Caregiver perspectives on cancer screening for persons with dementia: "why put them through it?"

Rural-urban disparities in preventive breast and cervical cancer screening among women with early-onset dementia

BACKGROUND

The early onset of Alzheimer's disease and related dementias (ADRD) before age 65 can introduce life and health care complications. Preserving an early-onset ADRD patient's daily functioning longer and delaying declines in health from non-ADRD conditions become important preventive goals. This study examined the differences in utilization of preventive cancer screenings between patients with and without early-onset ADRD, and compared utilization of the screenings in rural versus urban areas among women with early-onset ADRD in the United States.

METHODS

We conducted a cross-sectional study of women aged 40 to 64 years eligible for mammogram and cervical cancer screenings using commercial insurance claims from 2012 to 2018. We measured the use of biennial mammogram among women 50 to 64 years old, and the use of triennial Pap smear test among women 40 to 64 years old. We used inverse probability weighted logistic regressions to estimate the odds of receiving preventive cancer screenings by the presence of early-onset ADRD or cognitive impairments (CI). We used multivariable logistic regressions to estimate the odds of receiving preventive cancer screenings by rural or urban residence among women with early-onset ADRD/CI.

RESULTS

Among 6,349,308 women in the breast cancer screening sample (mean [SD] age, 56.52 [4.03] years), 36,131 had early-onset ADRD/CI (mean [SD] age, 57.99 [3.98] years). Among 6,583,088 women in the cervical cancer screening sample (mean [SD] age, 52.37 [6.81] years), 30,919 had early-onset ADRD/CI (mean [SD] age, 55.79 [6.22] years). Having early-onset ADRD/CI was associated with lower utilization of mammogram (OR: 0.92, 95% CI: 0.90-0.95). No significant difference was observed in Pap smear screening (OR: 0.99, 95% CI: 0.96-1.02) between patients with and without early-onset ADRD/CI. Among patients with early-onset ADRD/CI, those in rural areas were less likely than those in urban areas to have mammograms (OR: 0.91, 95% CI: 0.85-0.97) and Pap smears (OR: 0.65, 95% CI: 0.61-0.71).

CONCLUSIONS

The observed pattern of rural-urban differences in cancer screening in our study emphasizes the need for efforts to promote evidence-based, individualized decision-making processes in the early-onset ADRD population.

A model for predicting both breast cancer risk and non-breast cancer death among women > 55 years old

BACKGROUND

Guidelines recommend shared decision making (SDM) for mammography screening for women ≥ 75 and not screening women with < 10-year life expectancy. High-quality SDM requires consideration of women's breast cancer (BC) risk, life expectancy, and values but is hard to implement because no models simultaneously estimate older women's individualized BC risk and life expectancy.

METHODS

Using competing risk regression and data from 83,330 women > 55 years who completed the 2004 Nurses' Health Study (NHS) questionnaire, we developed (in 2/3 of the cohort, n = 55,533) a model to predict 10-year non-breast cancer (BC) death. We considered 60 mortality risk factors and used best-subsets regression, the Akaike information criterion, and c-index, to identify the best-fitting model. We examined model performance in the remaining 1/3 of the NHS cohort (n = 27,777) and among 17,380 Black Women's Health Study (BWHS) participants, ≥ 55 years, who completed the 2009 questionnaire. We then included the identified mortality predictors in a previously developed competing risk BC prediction model and examined model performance for predicting BC risk.

RESULTS

Mean age of NHS development cohort participants was 70.1 years (± 7.0); over 10 years, 3.1% developed BC, 0.3% died of BC, and 20.1% died of other causes; NHS validation cohort participants were similar. BWHS participants were younger (mean age 63.7 years [± 6.7]); over 10-years 3.1% developed BC, 0.4% died of BC, and 11.1% died of other causes. The final non-BC death prediction model included 21 variables (age; body mass index [BMI]; physical function [3 measures]; comorbidities [12]; alcohol; smoking; age at menopause; and mammography use). The final BC prediction model included age, BMI, alcohol and hormone use, family history, age at menopause, age at first birth/parity, and breast biopsy history. When risk factor regression coefficients were applied in the validation cohorts, the c-index for predicting 10-year non-BC death was 0.790 (0.784-0.796) in NHS and 0.768 (0.757-0.780) in BWHS; for predicting 5-year BC risk, the c-index was 0.612 (0.538-0.641) in NHS and 0.573 (0.536-0.611) in BWHS.

