Palliative Care in Advanced Dementia

Prognostic understanding among caregivers of persons with dementia: A scoping review

INTRODUCTION

Despite the influence of caregivers' prognostic understanding (PU) on the end-of-life care for persons with dementia (PwDs), the literature on PU of caregivers of PwDs is sparse. We conducted a scoping review to understand the variation in existing definitions and measurement of caregivers' PU for PwDs. We also aimed to synthesize the prevalence of caregivers' correct PU and the factors (caregiver, PwD and healthcare related) associated with it.

METHODS

We systematically searched four databases-MEDLINE/PubMed, EMBASE, SCOPUS, and CINAHL. We included studies where study participants were informal caregivers, their PU was assessed, and measurement tool was implicitly described. We excluded studies where study participants were paid caregivers.

RESULTS

Out of the 2160 studies screened, we included 15 published between 2009 and 2023. The included studies measured caregivers' PU as limited estimated life expectancy, understanding that dementia is incurable and life-limiting. Estimated life expectancy was the most common measure of PU among caregivers to PwDs. Across studies, around 90% of caregivers acknowledged dementia as incurable, while only about 40% acknowledged it as life-limiting. Caregivers of PwDs who were sicker (acute medical problems or functional dependence) and those who had discussed goals of care with healthcare providers were more likely to have more accurate PU for PwDs. Caregivers' with better PU were more likely to state a preference for comfort-focused care, and their PwDs were likely to receive fewer burdensome interventions and experience greater comfort during the dying process.

CONCLUSION

Our findings highlight the need for a comprehensive measure to assess the multifaceted nature of caregivers' PU, delve deeper into factors influencing caregivers' PU, and explore its impact on caregivers themselves.

Symptom management for people with advanced dementia who are receiving end of life care

PURPOSE OF REVIEW

This review aims to synthesise contemporary research on symptom management for people with advanced dementia who are thought to be in the final year of life. It highlights the unique challenges faced by palliative care and dementia care specialists, offering insights into the clinical decision-making required to support those with advanced dementia in various care settings.

RECENT FINDINGS

Recent studies indicate that people with advanced dementia often experience significant unmet palliative care needs, particularly regarding symptom management. Pain, breathlessness, and psychological distress are frequently mismanaged, which contributes to suboptimal care. Moreover, the unpredictable trajectory of dementia complicates the identification of end-of-life needs, which can result in fragmented care. Caregivers, both professional and family, struggle with managing complex symptoms, while family caregivers in home settings face added burdens in providing care without sufficient support.

SUMMARY

Palliative care for people with advanced dementia is currently inadequate due to a lack of tailored interventions, poor symptom management, and disjointed care systems. Enhancing training for caregivers, fostering interdisciplinary collaboration, and focusing on integrated care approaches across home and institutional settings are crucial to improving quality of life and symptom control for people with advanced dementia.

Changes in Place of Death Among Patients With Dementia During the COVID-19 Pandemic in Japan: A Time-series Analysis

BACKGROUND

A key measure of the effectiveness of end-of-life care is the place of death. The coronavirus disease 2019 (COVID-19) pandemic affected end-of-life care and the circumstances of patients with dementia.

METHODS

This observational, retrospective cohort study used Japanese national data to examine the numbers and locations of reported deaths among patients with dementia older than 65 years during the COVID-19 pandemic. Locations were grouped as medical institutions, nursing facilities, homes, or all settings. The quasi-Poisson regression model known as the Farrington algorithm was employed.

RESULTS

Between December 30, 2019, and January 29, 2023, 279,703 patients who died of causes related to dementia were reported in Japan. A decline was seen in early 2020, followed by increased numbers of deaths in homes, medical facilities, and nursing homes beginning in October 2020, December 2020, and March 2021, respectively. In 2021, the percentage of excess deaths at home peaked at 35.2%, while in 2022, those in medical facilities and nursing homes peaked at 18.8% and 16.6%, respectively. In 2022, the percentage of excess deaths in nursing homes exceeded that of other locations.

CONCLUSION

The results suggest a change in the preferred place of death, along with pandemic-related visitation restrictions among healthcare facilities. Excess deaths also suggest strained medical resources and limited access to care. Methodological limitations include data from a limited period (2017 onwards) and post-2020 data used to estimate data after 2021, albeit with weighting. Considering these findings, physicians should reconfirm preferred places of death among older patients with dementia.

Comfort feeding in hospitalised people with dementia: a retrospective study of survival following comfort feeding recommendations

OBJECTIVES

Persistent and significant swallowing impairment can occur in individuals with dementia. Determining prognosis and establishing realistic goals of care in this population is complex and comfort feeding may be recommended. This study aimed to establish evidence relating to patient outcomes following recommendation of comfort feeding to aid informed decision making.

DESIGN

A multi-centre, retrospective audit was conducted for a two-year period to establish the survival and readmission rates for hospitalised people with dementia, following recommendation of a comfort feeding plan.

SETTING

The study was conducted at three acute care hospitals in Adelaide, South Australia.

PARTICIPANTS

A total of 163 participants were included, 90 male and 73 female, with a median age of 88 years.

MEASUREMENTS

Mortality within 30 and 90 days of admission and readmission rates within 30 days of discharge were calculated.

RESULTS

Forty-two percent of participants died during the admission during which a comfort feeding plan was recommended. Overall median survival time and one month survival was 13 days and 25%, respectively. Readmission rates were low (7.4% of those discharged). Comfort feeding recommendations aligned with dysphagia severity and those for whom Nil By Mouth (NBM) or ice chips only were recommended were at highest risk of dying in hospital, those recommended thickened fluids +/- ice chips were most likely to be alive 30 days after their original admission date.

CONCLUSION

Dementia and comfort feeding were associated with high mortality rates, high rates of discharge to a supportive care facility and low readmission rates. Dysphagia severity associated with the consistency of fluids recommended.

Care trajectories and transitions at the end of life: a population-based cohort study

BACKGROUND

End-of-life periods are often characterised by suboptimal healthcare use (HCU) patterns in persons aged 65 years and older, with negative effects on health and quality of life. Understanding care trajectories (CTs) and transitions in this period can highlight potential areas of improvement, a subject yet only little studied.

OBJECTIVE

To propose a typology of CTs, including care transitions, for older individuals in the 2 years preceding death.

DESIGN

Retrospective cohort study.

METHODS

We used multidimensional state sequence analysis and data from the Care Trajectories-Enriched Data (TorSaDE) cohort, a linkage between a Canadian health survey and Quebec health administrative data.

RESULTS

In total, 2080 decedents were categorised into five CT groups. Group 1 demonstrated low HCU until the last few months, whilst group 2 showed low HCU over the first year, followed by a steady increase. A gradual increase over the 2 years was observed for groups 3 and 4, though more pronounced towards the end for group 3. A persistent high HCU was observed for group 5. Groups 2 and 4 had higher proportions of cancer diagnoses and palliative care, as opposed to comorbidities and dementia for groups 3 and 5. Overall, 68.4% of individuals died in a hospital, whilst 27% received palliative care there. Care transitions increased rapidly towards the end, most notably in the last 2 weeks.

CONCLUSION

This study provides an understanding of the variability of CTs in the last two years of life, including place of death, a critical step towards quality improvement.

Characteristics of people diagnosed with dementia vs lung cancer and cardiovascular disease at commencement of community palliative care: a population-based study

BACKGROUND

Most people diagnosed with dementia live and die in community settings. This study aimed to: (i) describe the palliative care needs of patients with dementia at commencement of community palliative care; (ii) compare palliative care needs between patients with dementia and those with lung cancer and cardiovascular disease (CVD).

METHODS

This is a population-based descriptive study that involved 8,727, 7,539 and 25,279 patients who accessed community palliative care across Australia principally because of dementia, CVD and lung cancer. Patients' functional abilities, symptom burden and clinical condition were assessed at commencement of community alliative care using five validated instruments: Resource Utilisation Groups-Activities of Daily Living, Australia-modified Karnofsky Performance Status, Symptoms Assessment Scale, Palliative Care Problem Severity Score and Palliative Care Phase. We fitted ordinal logistic regression models to examine the differences in these assessments for dementia versus CVD and lung cancer, respectively.

