ana Hernández Moreno
- Sección de Nutrición Clínica y Dietética, Servicio de Endocrinología y Nutrición, Complejo Hospitalario de Navarra, Navarra, Spain
| | - Javier Júdez
- Asociación de Bioética Fundamental y Clínica, Coordinación Regional Estratégica para la Cronicidad Avanzada y la Atención Sociosanitaria (CORECAAS), Servicio Murciano de Salud, Murcia, Spain
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Pei Y, Qi X, Schulman-Green D, Hu M, Wang K, Wu B. Decision Aid Interventions for Family Caregivers of Persons With Advanced Dementia in Decision-Making About Feeding Options: A Scoping Review. J Am Med Dir Assoc 2022; 23:1927.e1-1927.e6. [PMID: 36150408 PMCID: PMC10421649 DOI: 10.1016/j.jamda.2022.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 08/02/2022] [Accepted: 08/20/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES We provided an overview of the literature on decision aid interventions for family caregivers of older adults with advanced dementia regarding decision making about tube feeding. We synthesized (1) the use of theory during the development, implementation, and evaluation of decision aids; (2) the development, content, and delivery of decision aid interventions; (3) caregivers' experience with decision aid interventions; and (4) the effect of decision aid interventions on caregivers' quality of decision-making about feeding options. DESIGN Scoping review. METHODS We conducted a scoping review of peer-reviewed studies published January 1, 2000-June 30, 2022, in MEDLINE, EMBASE, The Cochrane Library, CINAHL, and Web of Science databases. The process was guided by Arksey and O'Malley's methodological framework, which includes identifying the research question, choosing related studies, charting the data, and summarizing results. Empirical articles concerning the decision aid interventions about feeding options were selected. RESULTS Six publications reporting 4 unique decision aid interventions were included. All the interventions targeted caregivers of older adults with advanced dementia. Three decision aids were culturally adapted from existing decision aids. The Ottawa Decision Support Framework and the International Patient Decision Aid Standards Framework were used in these 6 publications. Interventions aimed to improve decision making regarding tube feeding for caregivers through static delivery methods. Caregivers rated these decision aids as helpful and acceptable. Decisional conflict and knowledge of feeding options were the most common outcomes evaluated. Reduction in decisional conflict and increase in knowledge were consistently found among dementia caregivers, but no intervention effects were found on preferences for the use of tube feeding. CONCLUSIONS AND IMPLICATIONS Decision aid interventions effectively improve decision-making regarding tube feeding among the target population. Cultural adaptation of an existing decision aid intervention is the main strategy. However, the lack of guidance of a cultural adaptation framework in this process may lead to difficulties explaining caregivers' behavioral changes. Moreover, merely providing information is not enough to change caregivers' preferences or behavior of use of tube feeding. A systematic approach to cultural adaptation and interactive intervention is needed in future studies.
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Affiliation(s)
- Yaolin Pei
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Xiang Qi
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | | | - Mengyao Hu
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Kaipeng Wang
- Graduate School of Social Work, University of Denver, Denver, CO, USA
| | - Bei Wu
- Rory Meyers College of Nursing, New York University, New York, NY, USA.
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Gómez-Vírseda C, Gastmans C. Euthanasia in persons with advanced dementia: a dignity-enhancing care approach. JOURNAL OF MEDICAL ETHICS 2022; 48:907-914. [PMID: 34016647 DOI: 10.1136/medethics-2021-107308] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/12/2021] [Accepted: 04/20/2021] [Indexed: 06/12/2023]
Abstract
In current Western societies, increasing numbers of people express their desire to choose when to die. Allowing people to choose the moment of their death is an ethical issue that should be embedded in sound clinical and legal frameworks. In the case of persons with dementia, it raises further ethical questions such as: Does the person have the capacity to make the choice? Is the person being coerced? Who should be involved in the decision? Is the person's suffering untreatable? The use of Advance Euthanasia Directives (AED) is suggested as a way to deal with end-of-life wishes of persons with dementia. However, in the Netherlands-the only country in which this practice is legal-the experiences of patients, doctors, and relatives have been far from satisfactory.Our paper analyses this complex ethical challenge from a Dignity-Enhancing Care approach, starting from the Dutch experiences with AED as a case. We first consider the lived experiences of the different stakeholders, seeking out a dialogical-interpretative understanding of care. We aim to promote human dignity as a normative standard for end-of-life care practices. Three concrete proposals are then presented in which this approach can be operationalised in order to deal respectfully with the end-of-life choices of persons with dementia.
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Affiliation(s)
- Carlos Gómez-Vírseda
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Flanders, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Flanders, Belgium
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20
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Yous ML, Ploeg J, Kaasalainen S, McAiney C, Fisher K. Feasibility, acceptability, and preliminary effectiveness of the adapted Namaste Care program delivered by caregivers of community-dwelling older persons with moderate to advanced dementia: a mixed methods feasibility study. BMC Geriatr 2022; 22:797. [PMID: 36229789 PMCID: PMC9559259 DOI: 10.1186/s12877-022-03483-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/27/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Caregivers have considerable responsibilities in supporting persons in advanced stages of dementia, however they receive little education. Namaste Care is a multisensory program originally designed to be delivered by healthcare providers in long-term care homes for persons with advanced dementia. The program has not yet been adapted and evaluated for use by caregivers of persons with moderate to advanced dementia living at home. The purpose of this feasibility study is to determine the feasibility, acceptability and preliminary effectiveness of the adapted Namaste Care program for use by caregivers of community-dwelling older persons with moderate to advanced dementia. METHODS This feasibility study, with a one-group before-after design and interviews, was part of a larger study using a multiphase mixed methods design. A total of 12 caregivers delivered the program over three months. Caregivers completed questionnaires on caregiver quality of life, perceptions of caregiving, self-efficacy, and burden at baseline and 3-month follow-up. Caregivers participated in interviews at the 3-month follow-up to explore acceptability and perceived benefit. Descriptive statistics and paired t-tests were used to analyze quantitative data. A secondary analysis used multiple imputation to explore the impact of missing data. Experiential thematic analysis was used in analyzing qualitative data. RESULTS The adapted Namaste Care program was judged to be feasible, given that all caregivers used it at least twice a week over the 3-month period. The retention rate of caregivers was 83% (10 of 12). Caregivers perceived that the program was practical, enhanced the wellbeing of persons with dementia, and brought them closer in their relationships with persons with dementia. There were no statistically significant changes for quality of life, perceptions of caregiving, self-efficacy, or burden outcomes. Multiple imputation results revealed promising findings for an improvement in caregiver wellbeing related to quality of life. CONCLUSIONS The adapted Namaste Care program for use by caregivers of community-dwelling older persons with moderate to advanced dementia was feasible and acceptable. The program has the potential to enhance the quality of life and other outcomes of caregivers, however there is a need to conduct a larger trial that is adequately powered to detect these effects.
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Affiliation(s)
- Marie-Lee Yous
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Jenny Ploeg
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Sharon Kaasalainen
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Carrie McAiney
- School of Public Health Sciences, Schlegel Research Chair in Dementia, Schlegel-UW Research Institute for Aging, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1 Canada
| | - Kathryn Fisher
- School of Nursing, Aging, Community and Health Research Unit, Faculty of Health Sciences, McMaster University, 1280 Main Street West, Room HSc3N25, Hamilton, ON L8S 4K1 Canada
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Exploring the Clinical Utility of the Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC) with People with End-Stage Dementia. Brain Sci 2022; 12:brainsci12101306. [PMID: 36291240 PMCID: PMC9599261 DOI: 10.3390/brainsci12101306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Dementia is a major health concern globally and cross-culturally with progressive decline in cognition, mobility and communication. There are few interventions for end-stage dementia (ESD) although music interventions have been observed to be accessible for people with mid to late-stage dementia. The lack of protocols and measures suited to ESD has limited research into the effects of music therapy. Measure sensitivity to minimal responsiveness is one limitation to the use of existing music intervention measures with ESD. This exploratory study examined the clinical utility of the Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC) for use with people with end-stage dementia, including preliminary reliability and validity. The MATADOC is a standardized assessment for minimally responsive patients with disorders of consciousness and may be useful for ESD. Using repeated measures with blinded MATADOC-trained raters, MATADOC data were collected with a small convenience sample of people with ESD in a residential care setting. Clinical utility data were collected from the raters and evaluated using a multidimensional model. To explore its functionality, MATADOC outcomes were compared to another measure for music interventions in dementia. The MATADOC may be useful for assessing functioning and responsiveness to music interventions for people with ESD without the risk of floor effects. Modifying the MATADOC protocol and assessment documentation prior to testing with a larger sample will enhance its sensitivity specific to ESD and age-related needs, providing a new music-based ESD assessment.