CONCLUSIONS

We developed and validated a novel competing-risk model that predicts 10-year non-BC death and 5-year BC risk. Model risk estimates may help inform SDM around mammography screening.

Cancer care for people with dementia: Literature overview and recommendations for practice and research

As many countries experience population aging, patients with cancer are becoming older and have more preexisting comorbidities, which include prevalent, age-related, chronic conditions such as dementia. People living with dementia (PLWD) are vulnerable to health disparities, and dementia has high potential to complicate and adversely affect care and outcomes across the cancer trajectory. This report offers an overview of dementia and its prevalence among patients with cancer and a summary of the research literature examining cancer care for PLWD. The reviewed research indicates that PLWD are more likely to have cancer diagnosed at an advanced stage, receive no or less extensive cancer treatment, and have poorer survival after a cancer diagnosis. These cancer disparities do not necessarily signify inappropriately later diagnosis or lower treatment of people with dementia as a group, and they are arguably less feasible and appropriate targets for care optimization. The reviewed research indicates that PLWD also have an increased risk of cancer-related emergency presentations, lower quality processes of cancer-related decision making, accessibility-related barriers to cancer investigations and treatment, higher experienced treatment burden and higher caregiver burden for families, and undertreated cancer-related pain. The authors propose that optimal cancer care for PLWD should focus on proactively minimizing these risk areas and thus must be highly person-centered, with holistic decision making, individualized reasonable adjustments to practice, and strong inclusion and support of family carers. Comprehensive recommendations are made for clinical practice and future research to help clinicians and providers deliver best and equitable cancer care for PLWD and their families.

Process of Advance Care Planning in Nursing Home Settings: An Integrative Literature Review

Advance care planning (ACP) allows individuals to communicate their wishes for future medical care. ACP is particularly important among those diagnosed with Alzheimer's disease and related dementias (ADRD) due to decline in cognition. In the nursing home setting, conducting ACP with residents with ADRD and their family caregivers is challenging. The purpose of the current integrative review was to: (a) examine the evidence on the process of conducting ACP with residents with ADRD and their family caregivers in nursing home settings, and (b) understand who conducts ACP and when and how ACP is being conducted with residents with ADRD and their family caregivers. Gaps were identified, such as lack of a systematic approach to addressing ACP in nursing homes, lack of clear roles in conducting ACP, family caregivers' and nursing home staff's lack of knowledge and skills to engage in ACP, and lack of diversity in study samples. To improve clinical practice, future studies should explore standardization of the ACP process in the nursing home setting. [Research in Gerontological Nursing, xx(x), xx-xx.].

Impact of Alzheimer’s disease and related dementias on colorectal cancer screening utilization, knowledge, and associated health disparities

Background: Colorectal cancer screening can detect colorectal cancer at an early stage and reduce mortality. None of the existing clinical practice guidelines provide specific recommendations for colorectal cancer screening in patients with Alzheimer’s disease and related dementias (ADRD). Limited studies have assessed the impacts of ADRD on colorectal cancer screening use and knowledge, and no studies have focused on the associated health disparities.

Objectives: To examine the utilization, knowledge, and associated health disparities of colorectal cancer screening in older adults with ADRD.

Methods: This study used the Medicare Current Beneficiary Survey from 2015 to 2018. Two types of colorectal cancer screening, including fecal occult blood test (FOBT) and colonoscopy/sigmoidoscopy, were measured. The colorectal cancer screening knowledge was evaluated by asking if the participants have heard of two screening methods and whether they knew Medicare pays for colorectal cancer screenings. Logistic regression models were used to examine the impact of ADRD diagnosis on the utilization and knowledge of colorectal cancer screening.