RESULTS

Overall, patients with dementia generally had low levels of distress from symptoms but poor functional problems. Compared to the other two diagnostic groups, palliative care for dementia was often initiated later and with shorter contacts. Also, patients with dementia presented with poorer functional performance (adjusted OR (aOR) = 4.02, Confidence Interval (CI): 3.68 - 4.38 for dementia vs CVD; aOR = 17.59, CI: 15.92 - 19.44 for dementia vs lung cancer) and dependency (aOR = 5.68, CI: 5.28 - 6.12 for dementia vs CVD; aOR = 24.97, CI: 22.77 - 27.39 for dementia vs lung cancer), but experienced lower levels of distress and problem severity for the majority of symptoms.

CONCLUSION

Community palliative care is often an ideal care option for many patients, particularly for those with dementia. We call for expansion of the palliative care workforce and options for home care support to optimize accessibility of community palliative care for dementia.

Dementia patients in palliative care according to data from the German National Hospice and Palliative Care Register (2009-2021)

BACKGROUND

People with dementia are less in focus of palliative care research than other patient groups even though the awareness of their palliative and end-of-life care needs is rising. Empirical data analyses on people with dementia in palliative care services are lacking.

AIM

To explore the prevalence of dementia diagnoses as per the ICD criteria among users of various palliative care settings and to compare use of palliative services, care pathways, and outcomes in people with and without a dementia diagnosis.

DESIGN

We conducted retrospective analysis of dementia diagnoses as per ICD (F00-F03/G30) in the German National Hospice and Palliative Care Register between 2009 and 2021. The analysis used methods of descriptive and inferential statistics, including the Bonferroni correction for alpha error inflation.

SETTING/PARTICIPANTS

We limited the analysis to the subsample of people aged over 64.

RESULTS

The prevalence of dementia in the different settings of palliative care was lower than in the age-comparable population: Of the 69,116 data sets included in the analysis, a small minority (3.3%) was coded with dementia as the principal diagnosis. Among patients on inpatient palliative care wards, 0.8% (148 of 19,161) had a dementia diagnosis, as did 2.2% (52 of 2,380) of those under hospital palliative care support teams and 4.3% (2,014 of 46,803) of those receiving specialized palliative care at home.

CONCLUSIONS

The records of the German National Hospice and Palliative Care Register suggest that the prevalence of dementia is lower than one might expect from general population data, though numbers are in line with international studies on proportion of dementia patients receiving palliative care. Future research could usefully examine whether this discrepancy stems either from omissions in coding dementia as patients' principal diagnosis respectively from lapses in documentation of a dementia diagnosis previously made, or from barriers to accessing palliative care services or even displays being excluded from palliative care when trying to access it.

TRIAL REGISTRATION

No registration.

Implementation of the Macao dementia policy: a scoping review for the way forward

Background

The implementation of dementia policy is a complex process of translating policy goals to actions to address the changing needs of people living with dementia. Leveraging on others' experiences would help policy decision-makers and actors better prepare for the challenges.

Purpose

This study explored the development, the implementation and the impact of the dementia policy in Macao, a "role model" recognized by the Alzheimer's Disease International.

Methods

A scoping review of policies, strategies, and news articles, as well as scholarly work from 6 scientific databases dated till March 2023 was conducted under the guidance of the Health Policy Triangle Framework.

Results

According to 284 documents, the dementia policy in Macao, driven by government leadership and supported with public-private partnership, aimed to integrate health and social services to achieve the goals of "Early prevention, Early detection, Early diagnosis, Early treatment and Early support." Promoting the preparedness according to the dementia burden trajectory, empowering the public and the service providers with training and education, and encouraging services-related research were among the key actions. With major changes in dementia care configuration, a dementia service network, a dementia-friendly community and a one-stop service model for disease screening, diagnosis, treatment and support have been developed.

Discussion

Reconfiguring existing resources in the health and social services to form an integrated service network at the community level could be considered a priority of action. Continuous engagement, collaboration and empowerment at different levels across these sectors is crucial for the sustainability of a dementia policy.

Experiences of Individual Care Workers in Oral Care of Dementia Patients

Objective: Dementia is one of the most common diseases in the elderly population. The aim of this study was to reveal the experiences of individual care workers performing oral care for dementia patients. The oral health of the elderly is in a critical state and in most cases not enough attention is paid to this problem. Material and methods: A qualitative research method was chosen for the research. The data collection instrument was a semi-structured interview, the purpose of which was to reveal the experience, knowledge, and attitude of individual care workers towards the importance of oral care and the oral hygiene habits of patients with dementia. The number of research informants was 10. The inclusion criteria were individual care workers working in social care institutions who were responsible for the personal care of dementia patients. Results: The analysis of the study showed that the main obstacles facing individual care workers in performing oral care for dementia patients are related to their cognitive disorders. For this reason, unreasonable fears of patients may arise, which also affect the proper performance of individual oral hygiene and other tasks assigned to employees. Conclusions: The results of the study showed that according the informants' opinions it is crucial to take care of dementia patients' oral care daily.

Desired dementia care towards end of life: Development and experiences of implementing a new approach to improve person-centred dementia care

AIMS

To describe the co-creation of the 'Desired Dementia Care Towards End of Life' (DEDICATED) approach to improve person-centred palliative care for individuals with dementia and to describe the experiences of healthcare professionals during the approach's implementation.

METHODS

A needs assessment, comprising both qualitative and quantitative studies, informed palliative care needs of healthcare professionals, family caregivers and individuals with dementia. The approach was co-created with healthcare and education professionals, guided by the findings. Then, healthcare professionals were trained to implement the approach in their organizations. From April to June 2022, semi-structured interviews with actively engaged professionals were analysed using Conventional Content Analysis.

RESULTS

The needs assessment yielded six key themes: (1) raising palliative care awareness, (2) familiarization with a person with dementia, (3) communication about future care preferences, (4) managing pain and responsive behaviour, (5) enhancing interprofessional collaboration in advance care planning and (6) improving interprofessional collaboration during transitions to nursing homes. Interviews with 17 healthcare professionals revealed that active involvement in co-creating or providing feedback facilitated implementation. Overall, the DEDICATED approach was perceived as a valuable toolkit for optimizing palliative care for people with dementia and their loved ones.

CONCLUSION

Co-creating the DEDICATED approach with healthcare professionals facilitated implementation in daily practice. The approach was considered helpful in enhancing person-centred palliative dementia care.

IMPACT STATEMENT

This study underscores the importance of active involvement of healthcare professionals in the research and development of new interventions or tools for palliative care, which can influence the successful implementation, dissemination and sustained usage of the developed tools.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The developed approach can improve person-centred palliative care for individuals with dementia, ultimately improving their quality of life and that of their loved ones.

REPORTING METHOD

This study used the Consolidated Criteria for Reporting Qualitative Research.

PATIENT OF PUBLIC CONTRIBUTION

No patient or public contribution.

Evaluation of a dementia awareness game for health professions students in Northern Ireland: a pre-/post-test study

BACKGROUND

Dementia is a prevalent global health issue, necessitating comprehensive education for healthcare practitioners and students. Nursing and pharmacy students, provide support across healthcare settings often working as frontline caregivers. Therefore, it is imperative to equip these students with a profound understanding of dementia. The aim of this study was to evaluate whether a serious dementia game co-designed with stakeholders, students, and people living with dementia improved the attitudes of nursing and pharmacy students.

METHODS

A pretest-posttest design was used to assess the attitudes of health professions students (nursing and pharmacy) towards dementia. The Approaches to Dementia Questionnaire (ADQ) was administered before and after playing a serious Dementia Game. The ADQ measured the total score, Hope subscale, and Recognition of Personhood subscale. Matched pairs t-test was used for analysis conducted with IBM SPSS statistics 27.