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22
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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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23
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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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Makmee P, Wongupparaj P. Virtual Reality-based Cognitive Intervention for Enhancing Executive Functions in Community-dwelling Older Adults. INTERVENCION PSICOSOCIAL 2022; 31:133-144. [PMID: 37361011 PMCID: PMC10268555 DOI: 10.5093/pi2022a10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/22/2022] [Indexed: 06/28/2023]
Abstract
With the rapid growth of the older population globally, it is anticipated that age-related cognitive decline in the prodromal phase and more severe pathological decline will increase. Moreover, currently, no effective treatment options for the disease exist. Thus, early and timely prevention actions are promising and prior strategies to preserve cognitive functions by preventing symptomatology from increasing the age-related deterioration of the functions in healthy older adults. This study aims to develop the virtual reality-based cognitive intervention for enhancing executive functions (EFs) and examine the EFs after training with the virtual reality-based cognitive intervention in community-dwelling older adults. Following inclusion/exclusion criteria, 60 community-dwelling older adults aged 60-69 years were involved in the study and randomly divided into passive control and experimental groups. Eight 60 min virtual reality-based cognitive intervention sessions were held twice a week and lasted for 1 month. The EFs (i.e., inhibition, updating, and shifting) of the participants were assessed by using standardized computerized tasks, i.e., Go/NoGo, forward and backward digit span, and Berg's card sorting tasks. Additionally, a repeated-measure ANCOVA and effect sizes were applied to investigate the effects of the developed intervention. The virtual reality-based intervention significantly improved the EFs of older adults in the experimental group. Specifically, the magnitudes of enhancement were observed for inhibitory as indexed by the response time, F(1) = 6.95, p < .05, ηp2 = .11, updating as represented by the memory span, F(1) = 12.09, p < .01, ηp2 = .18, and the response time, F(1) = 4.46, p = .04, ηp2 = .07, and shifting abilities as indexed by the percentage of correct responses, F(1) = 5.30, p = .03, ηp2 = .09, respectively. The results indicated that the simultaneous combined cognitive-motor control as embedded in the virtual-based intervention is safe and effective in enhancing EFs in older adults without cognitive impairment. Nevertheless, further studies are required to investigate the benefits of these enhancements to motor functions and emotional aspects relating to daily living and the well-being of older populations in communities.
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Affiliation(s)
- Pattrawadee Makmee
- Burapha UniversityCollege of Research Methodology and Cognitive ScienceCognitive Science and Innovation Research UnitThailandCognitive Science and Innovation Research Unit, College of Research Methodology and Cognitive Science, Burapha University, Thailand
| | - Peera Wongupparaj
- Burapha UniversityCollege of Research Methodology and Cognitive ScienceCognitive Science and Innovation Research UnitThailandCognitive Science and Innovation Research Unit, College of Research Methodology and Cognitive Science, Burapha University, Thailand
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A Survey of Mobile Apps for the Care Management of Patients with Dementia. Healthcare (Basel) 2022; 10:healthcare10071173. [PMID: 35885700 PMCID: PMC9317040 DOI: 10.3390/healthcare10071173] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/18/2022] [Accepted: 06/21/2022] [Indexed: 11/17/2022] Open
Abstract
Objective: Dementia is a progressive neurocognitive disorder that currently affects approximately 50 million people globally and causes a heavy burden for their families and societies. This study analyzed mobile apps for dementia care in different languages and during the COVID-19 pandemic. Methods: We searched PubMed, Cochrane Collaboration Central Register of Con-trolled Clinical Trials, Cochrane Systematic Reviews, Google Play Store, Apple App Store, and Huawei App Store for mobile applications for dementia care. The Mobile Application Rating Scale (MARS) was used to assess the quality of applications. Results: We included 99 apps for dementia care. No significant difference in MARS scores was noted between the two language apps (Overall MARS: English: 3.576 ± 0.580, Chinese: 3.569 ± 0.746, p = 0.962). In the subscale analysis, English apps had higher scores of perceived impact than Chinese apps but these were not significant (2.654 ± 1.372 vs. 2.000 ± 1.057, p = 0.061). (2) Applications during the COVID-19 pandemic had higher MARS scores than those before the COVID-19 pandemic but these were not significant (during the COVID-19 pandemic: 3.722 ± 0.416; before: 3.699 ± 0.615, p = 0.299). In the sub-scale analysis, apps during the COVID-19 pandemic had higher scores of engagement than apps before the COVID-19 pandemic but these were not significant (3.117 ± 0.594 vs. 2.698 ± 0.716, p = 0.068). Conclusions: Our results revealed that there is a minor but nonsignificant difference between different languages and during the COVID-19 pandemic. Further cooperation among dementia professionals, technology experts, and caregivers is warranted to provide evidence-based and user-friendly information to meet the needs of users.
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Siniora DN, Timms O, Ewuoso C. Managing feeding needs in advanced dementia: perspectives from ethics of care and ubuntu philosophy. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2022; 25:259-268. [PMID: 35253096 DOI: 10.1007/s11019-022-10073-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 06/14/2023]
Abstract
The response to feeding needs in advanced dementia patients is a subject of ethical inquiry. Advanced dementia is the debilitating result of a range of neurodegenerative diseases. As this terminal illness progresses, patients develop mild to severe dysphagia that can make swallowing difficult. Of the two available options, artificial tube feeding or oral hand feeding, an estimated one-third of these patients will receive artificial tube feeding. However, observational studies have failed to validate the clinical benefits of tube feeding. Ethics of care, the feminist philosophical perspective, and Ubuntu philosophy offer arguments for the choice of oral hand-feeding as a preferrable first option by caregivers as far as possible. These moral theories acknowledge that human beings can be dependent for long periods, mostly early and later years of life. Both views reflect an approach that draws people into a system of interdependent caring relationships. They encourage hand feeding as a way of exhibiting solidarity and respecting human dignity even at the end of life.
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Affiliation(s)
| | - Olinda Timms
- Division of Health and Humanities, St Johns' Research Institute, Bangalore, India
| | - Cornelius Ewuoso
- Steve Biko Centre for Bioethics, University of Witwatersrand, Gauteng, South Africa
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Marsilli P, Funtowicz G, Epstein L, Giunta D, Peroni L, Vergara A. [Mortality in patients with dementia admitted in critical care units]. Rev Esp Geriatr Gerontol 2022; 57:150-155. [PMID: 35597699 DOI: 10.1016/j.regg.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 03/15/2022] [Accepted: 03/21/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the mortality and comorbidities associated of patients with dementia admitted to the Intensive Care Unit (ICU) on the hospitalization and at one year of follow-up. MATERIALS AND METHODS A retrospective observational cohort study was carried out between 2012 and 2017 at the Hospital Italiano de San Justo, of patients who were admitted to the ICU, these were observed up to hospitalary death, out hospital death one year of hospitalization, the disenrollment from the institution's health plan or the end of the follow-up. RESULTS A total of 163 patients were included for analysis. We recorded those 79 patients (48.47%) died one year after the hospitalization, of them 25 (15.34%) in ICU and 8 (4.91%) in general room. The most frequent causes of death were respiratory. The factors most associated with mortality were: orotracheal intubation (HR=2.01; 95% CI: 1.11-3.65; P=.02), history of leukemia (HR=8.55; 95% CI: 1.82-40.05; P≤.05), elevated Charlson (HR=1.16, 95% CI: 1.04-1.41; P=.05), and elevated APACHE II at admission (HR=1.07; 95% CI: 1.03-1.11; P≤.05). CONCLUSIONS The present study expresses the prognosis of patients with a diagnosis of dementia admitted to the ICU and that depends not only on their baseline neurological status but also on the severity at admission and comorbidities.