Results: The overall colorectal cancer screening rate in older adults increased from 86.4% to 88.96% from 2015 to 2018. Patients with AD were 39% (OR: 0.61; 95% CI: 0.50–0.76) less likely and those with RD were 25% (OR: 0.75; 95% CI: 0.62–0.91) less likely to use any colorectal cancer screening when compared to older adults without ADRD. The rate of knowledge of colonoscopy/sigmoidoscopy remained high between 84.23% and 84.57% while the knowledge of FOBT increased from 64.32% to 78.69% during the study period. Compared to older adults without ADRD, those with AD were 77% (OR: 1.77; 95% CI: 1.12–2.81) more likely to hear of colonoscopy/sigmoidoscopy. The rate of knowledge of Medicare pay for colorectal cancer screening increased from 42.19% to 45.27% during the study period. Compared to older adults without ADRD, those with AD were 19% (OR: 0.81; 95% CI: 0.70–0.94) less likely to know that Medicare pays for colorectal cancer screening.

Conclusion: ADRD was significantly associated with colorectal cancer screening utilization and knowledge. In addition, this study identified health disparities in race/ethnicity, gender, and urban/rural residence in colorectal cancer screening use and knowledge.

The Impact of Morbidity and Disability on Attendance at Organized Breast Cancer-Screening Programs: A Systematic Review and Meta-Analysis

Individuals with morbidity experience worse breast cancer outcomes compared with those without. This meta-analysis assessed the impact of morbidity on breast cancer-screening attendance and subsequent early detection (PROSPERO pre-registration CRD42020204918). MEDLINE, PsychInfo, and CINAHL were searched. Included articles published from 1988 measured organized breast-screening mammography attendance using medical records by women with morbidity compared with those without. Morbidities were assigned to nine diagnostic clusters. Data were pooled using random-effects inverse meta-analyses to produce odds ratios (OR) for attendance. 25 study samples (28 articles) were included. Data were available from 17,755,075 individuals, including at least 1,408,246 participants with one or more conditions;16,250,556 had none. Individuals with any morbidity had lower odds of attending breast screening compared with controls [k = 25; OR, 0.76; 95% confidence interval (CI), 0.70-0.81; P = <0.001; I2 = 99%]. Six morbidity clusters had lower odds of attendance. The lowest were for neurological, psychiatric, and disability conditions; ORs ranged from 0.45 to 0.59 compared with those without. Morbidity presents a clear barrier for breast-screening attendance, exacerbating health inequalities and, includes a larger number of conditions than previously identified. Consensus is required to determine a standardized approach on how best to identify those with morbidity and determine solutions for overcoming barriers to screening participation based on specific morbidity profiles.

Comparing the downstream costs and healthcare utilization associated with the use of low-dose computed tomography (LDCT) in lung cancer screening in patients with and without alzheimer's disease and related dementias (ADRD)

OBJECTIVE

This study aims to compare the downstream costs and healthcare utilization associated with using low-dose computed tomography (LDCT) for lung cancer screening in patients with and without Alzheimer's disease and related dementias (ADRD).

METHODS

Based on data from IBM MarketScan Commercial Claims Databases (2014-2018), we have identified four study cohorts: ADRD and non-ADRD patients who went through LDCT screening; ADRD and non-ADRD patients without LDCT screening. Annually healthcare utilization and cost were grouped into outpatient, inpatient, and pharmacy. We used difference-in-differences (DID) models to estimate the downstream healthcare utilization and cost associated with LDCT screening in both ADRD and non-ADRD population. We used a difference-in-difference-in-differences (DDD) model to explore whether LDCT screening was associated with higher downstream cost and healthcare utilization in ADRD population than non-ADRD population.

RESULT

Compared to individuals without LDCT screening, LDCT screening was associated with increased outpatient visits (2.1, 95% CI 0.7, 3.4) and outpatient cost ($2301.0, 95% CI 296.2, 4305.8) in the ADRD population and increased outpatient visits (0.6, 95% CI 0.1, 1.1) in the non-ADRD population within 1 year after screening. Compared with the non-ADRD population, LDCT screening was found to be associated with an additional 1.5 (95% CI 0.2, 2.8) outpatient visits, 0.7 (95% CI 0.1, 1.3) days of inpatient stays, and $4,960.4 (95% CI 532.7, 9388.0) in overall healthcare costs within 1-year after LDCT in the ADRD population (all p < .5).