RESULTS

A diverse cohort of 505 participants from one university in Northern Ireland participated, with 461 matched pairs used for analysis. Both nursing and pharmacy students demonstrated a significant increase in overall dementia attitudes post-gameplay, with nursing students showing an increase from 79.69 to 83.59 and pharmacy students from 75.55 to 79.86. Subscales for Hope (Nursing = 28.77 to 31.22, Pharmacy = 26.65 to 29.20). and Recognition of Personhood also exhibited significant improvement (Nursing = 50.93 to 52.38, Pharmacy = 48.89 to 50.67). Demographic data revealed predominantly female participants, a lack of personal connections to dementia, and varied training experiences.

DISCUSSION

The study highlights the efficacy of the serious Dementia Game in enhancing attitudes to dementia amongst health professions students, indicating its potential as an educational tool. The study contributes to the growing body of evidence supporting serious games and gamification in healthcare education.

Factors associated with dietitian referrals to support long-term care residents advancing towards the end of life

BACKGROUND

Dietitians are central members of the multidisciplinary long-term care (LTC) healthcare team. The overall aim of this current investigation is to gain a better understanding of dietitian involvement in LTC resident's end-of-life care via referrals.

METHODS

Retrospective chart reviews for 164 deceased residents (mean age = 88.3 ± 7.3; 61% female) in 18 LTC homes in Ontario, Canada, identified dietitian referrals and documented eating challenges recorded over 2-week periods at four time points (i.e., 6 months, 3 months, 1 month and 2 weeks) prior to death. Nutrition care plans at the beginning of these time points were also noted. Logistic mixed effects regression models identified time-varying predictors of dietitian referrals. Bivariate tests identified associations between nutrition orders and dietitian referrals that occurred in the last month of life.

RESULTS

Nearly three-quarters (73%) of participants had at least one dietitian referral across the four observations. Referrals increased significantly with proximity to death; 45% of residents had a referral documented in the last 2 weeks of life. Dietitian referrals were associated with the number of eating challenges (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.27, 1.58). Comfort-focused nutrition care orders were significantly more common when a dietitian was referred (25%) compared with when a dietitian was not referred (12%) in the final month of life (p = 0.04).

CONCLUSIONS

Our findings suggest that dietitians are involved in end-of-life and comfort-focused nutrition care initiatives, yet they are not engaged consistently for this purpose. This presents a significant opportunity for dietitians to upskill and champion palliative approaches to nutrition care within the multidisciplinary LTC team.

End-of-Life Symptoms in Adult Patients With Stroke in the Last Two Years of Life: An Integrative Review

BACKGROUND

Stroke is a leading cause of death globally, yet End-of-Life (EOL) symptoms and their management in these patients are not well understood.

PURPOSE

This integrative review aims to critique and synthesize research on EOL symptoms and symptom management in adult patients with stroke in the last 2 years of life in all settings.

METHODS

The Whittemore and Knafl integrative review methodology guided this review. PubMed, CINAHL, Scopus, Web of Science, and Google Scholar were used for the literature search. Included studies were published in English and quantitatively examined symptoms and symptom management. Quality appraisal was guided by the Effective Public Health Practice Project (EPHPP) assessment tool.

RESULTS

Seven studies, all rated weak, were included in this review. A total of 2175 adult patients from six countries were represented. Results are classified into three main themes: EOL symptom experience, symptom assessment, and symptom management. Commonly reported EOL symptoms among adults with stroke include both stroke-specific (dysphagia, dysarthria) and non-specific symptoms (pain, dyspnea, constipation, and psychological distress). However, communication difficulties and the infrequent use of standardized tools for symptom assessment limit what is known about the EOL symptom experience. Although the relief of pain is generally well-documented, dyspnea and anxiety are much more poorly controlled.

CONCLUSIONS

There is a need for better assessment and management of EOL symptoms in patients with stroke. Established palliative and EOL care guidelines need to be incorporated into clinical practice to ensure access to high-quality care.

End-of-Life Care of Persons with Alzheimer's Disease and Other Dementias

End-of-life (EOL) care has been a common option for patients with terminal medical conditions such as cancers. However, the utilization of EOL care in Alzheimer disease and other dementing conditions have become available relatively recently. As the end-stage dementia approaches, the clinicians and caregivers become faced with numerous clinical challenges-delirium, neuropbehavioral symptoms, the patient's inability to communicate pain and associated discomfort, food refusal, and so on. In addition to providing quality clinical care to the EOL patients, clinicians should pay special attention to their families, assuring that their loved ones will receive supportive measures to improve quality of life (QOL).

Risk management and decision-making in dementia care

What constitutes a risk for a person living with dementia may be perceived and prioritised differently by nurses from varying clinical backgrounds. Furthermore, risk may be perceived differently according to the context. This article outlines some of the social, psychological and physical risk factors relevant to people living with dementia across the life course of the condition. It is important that nurses understand their role in identifying, assessing and managing risk and are aware of the resources, policies, legislation and processes designed to support decision-making and minimise the risk of harm to people living with dementia, their families and carers. The authors hope that this article will support nurses to become more confident in identifying risk while encouraging them to adopt a proactive and person-centred approach to risk assessment and management.

Place of care in the last three years of life for Medicare beneficiaries

BACKGROUND

Most older adults prefer aging in place; however, patients with advanced illness often need institutional care. Understanding place of care trajectory patterns may inform patient-centered care planning and health policy decisions. The purpose of this study was to characterize place of care trajectories during the last three years of life.

METHODS

Linked administrative, claims, and assessment data were analyzed for a 10% random sample cohort of US Medicare beneficiaries who died in 2018, aged fifty or older, and continuously enrolled in Medicare during their last five years of life. A group-based trajectory modeling approach was used to classify beneficiaries based on the proportion of days of institutional care (hospital inpatient or skilled nursing facility) and skilled home care (home health care and home hospice) used in each quarter of the last three years of life. Associations between group membership and sociodemographic and clinical predictors were evaluated.

RESULTS

The analytic cohort included 199,828 Medicare beneficiaries. Nine place of care trajectory groups were identified, which were categorized into three clusters: home, skilled home care, and institutional care. Over half (59%) of the beneficiaries were in the home cluster, spending their last three years mostly at home, with skilled home care and institutional care use concentrated in the final quarter of life. One-quarter (27%) of beneficiaries were in the skilled home care cluster, with heavy use of skilled home health care and home hospice; the remaining 14% were in the institutional cluster, with heavy use of nursing home and inpatient care. Factors associated with both the skilled home care and institutional care clusters were female sex, Black race, a diagnosis of dementia, and Medicaid insurance. Extended use of skilled home care was more prevalent in southern states, and extended institutional care was more prevalent in midwestern states.

CONCLUSIONS

This study identified distinct patterns of place of care trajectories that varied in the timing and duration of institutional and skilled home care use during the last three years of life. Clinical, socioregional, and health policy factors influenced where patients received care. Our findings can help to inform personal and societal care planning.

Hospice and Palliative Care-Men and Gender-Specific Roles

All people face end of life as the final health outcome. When a person's health focus shifts from quantity to quality of life, palliative care comes into view. Clinicians serving patients across the health care spectrum must be aware of the nature and efficacy of palliative and hospice care, indications for referral to services, and current best practices. Creating an end-of-life trajectory requires an individualized and global personal plan, which palliative and hospice care can provide. Gender-specific care that includes gender minorities provides special and unique challenges to those seeking palliative and hospice care.