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Affiliation(s)
- Pablo Marsilli
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | | | - Lucas Epstein
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Diego Giunta
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Leticia Peroni
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Erel M, Marcus EL, Dekeyser-Ganz F. Practice of end-of-life care for patients with advanced dementia by hospital physicians and nurses: Comparison between medical and surgical wards. DEMENTIA 2022; 21:1328-1342. [PMID: 35344387 PMCID: PMC9109210 DOI: 10.1177/14713012221077533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with advanced dementia are commonly hospitalized in acute care wards, yet there is limited data regarding the end-of-life (EOL) care delivered to this population. The aim of the study was to examine EOL care delivered to patients with advanced dementia hospitalized on acute wards as reported by physicians and nurses. METHODS Participants were physicians and nurses from medical and surgical wards of two tertiary hospitals in Israel. Participants completed a self-report questionnaire evaluating EOL care experiences, knowledge, performance, assessment, communication, and perceived futile care regarding patients with dementia. RESULTS The questionnaire was completed by 315 providers. There were 190 medical ward respondents and 125 from general surgical wards. Of them, 48.6% recognized dementia as a terminal disease, while 26.0% of the participants reported that they knew the end-of-life preferences for less than 10% of their patients. Among the providers, 53.3% reported that end-of-life ward discussions took place only when there was a life-threatening situation and 11.1%-16.5% never engaged in end-of-life communication regarding EOL patient's preferences, appointing an attorney for the patient, disease trajectory or the essence of palliative care, with patients or their representatives. Only 17.1% reported "never" performing care they considered to be futile for patients with advanced dementia. Controlling for gender, age, role, position (senior/junior), and exposure to patients with advanced dementia, surgical ward respondents reported performing less EOL care than medical ward respondents in almost all aspects of palliative care. CONCLUSIONS Despite growing attention, a significant portion of staff in acute care wards do not report applying EOL care to patients with advanced dementia in clinical practice, especially surgical ward staff.
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Affiliation(s)
- Meira Erel
- 108369Henrietta Szold Hadassah University School of Nursing, Jerusalem, Israel
| | - Esther-Lee Marcus
- Faculty of Medicine, 54621Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Geriatrics, 26733Herzog Medical Center, Jerusalem, Israel
| | - Freda Dekeyser-Ganz
- 108369Henrietta Szold Hadassah University School of Nursing, Jerusalem, Israel
- Faculty of Health and Life Sciences, Jerusalem College of Technology, Jerusalem, Israel
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Wu CH, Peng CK, Chung CH, Chien WC, Tzeng NS. Real-World Evidence for the Association Between Pneumonia-Related Intensive Care Unit Stay and Dementia. Psychiatry Investig 2022; 19:247-258. [PMID: 35500898 PMCID: PMC9058270 DOI: 10.30773/pi.2021.0277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 01/27/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE There is limited clarity concerning the risk of dementia after pneumonia with intensive care unit (ICU) stay. We conducted a nationwide cohort study, which aimed to investigate the impact of dementia after pneumonia with and without intensive care unit admission. METHODS Data was obtained from Taiwan's National Health Insurance Research Database between 2000 and 2015. A total of 7,473 patients were identified as having pneumonia required ICU stay, along with 22,419 controls matched by sex and age. After adjusting for confounding factors, multivariate Cox regression model analysis was used to compare the risk of developing dementia during the 15-years follow-up period. RESULTS The enrolled pneumonia patients with ICU admission had a dementia rate of 9.89%. Pneumonia patients without ICU admission had a dementia rate of 9.21%. The multivariate Cox regression model analysis revealed that the patients with ICU stay had the higher risk of dementia, with a crude hazard ratio of 3.371 (95% confidence interval, 3.093-3.675; p<0.001). CONCLUSION This study indicated that pneumonia with ICU stay is associated with an increased risk of dementia. A 3-fold risk of dementia was observed in patients admitted to the ICU compared to the control group.
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Affiliation(s)
- Chun-Han Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Kan Peng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Hsian Chung
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan.,School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan.,School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Nian-Sheng Tzeng
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Student Counseling Center, National Defense Medical Center, Taipei, Taiwan
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Erel M, Marcus EL, Dekeyser-Ganz F. Practitioner Bias as an Explanation for Low Rates of Palliative Care Among Patients with Advanced Dementia. HEALTH CARE ANALYSIS 2022; 30:57-72. [PMID: 33782805 DOI: 10.1007/s10728-021-00429-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 02/05/2023]
Abstract
Patients with advanced dementia are less likely than those with other terminal illnesses to receive palliative care. Due to the nature and course of dementia, there may be a failure to recognize the terminal stage of the disease. A possible and under-investigated explanation for this healthcare disparity is the healthcare practitioner who plays a primary role in end-of-life decision-making. Two potential areas that might impact provider decision-making are cognitive biases and moral considerations. In this analysis, we demonstrate how the cognitive biases and moral considerations of practitioners related to clinical decision-making are inherent in clinical practice and may impact on providers' accuracy related to diagnostic and treatment related decision-making associated with patients with advanced dementia. Anchoring, default, availability, representativeness and framing biases are cognitive biases based on the "Two System Model" that relate to decision-making in end-of-life care. In patients with advanced dementia, those biases may result in a tendency to adhere to traditional mandatory care, involving an aggressive approach to care, which values saving lives at all costs, without taking into account the possible suffering and long-term consequences. Aspects such as moral sensitivity and moral courage play an important role in ethical decision-making related to advanced dementia. Investigations of clinical decision-making that include the cognitive biases and ethical considerations of practitioners might advance the comprehensive understanding of the clinical decision-making process related to care of patients with advanced dementia and promote the quality of care given to this population.
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Affiliation(s)
- Meira Erel
- Henrietta Szold Hadassah-Hebrew University School of Nursing, Kiryat Hadassah, POB 1200, 9112001, Jerusalem, Israel.
- Faculty of Medicine, Hadassah-Hebrew University, Jerusalem, Israel.
| | - Esther-Lee Marcus
- Henrietta Szold Hadassah-Hebrew University School of Nursing, Kiryat Hadassah, POB 1200, 9112001, Jerusalem, Israel
- Faculty of Medicine, Hadassah-Hebrew University, Jerusalem, Israel
- Geriatric Division, Herzog Medical Center, Givat Shaul Street, POB 3900, 9103702, Jerusalem, Israel
| | - Freda Dekeyser-Ganz
- Henrietta Szold Hadassah-Hebrew University School of Nursing, Kiryat Hadassah, POB 1200, 9112001, Jerusalem, Israel
- Jerusalem College of Technology, 11 Beit-Hadfus, Jerusalem, 9548311, Israel
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Liu CK, Seo J, Pravodelov V, Frazier S, Guy M, Concilio K, Lau-Ng R, Brandeis G, Watson J, van der Velde J, Olesen SW, Budree S, Njenga M, Kassam Z, Osman M. Pilot study of autologous fecal microbiota transplants in nursing home residents: Feasibility and safety. Contemp Clin Trials Commun 2022; 27:100906. [PMID: 35299780 PMCID: PMC8921299 DOI: 10.1016/j.conctc.2022.100906] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 02/18/2022] [Accepted: 02/26/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Antibiotic resistant bacterial infections (ARBIs) are extremely common in nursing home residents. These infections typically occur after a course of antibiotics, which eradicate both pathological and beneficial organisms. The eradication of beneficial organisms likely facilitates subsequent ARBIs. Autologous fecal microbiota transplant (aFMT) has been proposed as a potential treatment to reduce ARBIs in nursing home residents. Our objective was to determine the feasibility and safety of aFMT in a nursing home population. Methods Pilot clinical trial. We evaluated feasibility as total number of stool samples collected for aFMT production and safety as the number and relatedness of serious (SAE) and non-serious adverse events (AE). Results We screened 468 nursing home residents aged ≥18 years for eligibility; 67 enrolled, distributed among three nursing homes. Participants were 62.7% female and 35.8% Black. Mean age was 82.2 ± 8.5 years. Thirty-three participants underwent successful stool collection. Seven participants received antibiotics; four participants underwent aFMT. There were 40 SAEs (17 deaths) and 11 AEs. In the aFMT group, there were 3 SAEs (2 deaths) and 10 AEs. All SAEs and AEs were judged unrelated to the study intervention. Conclusions In this pilot study of aFMT in nursing home residents, less than half were able to provide adequate stool samples for aFMT. There were no related SAEs or AEs during the study. In sum, we conclude aFMT has limited feasibility in a nursing home population due to logistic and technical challenges but is likely safe. Trial registration ClinicalTrials.gov Identifier: NCT03061097.
