Dr Mary Cosgrave

Dying from Dementia Dying with Dementia and something else Levels of Palliative care: Palliative Care

Approach, General Palliative Care interfacing with good Dementia Care, Specialist Palliative Care

Concerns of Staff, Family and MDT Communication and Education

• Diagnosis• Advanced plans or what (s)he would want• Admission to Care• Depression, malaise• Investigations• First trip to Accident and Emergency• Infections• Feeding• End of Life

F, 70 years old, long term patient in the Community

Lived with wife, started respite in St Ita’s Became long-stay, minimal BPSD but

resistive: intolerant of procedures Pale, Hb 9.0 g/dl WHAT DO WE DO?

T 68 years old, dementia and cancer Extremely disturbed at home: would not go

to bedroom to sleep and agitated No support services: admitted St Ita’s

involuntary and transferred to long-stay Diagnosis of metastases, increasing

agitation: ? Pain. Family unhappy with Ita’s DO WE TRANSFER?

G 59 years, dx dementia after a long haul in St James’s Memory Clinic

Unusual variant: insight preserved Uneasy from Day 1 “Will I become an

incontinent?” Three admissions for depression 2006, admitted with agitation STOPPED EATING: WHAT DID WE DO?

D 66 years; lived with husband Three of her siblings presented with AD Husband hid her from services, very

agitated by time of admission to St Ita’s Never settled, ? In pain Full investigations HOW DID WE MANAGE?

James: 68 year old man with advanced Parkinson’s disease with dementia, aphonia and diagnosed depression

Admitted BH, very ill, resuccitated but poor recovery.

Rehabilitation poor, needed enteral feeding Pulled out tubes, tried to harm himself WHAT DID WE DO?

M, 65 year old married woman with end-stage AD on 1:4 week respite

Husband did not take advice and had PEG inserted by gastro team

Frequent problems with infections, insisted on full resuccitation for all illnesses

BECAME ACUTELY ILL. WHAT DID WE DO?

All had advanced dementia Palliative Care Approach: same outlined to

families, explaining likely life-span and aim to ensure quality of remaining time

Medical Advice sought for confirmation of underlying illnesses

Palliative Care advice sought for all Specialist Palliative Care Advice obtained for

those with malignancy and intractable symptoms

Communication with Families: frequent and detailed was key strategy.

Understanding of dementia, course, prognosis, duration.

Changing expectations, targets with disease change

Changing treatment target as appropriate Balance of over and under investigation Realism of health environment