The Social Construction of Dementia: Implications for Healthcare Experiences of Caregivers and People Living with Dementia

Globally, systems have invested in a variety of dementia care programs in response to the aging population and those who have been diagnosed with dementia. This study is a qualitative secondary analysis of interview data from a larger study investigating stakeholder perceptions of programs that support caregivers and people living with an Alzheimer's Disease or Alzheimer's Disease-related dementia (AD/ADRD) in five North American jurisdictions. This study analyzed interviews with individuals living with an AD/ADRD and caregivers of individuals living with an AD/ADRD (n = 11). Thematic analysis was conducted to understand how the perception of dementia may have shaped their engagement and experience with healthcare systems. Our analysis resulted in three main themes of care users' experience: (i) undesirable experience owing to the overarching negative shared understanding and stereotyping of dementia; (ii) dismissal throughout disease progression when seeking health and social care support; and (iii) dehumanization during care interactions. The findings carry critical social and clinical implications, for example, in informing person-centered approaches to care, and communication tools clinicians can use to enhance provider, patient, and caregiver well-being.

Supportive care decision-making processes of persons with dementia and their caregivers

Little is known about the decision-making processes around seeking more supportive care for dementia. Persons with dementia are often left out of decision-making regarding seeking more supportive care as their dementia progresses. This paper provides a description of findings from the Decision-making in Alzheimer's Research project (DMAR) investigating the process of decision-making about transitions to more supportive care. We conducted 61 qualitative interviews with two stakeholder groups: 24 persons with dementia, and 37 informal caregivers to explore supportive care decisions and associated decision-making factors from the perspectives of persons with dementia and their caregivers. We identified four main decisions that persons with dementia and their informal caregivers played a role in: (1) sharing household responsibilities; (2) limiting routine daily activities; (3) bringing in formal support; and (4) moving to a care facility. Based on our findings we developed a schematized roadmap of decision-making that we used to guide the discussion of our findings. Four crosscutting themes emerged from our analysis: unknowns and uncertainties, maintaining life as you know it, there's no place like home and resource constraints. These results will be incorporated into the development of instruments whose goal is to identify preferences of persons with dementia and their caregivers, in order to include persons with dementia in care decisions even as their dementia progresses.

I want to be seen as myself: needs and perspectives of persons with dementia concerning collaboration and a possible future move to the nursing home in palliative dementia care

Introduction: Interprofessional collaboration (IPC) within and during movements between care settings is crucial for optimal palliative dementia care. The objective of this study was to explore the experiences of persons with dementia regarding collaboration with and between healthcare professionals (HCPs) and their perceptions of a possible future move to the nursing home (NH) in palliative dementia care. Method: We conducted a cross-sectional qualitative study and performed semi-structured interviews with a purposive sample of persons with dementia living at home (N = 18). Data analysis involved content analysis. Results: Our study demonstrated that even though most persons with dementia find it difficult to perceive the collaboration amongst HCPs, they could describe their perceived continuity of care (Theme 1. My perception of collaboration among HCPs). Their core needs in collaboration with HCPs were receiving information, support from informal caregivers, personal attention and tailored care (Theme 2. My needs in IPC). Regarding a possible future move to the NH, persons with dementia cope with their current decline, future decline and a possible future move to the NH (Theme 3. My coping strategies for a possible future move to the NH). They also prefer to choose the NH, and continue social life and activities in their future NH (Theme 4. My preferences when a NH becomes my possible future home). Conclusion: Persons with dementia are collaborative partners who could express their needs and preferences, if they are willing and able to communicate, in the collaboration with HCPs and a possible future move to the NH.

'Making the most of time during personal care': nursing home staff experiences of meaningful engagement with residents with advanced dementia

OBJECTIVES

Dementia progressively affects cognitive functioning, including the ability to communicate. Those who struggle to communicate are often considered unable to relate to other people. Frontline care workers are in a position to connect with residents. However, we know little about their perspectives. The aim of this study was to understand how and when nursing home staff meaningfully engaged with residents with advanced dementia.

METHODS

Semi-structured interviews, supplemented by informal conversations, were conducted with 21 staff from seven nursing homes. Inductive thematic analysis identified themes in the accounts.

RESULTS

Four themes related to how staff engaged with residents with advanced dementia (initiating meaningful engagement, recognising subtle reactions, practising caring behaviours, patience and perseverance). Two themes related to when meaningful engagement occurred (lacking time to connect, making the most of time during personal care).

CONCLUSION

A key barrier to implementing formal interventions to improve care is lack of staff time. Staff overcome this by using personal care time for meaningful engagement with residents. Their approach, developed through experience, is consonant with person-centred dementia care. Building on this, future research should use participatory approaches building on practice wisdom to further develop and evaluate meaningful engagement with residents with advanced dementia.

Using Functional Status at the Time of Palliative Care Consult to Identify Opportunities for Earlier Referral

Background: In order to improve early access to palliative care, strategies for monitoring referral practices in real-time are needed. Objective: To evaluate how Australia-Modified Karnofsky Performance Status (AKPS) at the time of initial palliative care consult differs between serious illnesses and could be used to identify opportunities for earlier referral. Methods: We retrospectively evaluated data from an inpatient palliative care consult registry. Serious illnesses were classified using ICD-10 codes. AKPS was assessed by palliative care clinicians during consult. Results: The AKPS distribution varied substantially between the different serious illnesses (p < 0.001). While patients with cancer and heart disease often had preserved functional status, the majority of patients with dementia, neurological, lung, liver, and renal disease were already completely bedbound at the time of initial palliative care consult. Conclusion: Measuring functional status at the time of palliative care referral could be helpful for monitoring referral practices and identifying opportunities for earlier referral.

Staff and Proxy Views of Multiple Family Member Involvement in Decision Making for Nursing Home Residents With Advanced Dementia

Decision making for nursing home (NH) residents with Alzheimer disease and related dementias often involves input from multiple family members and NH staff to address goals of care at the end of life. Using data from the Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life research study, a secondary analysis of qualitative data was conducted involving interviews of 144 NH staff and 44 proxies in 14 NHs to examine the perspectives of NH staff and proxies for NH residents with Alzheimer disease and related dementias on the involvement of multiple family members in decision making about end-of-life care decisions. Interviews took place between 2018 and 2021. Nursing home staff and proxies had differing perspectives of the involvement of multiple family members in decision making, with NH staff primarily viewing families as a source of conflict, whereas proxies viewed families as a source of support. Nursing home staff also had differing opinions of their role with families; some attempted to ameliorate conflict, and some did not get involved. Some NH staff felt that Black families had more conflict than White families, indicating unacceptable bias and stereotyping of Black families by NH staff. These findings suggest training and education is needed for NH staff to facilitate better communication with families and to support proxies in end-of-life decision making to address goals of care for NH residents with Alzheimer disease and related dementias.

Nutrition and Non-Nutrition-Related Challenges Predict Time to Death in Long-Term Care Residents: A Retrospective Chart Review

Purpose

Signals of end-of-life decline observed in daily habits, such as mealtime participation, are important for moving towards comfort-focused goals of care in the final months of life of long-term care (LTC) residents. It is unclear how eating issues observed in real-time in LTC homes are used as indicators of suspected end of life. The study quantifies nutrition and key non-nutrition related signals (eg, general decline, unstable vitals) documented to describe end-of-life decline and the subsequent time to death.

Patients and Methods

A retrospective chart review identified the first documented conversation where end-of-life decline was considered by members of the care team (eg, nurses, physicians, dietitian, family member) for 76 randomly selected decedents from 9 LTC homes in southwestern Ontario, Canada. Time (days) to death was calculated. A directed content analysis of the free-text description of the suspected end-of-life decline was used to categorize signals. Cox proportional hazards regression analysis tested the risk of mortality associated with each categorized signal.

Results

Time to death of residents (mean age = 88 ± 7 years; 60% female) from the first documentation of potential end-of-life decline ranged from 0 days to over 2 years prior to death (median = 27.5 days). Seven nutrition-related and 18 non-nutrition related signals were identified. Swallowing difficulty (HR = 2.99; 95% CI = 1.41, 6.33), cognitive decline (HR = 0.40; 95% CI = 0.20, 0.77), delirium (HR = 13.23; 95% CI = 1.57, 111.69), and cancer (HR = 0.18; 95% CI = 0.07, 0.48) were associated with time to death.

