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Allred D. Management of Medical Complications during the Rehabilitation of Moderate-Severe Traumatic Brain Injury. Phys Med Rehabil Clin N Am 2024; 35:507-521. [PMID: 38945647 DOI: 10.1016/j.pmr.2024.02.004] [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] [Indexed: 07/02/2024]
Abstract
According to the Centers for Disease Control, in 2019, there were approximately 223,135 hospitalizations in the United States related to traumatic brain injury (TBI). If not managed properly, these patients can suffer complications with significant negative implications with respect to morbidity, mortality, and long-term functional prognosis. It is imperative that medical providers who care for patients with TBI across the entire spectrum of care readily diagnose and treat the sequela associated with moderate-severe brain trauma. This article will focus on some of the key medical issues that providers may encounter during acute inpatient rehabilitation.
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Affiliation(s)
- Derrick Allred
- Department of Physical Medicine & Rehabilitation, University of Utah Health, 85 N Medical Drive, Salt Lake City, UT 84132, USA.
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Öner Ö, Hanci V, Gürkok MÇ, Ergan B, Yaka E, Gökmen AN. The effect of amantadine treatment on neurological outcome and mortality in mechanically ventilated severe head trauma patients in intensive care unit. Medicine (Baltimore) 2024; 103:e38172. [PMID: 38758901 PMCID: PMC11098193 DOI: 10.1097/md.0000000000038172] [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: 04/19/2023] [Accepted: 04/17/2024] [Indexed: 05/19/2024] Open
Abstract
This study aims to investigate the effect of amantadine use on neurological outcomes and mortality in patients with severe traumatic brain injury (TBI) (Glasgow coma score [GCS] between 3 and 8) who have been followed up on mechanical ventilators in the intensive care unit (ICU). Data from the hospital's electronic records were retrospectively searched. Patients over 18 years of age, with severe brain trauma (GCS between 3-8), who were treated with endotracheal intubation and invasive mechanical ventilation at admission to the ICU, and who were treated with Amantadine hydrochloride at least once in the first week of follow-up were included in the study. To evaluate the patients' neurological outcomes, the GCS and FOUR scores were used. GCS and FOUR scores were recorded on the 1st, 3rd, and 7th days of the first week. In addition, the score difference between the 1st and 7th day was calculated for both scores. The patients were divided into 2 groups: those receiving amantadine treatment (Group A, n = 44) and the control group (Group C, n = 47). The median age of all patients was 39 (18-81) (P = .425). When Group A and Group C were compared, no statistically significant results were found between the 1st, 3rd, and 7th day GCS values (P = .474, P = .483, and P = 329, respectively). However, the difference in GCS values between day 1 and day 7 (∆ GCS 7-1) was statistically significant (P = .012). Similarly, when Group A and Group C were compared, no statistically significant results were found between the 1st, 3rd, and 7th day FOUR score values (P = .948, P = .471, and P = .057, respectively). However, the FOUR score values between day 1 and day 7 (∆ FOUR score 7-1) were statistically significant (P = .004). There was no statistically significant difference among the groups in terms of ICU length of stay, duration of non-ICU hospital stay, and length of hospital stay (P = .222, P = .175, and P = .067, respectively). Amantadine hydrochloride may help improve neurological outcomes in patients with severe TBI. However, further research is needed to investigate this topic.
