Transcript of End stage dementia and palliative care
- 1. Toluwalase Ajayi MD Palliative Care Fellow San Diego Hospice
and Institute for Palliative Care
- 2. Objective The overall objective of this talk is to
understand how dementia is unique and important in our line of work
and how we, as a multidisciplinary palliative care team can help
patients and their families navigate through the challenges of this
disease.
- 3. Central Intelligence Agency 2011. Statistics Division 2010,
Social indicators, Indicators on health.
- 4. Epidemiology Population > 65 expected to increase from
12.6% in 2010 to 19.3% in 2030 > 80 years increase from 3.7% to
5.1% Life expectancy increase to 79.5 by 2020 US Census Bureau
Accessed July 22, 2010. US Census Bureau. Expectations of life at
birth.
- 5. Epidemiology Dementia increases exponentially with age 1% at
60 yrs to more than 20% at 85 yrs People with dementia estimated to
reach 81.1 million by 2030 OConnor DW. Ferri CP et al.
- 6. Definition Dementia: significant deterioration in cognitive
abilities severe enough to interfere with everyday life Palliative
care: Improves quality of life for patients and families OConnor
DW.
- 7. Definition Most frequent cause is Alzheimer followed by
vascular dementia and then dementia with Lewy body ( DLB ) Langa
KM, et al.
- 8. Alzheimer Dementia Memory Impairment Neuropsychiatric
Symptoms Main Features Neurologic signs Lussier et al.
- 9. Vascular Dementia Memory Impairment Neuropsychiatric
Symptoms Main Features Neurologic signs Lussier et al.
- 10. Lewy Body Dementia Memory Impairment Neuropsychiatric
Symptoms Main Features Neurologic signs Lussier et al.
- 11. Dementia Memory Impairment Neuropsychiatric Symptoms Main
Features Neurologic signs Contented Dementia Trust
- 12. Secondary Symptoms Urinary Incontinence ( 72% )-Please
refer to module #... Pain ( 64% )- Please refer to module #...
Depression/Low Mood ( 61% )- Please refer to module #...
Constipation ( 59% )- Please refer to module #... Loss of appetite
( 57% )- Please refer to module #... McCarthy et al.
- 13. Management General Approach to management of cognitive
dysfunction Multidisciplinary Team
- 14. Non Pharm Management Cognitive Dysfunction Diminish quality
of life Agitation Conflict of caregiver vs patient Non
pharmacologically first Koopmans RT et al. Kverno KS et al.
- 15. Non Pharm Management Art Therapy Music Therapy Activity
Therapy Aroma Therapy Douglas, S et al. Burns, A et al.
- 16. Non Pharm Management Cognitive Dysfunction SPECAL
method-Three Golden Rules Dont Ask Questions Listen to the expert
Dont Contradict Contented Dementia Trust
- 17. Non Pharm Management Cognitive Dysfunction Snoezelen
approach Van Weert JC et al. multisensory stimulation
- 18. Pharmacology Treatment Cognitive Dysfunction Rule out
medical causes Pharmacologic interventions concurrently Risperidone
and olazapine Some antidepressants and neuroleptics Ballard C et
al. Pollock BG et al. Lanctot KL et al.
- 19. Pharmacology Treatment Cholinesterase inhibitors ( eg.
donepezil) Delays progression for about 6 mo Memantine for more
advanced disease Mainstay for vascular dementia is risk reduction
Burns A, et al. Roman G.
- 20. Pharmacology Treatment Pharmacologic treatment not curative
Dementia is a progressive terminal illness Final stages similar for
all dementia Mod to severe dementia (MMSE 4 yrs Corey-Bloom J et
al. McKeith IG, et al. Larson EB et al.
- 21. Gazing into the Crystal Ball Encourage advanced care
planning!
- 22. Challenging Decisions Study showed 40.7% with advanced
dementia underwent at least one of following in last 3 months of
life Hospitalizations ER visit Parenteral Therapy Feeding tube
Mitchell SL, et al.
- 23. Challenging Decisions CPR Unless witnessed in-hospital
arrest caused by V-fib; survival is 0.8% Chances of being
discharged alive following arrest are almost nil Herlitz J, et
al.
- 24. Challenging Decisions Feeding Knowledge versus emotion Does
not improve survival or functional status Associated with post op
complications Advocate for comfort feeding Sampson EL, et al.
Finucane TE, et al.
- 25. Challenging Decisions Information to be provided to the
resident and family should include: Common causes of eating and
swallowing Technical considerations regarding placement and use of
peg tubes Principles of benefits of tube feeding Considerations
regarding future discontinuation of PEG tube. Data from Mitchell SL
et al. Steps to Decision Making Include Guiding residents and their
families through what they have learned about PEG tubes How to
apply this knowledge to the resident's preferences, personal values
and clinical situation What is the residents' situation? What would
the resident want? How is the decision affecting the family? What
questions need answering Who should decide about the PEG tube
placement? When should the PEG be disbanded? What is the residents
or the familys overall thoughts about the decision?