CONCLUSION

The downstream cost and healthcare utilization associated with LDCT screening were found to be higher in the ADRD population compared to the average population.

Navigating the Cancer Screening Decision for Patients with Dementia

PURPOSE OF REVIEW

The risks of developing cancer and dementia both increase with age, giving rise to the complex question of whether continued cancer screening for older dementia patients is appropriate. This paper offers a practice-based clinical approach to determine an answer to this challenging question.

RECENT FINDINGS

There is no consensus on the prevalence of cancer and dementia as co-diagnoses. Persons with dementia are screened less often compared to those without dementia. There is significant literature focusing on screening in the geriatric population, but there is little evidence to support decision-making for screening for older patients with dementia. Given this lack of evidence, individualized decisions should be made in collaboration with patients and family caregivers. Four considerations to help guide this process include prognosis, behavioral constraints, cognitive capacity, and goals for care. Future research will be challenging due to variability of factors that inform screening decisions and the vulnerable nature of this patient population.

Examining Older Adults' Attitudes and Perceptions of Cancer Screening and Overscreening: A Qualitative Study

Introduction/Objectives:

Screening guidelines for breast, cervical, and colorectal cancer (CRC) are less clear for older adults due to the potential harms that may result from screening. Understanding older adults’ attitudes and perceptions, especially racial/ethnic minority and underserved adults, of cancer screening can help health care providers determine how best to communicate with older adults about cancer screening and screening cessation. The objective of this study was to determine how older adults primarily from minority/underserved backgrounds perceive cancer screening and overscreening.

Methods:

Four focus groups (n = 39) were conducted with adults (>=65 years of age) in 3 community settings in south-central Pennsylvania. Two focus groups were conducted in Spanish and translated to English upon transcription. Focus group data was managed and analyzed using QSR NVivo 12. Inductive thematic analysis was used to analyze the data where themes emerged following the coding process.

Results:

The focus group participants had an average age of 74 years and were primarily female (74%) and Hispanic (69%), with 69% reporting having less than a high school degree. Four key themes were identified from the focus groups: (1) importance of tailored and targeted education/information; (2) impact of physician/patient communication; (3) impact of barriers and facilitators to screening on cancer screening cessation; and (4) awareness of importance of screening. Participants were more likely to be agreeable to screening cessation if they received specific information regarding their health status and previous medical history from their physician as to why screening should be stopped and told by their physician that the screening decision is up to them.

Conclusions:

Older adults prefer individualized information from their physician in order to justify screening cessation but are against incorporating life expectancy into the discussion. Future research should focus on developing interventions to test the effectiveness of culturally tailored screening cessation messages for older adults.

How Do Older Adults Consider Age, Life Expectancy, Quality of Life, and Physician Recommendations When Making Cancer Screening Decisions? Results from a National Survey Using a Discrete Choice Experiment

Background. Older adults with limited life expectancy frequently receive cancer screening, although on average, harms outweigh benefits. We examined the influence of life expectancy on older adults' cancer screening decisions relative to three other factors. Methods. Adults aged 65+ years (N = 1272) were recruited from a national online survey panel. Using a discrete choice experiment, we systematically varied a hypothetical patient's life expectancy, age, quality of life, and physician's recommendation and asked whether the participant would choose screening. Participants were randomized to questions about colonoscopy or prostate-specific antigen/mammography screenings. Logistic regression produced preference weights that quantified the relative influence of the 4 factors on screening decisions. Results. 879 older adults completed the survey, 660 of whom varied their screening choices in response to the 4 factors we tested. The age of the hypothetical patient had the largest influence on choosing screening: the effect of age being 65 versus 85 years had a preference weight of 2.44 (95% confidence interval [CI]: 2.22, 2.65). Life expectancy (10 versus 1 year) had the second largest influence (preference weight: 1.64, CI: 1.41, 1.87). Physician recommendation (screen versus do not screen) and quality of life (good versus poor) were less influential, with preference weights of 0.90 (CI: 0.72, 1.08) and 0.68 (CI: 0.52, 0.83), respectively. Conclusions. While clinical practice guidelines increasingly use life expectancy in addition to age to guide screening decisions, we find that age is the most influential factor, independent of life expectancy, quality of life, and physician recommendation, in older adults' cancer screening choices. Strategies to reduce overscreening should consider the importance patients give to continuing screening at younger ages, even when life expectancy is limited.