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Affiliation(s)
- Özlem Öner
- Anesthesiologist and Intensivist Neuroscience, Dokuz Eylül University Faculty of Medicine Department of Anesthesiology and Reanimation, Subdivision of Critical Care Medicine, İzmir, Turkey
| | - Volkan Hanci
- Anesthesiologist and Intensivist, Dokuz Eylül University Faculty of Medicine Department of Anesthesiology and Reanimation, Subdivision of Critical Care Medicine, İzmir, Turkey
| | - Mehmet Çağatay Gürkok
- General Surgery Specialist and Intensivist, Dokuz Eylül University Faculty of Medicine Department of General Surgery, Subdivision of Critical Care Medicine, İzmir, Turkey
| | - Begüm Ergan
- Pulmonologist and Intensivist, Dokuz Eylül University Faculty of Medicine Department of Pulmonary, Subdivision of Critical Care Medicine, İzmir, Turkey
| | - Erdem Yaka
- Neurologist Professor, Dokuz Eylül University Faculty of Medicine, Department of Neurology, Subdivision of Critical Care Medicine, İzmir, Turkey
| | - Ali Necati Gökmen
- Anaesthesiologist and Intensivist Professor, Dokuz Eylül University Faculty of Medicine, Department of Anesthesiology and Reanimation Subdivision of Critical Care Medicine, İzmir, Turkey
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Pszczołowska M, Walczak K, Miśków W, Antosz K, Batko J, Kurpas D, Leszek J. Chronic Traumatic Encephalopathy as the Course of Alzheimer's Disease. Int J Mol Sci 2024; 25:4639. [PMID: 38731858 PMCID: PMC11083609 DOI: 10.3390/ijms25094639] [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: 03/19/2024] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
This editorial investigates chronic traumatic encephalopathy (CTE) as a course of Alzheimer's disease (AD). CTE is a debilitating neurodegenerative disease that is the result of repeated mild traumatic brain injury (TBI). Many epidemiological studies show that experiencing a TBI in early or middle life is associated with an increased risk of dementia later in life. Chronic traumatic encephalopathy (CTE) and Alzheimer's disease (AD) present a series of similar neuropathological features that were investigated in this work like recombinant tau into filaments or the accumulation and aggregation of Aβ protein. However, these two conditions differ from each other in brain-blood barrier damage. The purpose of this review was to evaluate information about CTE and AD from various articles, focusing especially on new therapeutic possibilities for the improvement in cognitive skills.
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Affiliation(s)
- Magdalena Pszczołowska
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland; (M.P.)
| | - Kamil Walczak
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland; (M.P.)
| | - Weronika Miśków
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland; (M.P.)
| | - Katarzyna Antosz
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland; (M.P.)
| | - Joanna Batko
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland; (M.P.)
| | - Donata Kurpas
- Faculty of Health Sciences, Wroclaw Medical University, Ul. Kazimierza Bartla 5, 51-618 Wrocław, Poland
| | - Jerzy Leszek
- Clinic of Psychiatry, Department of Psychiatry, Wroclaw Medical University, Ludwika Pasteura 10, 50-367 Wrocław, Poland
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Cataford G, Monton LA, Karzon S, Livernoche-Leduc C, Saavedra-Mitjans M, Potvin MJ, Bernard F, Burry L, Arbour C, Williamson DR. Cognitive and Motor Function Effects of Antipsychotics in Traumatic Brain Injury: A Systematic Review of Pre-Clinical Studies. Neurotrauma Rep 2024; 5:181-193. [PMID: 38463417 PMCID: PMC10924062 DOI: 10.1089/neur.2023.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
Traumatic brain injury (TBI) survivors often suffer from agitated behaviors and will most likely receive pharmacological treatments. Choosing an optimal and safe treatment that will not interfere with neurological recovery remains controversial. By interfering with dopaminergic circuits, antipsychotics may impede processes important to cognitive recovery. Despite their frequent use, there have been no large randomized controlled studies of antipsychotics for the management of agitated behaviors during the acute TBI recovery period. We conducted a systematic review and meta-analysis of pre-clinical studies evaluating the effects of antipsychotics post-TBI on both cognitive and motor recovery. MEDLINE and Embase databases were searched up to August 2, 2023. Pre-clinical studies evaluating the effects of antipsychotics on cognitive and motor functions post-TBI were considered. Risk of bias was evaluated with the Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE) tool. We identified 15 studies including a total of 1188 rodents, mostly conducted in male Sprague-Dawley rats using cortical impact injury. The analysis revealed no consistent effect of haloperidol on motor functions, but risperidone was associated with a significant impairment in motor function on day 5 post-injury (7.05 sec; 95% confidence interval [CI]: 1.47, 12.62; I2 = 92%). Other atypical antipsychotics did not result in impaired motor function. When evaluating cognitive function, haloperidol- (23.00 sec; 95% CI: 17.42-28.59; I2 = 7%) and risperidone-treated rats (24.27 sec; 95% CI: 16.18-32.36; I2 = 0%) were consistently impaired when compared to controls. In studies evaluating atypical antipsychotics, no impairments were observed. Clinicians should avoid the regular use of haloperidol and risperidone, and future human studies should be conducted with atypical antipsychotics.