Conclusion

This study provides insight into the signals used by care providers in LTC to suspect that residents are declining towards the end of life and identifies four signals that were associated with time to death. When identified by care providers as indicators of end-of-life decline, swallowing difficulty and delirium predicted a shorter time to death, while cancer and cognitive decline predicted a longer time to death. Recognition of nutrition and non-nutrition related signals may be leveraged to systematically introduce timely comfort care conversations.

Urgent needs of caregiving in ageing populations with Alzheimer's disease and other chronic conditions: Support our loved ones

The ageing process begins at birth. It is a life-long process, and its exact origins are still unknown. Several hypotheses attempt to describe the normal ageing process, including hormonal imbalance, formation of reactive oxygen species, DNA methylation & DNA damage accumulation, loss of proteostasis, epigenetic alterations, mitochondrial dysfunction, senescence, inflammation, and stem cell depletion. With increased lifespan in elderly individuals, the prevalence of age-related diseases including, cancer, diabetes, obesity, hypertension, Alzheimer's, Alzheimer's disease and related dementias, Parkinson's, and other mental illnesses are increased. These increased age-related illnesses, put tremendous pressure & burden on caregivers, family members, and friends who are living with patients with age-related diseases. As medical needs evolve, the caregiver is expected to experience an increase in duties and challenges, which may result in stress on themselves, and impact their own family life. In the current article, we assess the biological mechanisms of ageing and its effect on body systems, exploring lifestyle and ageing, with a specific focus on age-related disorders. We also discussed the history of caregiving and specific challenges faced by caregivers in the presence of multiple comorbidities. We also assessed innovative approaches to funding caregiving, and efforts to improve the medical system to better organize chronic care efforts, while improving the skill and efficiency of both informal and formal caregivers. We also discussed the role of caregiving in end-of-life care. Our critical analysis strongly suggests that there is an urgent need for caregiving in aged populations and support from local, state, and federal agencies.

Home-based care for people living with dementia at the end of life: the perspective of experts

BACKGROUND

In the last phase of their lives, people living with dementia often indicate restlessness, anxiety or pain. Further, their care is considered inadequate, as they are, for example, sometimes overtreated for curative care or undertreated for pain management. These patients also face multiple barriers in accessing palliative care. This qualitative study explores the perception of experts about how people living with dementia in Germany are cared for at home toward the end of their lives.

METHODS

A total of 12 experts involved in outpatient/palliative care were recruited to constitute a purposive, heterogeneous sample. Interviews, which were structured using an interview guide, were conducted with physicians, nurses, representatives of health insurance funds, welfare associations, municipal counselling centres, scientists and coordinators of outpatient palliative care and voluntary work; the interviews were transcribed and analysed via thematic content analysis, based on Kuckartz's method.

RESULTS

The analysis of the results led to the establishment of four main categories that focused on formal care arrangements, the roles of relatives in care arrangements, the specifics of dementia, and restrictions on access to palliative care.

CONCLUSIONS

Suitable end-of-life care for people living with dementia and support for their relatives require resources and the conceptualisation of specific care arrangements to help minimise potential barriers that prevent access to palliative care.

It is not depression: A case report of a 37-year-old firefighter with frontotemporal dementia

A 37-year-old married, right-handed active firefighter presented to the primary care clinic with a self-report of difficulties in memorising and recalling information associated with declining work performance. Collaborative history-taking revealed that he also experienced emotional and social withdrawal, apathy, irritability and distractibility. He was initially diagnosed with major depressive disorder but showed no improvement with an antidepressant. This young man with no history of hereditary neurodegenerative disorder had further deterioration in cognitive function, predominantly executive behaviours, with progressive aphasia. Brain magnetic resonance imaging revealed cerebral atrophy predominant over the frontotemporal lobe. Positron emission tomography showed fluorodeoxyglucose hypometabolism at the bifrontal and left parietal and temporal cortices, consistent with frontotemporal dementia. He required institutionalisation with full nursing care less than 24 months after the onset of the symptoms. This case highlights the need for diagnostic consideration of dementia in young individuals presenting with cognitive impairment among other symptoms. It also emphasises the importance of obtaining collateral information from close relatives to avoid misdiagnosis and addresses the psychosocial impact of dementia at a young age.

Inter-rating reliability of the Swiss easy-read integrated palliative care outcome scale for people with dementia

BACKGROUND

The Integrated Palliative Care Outcome Scale for People with Dementia is a promising instrument for nursing home quality improvement and research in dementia care. It enables frontline staff in nursing homes to understand and rate the needs and concerns of people with dementia. We recently adapted the measure to include easy language for users from various educational backgrounds.

OBJECTIVES

In this study, we examine the inter-rating reliability of the Integrated Palliative Care Outcome Scale for People with Dementia for frontline staff in nursing homes.

METHODS

In this secondary analysis of an experimental study, 317 frontline staff members in 23 Swiss nursing homes assessed 240 people with dementia from a convenience sample. Reliability for individual items was computed using Fleiss Kappa. Because of the nested nature of the primary data, a generalisability and dependability study was performed for an experimental IPOS-Dem sum score.

RESULTS

The individual Integrated Palliative Care Outcome Scale for People with Dementia items showed kappa values between .38 (95% CI .3-.48) and .15 (95% CI .08-.22). For the experimental IPOS-Dem sum score, a dependability index of .57 was found. The different ratings and time between ratings explain less than 2% of the variance in the sum score. The different nursing homes make up 12% and the people with dementia make up 43% of the sum score variance. The dependability study indicates that an experimental IPOS-Dem sum score could be acceptable for research by averaging two ratings.

CONCLUSION

Limited research has been conducted on the measurement error and reliability of patient-centred outcome measures for people with dementia who are living in nursing homes. The Swiss Easy-Read IPOS-Dem is a promising instrument but requires further improvement to be reliable for research or decision making. Future studies may look at its measurement properties for different rater populations or at different stages of dementia. Furthermore, there is a need to establish the construct validity and internal consistency of the easy-read IPOS-Dem.

Prevalence of Malnutrition in People with Dementia in Long-Term Care: A Systematic Review and Meta-Analysis

Dementia is a common syndrome in older people. Dementia alters eating behaviors, hunger and thirst cues, swallow function, ability to self-feed, and recognition and interest in food. There is significant variation in the reported prevalence of malnutrition among older people who live in long-term care. The aim was to conduct a systematic literature review and meta-analysis of the prevalence of malnutrition in those with dementia living in long-term care using a validated nutrition assessment tool. Scopus, Web of Science, CINAHL, and Medline were searched. A random effects model was used to determine the prevalence and risk of malnutrition. Data were retrieved from 24 studies. Most of the studies were from Europe or South Asia. The prevalence of malnutrition ranged from 6.8 to 75.6%, and the risk of malnutrition was 36.5-90.4%. The pooled prevalence of malnutrition in those with dementia in long-term care was 26.98% (95% CI 22.0-32.26, p < 0.0001, I² = 94.12%). The pooled prevalence of the risk of malnutrition in those with dementia was 57.43% (95% CI 49.39-65.28, p < 0.0001, I² = 97.38%). Malnutrition is widespread in those with dementia living in long-term care. Further research exploring malnutrition in other industrialized countries using validated assessment tools is required.

Predicting mortality in patients diagnosed with advanced dementia presenting at an acute care hospital: the PROgnostic Model for Advanced DEmentia (PRO-MADE)

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.

Palliative care and new technologies. The use of smart sensor technologies and its impact on the Total Care principle

BACKGROUND

Palliative care is an integral part of health care, which in term has become increasingly technologized in recent decades. Lately, innovative smart sensors combined with artificial intelligence promise better diagnosis and treatment. But to date, it is unclear: how are palliative care concepts and their underlying assumptions about humans challenged by smart sensor technologies (SST) and how can care benefit from SST?

AIMS

The paper aims to identify changes and challenges in palliative care due to the use of SST. In addition, normative guiding criteria for the use of SST are developed.