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Affiliation(s)
- Christine K. Liu
- Section of Geriatrics, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Jean Mayer United States Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
- Section of Geriatrics, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
- Geriatric Research and Education Clinical Center, Veteran Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Corresponding author. Section of Geriatrics, Division of Primary Care and Population Health, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA, 94305, USA.
| | - Janet Seo
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vassiliki Pravodelov
- Section of Geriatrics, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Susan Frazier
- Section of Geriatrics, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Marsha Guy
- Section of Geriatrics, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Katherine Concilio
- Section of Geriatrics, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Rossana Lau-Ng
- Section of Geriatrics, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Gary Brandeis
- Section of Geriatrics, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Henao D, Gregory C, Walters G, Stinson C, Dixon Y. Race and prevalence of percutaneous endoscopic gastrostomy tubes in patients with advanced dementia. Palliat Support Care 2022; 21:1-6. [PMID: 35078550 DOI: 10.1017/s1478951521002042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Millions of Americans may face hard decisions when it comes to providing nutrition for their loved ones with advanced dementia. This study aimed to ascertain whether there is a difference in feeding tube placement between White and Black patients with advanced dementia and whether this potential difference varied by patient's other demographic and clinical characteristics. METHOD This is a retrospective, observational study conducted at Novant Health, a 15-hospital system in the southeastern United States. Data were obtained from Epic systems and included all hospital admissions with a diagnosis of advanced dementia, a total of 21,939, between July 1, 2015, and December 31, 2018. Descriptive statistics and logistics analyses were conducted to assess the relationship between receiving percutaneous endoscopic gastrostomy (PEG) and race, controlling for demographic and clinical characteristics. RESULTS Among patients admitted with advanced dementia, the multivariable logistic regression, controlled for age, gender, LOS, palliative care, and vascular etiology showed that Blacks had higher odds of having PEG tubes inserted than White patients (OR 1.97; CI 1.51-2.55; P < 0.001). Patients with longer stays had higher odds of PEG tube insertion. Females had lower odds of PEG tube insertion than males. There was no statistical significance in PEG insertion based on age, etiology, and palliative care consult. SIGNIFICANCE OF RESULTS The reasons for the observed higher odds of receiving PEG tubes among Black patients than White patients are likely multifactorial and embedded in a different approach to end-of-life care conversations by providers and caregivers of Black and White patients. Providers may need to be more aware of potential unconscious biases when talking to caregivers, especially in race-discordant relationships, have courageous conversations with caregivers, and be more aware of the importance of keeping in mind families' and caregivers' culture, including spirituality, when making end-of-life decisions.
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Affiliation(s)
- David Henao
- Office of Diversity, Inclusion, and Equity, Novant Health, Winston-Salem, NC27103
| | - Chere Gregory
- Office of Diversity, Inclusion, and Equity, Novant Health, Winston-Salem, NC27103
| | - Gloria Walters
- Center for Professional Practice & Development, Novant Health, Winston-Salem, NC27103
| | | | - Yvonne Dixon
- Office of Diversity, Inclusion, and Equity, Novant Health, Winston-Salem, NC27103
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Lopes BNA, Garcez FB, Suemoto CK, Morillo LS. Accuracy of two prognostic indexes to predict mortality in older adults with advanced dementia. Dement Neuropsychol 2022; 16:52-60. [PMID: 35719252 PMCID: PMC9170258 DOI: 10.1590/1980-5764-dn-2021-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 08/05/2021] [Accepted: 09/16/2021] [Indexed: 11/25/2022] Open
Abstract
Dementia is a cause of disability among older adults. Accessing advanced dementia prognosis is a challenge.
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Affiliation(s)
| | - Flavia Barreto Garcez
- Universidade de São Paulo, Faculdade de Medicina, Divisão de Geriatria, São Paulo SP, Brazil
| | - Claudia Kimie Suemoto
- Universidade de São Paulo, Faculdade de Medicina, Divisão de Geriatria, São Paulo SP, Brazil
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Wang X, Ezeana CF, Wang L, Puppala M, Huang Y, He Y, Yu X, Yin Z, Zhao H, Lai EC, Wong STC. Risk factors and machine learning model for predicting hospitalization outcomes in geriatric patients with dementia. ALZHEIMER'S & DEMENTIA: TRANSLATIONAL RESEARCH & CLINICAL INTERVENTIONS 2022; 8:e12351. [PMID: 36204350 PMCID: PMC9520763 DOI: 10.1002/trc2.12351] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/26/2022]
Abstract
Introduction Geriatric patients with dementia incur higher healthcare costs and longer hospital stays than other geriatric patients. We aimed to identify risk factors for hospitalization outcomes that could be mitigated early to improve outcomes and impact overall quality of life. Methods We identified risk factors, that is, demographics, hospital complications, pre‐admission, and post‐admission risk factors including medical history and comorbidities, affecting hospitalization outcomes determined by hospital stays and discharge dispositions. Over 150 clinical and demographic factors of 15,678 encounters (8407 patients) were retrieved from our institution's data warehouse. We further narrowed them down to twenty factors through feature selection engineering by using analysis of variance (ANOVA) and Glmnet. We developed an explainable machine‐learning model to predict hospitalization outcomes among geriatric patients with dementia. Results Our model is based on stacking ensemble learning and achieved accuracy of 95.6% and area under the curve (AUC) of 0.757. It outperformed prevalent methods of risk assessment for encounters of patients with Alzheimer's disease dementia (ADD) (4993), vascular dementia (VD) (4173), Parkinson's disease with dementia (PDD) (3735), and other unspecified dementias (OUD) (2777). Top identified hospitalization outcome risk factors, mostly from medical history, include encephalopathy, number of medical problems at admission, pressure ulcers, urinary tract infections, falls, admission source, age, race, anemia, etc., with several overlaps in multi‐dementia groups. Discussion Our model identified several predictive factors that can be modified or intervened so that efforts can be made to prevent recurrence or mitigate their adverse effects. Knowledge of the modifiable risk factors would help guide early interventions for patients at high risk for poor hospitalization outcome as defined by hospital stays longer than seven days, undesirable discharge disposition, or both. The interventions include starting specific protocols on modifiable risk factors like encephalopathy, falls, and infections, where non‐existent or not routine, to improve hospitalization outcomes of geriatric patients with dementia. Highlights A total 15,678 encounters of Geriatrics with dementia with a final 20 risk factors. Developed a predictive model for hospitalization outcomes for multi‐dementia types. Risk factors for each type were identified including those amenable to interventions. Top factors are encephalopathy, pressure ulcers, urinary tract infection (UTI), falls, and admission source. With accuracy of 95.6%, our ensemble predictive model outperforms other models.
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Affiliation(s)
- Xin Wang
- T.T. & W.F. Chao Center for BRAIN Houston Methodist Academic Institute Houston Methodist Hospital Houston Texas USA
| | - Chika F. Ezeana
- T.T. & W.F. Chao Center for BRAIN Houston Methodist Academic Institute Houston Methodist Hospital Houston Texas USA
| | - Lin Wang
- T.T. & W.F. Chao Center for BRAIN Houston Methodist Academic Institute Houston Methodist Hospital Houston Texas USA
| | - Mamta Puppala
- T.T. & W.F. Chao Center for BRAIN Houston Methodist Academic Institute Houston Methodist Hospital Houston Texas USA
| | | | - Yunjie He
- T.T. & W.F. Chao Center for BRAIN Houston Methodist Academic Institute Houston Methodist Hospital Houston Texas USA
| | - Xiaohui Yu
- T.T. & W.F. Chao Center for BRAIN Houston Methodist Academic Institute Houston Methodist Hospital Houston Texas USA
| | - Zheng Yin
- T.T. & W.F. Chao Center for BRAIN Houston Methodist Academic Institute Houston Methodist Hospital Houston Texas USA
| | - Hong Zhao
- T.T. & W.F. Chao Center for BRAIN Houston Methodist Academic Institute Houston Methodist Hospital Houston Texas USA
| | - Eugene C. Lai
- Neurological Institute Houston Methodist Hospital Houston Texas USA
| | - Stephen T. C. Wong
- T.T. & W.F. Chao Center for BRAIN Houston Methodist Academic Institute Houston Methodist Hospital Houston Texas USA
- Brain and Mind Research Institute Weill Cornell Medical College New York USA
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Resumen ejecutivo del documento de posicionamiento sobre el empleo de la nutrición enteral en la demencia avanzada. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Wilkins JM. Reconsidering Gold Standards for Surrogate Decision Making for People with Dementia. Psychiatr Clin North Am 2021; 44:641-647. [PMID: 34763796 PMCID: PMC8597910 DOI: 10.1016/j.psc.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
As dementia progresses and cognitive function declines, surrogate decision making becomes increasingly prevalent. By convention, there is a hierarchical approach to proxy decision making beginning with known wishes, followed by a substituted judgment standard, and then a best-interests standard. For people with dementia, discrepancy in proxy assessments is common and associated with negative behavioral outcomes. Therefore, optimal approaches to proxy decision making for people with dementia should instead prioritize and implement options that encourage direct participation of persons with dementia and standards that explicitly rely on consideration of longitudinal changes in values and preferences for persons with dementia.