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Affiliation(s)
| | | | - Stephanie Karzon
- Faculté de Médecine, Université de Montréal, Montreal, Quebec, Canada
| | - Camille Livernoche-Leduc
- Départment de psychologie, Université du Québec à Montréal, Montreal, Quebec, Canada
- Research center, CIUSSS-Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal. Montreal, Quebec, Canada
| | - Mar Saavedra-Mitjans
- Faculté de pharmacie, Université de Montréal, Montreal, Quebec, Canada
- Research center, CIUSSS-Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal. Montreal, Quebec, Canada
| | - Marie-Julie Potvin
- Départment de psychologie, Université du Québec à Montréal, Montreal, Quebec, Canada
- Research center, CIUSSS-Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal. Montreal, Quebec, Canada
| | - Francis Bernard
- Faculté de Médecine, Université de Montréal, Montreal, Quebec, Canada
- Research center, CIUSSS-Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal. Montreal, Quebec, Canada
| | - Lisa Burry
- Pharmacy Department, Mount Sinai Hospital. Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Caroline Arbour
- Research center, CIUSSS-Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal. Montreal, Quebec, Canada
- Faculté de sciences infirmières, Université de Montréal, Montreal, Quebec, Canada
| | - David R Williamson
- Faculté de pharmacie, Université de Montréal, Montreal, Quebec, Canada
- Research center, CIUSSS-Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal. Montreal, Quebec, Canada
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Zhu Y, Zheng P, Lin Y, Wang J, You W, Wang Y, Zheng H, Wen L, Yang X. The alteration of serum bile acid profile among traumatic brain injury patients: a small-scale prospective study. J Clin Biochem Nutr 2023; 73:97-102. [PMID: 37534094 PMCID: PMC10390815 DOI: 10.3164/jcbn.23-10] [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: 02/10/2023] [Accepted: 04/03/2023] [Indexed: 08/04/2023] Open
Abstract
Traumatic brain injury is one of the major causes of morbidity and mortality worldwide. With the development of bile acids as a potential treatment, to identify the influence of traumatic brain injury on bile acid metabolism shows growing importance. This present study did a preliminary exploration of the bile acid profile alteration among traumatic brain injury patients. In total, 14 patients and 7 healthy volunteers were enrolled. The bile acid profile of the blood samples were detected by an Ultra-performance Liquid Chromatography Mass Spectrometer/Mass Spectrometer system. It was found that 6 bile acids were statistically decreased in traumatic brain injury patients comparing with healthy volunteers: glycocholic acid (median level 44.4 ng/ml vs 98.7 ng/ml, p = 0.003), taurocholic acid (median level 10.9 ng/ml vs 19.5 ng/ml, p = 0.006), glycoursodeoxycholic acid (median level 17.4 ng/ml vs 71.4 ng/ml, p = 0.001), ursodeoxycholic acid (median level <1 ng/ml vs 32.4 ng/ml, p = 0.002), taurochenodeoxycholic acid (median level <1 ng/ml vs 53.6 ng/ml, p = 0.003) and glycochenodeoxycholic acid (GCDCA, median level 160 ng/ml vs 364 ng/ml, p<0.001). In conclusion, traumatic brain injury events are able to induce bile acid metabolism alteration in plasma and might cause reduction in glycocholic, taurocholic, glycoursodeoxycholic, ursodeoxycholic, taurochenodeoxycholic and glycochenodeoxycholic acid levels.