METHODS

The principle of Total Care used by the European Association for Palliative Care (EAPC) forms the basis for the ethical analysis. Drawing on this, its underlying conceptions of the human and its socio-ethical aspects are examined with a phenomenological focus. In the second step, the advantages, limitations, and socio-ethical challenges of using SST with respect to the Total Care principle are explored. Finally, ethical-normative requirements for the application of SST are derived.

RESULTS AND CONCLUSION

First, SST are limited in their measurement capabilities. Second, SST have an impact on human agency and autonomy. This concerns both the patient and the caregiver. Third, some aspects of the Total Care principle are likely to be marginalized due to the use of SST. The paper formulates normative requirements for using SST to serve human flourishing. It unfolds three criteria according to which SST must be aligned: (1) evidence and purposefulness, (2) autonomy, and (3) Total Care.

Staff perspectives on end-of-life care for people living with dementia in residential aged care homes: qualitative study

Introduction

People living with dementia in care homes can benefit from palliative approaches to care; however, not all will require specialist palliative care. The generalist aged care workforce is well placed to provide most of this care with adequate training and support systems in place, but little is known about their experiences.

Objective

To describe staff perspectives on providing quality end-of-life care for people living with dementia in residential care and their families.

Methods

Focus groups and semi-structured interviews were conducted with residential aged care managerial and frontline staff in Australia who were caring for residents living with dementia and end-of life needs. A comprehensive, then snowballing sampling strategy was used in participating care homes. Transcripts were analyzed using reflexive thematic analysis.

Results

Fifteen semi-structured interviews and six focus groups were undertaken with 56 participants across 14 sites across two Australian states. Five themes were identified: putting the resident at the center (creating homes not hospitals, knowing the individual, a case management approach); articulating goals to grant wishes (initiating the conversation, broadening death literacy, avoiding hospitalization); a collective call to action (staffing the home, recognizing deterioration and escalating issues, communication channels and engaging GPs, managing medications, psychosocial supports); educating to empower staff (governance and guidance, mentoring juniors, self-care); and facilitating family acceptance (setting expectations, partnering in care, access at all hours).

Discussion

Aged care staff are committed to providing person-centered palliative and end-of-life care for people living with dementia, recognizing the intrinsic value of each resident, regardless of their declining state. Frontline and managerial staff consider advance care planning, collectively working as part of a multidisciplinary team, access to targeted palliative and end-of-life education and training, and engaging families as key priorities to providing high quality care in care homes.

Total pain in advanced dementia: a quick literature review

Objective: This quick literature review aimed to organize information on the detailed components of total pain in older people with advanced dementia in a holistic manner. Materials and Methods: The authors analyzed qualitative data from relevant clinical guidelines or textbooks, focusing on certain types of pain and distress in older people with advanced dementia, followed by an expert panel review by research team members. In the search, the authors defined a person with advanced dementia as having a functional assessment staging tool scale score greater than or equal to six. Results: The model covered a wide variety of pain, from physical pain to dementia-related psychological and spiritual aspects of total pain, including living environment change, stigma, discrimination, lack of communication and understanding, loss of sense of control and dignity, and cultural distress. It also identified physical appearance as an important factor in dying with dignity, as established by existing research on individuals with incurable cancers. Conclusion: The conceptual model of total pain in people with advanced dementia is expected to help turn healthcare professionals' attention to physical, psychological, social, and spiritual contributors to total pain in advanced dementia.

Dementia Care at the End of Life: A Clinically Focused Review

With the geriatric population in the United States growing rapidly, the prevalence of dementia is expected to rise concomitantly. As dementia is an invariably progressive and terminal illness, planning for and managing end of life care in dementia is an important part of the overall process of dementia care. Unfortunately, this is often neglected outside of formal palliative and hospice medicine training programs and geriatric psychiatrists are left without preparation on how to manage, as well as counsel patients and families on, this important phase of dementia care. This review aims to explore the potential contributors to this historic disparity in geriatric education and care delivery, as well as its impact, while also attempting to shift the field's focus toward a palliative approach to dementia care. To begin to accomplish this, this review explores the natural illness history/disease trajectory of the various dementing illnesses, as well as the topic of prognostication as it pertains to the end of life for patients with dementia and how this information can be used in advanced care planning and symptom management.

Nurses' support needs in providing high-quality palliative care to persons with dementia in the hospital setting: A cross-sectional survey study

BACKGROUND

Since dementia is an irreversible progressive disease characterized by a decline in mental functions and overall health, a palliative care approach is recommended. Nevertheless, many persons with dementia experience burdensome hospitalizations in end-of-life care. Their quality of life during hospitalization can be improved by palliative nursing care that suits their fragile health.

AIM

To explore hospital nurses' perceived support needs while providing high-quality palliative care for persons with dementia and to identify differences between nurses in different ward types and at different educational levels.

DESIGN

Cross-sectional, multicenter survey study.

METHOD

Between January 2021 and April 2021, a convenience sample of Dutch hospital nurses received a web-based questionnaire on the topics of palliative caregiving, communication, collaboration, and hospital admissions. The data were analyzed using descriptive statistics.

RESULTS

The survey was completed by 235 nurses. The most frequently endorsed support needs were "communicating with persons with severe dementia" (58.3%), "appointing a permanent contact person in the care for persons with dementia" (53.6%), and "dealing with family disagreement in end-of-life care" (53.2%). If nurses had more time to provide care, 66.4% of them would prioritize providing personal attention. Most support needs identified by nurses were similar.

CONCLUSION

A heterogeneous group of nurses demonstrates overall similar support needs in providing palliative care for persons with dementia and their families in the hospital setting.

CLINICAL RELEVANCE

Nursing practices should implement dementia-friendly interventions to improve the quality of dementia care in the hospital.

Triggering palliative care referrals through the identification of poor prognosis in older patients presented to emergency departments in rural Australia

Background: Without objective screening for risk of death, the palliative care needs of older patients near the end of life may be unrecognised and unmet. Aim: This study aimed to estimate the usefulness of the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL) tool in determining older patients' risk of death within 3-months after initial hospital admission. Methods: A prospective cohort study of 235 patients aged 70+ years, who presented to two rural emergency departments in two adjacent Australian states, was utilised. The 'risk of death' of each patient was screened with the CriSTAL prognostic tool. Their 3-month follow-up outcomes were assessed through telephone interviews and a clinical record review. Findings: A CriSTAL cut-off score of more than 7 yielded a sensitivity of 80.7% and specificity of 70.81% for a 3-month risk of death. Palliative care services were only used by 31% of the deceased in their last trimester of life. Conclusion: Prognostic tools provide a viable means of identifying individuals with a poor prognosis. Identification can trigger an earlier referral to palliative care, which will benefit the patient's wellbeing and quality of life.

Dementia palliative care education and training for healthcare professionals: A scoping review protocol

Background: Global mortality rates from dementia continue to rise.  Evidence suggests that there is limited provision of palliative care for people with dementia and this is a cause of grave concern. The coronavirus disease 2019 (COVID-19) pandemic has further exposed the inequalities of care for this vulnerable population. Proactive palliative care, delivered by multidisciplinary healthcare professionals (HCPs), can offer significant benefits to people with dementia.  However, little is known about the components of effective education and training for HCPs who care for people with advancing dementia at end of life. Objective: The aim of this scoping review is to identify effective education and training interventions for HCPs, who care for people with advanced dementia approaching end of life. Inclusion criteria: Studies that used a palliative care educational intervention for HCPs working with patients with dementia will be included. Studies that explore undergraduate or postgraduate education and training in dementia palliative care for HCPs will be included.  Study designs such as quantitative, qualitative, mixed method studies, and case studies will be included. Methods: The Joanna Briggs Institute (JBI) methodology for scoping reviews will be used for this review. The following databases will be searched: CINAHL, ERIC, Medline, SocIndex, PsycINFO. In addition, grey literature searches will be limited to the first 100 searches using Google Scholar and Open-Grey. Study selection will involve the reviewer screening titles and abstracts. Then, two independent reviewers will further assess the studies in full for those that meet the inclusion criteria. In line with the JBI framework, data will be extracted using a draft data extraction tool. This will facilitate a chronological narrative synthesis of results in line with the study's overall aim to identify effective education and training interventions for HCPs, who care for patients with dementia, nearing end of life.