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Affiliation(s)
- James M. Wilkins
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, USA,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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37
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Armstrong MJ. Advances in dementia with Lewy bodies. Ther Adv Neurol Disord 2021; 14:17562864211057666. [PMID: 34840608 PMCID: PMC8613883 DOI: 10.1177/17562864211057666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022] Open
Abstract
Dementia with Lewy bodies (DLB) is a clinical diagnosis representing a specific presentation of a pathological α-synucleinopathy (Lewy body disease). DLB is one entity under the broader term Lewy body dementia, which also includes Parkinson’s disease dementia. Recent advances in DLB include publication of updated diagnostic criteria and recognition of prodromal DLB states, including mild cognitive impairment, delirium-onset, and psychiatric-onset forms. Research criteria for the mild cognitive impairment form of DLB were published in 2020. Increasing research shows that concomitant Alzheimer’s disease pathology in individuals with DLB is common in addition to the α-synucleinopathy pathology. This has implications for biomarker use and expected progression. Identifying biomarkers for DLB is an area of active research. Cerebrospinal fluid and skin biopsy tests are now commercially available in the United States, but their role in routine clinical care is not yet established. Additional research and biomarkers are needed. Research suggests that median survival after DLB diagnosis is 3–4 years, but there are rapidly and slowly progressive forms. Most individuals with DLB die of complications of the disease. Clinical trials for individuals with DLB have increased over the last 5 years, targeting both symptoms and underlying pathology. Effective therapies remain an unmet need, however. This review focuses on recent advances with an emphasis on literature that informs clinical care.
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Affiliation(s)
- Melissa J Armstrong
- Department of Neurology, College of Medicine, University of Florida, P.O. Box 100268, Gainesville, FL 32611, USA
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Haapasalmi S, Piili RP, Metsänoja R, Kellokumpu-Lehtinen PLI, Lehto JT. Physicians' decreased tendency to choose palliative care for patients with advanced dementia between 1999 and 2015. BMC Palliat Care 2021; 20:119. [PMID: 34311739 PMCID: PMC8312352 DOI: 10.1186/s12904-021-00811-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 06/11/2021] [Indexed: 11/26/2022] Open
Abstract
Background Physicians’ decision-making for seriously ill patients with advanced dementia is of high importance, especially as the prevalence of dementia is rising rapidly, and includes many challenging ethical, medical and juridical aspects. We assessed the change in this decision-making over 16 years (from 1999 to 2015) and several background factors influencing physicians’ decision. Methods A postal survey including a hypothetical patient-scenario representing a patient with an advanced dementia and a life-threatening gastrointestinal bleeding was sent to 1182 and 1258 Finnish physicians in 1999 and 2015, respectively. The target groups were general practitioners (GPs), surgeons, internists and oncologists. The respondents were asked to choose between several life-prolonging and palliative care approaches. The influence of physicians’ background factors and attitudes on their decision were assessed. Results The response rate was 56%. A palliative care approach was chosen by 57 and 50% of the physicians in 1999 and 2015, respectively (p = 0.01). This change was statistically significant among GPs (50 vs 40%, p = 0.018) and oncologists (77 vs 56%, p = 0.011). GPs chose a palliative care approach less often than other responders in both years (50 vs. 63% in 1999 and 40 vs. 56% in 2015, p < 0.001). In logistic regression analysis, responding in 2015 and being a GP remained explanatory factors for a lower tendency to choose palliative care. The impact of family’s benefit on the decision-making decreased, whereas the influence of the patient’s benefit and ethical values as well as the patient’s or physician’s legal protection increased from 1999 to 2015. Conclusions Physicians chose a palliative care approach for a patient with advanced dementia and life-threatening bleeding less often in 2015 than in 1999. Specialty, attitudes and other background factors influenced significantly physician decision-making. Education on the identification and palliative care of the patients with late-stage dementia are needed to make these decisions more consistent.
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Affiliation(s)
- Saila Haapasalmi
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. .,Palliative Care Centre and Department of Geriatrics, Tampere University Hospital, Tampere, Finland. .,Tays Hatanpää Hospital, Hatanpäänkatu 24, T-Building, 4th floor, 33900, Tampere, Finland.
| | - Reetta P Piili
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Palliative Care Centre and Tays Cancer Centre, Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Riina Metsänoja
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Pirkko-Liisa I Kellokumpu-Lehtinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Tays Cancer Centre, Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Juho T Lehto
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Palliative Care Centre and Tays Cancer Centre, Department of Oncology, Tampere University Hospital, Tampere, Finland
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Chiong W, Tsou AY, Simmons Z, Bonnie RJ, Russell JA. Ethical Considerations in Dementia Diagnosis and Care: AAN Position Statement. Neurology 2021; 97:80-89. [PMID: 34524968 DOI: 10.1212/wnl.0000000000012079] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 03/08/2021] [Indexed: 11/15/2022] Open
Abstract
Alzheimer disease and other dementias present unique practical challenges for patients, their families, clinicians, and health systems. These challenges reflect not only the growing public health effect of dementia in an aging global population, but also more specific ethical complexities including early loss of patients' capacity to make decisions regarding their own care, the stigma often associated with a dementia diagnosis, the difficulty of balancing concern for patients' welfare with respect for patients' remaining independence, and the effect on the physical, emotional, and financial well-being of family caregivers. Caring for patients with dementia requires respecting patient autonomy while acknowledging progressively diminishing decisional capacity and continuing to provide care in accordance with other core ethical principles (beneficence, justice, and nonmaleficence). Whereas these ethical principles remain unchanged, neurologists must reconsider how to apply them given changes across multiple domains including our understanding of disease, clinical and legal tools for addressing manifestations of illness, our expanding awareness of the crucial role of family caregivers in providing care and maintaining patient quality of life, and societal conceptions of dementia and individuals' personal expectations for aging. This revision to the American Academy of Neurology's 1996 position statement summarizes ethical considerations that often arise in caring for patients with dementia; although it addresses how such considerations influence patient management, it is not a clinical practice guideline.
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Affiliation(s)
- Winston Chiong
- From the Department of Neurology (W.C.), University of California San Francisco; Evidence-Based Practice Center (A.Y.T.), ECRI, Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Neurology (Z.S.), The Pennsylvania State University, Hershey; School of Law (R.J.B.), University of Virginia, Charlottesville; and Department of Neurology (J.A.R.), Lahey Medical Center, Burlington, MA.