- 26. Challenging Decisions Hydration Differentiate dehydration
and thirst Hydration doesn't improve symptoms associated with
dehydration Risk of complications Start based on individual cases
Jenkins CA et al. Viola RA et al.
- 27. Challenging Decisions Acute Care Hospitalizations
Complications Transfer to acute care hospital for pneumonia might
increase mortality Mitchell SL, Kiely DK et al. Thompson RS et
al.
- 28. Challenging Decisions Acute Illness/Pneumonia No consensus
No benefit from abx vs better short term survival with more
aggressive abx therapy Lack of scientific evidence of this area
Congedo M et al. Volicer L et al. Van Der Steen JT et al. Kruse RL
et al.
- 29. Challenging Decisions Chronic Diseases Always Appropriate
Analgesics Expectorant Parsons C et al. Antidiarrials Lubricating
eye drops Antiemetic Pressure ulcer treatments Laxatives
Anxiolytics Inhaled Bronchodila tors Antiepileptic
- 30. Challenging Decisions Chronic Diseases Sometimes
Appropriate PPIs H2 Blockers Antihypertensive Thyroids Hormones
AntiIschemic Parsons C et al. Antiemetic Diuretics Pressure ulcer
treatments Digoxin AntiThyroid InhaledSteroids Hypoglycem ic
Antipyschotics Antidepressants
- 31. Challenging Decisions Chronic Diseases Rarely Appropriate
AntiAndrogens Parsons C et al. Bisphosphonates Minerals Heparin
Vitamins Warfarin Appetite Stimulants Bladder Relaxants
- 32. Challenging Decisions Chronic Diseases Never Appropriate
LipidLowering Medication Parsons C et al. Anti-platelets excluding
aspirin Antiestrogens Sex Hormone Cytotoxic Chemotherapy Hormone
Antagonist
- 33. Challenging Decisions Dementia Medications Recommended as
long as clinic benefit Stopped in MMSE< 10 for Cholinesterase
inhibitors; < 3 for Memantine 80% medical directors recommend
stopping at hospice 30% accelerated cognitive and functional
decline Shega et al. Sengstaken et al.
- 34. Understanding the Loss Developmental milestone of children
Developmental regression of dementia
- 35. Reframing Loss
- 36. Summary Prevalence of Dementia is increasing
internationally Management of advanced dementia involves a
multidisciplinary team Advance care planning is critical Reframing
dementia rather than battling dementia is vital
- 37. Work Cited US Census Bureau. International data base.
Available at: www.census.gov/ipc/www/idb/groups.php. Accessed July
22, 2010. Statistics Division 2010, Social indicators, Indicators
on health, United Nations, New York NY 10017 USA, viewed 5th May,
2011, . US Census Bureau. Expectations of life at birth, 1970 to
2006, and projections,2010 to 2020. Available at:
www.census.gov/compendia/statab/2010/tables/ 10s0102.pdf. Accessed
July 22, 2010. OConnor DW. Epidemiology. In: Burns A, OBrien J,
Ames D, editors. Dementia. 3rd edition. London: Edward Arnold;
2005. p. 1623. Langa KM, Foster NL, Larson EB. Mixed dementia:
emerging concepts and therapeutic implications. J Am Med Assoc
2004;292:29018. Burns A, OBrien J, Auriacombe S, et al. Clinical
practice with anti-dementia drugs: a consensus statement from
British association for psychopharmacology. J Psychopharmacol
2006;20:73255. Roman G. Therapeutic strategies for vascular
dementia. In: Burns A, OBrien J, Ames D, editors. Dementia. 3rd
edition. London: Edward Arnold; 2005. p. 574600. Corey-Bloom J,
Fleisher AS. The natural history of Alzheimers disease. In: Burns
A, OBrien J, Ames D, editors. Dementia. 3rd edition. London: Edward
Arnold; 2005. p. 37686.
- 38. Work Cited McKeith IG, Ince P, Jaros EB, et al. What are
the relations between Lewy body disease and AD J Neural Transm
Suppl 1998;54:10716. Mitchell SL, Teno JM, Kiely DK, et al. The
clinical course of advanced dementia. N Engl J Med 2009;361:152938.
Larson EB, Shadlen MF, Wang L, et al. Survival after initial
diagnosis of Alzheimer disease. Ann Intern Med 2004;140:5019.
Herlitz J, Eek M, Engdahl J, et al. Factors at resuscitation and
outcome among patients suffering from out of hospital cardiac
arrest in relation to age. Resuscitation 2003;58:309 17. Mitchell
SL, Kiely DK, Hamel MB. Dying with advanced dementia in the nursing
home. Arch Intern Med 2004;164:3216. Sampson EL, Candy B, Jones L.