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Affiliation(s)
- Yuanrun Zhu
- The First Affiliated Hospital, School of Medicine, Zhejiang University, 1367 West Wenyi Rd., Hangzhou, Zhejiang Province 310003, China
| | - Peidong Zheng
- Zhejiang University School of Medicine, 866 Yuhangtang Rd., Hangzhou, Zhejiang Province 310003, China
| | - Yajun Lin
- Zhejiang University School of Medicine, 866 Yuhangtang Rd., Hangzhou, Zhejiang Province 310003, China
| | - Juehan Wang
- Zhejiang University School of Medicine, 866 Yuhangtang Rd., Hangzhou, Zhejiang Province 310003, China
| | - Wendong You
- Zhejiang University School of Medicine, 866 Yuhangtang Rd., Hangzhou, Zhejiang Province 310003, China
- The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Rd., Fuzhou, Fujian Province 350000, China
| | - Yadong Wang
- The First Affiliated Hospital, School of Medicine, Zhejiang University, 1367 West Wenyi Rd., Hangzhou, Zhejiang Province 310003, China
| | - Huiqing Zheng
- Zhejiang University School of Medicine, 866 Yuhangtang Rd., Hangzhou, Zhejiang Province 310003, China
| | - Liang Wen
- The First Affiliated Hospital, School of Medicine, Zhejiang University, 1367 West Wenyi Rd., Hangzhou, Zhejiang Province 310003, China
| | - Xiaofeng Yang
- The First Affiliated Hospital, School of Medicine, Zhejiang University, 1367 West Wenyi Rd., Hangzhou, Zhejiang Province 310003, China
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Kalra ID, Watanabe TK. Enhancing management of agitation after traumatic brain injury: Psychiatric perspectives and quantitative assessments. NeuroRehabilitation 2023; 53:177-185. [PMID: 37694312 DOI: 10.3233/nre-230009] [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] [Indexed: 09/12/2023]
Abstract
BACKGROUND Post-traumatic agitation is a common and problematic complication after traumatic brain injury. It may present with features consistent with psychiatric disorders, which may provide clues as to management. OBJECTIVE This is a narrative review of pertinent literature and a description of a collaborative clinical approach utilizing psychiatric and brain injury rehabilitation strategies to optimize outcomes in the management of post-traumatic agitation. METHODS Describe and provide evidence for a transdisciplinary clinical approach supported by existing literature and clinical experience. RESULTS Given the heterogeneity of the problem and limitations in the current literature there is no standardized approach to manage post-traumatic agitation; nevertheless, a strategy is proposed that clinicians may utilize to guide treatment and assess efficacy of the chosen intervention(s). CONCLUSION A clinical approach that uses quantitative assessment of targeted behavior to objectively evaluate pharmacological interventions that are generated by a collaborative approach may yield improved outcomes for managing post-traumatic agitation.
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Affiliation(s)
- Inder D Kalra
- Department of Psychiatry, Einstein Healthcare Network, Elkins Park, PA, USA
| | - Thomas K Watanabe
- Department of Physical Medicine and Rehabilitation, MossRehab at Elkins Park, Einstein Healthcare Network, Elkins Park, PA, USA
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Muacevic A, Adler JR, Nielson JA. An Uncontrollable, Aggressive Patient at a Free-Standing Emergency Department. Cureus 2022; 14:e32742. [PMID: 36686138 PMCID: PMC9851284 DOI: 10.7759/cureus.32742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
We present the case of an aggressive male patient who was unable to be successfully sedated with conventional medications in the ED and ultimately required intubation to ensure the safety of the patient himself and the staff. After admission to the ICU, he was found to have atrophy of the frontal and bilateral lobes secondary to a traumatic brain injury (TBI) 19 years prior. Managing the patient required collaboration with the intensivist, hospitalist, and psychiatry and neurology teams for 10 months, and he was refused admission to multiple psychiatric facilities due to safety concerns because of his high level of aggression and unpredictability. An out-of-state, high-security facility eventually accepted the patient. The second challenge was finding a highly trained medical team willing to transport the patient. This case illustrates the difficulty and safety concerns with regard to managing an aggressive patient with previous TBI when the commonly used medications do not produce the desired effect. A literature search did not reveal a standard protocol or consensus on managing these types of patients in emergent situations.