| | - Amy Y Tsou
- From the Department of Neurology (W.C.), University of California San Francisco; Evidence-Based Practice Center (A.Y.T.), ECRI, Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Neurology (Z.S.), The Pennsylvania State University, Hershey; School of Law (R.J.B.), University of Virginia, Charlottesville; and Department of Neurology (J.A.R.), Lahey Medical Center, Burlington, MA
| | - Zachary Simmons
- From the Department of Neurology (W.C.), University of California San Francisco; Evidence-Based Practice Center (A.Y.T.), ECRI, Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Neurology (Z.S.), The Pennsylvania State University, Hershey; School of Law (R.J.B.), University of Virginia, Charlottesville; and Department of Neurology (J.A.R.), Lahey Medical Center, Burlington, MA
| | - Richard J Bonnie
- From the Department of Neurology (W.C.), University of California San Francisco; Evidence-Based Practice Center (A.Y.T.), ECRI, Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Neurology (Z.S.), The Pennsylvania State University, Hershey; School of Law (R.J.B.), University of Virginia, Charlottesville; and Department of Neurology (J.A.R.), Lahey Medical Center, Burlington, MA
| | - James A Russell
- From the Department of Neurology (W.C.), University of California San Francisco; Evidence-Based Practice Center (A.Y.T.), ECRI, Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Neurology (Z.S.), The Pennsylvania State University, Hershey; School of Law (R.J.B.), University of Virginia, Charlottesville; and Department of Neurology (J.A.R.), Lahey Medical Center, Burlington, MA
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Shepard V, Chou LN, Kuo YF, Raji M. Characteristics Associated with Feeding Tube Placement: Retrospective Cohort Study of Texas Nursing Home Residents with Advanced Dementia. J Am Med Dir Assoc 2021; 22:1471-1476.e4. [PMID: 33238144 PMCID: PMC10928907 DOI: 10.1016/j.jamda.2020.10.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To investigate resident-level, provider-type, nursing home (NH), and regional factors associated with feeding tube (FT) placement in advanced dementia. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS NH residents in Texas with dementia diagnosis and severe cognitive impairment (N = 20,582). METHODS This study used 2011-2016 Texas Medicare data to identify NH residents with a stay of at least 120 days who had a diagnosis of dementia on Long Term Care Minimum Data Set (MDS) evaluation and severe cognitive impairment on clinical score. Multivariable repeated measures analyses were conducted to identify associations between FT placement and resident-level, provider-type, NH, and regional factors. RESULTS The prevalence of FT placement in advanced dementia in Texas between 2011 and 2016 ranged from 12.5% to 16.1% with a nonlinear trend. At the resident level, the prevalence of FT decreased with age [age > 85 years, prevalence ratio (PR) 0.60, 95% confidence interval (CI) 0.52-0.69] and increased among residents who are black (2.74, 95% CI 2.48-3.03) or Hispanic (PR 1.91, 95% CI 1.71-2.13). Residents cared for by a nurse practitioner or physician assistant were less likely to have an FT (PR 0.90, 95% CI 0.85-0.96). No facility characteristics were associated with prevalence of FT placement in advanced dementia. There were regional differences in FT placement with the highest use areas on the Texas-Mexico border and in South and East Texas (Harlingen border area, PR 4.26, 95% CI 3.69-4.86; San Antonio border area, PR 3.93, 95% CI 3.04-4.93; Houston, PR 2.17, 95% CI 1.87-2.50), and in metro areas (PR 1.36, 95% CI 1.22-1.50). CONCLUSIONS AND IMPLICATIONS Regional, race, and ethnic variations in prevalence of FT use among NH residents suggest opportunities for clinicians and policy makers to improve the quality of end-of-life care by especially considering other palliative care measures for minorities living in border towns.
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Affiliation(s)
- Victoria Shepard
- Department of Population Health, University of Texas Dell Medical School, Austin, TX, USA
| | - Lin-Na Chou
- University of Texas Medical Branch, Office of Biostatistics, Galveston, TX, USA
| | - Yong-Fang Kuo
- University of Texas Medical Branch, Office of Biostatistics, Galveston, TX, USA; Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA; University of Texas Medical Branch Division of Geriatrics and Palliative Care; Galveston, Texas, USA
| | - Mukaila Raji
- University of Texas Medical Branch Division of Geriatrics and Palliative Care; Galveston, Texas, USA.
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Jaul E, Meiron O. Advanced Dementia: Brain-State Characteristics and Clinical Indicators of Early Mortality. J Alzheimers Dis 2021; 81:933-941. [PMID: 33843676 DOI: 10.3233/jad-201563] [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: 11/15/2022]
Abstract
There is an urgent need in advanced dementia for evidence-based clinical prognostic predictors that could positively influence ethical decisions allowing health provider and family preparation for early mortality. Accordingly, the authors review and discuss the prognostic utility of clinical assessments and objective measures of pathological brain states in advanced dementia patients associated with accelerated mortality. Overall, due to the paucity of brain-activity and clinical-comorbidity predictors of survival in advanced dementia, authors outline the potential prognostic value of brain-state electroencephalography (EEG) measures and reliable clinical indicators for forecasting early mortality in advanced dementia patients. In conclusion, two consistent risk-factors for predicting accelerated mortality in terminal-stage patients with advanced dementia were identified: pressure ulcers and paroxysmal slow-wave EEG parameters associated with cognitive impairment severity and organic disease progression. In parallel, immobility, malnutrition, and co-morbid systemic diseases are highly associated with the risk for early mortality in advanced dementia patients. Importantly, the authors' conclusions suggest utilizing reliable quantitative-parameters of disease progression for estimating accelerated mortality in dementia patients entering the terminal disease-stages characterized by severe intellectual deficits and functional disability.
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Affiliation(s)
- Efraim Jaul
- Geriatric Skilled Nursing Department, Herzog Medical Center, Hebrew University, Jerusalem, Israel
| | - Oded Meiron
- Clinical Research Center for Brain Sciences, Herzog Medical Center, Jerusalem, Israel
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Nakanishi A, Cuthbertson L, Chase J. Advance Requests for Medical Assistance in Dying in Dementia: a Survey Study of Dementia Care Specialists. Can Geriatr J 2021; 24:82-95. [PMID: 34079602 PMCID: PMC8137455 DOI: 10.5770/cgj.24.496] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Current Canadian Medical Assistance in Dying (MAiD) legislation requires individuals to have the mental capacity to consent at the time of the procedure. Advance requests for MAiD (ARs for MAiD) could allow individuals to document conditions where MAiD would be desired in the setting of progressive dementia. Methods Greater Vancouver area dementia care clinicians from family practice, geriatric medicine, geriatric psychiatry, and palliative care were approached to participate in an online survey to assess attitudes around the appropriateness of ARs for MAiD. Quantitative analysis of survey questions and qualitative analysis of open-ended response questions were performed. Results Of 630 clinicians approached, 80 were included in the data analysis. 64% of respondents supported legislation allowing ARs for MAiD in dementia. 96% of respondents articulated barriers and concerns, including determination of capacity, protecting the interests of the future individual, navigating conflict among stakeholders, and identifying coercion. 78% of respondents agreed with a mandatory capacity assessment to create an AR, and 59% agreed that consensus between clinicians and substitute decision-makers was required to enact an AR. Conclusion The majority of Vancouver dementia care clinicians participating in this study support legislation allowing ARs for MAiD in dementia, while also articulating ethical and logistical concerns with its application.
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Affiliation(s)
- Allison Nakanishi
- Geriatric Medicine, Vancouver Island Health Authority, Victoria, BC.,Division of Geriatric Medicine, University of British Columbia, Vancouver, BC
| | - Lauren Cuthbertson
- Division of Geriatric Medicine, University of British Columbia, Vancouver, BC
| | - Jocelyn Chase
- Division of Geriatric Medicine, University of British Columbia, Vancouver, BC.,Geriatric Medicine, Providence Health Care, Vancouver, BC
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Armstrong MJ, Paulson HL, Maixner SM, Fields JA, Lunde AM, Boeve BF, Manning C, Galvin JE, Taylor AS, Li Z. Protocol for an observational cohort study identifying factors predicting accurately end of life in dementia with Lewy bodies and promoting quality end-of-life experiences: the PACE-DLB study. BMJ Open 2021; 11:e047554. [PMID: 34039578 PMCID: PMC8160156 DOI: 10.1136/bmjopen-2020-047554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Dementia with Lewy bodies (DLB) is one of the most common degenerative dementias. Despite the fact that most individuals with DLB die from complications of the disease, little is known regarding what factors predict impending end of life or are associated with a quality end of life. METHODS AND ANALYSIS This is a multisite longitudinal cohort study. Participants are being recruited from five academic centres providing subspecialty DLB care and volunteers through the Lewy Body Dementia Association (not receiving specialty care). Dyads must be US residents, include individuals with a clinical diagnosis of DLB and at least moderate-to-severe dementia and include the primary caregiver, who must pass a brief cognitive screen. The first dyad was enrolled 25 February 2021; recruitment is ongoing. Dyads will attend study visits every 6 months through the end of life or 3 years. Study visits will occur in-person or virtually. Measures include demographics, DLB characteristics, caregiver considerations, quality of life and satisfaction with end-of-life experiences. For dyads where the individual with DLB dies, the caregiver will complete a final study visit 3 months after the death to assess grief, recovery and quality of the end-of-life experience. Terminal trend models will be employed to identify significant predictors of approaching end of life (death in the next 6 months). Similar models will assess caregiver factors (eg, grief, satisfaction with end-of-life experience) after the death of the individual with DLB. A qualitative descriptive analysis approach will evaluate interview transcripts regarding end-of-life experiences. ETHICS AND DISSEMINATION This study was approved by the University of Florida institutional review board (IRB202001438) and is listed on clinicaltrials.gov (NCT04829656). Data sharing follows National Institutes of Health policies. Study results will be disseminated via traditional scientific strategies (conferences, publications) and through collaborating with the Lewy Body Dementia Association, National Institute on Aging and other partnerships.