Enteral tube feeding for older people with advanced dementia.
Cochrane Database Syst Rev 2009;2:CD007209. Finucane TE, Christmas
C, Travis K. Tube feeding in patients with advanced dementia: a
review of the evidence. J Am Med Assoc 1999;282:136570. Jenkins CA,
Schulz M, Hanson J, et al. Demographic, symptom, and medication
profiles of cancer patients seen by a palliative care consult team
in a tertiary referral hospital. J Pain Symptom Manage
2000;19:17484.
- 39. Work Cited Central Intelligence Agency 2011, The World
Factbook, ISSN 1553-8133, Central Intelligence Agency, Washington,
DC, viewed 5th May, 2011, . Viola RA, Wells GA, Peterson J. The
effects of fluid status and fluid therapy on the dying: a
systematic review. J Palliat Care 1997;13:4152. Thompson RS, Hall
NK, Szpiech M, et al. Treatments and outcomes of
nursinghomeacquired pneumonia. J Am Board Fam Pract 1997;10:827.
Congedo M, Causarano RI, Alberti F, et al. Ethical issues in end of
life treatments for patients with dementia. Eur J Neurol
2010;17:7749. Volicer L, Rheaume Y, Brown J, et al. Hospice
approach to the treatment of patients with advanced dementia of the
Alzheimer type. J Am Med Assoc 1986;256:22103. Van der Steen JT,
Kruse RL, Ooms ME, et al. Treatment of nursing home residents with
dementia and lower respiratory tract infection in the United States
and The Netherlands: an ocean apart. J Am Geriatr Soc 2004;52:6919.
Van der Steen JT, Mehr DR, Kruse RL, et al. Treatment strategy and
risk of functional decline and mortality after nursing-home
acquired lower respiratory tract infection: two prospective studies
in residents with dementia. Int J Geriatr Psychiatry
2007;22:10139.
- 40. Work Cited Shega JW, Ellner L, Lau DT, et al.
Cholinesterase inhibitor and N-methyl-D-aspartic acid receptor
antagonist use in older adults with end-stage dementia: a survey of
hospice medical directors. J Palliat Med 2009;12:77983. Sengstaken
EA, King SA. The problems of pain and its detection among geriatric
nursing home residents. J Am Geriatr Soc 1993;41:5414. Morrison RS,
Siu AL. A comparison of pain and its treatment in advanced dementia
and cognitively intact patients with hip fracture. J Pain Symptom
Manage 2000;19:2408. Kverno KS, Black BS, Blass DM, et al.
Neuropsychiatric symptom patterns in hospiceeligible nursing home
residents with advanced dementia. J Am Med Dir Assoc 2008;9:50915.
Koopmans RT, van der Molen M, Raats M, et al. Neuropsychiatric
symptoms and quality of life in patients in the final phase of
dementia. Int J Geriatr Psychiatry 2009;24:2532. Van Weert JC, van
Dulmen AM, Spreeuwenberg PM, et al. Behavioral and mood effects of
snoezelen integrated into 24-hour dementia care. J Am Geriatr Soc
2005;53:2433. Ballard C, Waite J. The effectiveness of atypical
antipsychotics for the treatment of aggression and psychosis in
Alzheimers disease. Cochrane Database Syst Rev
2006;1:CD003476.
- 41. Work Cited Van der Steen JT, Mehr DR, Kruse RL, et al.
Treatment strategy and risk of functional decline and mortality
after nursing-home acquired lower respiratory tract infection: two
prospective studies in residents with dementia. Int J Geriatr
Psychiatry 2007;22:10139. Kruse RL, Mehr DR, van der Steen JT, et
al. Antibiotic treatment and survival of nursing home patients with
lower respiratory tract infection: a cross-national analysis. Ann
Fam Med 2005;3:4229. Pollock BG, Mulsant BH, Rosen J, et al. A
double-blind comparison of citalopram and risperidone for the
treatment of behavioral and psychotic symptoms associated with
dementia. Am J Geriatr Psychiatry 2007;15:94252. Lancto t KL,
Herrmann N, van Reekum R, et al. Gender, aggression and
serotonergic function are associated with response to sertraline
for behavioral disturbances in Alzheimers disease. Int J Geriatr
Psychiatry 2002;17:53141. Ferri CP et al. Global prevalence of
dementia: a Delphi consensus study. Lancet, 2005, 366 (9503):
21122117. Takeda et al. (2008), Mild cognitive impairment and
subjective cognitive impairment. Psychogeriatric, 8: 155160. doi:
10.1111/j.1479-8301.2008.00258 Kruse RL, Mehr DR, van der Steen JT,
et al. Antibiotic treatment and survival of nursing home patients
with lower respiratory tract infection: a cross-national analysis.
Ann Fam Med 2005;3:4229.