How are caregivers involved in treatment decision making for older people with dementia and a new diagnosis of cancer?

OBJECTIVE

To explore how caregivers are involved in making treatment decisions for older people living with dementia and a new diagnosis of cancer.

METHOD

A systematic review of PubMed, CINAHL, PsycINFO, Web of Science, and Scopus databases was conducted. Studies recruiting formal or informal caregivers for older people with dementia and a diagnosis of cancer were considered for inclusion.

RESULTS

Of 1761 articles screened, 36 full texts were assessed for eligibility, and six were included in the review. This review has identified that health care professionals (HCPs) are often unaware of the coexistence or severity of dementia in cancer patients, and therefore fail to properly address care needs as a result. While caregivers are relied on to help make decisions, they have unmet information needs and feel excluded from decision-making.

CONCLUSION

Treatment decision making in the context of older adults with dementia and a new diagnosis of cancer needs further research. This will help HCPs to understand their needs and improve the experience of decision making for both caregivers and the people that they care for.

Supporting breast cancer screening decisions for caregivers of older women with dementia: study protocol for a randomized controlled trial

BACKGROUND

Alzheimer's disease and related dementias (ADRD) impact a woman's life expectancy and her ability to participate in medical decision-making about breast cancer screening, necessitating the involvement of family caregivers. Making decisions about mammography screening for women with ADRD is stressful. There are no data that suggest that breast cancer screening helps women with ADRD live longer or better. Decision aids may improve the quality of decision-making about mammography for ADRD patients and may inform family caregivers about the risks, benefits, and need for decision-making around mammography screening.

METHODS/DESIGN

The Decisions about Cancer Screening in Alzheimer's Disease (DECAD) trial, a randomized controlled clinical trial, will enroll 426 dyads of older women with ADRD (≥75 years) and a family caregiver from clinics and primary-care practices in Indiana to test a novel, evidence-based decision aid. This decision aid includes information about the impact of ADRD on life expectancy, the benefit of mammograms, and the impact on the quality of life for older women with ADRD. Dyads will be randomized to receive the decision aid or active control information about home safety. This trial will examine the effect on the caregiver's decisional conflict (primary outcome) and the caregiver's decision-making self-efficacy (secondary outcome). A second follow-up at 15 months will include a brief, semi-structured interview with the caregiver regarding the patient's experience with mammograms and decision-making about mammograms. At the same time, a review of the patient's electronic medical record (EMR) will look at discussions about mammography with their primary-care physician and mammogram orders, receipt, results, and burden (e.g., additional diagnostic procedures due to false-positive results, identification of an abnormality on the screening exam but further work-up declined, and identification of a clinically unimportant cancer). A third follow-up at 24 months will extract EMR data on mammogram orders, occurrences, results, and the burden of mammograms.

DISCUSSION

We hypothesize that caregivers who receive the decision aid will have lower levels of decisional conflict and higher levels of decision-making self-efficacy compared to the control group. We also hypothesize that the DECAD decision aid will reduce mammography use among older women with ADRD.

TRIAL REGISTRATION

Clinical Trials Register, NCT03282097 . Registered on 13 September 2017.

A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care

OBJECTIVES

A comorbid diagnosis of cancer and dementia (cancer-dementia) may have unique implications for patient cancer-related experience. The objectives were to estimate prevalence of cancer-dementia and related experiences of people with dementia, their carers and cancer clinicians including cancer screening, diagnosis, treatment and palliative care.

