Artificial hydration and nutrition in advanced Alzheimer's disease: facilitating family decision-making

Resources to Support Decision-Making Regarding End-of-Life Nutrition Care in Long-Term Care: A Scoping Review

Resources are needed to aid healthcare providers and families in making end-of-life nutrition care decisions for residents living in long-term care settings. This scoping review aimed to explore what is reported in the literature about resources to support decision-making at the end of life in long-term care. Four databases were searched for research published from 2003 to June 2023. Articles included peer-reviewed human studies published in the English language that reported resources to support decision-making about end-of-life nutrition in long-term care settings. In total, 15 articles were included. Thematic analysis of the articles generated five themes: conversations about care, evidence-based decision-making, a need for multidisciplinary perspectives, honouring residents' goals of care, and cultural considerations for adapting resources. Multidisciplinary care teams supporting residents and their families during the end of life can benefit from resources to support discussion and facilitate decision-making.

Caregivers' roles in preventing patients with severe Alzheimer's disease from becoming distracted during mealtimes: two case reports

[Purpose] The purpose of this study was to identify the roles of caregivers in preventing patients with severe Alzheimer’s disease with loss of language skills from becoming distracted while eating their meals. [Participants and Methods] The study was conducted on two residents of a nursing home with severe Alzheimer’s disease who had lost their language skills. In this study, by comparing the scenes in which the two participants were distracted and not distracted from eating, we analyzed the factors associated with patients with severe Alzheimer’s disease who had lost their language skills becoming distracted and factors that prevented them from becoming distracted from eating at mealtimes and considered the roles of caregivers. [Results] The participants became distracted from eating where they were in a lively environment. On the other hand, they were not distracted when they were made to sit and eat in quiet environments. [Conclusion] Patients with severe Alzheimer’s disease who have lost their language skills cannot filter out a range of other information around them and focus on the information necessary to oneself. The role of caregivers is to serve as filters for patients with severe Alzheimer’s disease who have lost their language skills and whose selective attention abilities have become impaired.

A systematic review of ethical and legal issues in elder care

BACKGROUND

Ethical and legal issues are increasingly being reported by health caregivers; however, little is known about the nature of these issues in geriatric care. These issues can improve work and care conditions in healthcare, and consequently, the health and welfare of older people.

AIM

This literature review aims to identify research focusing on ethical and legal issues in geriatric care, in order to give nurses and other health care workers an overview of existing grievances and possible solutions to take care of old patients in a both ethical and legally correct way.

METHODS

Using a systematic approach based on Aveyard, a search of the PubMed, CINAHL, and Ethicshare databases was conducted to find out the articles published on ethical and legal issues in geriatric care.

ETHICAL CONSIDERATIONS

The approval for the study was obtained from UMIT-The Health and Life Sciences University, Austria.

RESULTS

Only 50 articles were included for systematic analysis reporting ethical and legal issues in the geriatric care. The results presented in this article showed that the main ethical issues were related to the older people's autonomy, respect for their needs, wishes and values, and respect for their decision-making. The main legal issues were related to patients' rights, advance directives, elderly rights, treatment nutrition dilemma, and autonomy.

CONCLUSION

Further education for professional caregivers, elderly people, and their families is needed on following topics: care planning, directive and living wills, and caregiver-family member relationships to guide and support the elderly people within their decision-making processes and during the end-of-life care.

Prolonged drug release properties for orodispersible films by combining hot-melt extrusion and solvent casting methods

Orodispersible films (ODFs) are an advantageous dosage form to accomplish patient convenience and compliance in oral drug delivery. They provide a number of special application features, such as the ease of administration without water and suitability for patients with swallowing problems. However, this promising dosage form has been limited to immediate release formulations so far. The aim of this study was to develop a thin film produced by solvent casting, which is rapidly disintegrating when placed in the mouth, but which provides prolonged drug release characteristics by incorporating drug-loaded matrix particles (MPs). MPs were produced by hot-melt extrusion and subsequent milling, using theophylline anhydrous as model drug and Eudragit^® RS as matrix-forming agent enabling prolonged drug release. ODFs were manufactured using hypromellose as film former. Dissolution studies were performed to investigate the kinetics and the duration of drug release. Additionally, disintegration time was determined using the PharmaTest^® disintegration tester equipped with a specific sample holder for ODFs. All produced ODFs containing theophylline-loaded MPs show fast disintegration while the drug release was prolonged. The degree of release prolongation increases with increasing sizes of incorporated MPs. Matrix-controlled release kinetics were found for ODFs containing MPs with at least 315 µm in size. In summary, the production of fast disintegrating ODFs with prolonged release properties was feasible. Furthermore, freely adjustable dissolution profiles could be realized for ODFs by incorporating MPs of various particle sizes.