Dementia palliative care education and training for healthcare professionals: A scoping review protocol

Background: Global mortality rates from dementia continue to rise.  Evidence suggests that there is limited provision of palliative care for people with dementia and this is a cause of grave concern. The coronavirus disease 2019 (COVID-19) pandemic has further exposed the inequalities of care for this vulnerable population. Proactive palliative care, delivered by multidisciplinary healthcare professionals (HCPs), can offer significant benefits to people with dementia.  However, little is known about the components of effective education and training for HCPs who care for people with advancing dementia at end of life. Objective: The aim of this scoping review is to identify effective education and training interventions for HCPs, who care for people with advanced dementia approaching end of life. Inclusion criteria: Studies that used a palliative care educational intervention for HCPs working with patients with dementia will be included. Studies that explore undergraduate or postgraduate education and training in dementia palliative care for HCPs will be included.  Study designs such as quantitative, qualitative, mixed method studies, and case studies will be included. Methods: The Joanna Briggs Institute (JBI) methodology for scoping reviews will be used for this review. The following databases will be searched: CINAHL, ERIC, Medline, SocIndex, PsycINFO. In addition, grey literature searches will be limited to the first 100 searches using Google Scholar and Open-Grey. Study selection will involve the reviewer screening titles and abstracts. Then, two independent reviewers will further assess the studies in full for those that meet the inclusion criteria. In line with the JBI framework, data will be extracted using a draft data extraction tool. This will facilitate a chronological narrative synthesis of results in line with the study's overall aim to identify effective education and training interventions for HCPs, who care for patients with dementia, nearing end of life.

The Complexity of Nutritional Problems in Persons with Dementia: Expanding a Theoretical Model

BACKGROUND

Persons with dementia are at risk of developing nutritional problems. Theoretical models on nutritional problems have been developed, but have not been evaluated with healthcare professionals.

OBJECTIVE

This study aimed to explore the comprehensiveness and applicability of a theoretical model of nutritional problems in persons with dementia for daily nursing home practice.

METHODS

A qualitative design employing a combined deductive and inductive approach was used. Healthcare professionals were eligible to participate if they 1) had expert knowledge of and experience with nutritional problems related to dementia, and 2) worked in a nursing home affiliated with an academic network covering the east and south of the Netherlands. Three focus group interviews with 20 healthcare professionals from seven professions were held. We conducted thematic analysis and we compared themes with existing theoretical models from the literature.

RESULTS

We identified six themes, four of which corresponded with the existing models (observing and analysing nutritional problems; consequences of nutritional problems; functioning of the person with dementia; environmental factors). Interprofessional collaboration and ethical factors were identified as new themes. The analyses indicated interactions within each theme, between themes, and a bidirectional connection between themes.

CONCLUSIONS

This study demonstrated the relevance of interprofessional collaboration and ethical considerations in nutritional problems related to dementia. It uncovered complex bidirectional relations within and between factors regarding nutritional problems. All aspects should be taken into account to minimize the consequences of nutritional problems for persons with dementia.

Do Healthy People Engage With Education About Death, Dying and Advance Care Planning? An Early Evaluation of the Omega Course

Background: Death can be difficult to address personally, to discuss and to plan for. Since 2016 The Omega Course (Omega) has educated local people in Kenilworth, UK, about death and dying; broaching these issues and teaching communication skills whilst enabling social interaction. It aspires to produce practical outcomes with positive implications for end of life (EoL) planning and future neighbourhood care within the town. Aim: To investigate the impact of Omega on the attitudes and actions of participants. Method: Anonymous questionnaires, distributed by Qualtrics, or by post if preferred, were sent to 62 participants of Omega aged 22-94 two and a half years post course institution. Thematic analysis and inferential statistics were used. Results: 23 replies (37%) scored changes across 4 areas; barriers to discussion, ease discussing death, fears about death and future planning capability. All showed a significant beneficial change using a Paired Sample t-test (P< .01). Respondents noted common fears of death and dying, barriers to discussing the topic and planning for it. The course helped to allay fear, enabled discussion and encouraged planning for death and EoL. Respondents rated the course as 9.1/10 for achieving its aims. They appreciated discussing death and dying in a supportive environment and found the approach effective in developing their skills and changing attitudes. Conclusion: Omega has the potential to change attitudes towards death; promoting discussion, planning, and tackling misconceptions.

End-of-life care for people with dementia on a green care farm during the COVID-19 pandemic: a qualitative study

OBJECTIVE

Green care farms combine agriculture production with health-related, social and educational services. In the Netherlands, they form an alternative to traditional nursing homes for people with dementia. Green care farms that offer 24-hour care, also offers end-of-life care. To date, little is known about end-of-life care for people with dementia on green care farms. This study aimed to explore the experiences of healthcare workers and family caregivers with end-of-life care for people with dementia who died on a green care farm.

DESIGN

An explorative, descriptive qualitative design with a phenomenological approach.

SETTING AND PARTICIPANTS

A purposive sample of 15 participants - seven healthcare workers and eight family caregivers - from three green care farms in the Netherlands.

METHODS

Semi-structured, in-depth interviews were conducted to explore participants' experiences with end-of-life care, including topics such as advance care planning, the influence of COVID-19, and bereavement support. Transcripts were thematically analysed using Braun and Clarke's approach.

RESULTS

Four main themes were extracted: 1) tailored care and attention for the individual resident, 2) reciprocal care relationships between healthcare workers and family caregivers, 3) compassionate care and support in the dying phase, and 4) the influence of COVID-19 on end-of-life care.

CONCLUSION AND IMPLICATIONS

The overall experience of the healthcare workers and family caregivers was that end-of-life care offered on green care farms is person-centred and compassionate and is tailored to the person with dementia and their family caregivers. Despite the COVID-19 pandemic, healthcare workers and family caregivers were satisfied with end-of-life care on the green care farms. Green care farms may offer a valuable alternative care setting for people with dementia in their last phase of life. More research is needed to investigate green care farms'benefits compared to other, more traditional settings.

Palliative psychiatry in a narrow and in a broad sense: A concept clarification

Even with optimal treatment, some persons with severe and persistent mental illness do not achieve a level of mental health, psychosocial functioning and quality of life that is acceptable to them. With each unsuccessful treatment attempt, the probability of achieving symptom reduction declines while the probability of somatic and psychological side effects increases. This worsening benefit-harm ratio of treatment aiming at symptom reduction has motivated calls for implementing palliative approaches to care into psychiatry (palliative psychiatry). Palliative psychiatry accepts that some cases of severe and persistent mental illness can be irremediable and calls for a careful evaluation of goals of care in these cases. It aims at reducing harm, relieving suffering and thus improving quality of life directly, working around irremediable psychiatric symptoms. In a narrow sense, this refers to patients likely to die of their severe and persistent mental illness soon, but palliative psychiatry in a broad sense is not limited to end-of-life care. It can - and often should - be integrated with curative and rehabilitative approaches, as is the gold standard in somatic medicine. Palliative psychiatry constitutes a valuable addition to established non-curative approaches such as rehabilitative psychiatry (which focuses on psychosocial functioning instead of quality of life) and personal recovery (a journey that persons living with severe and persistent mental illness may undertake, not necessarily accompanied by mental health care professionals). Although the implementation of palliative psychiatry is met with several challenges such as difficulties regarding decision-making capacity and prognostication in severe and persistent mental illness, it is a promising new approach in caring for persons with severe and persistent mental illness, regardless of whether they are at the end of life.