METHOD

Databases were searched (CINAHL, Psychinfo, Medline, Embase, BNI) using key terms such as dementia, cancer and experience. Inclusion criteria were as follows: (a) English language, (b) published any time until early 2016, (c) diagnosis of cancer-dementia and (d) original articles that assessed prevalence and/or cancer-related experiences including screening, cancer treatment and survival. Due to variations in study design and outcomes, study data were synthesised narratively.

RESULTS

Forty-seven studies were included in the review with a mix of quantitative (n = 44) and qualitative (n = 3) methodologies. Thirty-four studies reported varied cancer-dementia prevalence rates (range 0.2%-45.6%); the others reported reduced likelihood of receiving: cancer screening, cancer staging information, cancer treatment with curative intent and pain management, compared to those with cancer only. The findings indicate poorer cancer-related clinical outcomes including late diagnosis and higher mortality rates in those with cancer-dementia despite greater health service use.

CONCLUSIONS

There is a dearth of good-quality evidence investigating the cancer-dementia prevalence and its implications for successful cancer treatment. Findings suggest that dementia is associated with poorer cancer outcomes although the reasons for this are not yet clear. Further research is needed to better understand the impact of cancer-dementia and enable patients, carers and clinicians to make informed cancer-related decisions.

Rates of Screening for Breast, Colorectal, and Cervical Cancers in Older People With Cognitive Impairment or Dementia: A Meta-Analysis

Purpose: Cancer screening may not be appropriate for some older people. We compare the likelihood of screening for colorectal, breast, and cervical cancers in older people with versus without cognitive impairment or dementia. Method: Systematic search of MEDLINE, Embase, and PsycINFO (to March 9, 2018) for articles reporting screening for colon, breast, and cervical cancers in patients with and without cognitive impairment or dementia. Studies were summarized quantitatively (random effects meta-analysis), according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: Studies reported data 1989-2008. The rate of screening for breast cancer by mammography was lower in women with cognitive impairment or dementia compared with those without (pooled odds ratio [OR] = 0.81, 95% confidence interval [CI] = [0.71, 0.91], p = .0007, six studies, N = 18,562). The rates of screening for cervical cancer by Pap smear (pooled OR = 0.88, 95% CI = [0.71, 1.08], p = 0.22, five studies, N = 409,131) and colorectal cancer by fecal occult blood test (pooled OR = 0.87, 95% CI = [0.55, 1.38], p = .55, two studies, N = 2,718) were not significantly lower in people with cognitive impairment or dementia. Conclusion: These historical rates provide a baseline for discussions around the need for more specific guidance to assist with decisions to discontinue screening. The study also identifies a gap in reported knowledge with respect to screening under current guidelines.

The experiences and preparedness of family carers for best interest decision-making of a relative living with advanced dementia: A qualitative study

AIM

To explore the experience and the preparedness of family carers in their caregiving role as best interest decision-makers of a relative living with advanced dementia.

BACKGROUND

The prevalence of dementia is a global issue. The role of being a carer of a relative living with dementia does not necessarily lessen once they are admitted to a nursing home. Best interest decision-making including end-of-life care decisions need to be made and reaching these choices can be challenging. The preparedness of family carers in this role needs greater understanding.

DESIGN

Descriptive qualitative study.

METHODS

During 2015 twenty semi-structured interviews were conducted of family carers of nursing home residents living with advanced dementia, then analysed using Braun and Clarke's thematic analysis.

RESULTS

Three themes were identified: (1) Caring for someone living with dementia. The impact on the carer's holistic well-being and their experience of being a best interest decision-maker; (2) Accessing support. The influential nature of formal and informal networks; (3) Perceived knowledge and understanding of the dementia trajectory of carers and nursing staff.

CONCLUSION

The experiences and preparedness of informal carers is a reflection of their personal response, but the distress experienced highlights the significant need of adequate support availability and of enhancing nursing staffs' dementia expertise to maximize their role in facilitating best interest decision-making. This has significant implications for nursing practice and for service user and nursing staff education. Considering the global impact of dementia, our findings have international relevance to similar nursing homes across the world.

Decision-Making Experiences of Patients with Implantable Cardioverter Defibrillators

BACKGROUND

When patients are not adequately engaged in decision making, they may be at risk of decision regret. Our objective was to explore patients' perceptions of their decision-making experiences related to implantable cardioverter defibrillators (ICDs).