Patient-centred pharmaceutical design to improve acceptability of medicines: similarities and differences in paediatric and geriatric populations

Patient acceptability of a medicinal product is a key aspect in the development and prescribing of medicines. Children and older adults differ in many aspects from the other age subsets of population and require particular considerations in medication acceptability. This review highlights the similarities and differences in these two age groups in relation to factors affecting acceptability of medicines. New and conventional formulations of medicines are considered regarding their appropriateness for use in children and older people. Aspects of a formulation that impact acceptability in these patient groups are discussed, including, for example, taste/smell/viscosity of a liquid and size/shape of a tablet. A better understanding of the acceptability of existing formulations highlights opportunities for the development of new and more acceptable medicines and facilitates safe and effective prescribing for the young and older populations.

The perception and pharmacokinetics of a 20-mg dose of escitalopram orodispersible tablets in a relative bioavailability study in healthy men

BACKGROUND

Rapidly dissolving oral (orodispersible) drug formulations have been developed to overcome problems related to swallowing.

OBJECTIVE

The aim of this study was to compare the bioavailability of orodispersible and conventional immediate-release (IR) escitalopram tablets.

METHODS

This was a randomized, open-label, 3-way crossover trial in which healthy men received single doses of orodispersible escitalopram formulations (2 ×10 mg and 1 × 20 mg) and conventional (2 × 10 mg) oral escitalopram tablets. Blood samples for pharmacokinetic analysis were obtained during a 168-hour period after dosing. The safety profile and tolerability were assessed by monitoring of adverse events, physical examinations, ECGs, and clinical laboratory and vital signs assessments. A questionnaire was used to assess the perception of the orodispersible tablet (ODT).

RESULTS

The assumed bioequivalence assessment was based on pharmacokinetic and statistical analysis of data from the 29 men who completed the 3 treatments. The serum concentration-time profiles of escitalopram were similar after intake of the 3 treatments. The 90% CI for the mean treatment ratios of the log-transformed C(max), AUC(0-t), and AUC(0-∞) were all within the predefined equivalence range of 80% to 125%. Most subjects (87%) thought that the ODT was pleasant to take, and 85% of subjects thought that it was convenient to take the tablet without water. Most subjects (67%-90%) reported adverse events, with a similar incidence for all treatments. Most adverse events were mild, with somnolence and nausea being the most frequently reported. No clinically relevant changes were observed in physical, biochemical, hematologic, or urinalysis variables during the study.

CONCLUSIONS

In this small study population of fasting healthy male volunteers, 2 × 10-mg ODTs or 1 × 20-mg ODT and 2 × 10-mg conventional IR escitalopram tablets met the regulatory criteria for assumed bioequivalence. CLINICALTRIALS.GOV IDENTIFIER: NCT 01395433.

Artificial nutrition and hydration at the end of life

Considerable controversy surrounds the issue of care at the end of life (EOL) for older adults. Technological advances and the legal, ethical, clinical, religious, cultural, personal, and fiscal considerations in the provision of artificial hydration and nutrition support to older adults near death are presented in this comprehensive review.

Nurses' perspectives on feeding decisions for nursing home residents with advanced dementia

AIM

To develop a broad understanding of nursing beliefs, knowledge and roles in feeding decisions for nursing home residents with advanced dementia.

BACKGROUND

Concern is growing about the common use of feeding tubes in nursing home residents with advanced dementia. Nurses can play an important role in providing information and guiding family members through difficult feeding decisions. Little is known about nurses' perspectives on feeding decisions.

DESIGN

Qualitative descriptive.

METHODS

In-depth semi-structured interviews of 11 licensed nurses who were experienced in caring for nursing home residents with dementia.