Effects of reminiscence therapy in people with dementia: A systematic review and meta-analysis

WHAT IS KNOWN ABOUT ON THE SUBJECT?: Alternative option was developed to improve care due to the increasing costs of care cost and the number of people diagnosed with dementia. Reminiscence therapy is a commonly implemented alternative option used in long-term care facilities. Reminiscence therapy is designed for cognitive decline that is also known as life review. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Reminiscence therapy, known as psychosocial interventions in dementia care, can be used to assist people with dementia recollect prior events, activities, and experiences in order to improve their cognitive, mood, and overall well-being. Reminiscence therapy increased cognitive function and quality of life and reduced depressive and neuropsychiatric symptoms among people with dementia. Reminiscence therapy may be considered a useful non-pharmacological intervention for people with dementia living in nursing homes or other long-term care facilities. The development of a global standard protocol for the application of reminiscence therapy may be necessary for future randomized controlled trials (RCTs). ABSTRACT: Introduction Reminiscence therapy is an alternative to pharmaceutical intervention provided during long-term care, especially for individuals with dementia. However, the effects of reminiscence therapy in dementia care remain inconclusive. Aim The goal of this study is to examine the effects of reminiscence therapy implementation in people with dementia. Design Systematic literature review and meta-analysis were conducted in accordance with the PRISMA guidelines. Methods This study searched systematically using 6 databases. The eligibility criteria included patients with dementia, applied reminiscence therapy, randomized controlled trials or quasi-experimental studies, and published in the English language. The PEDro scale was used to assess the methodological quality of the included studies. The meta-analysis was performed using a random-effects model to calculate the pooled effects of reminiscence therapy. Stata 16.0 was used for statistical analysis. Result A total of 29 studies met the eligibility criteria, including 3102 participants. Overall, reminiscence therapy increased cognitive functions and quality of life and decreased depression and neuropsychiatric symptoms. Implication for Practice Reminiscence therapy may be considered a useful non-pharmacological intervention for people with dementia living in nursing homes or other long-term care facilities. A standard protocol for reminiscence therapy may be necessary for future studies.

Support from healthcare professionals in empowering family carers to discuss advance care planning: A population-based survey

BACKGROUND

Family carers have a prominent role in end-of-life care for seriously ill persons. However, most of the Advance Care Planning literature is focused on the role of healthcare professionals.

AIMS

To investigate (1) what proportion of family carers discussed advance care planning with their relative and associated socio-demographic and clinical characteristics (2) what proportion received support from healthcare professionals for these conversations, (3) what type of support they received and (4) to what extent the type of support received was considered sufficient.

DESIGN/PARTICIPANTS

Population-based cross-sectional survey in Belgium of bereaved family carers of persons with a serious chronic illness (N = 3000) who died 2-6 months before the sample was drawn, identified through three sickness funds. The survey explored support from healthcare professionals for family carers during the last 3 months of the patient's life.

RESULTS

Response rate was 55%. The proportion of family carers that engaged in an advance care planning conversation with their relative was 46.9%. Of these family carers, 78.1% received support from a healthcare professional, mostly by doing the advance care planning conversation together (53.8%). Of family carers receiving support from a healthcare professional, 57.4% deemed the support sufficient.

CONCLUSION

Many family carers engage in advance care planning conversations with their dying relative. Healthcare professionals often support them by performing the advance care planning conversations together. More insight into how family carers can be supported to conduct these advance care planning conversations, both with and without involvement of healthcare professionals, is necessary.

Evaluating a partnership model of hospice enabled dementia care: A three-phased monitoring, focus group and interview study

BACKGROUND

People with dementia and their caregivers often lack equitable access to hospice care which is a concern internationally. Domains of best practice in palliative care for this population exist and hospices are urged to become dementia friendly.

AIM

This study aimed to evaluate the model of 'Hospice Enabled Dementia Partnership' mapped to international domains of best practice.

DESIGN

Three-phased monitoring, group interview and individual interview study using a formative evaluation framework.

SETTINGPARTICIPANTS

The partnership model was a collaboration between a large specialist palliative care hospice, a dementia charity and a Health Care Trust in the United Kingdom. Service documents were subjected to documentary review of monitoring activity and key indicators of service success. Group interviews and individual interviews took place with family carers (n = 12), health care professionals involved in delivering the service (n = 32) and senior professionals (n = 5) responsible for service commissioning in palliative or dementia care.

RESULTS

One hundred people with dementia were referred to the service between May 2016 and December 2017. Thirty-eight of the 42 people who died, achieved their preferred place of care and died at home. Four themes were derived from the data 'Impact of Dementia', 'Value of the Service', 'Information and Learning Needs' and 'Working in Partnership'.

CONCLUSIONS

Positive outcomes resulted from this best practice model; achievement of preferred place of care and death at home, dual benefits of therapies for patients and families and partnership in cross working and learning between services. Replication of this model should be considered internationally.

Management in severe dementia: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology

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.

Manejo das demências em fase avançada: recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia

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.

Cross-cultural conceptualization of a good end of life with dementia: a qualitative study

Background

Research on the nature of a “good death” has mostly focused on dying with cancer and other life-limiting diseases, but less so on dementia. Conceptualizing common cross-cultural themes regarding a good end of life in dementia will enable developing international care models.

Methods

We combined published qualitative studies about end of life with dementia, focus group and individual interviews with the researchers, and video-conferencing and continuous email discussions. The interviews were audio-recorded and transcribed verbatim. The data were analyzed thematically, and the researchers developed common themes referring to their original studies.

Results

Fourteen qualitative researchers representing 14 cross-cultural studies covering qualitative data of 121 people with dementia and 292 family caregivers. The researchers and data were from eight countries UK, The Netherlands, Japan, Portugal, Germany, Canada, Brazil, and Ireland. Three focus groups, five individual interviews, and video-conferencing were conducted and feedback on multiple iterations was gained by 190 emails between May 2019 and April 2020 until consensus was achieved. Nine cross-culturally common themes emerged from the discussions and shared interpretation of the data of persons with dementia and family caregivers. Three represent basic needs: “Pain and Symptoms Controlled,” “Being Provided Basic Care,” and “A Place like Home.” Other themes were “Having Preferences Met,” “Receiving Respect as a Person,” “Care for Caregivers,” “Identity Being Preserved,” “Being Connected,” and “Satisfaction with Life and Spiritual Well-being.” “Care for Caregivers” showed the greatest difference in emphasis across cultures. Good relationships were essential in all themes.

Conclusions

The common cross-cultural themes comprise a framework underpinned by value placed on personhood and dignity, emphasizing that interdependency through relationships is essential to promote a good end of life with dementia. These themes and valuing the importance of relationships as central to connecting the themes could support care planning and further development of a dementia palliative care model.

Trial registration

The Graduate School and Faculty of Medicine Kyoto University (R1924–1).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00982-9.

Advanced cancer and concomitant dementia: access to specialized palliative care, emergency room, hospital care, and place of death

BACKGROUND

Dementia and advanced cancer are complex, life-limiting conditions that benefit from specialized palliative care (SPC) interventions at the end of life. The objective was to study possible differences in care for patients with concomitant advanced cancer and dementia (CA-DEM) or cancer only (CA) regarding access to SPC, acute hospital care, and place of death.

MATERIALS AND METHODS

A retrospective observational registry study on health care consumption data from the Stockholm Regional Council involving logistic regression analyses of age, sex, living arrangements, comorbidities, dementia diagnosis, and socio-economic status.

RESULTS

Of the 12,667 persons aged ≥65 years who died from advanced cancer between 2015 and 2019, 605 had concomitant dementia. Of these, 76% of patients with CA and 42% of patients with CA-DEM had access to SPC (p<.0001). There were more admissions to palliative care for persons not living in nursing homes (p<.0001), women (p<.0001), socioeconomically privileged patients (p<.05), those with fewer comorbidities (p<.0001), and younger patients (<85 years) (p<.0001). Access to SPC reduced ER visits, hospitalizations, and acute hospital deaths for CA, whereas access to SPC only reduced hospital deaths in the CA-DEM group.

CONCLUSIONS

The probability of being admitted to SPC was lower in cancer patients with known dementia. Access to SPC reduced emergency room visits and acute admissions to hospitals for the whole group, and hospital deaths both for CA and CA-DEM.