METHODS

Cross-sectional, mailed survey of 412 patients who received an ICD without cardiac resynchronization therapy for any indication between 2006 and 2009. Patients were asked about decision participation and decision regret.

RESULTS

A total of 295 patients with ICDs responded (72% response rate). Overall, 79% reported that they were as involved in the decision as they wanted. However, 28% reported that they were not told of the option of not getting an ICD and 37% did not remember being asked if they wanted an ICD. In total, 19% reported not wanting their ICD at the time of implantation. Those who did not want the ICD were younger (<65 years; 74% vs 43%, P < 0.001), had higher decision regret (31/100 vs 11/100, P < 0.001), and reported less participation in decision making (the doctor "totally" made the decision, 9% vs 3%; P < 0.001).

CONCLUSIONS

A considerable number of ICD recipients recalled not wanting their ICD at the time of implantation. While these findings may be prone to recall bias, they likely identify opportunities to improve ICD decision making.

Aggressiveness of End-of-Life Care for Hospitalized Individuals with Cancer with and without Dementia: A Nationwide Matched-Cohort Study in France

OBJECTIVES

To compare the aggressiveness of end-of-life care in hospitalized individuals with cancer with and without dementia in France.

DESIGN

Nationwide register-based matched-cohort study.

SETTING

Hospital facilities in France.

PARTICIPANTS

All individuals with cancer aged 65 and older with a diagnosis of dementia who died between January 1, 2010 and December 31, 2013, matched one-to-one with individuals with cancer without dementia (n = 26,782 matched pairs).

RESULTS

Older individuals with cancer with dementia were less likely to receive aggressive treatment in their last month of life than those who were not diagnosed with dementia. Dementia was associated with significantly greater likelihood of receiving chemotherapy (2.8% vs 8.5%, P < .001, adjusted odds ratio (aOR) = 0.33, 95% confidence interval (CI) = 0.31-0.36) in the month before death. Individuals with dementia were also less likely to receive radiation therapy (aOR = 0.49, 95% CI = 0.43-0.56), blood transfusions (aOR = 0.67, 95% CI = 0.64-0.70), artificial nutrition (aOR = 0.79, 95% CI = 0.73-0.85), and invasive ventilation (aOR = 0.62, 95% CI = 0.57-0.68), although they were more likely to remain hospitalized over their entire last month of life (aOR = 1.42, 95% CI = 1.37-1.48) and to have more than one emergency department visit (aOR = 1.22, 95% CI = 1.12-1.34).

CONCLUSION

Older hospitalized adults with cancer with dementia are less likely to receive aggressive cancer treatment near the end of life than those without dementia. This discrepancy raises important ethical questions for clinicians and healthcare policy-makers.

A systematic review of barriers and facilitators to and interventions for proxy decision-making by family carers of people with dementia

BACKGROUND

Relatives of people with dementia report that proxy decision-making is difficult and distressing. We systematically reviewed the literature about barriers and facilitators to family carers of people with dementia making proxy decisions, and interventions used to facilitate their decision-making.

METHODS

We searched electronic databases and references of included papers up to February 2014. Two authors independently evaluated study quality using a checklist.

RESULTS

We included the 30/104 papers from our search which fitted predetermined criteria and prioritized higher quality papers. Family carers report that proxy decision-making is challenging and can be distressing, especially when decisions are made against the wishes of the care recipient and support from healthcare professionals is lacking. Decision-specific manualized aids have been developed, and while results for those supporting decisions about respite and percutaneous endoscopic gastrostomy (PEG) feeding have shown promising results in pilot trials, no intervention has yet been shown to significantly reduce decisional conflict or carer burden, or increase knowledge in randomized controlled trials; a decision aid for advance care planning increased decisional conflict.

CONCLUSIONS

We recommend development and testing of decision aids targeting the decisions carers report finding most distressing, including those around where people should live, accessing services, and end of life treatments. Being provided with information to make decisions which have not previously been considered may increase feelings of conflict, suggesting these aids should be carefully targeted.