RESULTS

Analysis of the interview transcripts revealed three themes: insufficient empirical information, ambiguous role in feeding decisions and uncertainty about moral agency in decisions about the placement of feeding tubes.

CONCLUSIONS

Despite views that family members would benefit from guidance in decisions regarding the placement of feeding tubes, nurses were, nevertheless, reluctant to become involved in these difficult decisions.

RELEVANCE TO CLINICAL PRACTICE

If nurses are to guide family members in decisions about the use of feeding tubes, they need more education about evidence-based practice as well as support in exercising their nursing responsibilities.

Involvement of hospital nurses in care decisions related to administration of artificial nutrition or hydration (ANH) in patients with dementia: a qualitative study

BACKGROUND

Nurses that care for patients with advanced dementia are increasingly faced with consequences of disease progression, often requiring them to decide whether to artificially feed these patients. Clarifying how nurses can be better supported in complex care processes involving ethically sensitive decision-making requires that their practice be mapped out.

OBJECTIVES

The aims of this study were to explore and describe how nurses are involved in the care that surrounds decisions concerning artificial nutrition or hydration in hospitalized patients with dementia.

DESIGN

We used a qualitative interview design. Data collection and analysis were informed by the grounded theory approach.

SETTING

Nine hospitals geographically spread throughout the five provinces of Flanders, Belgium.

PARTICIPANTS

Twenty-one nurses were purposively selected for interview, with the aim of including nurses that reflected diverse personal characteristics and experiences with the subject matter.

METHODS

Between April 2008 and June 2009, we conducted 21 interviews that were audiotaped and later transcribed. Data processing involved (1) simultaneous and systematic data collection and analysis, (2) constant forwards-backwards wave, (3) continuous dialogue with the data, and (4) interactive team processes.

RESULTS

Nurses' involvement was characterized by a desire to provide 'good care', which was the basis for their motivation and aspiration during the care process. Early in the process, nurses developed a holistic picture of their patients, laying the foundation of their 'good care' view. During the actual decision-making, nurses fulfilled the roles of messengers and guiding communicators, as they attempted to realize their 'good care' view. Nurses judged the physicians' decisions in light of their care view. If a decision matched their view, they supported the decision. If not, they resisted it openly or covertly. Some nurses remained passively in the background, while others took action to override the decision. Nurses' involvement ended with the intensive aftercare of the patients and their family.

CONCLUSIONS

Nurses are closely and continuously involved in the care that surrounds decisions concerning artificial nutrition or hydration in hospitalized patients with advanced dementia. During the care process, nurses play several and specific roles, giving their contribution a unique and variable character.

Dysphagia: implications for older people

This review opens with an outline definition of dysphagia, its causes, and why it is vital that people involved in the health care of older people should be aware of it. A brief consideration of prevalence is followed by an overview of assessment options. We conclude with a section on management.

Exercising restraint: Clinical, legal and ethical considerations for the patient with Alzheimer’s disease

The number of older people using emergency care is increasing steadily and older people account for over half of all emergency admissions. In the emergency setting, nurses caring for older people with Alzheimer's disease can be faced with many complex ethical and legal challenges. Moreover, challenges such as the use of physical restraint can precipitate conflict when the nurse is placed in the precarious position of doing good, respecting autonomy and avoiding paternalism. Although, there is no complete set of "rules" that can provide nurses with an answer to each dilemma, it is of significant value for nurses to have sound knowledge of ethical and legal positions in order to analyse the many complex situations that they may encounter.

Dysphagia in the elderly--a management challenge for nurses

Dysphagia (swallowing difficulties) is relatively common in the general population, but the prevalence increases with age and poses particular problems in the older patient, potentially compromising nutritional status, complicating the administration of solid medications, increasing the risk of aspiration pneumonia and undermining the quality of life. The repercussions of dysphagia are not only physical but also emotional, affecting patient morale and leading to feelings of social isolation. There are various causes, including carcinoma, stroke and advanced Alzheimer's disease. The diverse range of causes may manifest in a number of different ways, but should always act as a warning sign, which requires further investigation. Management is multidisciplinary, depending on the underlying cause, extent of dysphagia and likely prognosis. This article examines the incidence, causes and management of dysphagia, based on a review of recent literature. The focus is on the nurse's role in the management of this challenging disorder with particular emphasis on the care of the elderly patient.