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Rahmani E, Lemelle T, Sharp H, Smarbafzadeh E, Kablinger A. A descriptive analysis of pharmacological management of aggression and/or agitation in patients with traumatic brain injury in a Southwest Virginia inpatient population. J Clin Pharm Ther 2022; 47:2083-2090. [PMID: 36543254 PMCID: PMC10087613 DOI: 10.1111/jcpt.13754] [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: 01/17/2022] [Revised: 05/24/2022] [Accepted: 07/10/2022] [Indexed: 12/24/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Traumatic brain injury (TBI) is a major cause of disability, and it has been associated with agitation and aggression. In a previous study, we reviewed the literature to identify evidence-based pharmacological agents for treatment of agitation in TBI. Based on the results of our previous study that summarizes the findings of several systematic reviews, the use of haloperidol and benzodiazepines is not supported by the available evidence while the use of amantadine, beta blockers, antiepileptics and methylphenidate is supported by the limited available evidence. In this study, we describe the psycho-pharmacological agents that were administered to patients with agitation and/or aggression in the context of TBI in inpatient facilities of a private, non-profit health care system in southwest Virginia. We will also compare the psycho-pharmacological agents ordered before and after psychiatric consultation. METHODS Adult patients who were admitted to Carilion Clinic's inpatient facilities from March 30, 2013, to March 30, 2018, had a diagnosis of TBI, and received psychiatric consultation for agitation and/or aggression were enrolled in this study. A retrospective review of electronic medical records was conducted by researchers and data were collected on the following measures: ordered psycho-pharmacological agents, frequency, dosing and duration of orders, whether each administered psycho-pharmacological agent was started before or after psychiatric consultation, and psycho-pharmacological agents prescribed upon discharge. RESULTS AND DISCUSSION About 68% of patients were started on benzodiazepines and/or typical antipsychotics and 23% of patients were subsequently discharged on these medication categories. Only 23% of patients were ordered to receive medications supported by the evidence such as amantadine, beta blockers or antiepileptics. The percentage of patient-days with an order to receive typical antipsychotics significantly decreased following psychiatric consultation (p = 0.0056), but the percentage of patient-days with an order to receive benzodiazepines significantly increased following psychiatric consultation (p = 0.0001). This finding remained statistically significant after excluding patients with active or unclear alcohol/benzodiazepine withdrawal (p < 0.0001). WHAT IS NEW AND CONCLUSION This study demonstrates the widespread use of typical antipsychotics and benzodiazepines in the management of agitation in TBI and the importance of multidisciplinary collaboration, research and education of providers to improve patient care.
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Affiliation(s)
- Elham Rahmani
- Department of Psychiatry and Behavioral Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Tricia Lemelle
- Department of Psychiatry and Behavioral Medicine, Georgetown University Hospital, Washington, Washington, USA
| | - Hunter Sharp
- Department of Health Analytics, Carilion Clinic, Roanoke, Virginia, USA
| | - Ehsan Smarbafzadeh
- Department of Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Anita Kablinger
- Department of Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
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Rajkumar RP. Physician-Assisted Suicide in Dementia: Paradoxes, Pitfalls and the Need for Prudence. FRONTIERS IN SOCIOLOGY 2021; 6:815233. [PMID: 35004941 PMCID: PMC8727695 DOI: 10.3389/fsoc.2021.815233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/07/2021] [Indexed: 06/14/2023]
Abstract
There has been an increasing drive towards the legalization of physician-assisted suicide (PAS) in patients with dementia, particularly in patients with advanced disease and severe cognitive impairment. Advocacy for this position is often based on utilitarian philosophical principles, on appeals to the quality of life of the patient and their caregiver(s), or on economic constraints faced by caregivers as well as healthcare systems. In this paper, two lines of evidence against this position are presented. First, data on attitudes towards euthanasia for twenty-eight countries, obtained from the World Values Survey, is analyzed. An examination of this data shows that, paradoxically, positive attitudes towards this procedure are found in more economically advanced countries, and are strongly associated with specific cultural factors. Second, the literature on existing attitudes towards PAS in cases of dementia, along with ethical arguments for and against the practice, is reviewed and specific hazards for patients, caregivers and healthcare professionals are identified. On the basis of these findings, the author suggests that the practice of PAS in dementia is not one that can be widely or safely endorsed, on both cultural and ethical grounds. Instead, the medical field should work in collaboration with governmental, social welfare and patient advocacy services to ensure optimal physical, emotional and financial support to this group of patients and their caregivers.
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