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Affiliation(s)
- Melissa J Armstrong
- Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Susan M Maixner
- Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Julie A Fields
- Psychiatry and Psychology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Angela M Lunde
- Psychiatry and Psychology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | | | - Carol Manning
- Neurology, University of Virginia, Charlottesville, Virginia, USA
| | - James E Galvin
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Zhigang Li
- Biostatistics, University of Florida College of Medicine, Gainesville, Florida, USA
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Supiano KP, Andersen T, Luptak M, Beynon C, Iacob E, Levitt SE. Pre-loss group therapy for dementia family care partners at risk for complicated grief. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2021; 7:e12167. [PMID: 34027022 PMCID: PMC8116857 DOI: 10.1002/trc2.12167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 03/07/2021] [Accepted: 03/14/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Dementia family caregiving may span more than a decade and places many family care partners (CPs) at risk for poor bereavement outcomes; estimates of complicated grief in bereaved dementia family CPs range from 10% to 20%. We adapted our efficacious complicated grief group therapy intervention for bereaved dementia caregivers for soon-to-be bereaved dementia CPs at risk for complicated grief to facilitate healthy death preparedness and eventual bereavement-pre-loss group therapy (PLGT). METHODS In this Stage IB pilot intervention study, we implemented and evaluated PLGT in three psychotherapy group cohorts with family CPs at-risk for complicated grief whose person living with dementia (PLWD) had a life expectancy of 6 months or less and resided in a nursing home. PLGT is a 10-session multi-modal psychotherapy administered by social workers. RESULTS Participants in PLGT realized significant improvement in their pre-loss grief and in reported preparedness for the death of their family member, and participants evidenced lowered pre-loss grief severity and improvement, as measured by facilitators. Participants also realized significant improvement in meaning making, particularly as a sense of peace and a reduction of loneliness. DISCUSSION The process and treatment elements of the PLGT intervention affirm the value of specialized care for those dementia family CPs at risk for complicated grief, as the PLGT groups demonstrated a steady progression toward improvement collectively and individually. PLGT participants realized statistical and clinical improvement across pre-loss grief measures suggesting that their risk for complicated grief risk was mitigated, and they were better prepared for the death of their PLWD.
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Affiliation(s)
| | - Troy Andersen
- University of Utah College of Social WorkSalt Lake CityUSA
| | - Marilyn Luptak
- University of Utah College of Social WorkSalt Lake CityUSA
| | | | - Eli Iacob
- University of Utah College of NursingSalt Lake CityUSA
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Miranda R, Smets T, Van Den Noortgate N, van der Steen JT, Deliens L, Payne S, Szczerbińska K, Pautex S, Van Humbeeck L, Gambassi G, Kylänen M, Van den Block L. No difference in effects of 'PACE steps to success' palliative care program for nursing home residents with and without dementia: a pre-planned subgroup analysis of the seven-country PACE trial. BMC Palliat Care 2021; 20:39. [PMID: 33678179 PMCID: PMC7937240 DOI: 10.1186/s12904-021-00734-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background ‘PACE Steps to Success’ is a multicomponent training program aiming to integrate generalist and non-disease-specific palliative care in nursing homes. This program did not improve residents’ comfort in the last week of life, but it appeared to improve quality of care and dying in their last month of life. Because this program included only three dementia-specific elements, its effects might differ depending on the presence or stage of dementia. We aimed to investigate whether the program effects differ between residents with advanced, non-advanced, and no dementia. Methods Pre-planned subgroup analysis of the PACE cluster-randomized controlled trial in 78 nursing homes in seven European countries. Participants included residents who died in the previous 4 months. The nursing home staff or general practitioner assessed the presence of dementia; severity was determined using two highly-discriminatory staff-reported instruments. Using after-death questionnaires, staff assessed comfort in the last week of life (Comfort Assessment in Dying–End-of-Life in Dementia-scale; primary outcome) and quality of care and dying in the last month of life (Quality of Dying in Long-Term Care scale; secondary outcome). Results At baseline, we included 177 residents with advanced dementia, 126 with non-advanced dementia and 156 without dementia. Post-intervention, respectively in the control and the intervention group, we included 136 and 104 residents with advanced dementia, 167 and 110 with non-advanced dementia and 157 and 137 without dementia. We found no subgroup differences on comfort in the last week of life, comparing advanced versus without dementia (baseline-adjusted mean sub-group difference 2.1; p-value = 0.177), non-advanced versus without dementia (2.7; p = 0.092), and advanced versus non-advanced dementia (− 0.6; p = 0.698); or on quality of care and dying in the last month of life, comparing advanced and without dementia (− 0.6; p = 0.741), non-advanced and without dementia (− 1.5; p = 0.428), and advanced and non-advanced dementia (0.9; p = 0.632). Conclusions The lack of subgroup difference suggests that while the program did not improve comfort in dying residents with or without dementia, it appeared to equally improve quality of care and dying in the last month of life for residents with dementia (regardless of the stage) and those without dementia. A generalist and non-disease-specific palliative care program, such as PACE Steps to Success, is a useful starting point for future palliative care improvement in nursing homes, but to effectively improve residents’ comfort, this program needs further development. Trial registration ISRCTN, ISRCTN14741671. Registered 8 July 2015 – Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00734-1.
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Affiliation(s)
- Rose Miranda
- Vrije Universiteit Brussel & Ghent University, End-of-Life Care Research Group, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.
| | - Tinne Smets
- Vrije Universiteit Brussel & Ghent University, End-of-Life Care Research Group, Laarbeeklaan 103, 1090, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium
| | | | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC-VU University Medical Center, Amsterdam, The Netherlands
| | - Luc Deliens
- Vrije Universiteit Brussel & Ghent University, End-of-Life Care Research Group, Laarbeeklaan 103, 1090, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, UK
| | - Katarzyna Szczerbińska
- Laboratory for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Sophie Pautex
- Hôpitaux Universitaires de Genève, University of Geneva, Geneva, Switzerland
| | | | - Giovanni Gambassi
- Department of Internal Medicine, Istituto di Medicina Interna e Geriatria, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marika Kylänen
- National Institute for Health and Welfare, Helsinki, Finland
| | - Lieve Van den Block
- Vrije Universiteit Brussel & Ghent University, End-of-Life Care Research Group, Laarbeeklaan 103, 1090, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium
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Miranda R, Smets T, Van Den Noortgate N, Deliens L, Van den Block L. Higher Prevalence of Dementia but No Change in Total Comfort While Dying among Nursing Home Residents with Dementia between 2010 and 2015: Results from Two Retrospective Epidemiological Studies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18042160. [PMID: 33672123 PMCID: PMC7926426 DOI: 10.3390/ijerph18042160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/12/2021] [Accepted: 02/18/2021] [Indexed: 11/16/2022]
Abstract
Important policy developments in dementia and palliative care in nursing homes between 2010 and 2015 in Flanders, Belgium might have influenced which people die in nursing homes and how they die. We aimed to examine differences between 2010 and 2015 in the prevalence and characteristics of residents with dementia in nursing homes in Flanders, and their palliative care service use and comfort in the last week of life. We used two retrospective epidemiological studies, including 198 residents in 2010 and 183 in 2015, who died with dementia in representative samples of nursing homes in Flanders. We found a 15%-point increase in dementia prevalence (p-value < 0.01), with a total of 11%-point decrease in severe to very severe cognitive impairment (p = 0.04). Controlling for residents’ characteristics, in the last week of life, there was an increase in the use of pain assessment (+20%-point; p < 0.03) but no change in total comfort. The higher prevalence of dementia in nursing homes with no change in residents’ total comfort while dying emphasizes an urgent need to better support nursing homes in improving their capacities to provide timely and high-quality palliative care services to more residents dying with dementia.
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Affiliation(s)
- Rose Miranda
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, 1090 Brussels, Belgium; (T.S.); (L.D.); (L.V.d.B.)
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium
- Correspondence:
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, 1090 Brussels, Belgium; (T.S.); (L.D.); (L.V.d.B.)
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium
| | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, 1090 Brussels, Belgium; (T.S.); (L.D.); (L.V.d.B.)
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University Hospital, 9000 Ghent, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, 1090 Brussels, Belgium; (T.S.); (L.D.); (L.V.d.B.)
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium
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Boniolo G. Demented patients and the quandaries of identity: setting the problem, advancing a proposal. HISTORY AND PHILOSOPHY OF THE LIFE SCIENCES 2021; 43:21. [PMID: 33587205 PMCID: PMC7884352 DOI: 10.1007/s40656-021-00365-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 01/01/2021] [Indexed: 05/19/2023]
Abstract
In the paper, after clarifying terms such as 'identity', 'self' and 'personhood', I propose an empirical account of identity based on the notion of "whole phenotype". This move allows one to claim the persistence of the individuals before and after their being affected by dementia. Furthermore, I show how this account permits us to address significant questions related to demented individuals' loss of the capacity of moral decisions.
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Affiliation(s)
- Giovanni Boniolo
- Dipartimento di Neuroscienze e Riabilitazione, University of Ferrara, Ferrara, Italy.
- Civitas Vitae Research Centre at Fondazione OIC onlus, Padova, Italy.
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Sullivan DR, Kim H, Gozalo PL, Bunker J, Teno JM. Trends in Noninvasive and Invasive Mechanical Ventilation Among Medicare Beneficiaries at the End of Life. JAMA Intern Med 2021; 181:93-102. [PMID: 33074320 PMCID: PMC7573799 DOI: 10.1001/jamainternmed.2020.5640] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 07/29/2020] [Indexed: 01/06/2023]
Abstract
Importance End-of-life care is costly, and decedents often experience overtreatment or low-quality care. Noninvasive ventilation (NIV) may be a palliative approach to avoid invasive mechanical ventilation (IMV) among select patients who are hospitalized at the end of life. Objective To examine the trends in NIV and IMV use among decedents with a hospitalization in the last 30 days of life. Design, Setting, and Participants This population-based cohort study used a 20% random sample of Medicare fee-for-service beneficiaries who had an acute care hospitalization in the last 30 days of life and died between January 1, 2000, and December 31, 2017. Sociodemographic, diagnosis, and comorbidity data were obtained from Medicare claims data. Data analysis was performed from September 2019 to July 2020. Exposures Use of NIV or IMV. Main Outcomes and Measures Validated International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification procedure codes were reviewed to identify use of NIV, IMV, both NIV and IMV, or none. Four subcohorts of Medicare beneficiaries were identified using primary admitting diagnosis codes (chronic obstructive pulmonary disease [COPD], congested heart failure [CHF], cancer, and dementia). Measures of end-of-life care included in-hospital death (acute care setting), hospice enrollment at death, and hospice enrollment in the last 3 days of life. Random-effects logistic regression examined NIV and IMV use adjusted for sociodemographic characteristics, admitting diagnosis, and comorbidities. Results A total of 2 470 435 Medicare beneficiaries (1 353 798 women [54.8%]; mean [SD] age, 82.2 [8.2] years) were hospitalized within 30 days of death. Compared with 2000, the adjusted odds ratio (AOR) for the increase in NIV use was 2.63 (95% CI, 2.46-2.82; % receipt: 0.8% vs 2.0%) for 2005 and 11.84 (95% CI, 11.11-12.61; % receipt: 0.8% vs 7.1%) for 2017. Compared with 2000, the AOR for the increase in IMV use was 1.04 (95% CI, 1.02-1.06; % receipt: 15.0% vs 15.2%) for 2005 and 1.63 (95% CI, 1.59-1.66; % receipt: 15.0% vs 18.2%) for 2017. In subanalyses comparing 2017 with 2000, similar trends found increased NIV among patients with CHF (% receipt: 1.4% vs 14.2%; AOR, 14.14 [95% CI, 11.77-16.98]) and COPD (% receipt: 2.7% vs 14.5%; AOR, 8.22 [95% CI, 6.42-10.52]), with reciprocal stabilization in IMV use among patients with CHF (% receipt: 11.1% vs 7.8%; AOR, 1.07 [95% CI, 0.95-1.19]) and COPD (% receipt: 17.4% vs 13.2%; AOR, 1.03 [95% CI, 0.88-1.21]). The AOR for increased NIV use was 10.82 (95% CI, 8.16-14.34; % receipt: 0.4% vs 3.5%) among decedents with cancer and 9.62 (95% CI, 7.61-12.15; % receipt: 0.6% vs 5.2%) among decedents with dementia. The AOR for increased IMV use was 1.40 (95% CI, 1.26-1.55; % receipt: 6.2% vs 7.6%) among decedents with cancer and 1.28 (95% CI, 1.17-1.41; % receipt: 5.7% vs 6.2%) among decedents with dementia. Among decedents with NIV vs IMV use, lower rates of in-hospital death (50.3% [95% CI, 49.3%-51.3%] vs 76.7% [95% CI, 75.9%-77.5%]) and hospice enrollment in the last 3 days of life (57.7% [95% CI, 56.2%-59.3%] vs 63.0% [95% CI, 60.9%-65.1%]) were observed along with higher rates of hospice enrollment (41.3% [95% CI, 40.4%-42.3%] vs 20.0% [95% CI, 19.2%-20.7%]). Conclusions and Relevance This study found that the use of NIV rapidly increased from 2000 through 2017 among Medicare beneficiaries at the end of life, especially among persons with cancer and dementia. The findings suggest that trials to evaluate the outcomes of NIV are warranted to inform discussions about the goals of this therapy between clinicians and patients and their health care proxies.
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Affiliation(s)
- Donald R. Sullivan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, Oregon
| | - Hyosin Kim
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland
| | - Pedro L. Gozalo
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Jennifer Bunker
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland
| | - Joan M. Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland
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49
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Yous ML, Ploeg J, Kaasalainen S, McAiney C. Namaste care delivered by caregivers of community-dwelling older adults with moderate to advanced dementia: A mixed methods study protocol. J Adv Nurs 2020; 77:1027-1036. [PMID: 33222232 DOI: 10.1111/jan.14623] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/15/2020] [Indexed: 12/13/2022]
Abstract
AIM The aim of this study is to adapt and evaluate the feasibility, acceptability, and preliminary effectiveness of a multisensory, psychosocial intervention called Namaste Care delivered by family and friend caregivers of community-dwelling older adults with moderate to advanced dementia. DESIGN A multiphase mixed methods design combining quantitative and qualitative methods will be used. METHODS This study is composed of two phases. Phase 1 is guided by a qualitative description approach. Small group workshop sessions with 8-10 caregivers of community-dwelling older adults with moderate to advanced dementia will be conducted to adapt Namaste Care. In Phase 2, 10-20 caregivers will receive training and implement the adapted Namaste Care approach at home. A one group, before-after design will be used to evaluate feasibility, acceptability and preliminary effectiveness of the approach over 3 months. Feasibility will be assessed using quantitative measures and acceptability will be explored using qualitative methods. Outcomes to evaluate preliminary effectiveness include quality of life (QoL), positive perceptions of caregiving, self-efficacy, and caregiver burden. DISCUSSION There are currently few skill-building interventions that can be delivered by caregivers of people with moderate to advanced dementia at home. Caregivers should be involved in developing programs to enhance program relevance. This research will be the first to explore the feasibility of implementing the Namaste Care approach at home by caregivers. IMPACT Study results will provide important information about the feasibility and preliminary effects of an adapted form of Namaste Care. This program has the potential to improve the QoL of caregivers and may prevent hospitalization or long-term care placement of older persons with moderate to advanced dementia. The revised Namaste Care program supports building the skills of caregivers so that their needs and the needs of older persons with dementia living at home are being addressed.
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Affiliation(s)
- Marie-Lee Yous
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Jenny Ploeg
- School of Nursing, Aging, Community and Health Research Unit, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Department of Health, Aging and Society, McMaster University, Hamilton, ON, Canada
| | | | - Carrie McAiney
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
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50
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Ansari AA, Pomerantz DH, Abedini N, Jayes RL, Matti-Orozco B, Havyer RD. Clinical Progress Note: Addressing Prognosis in Advanced Dementia. J Hosp Med 2020; 15:678-680. [PMID: 31634101 DOI: 10.12788/jhm.3316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 08/23/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Aziz A Ansari
- Division of Hospital Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Daniel H Pomerantz
- Division of General Internal Medicine and Department of Family Medicine (Palliative Care), Albert Einstein College of Medicine, Bronx, New York
- Department of Medicine, Montefiore New Rochelle Hospital, New Rochelle, New York
| | - Nauzley Abedini
- Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan
- National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan
| | - Robert L Jayes
- Division of Geriatrics and Palliative Medicine, George Washington University Medical Faculty Associates, Washington, DC
| | - Brenda Matti-Orozco
- Division of General Internal Medicine & Palliative Medicine, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Rachel D Havyer
- Division of Community Internal Medicine and Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota
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