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Palliative Medicine in Dementia Care PowerPoint Presentation

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Description : A difficult problem emerges in the context of palliative care in dementia since it is often not seen as a life threatening illness. The disease course that dementia usually follows is one of prolonged and progressive disability. The level of baseline function is often low as the disease primarily affects older people who will have already accumulated many other co-morbidities.

Tags : palliative care dementia,dementia,what is dementia,dementia in DSM V,mental disorders

Published on : Feb 14, 2021 | Views : 1112 | Downloads : 3

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Forget Me Not: Palliative Care in Dementia
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What is dementia? Dementia is a term used to describe a large group of conditions affecting the brain which cause a progressive decline in a person’s ability to function It is not a normal part of ageing. It generally affects people over 65, people as young as 30, 40 or 50 can have dementia. Quite often people, and especially carers, think that their loved one’s decline in functioning (i.e. starting to lose their memory and their ability to carry out daily tasks) is a normal part of ageing and so rarely seek care and support.
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What is dementia?
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Dementia in DSM V Dementia is included into “Major Neurocognitive Disorders (major NCD)” based on DSM V (Diagnostic and Statistical Manual of Mental Disorders) 6 principal domains of cognitive function Impairment in 2 or more cognitive functions and severe enough to interfere with activities of daily living Dementia:
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Signs and symptoms 1. Early stage: the early stage of dementia is often overlooked, because the onset is gradual. Common symptoms include: forgetfulness losing track of the time becoming lost in familiar places. 2. Middle stage: as dementia progresses to the middle stage, the signs and symptoms become clearer and more restricting. These include: becoming forgetful of recent events and people's names becoming lost at home having increasing difficulty with communication needing help with personal care experiencing behaviour changes, including wandering and repeated questioning. 3. Late stage: the late stage of dementia is one of near total dependence and inactivity. Memory disturbances are serious and the physical signs and symptoms become more obvious. Symptoms include: becoming unaware of the time and place having difficulty recognizing relatives and friends having an increasing need for assisted self-care having difficulty walking experiencing behaviour changes that may escalate and include aggression
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Palliative care in dementia Palliative care: an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual (WHO, 2002) A difficult problem emerges in the context of palliative care in dementia since it is often not seen as a life threatening illness (Hughes et al. Advance in Psychiatric Treatment. 2007;13:251-260) The disease course that dementia usually follows is one of prolonged and progressive disability. The level of baseline function is often low as the disease primarily affects older people who will have already accumulated many other co‐morbidities. This is in contrast to cancer (Murray et al. BMJ. 2005;330(7498):1007-11)
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Palliating dementia: current problems* Place of death & Resuscitation** Pain Infection and fever** Artificial nutrition and hydration** Access to specialist palliative care Care planning Neuropsychiatric symptoms *Postgrad Med J. 2007; 83(980): 362–366. **Advances in Psychiatric Treatment (2007), vol. 13, 251–260
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Place of death & resuscitation Despite the wish of the majority of dementia patients (and their families) to die in their own home, most will die in hospital in acute wards where staff may be poorly trained or have insufficient time to manage their individual needs, or in care homes where there may be inadequate staff training in palliative care, poor symptom control and lack of psychological and emotional support In severe dementia cardiopulmonary resuscitation (CPR) is unlikely to be successful. Outside hospital the chances of survival are low and CPR itself may be harmful If families (or people with dementia) wish to discuss the prognosis and how things might go in the end of life, clinicians would have to discuss whether CPR would be performed or not Palliating dementia: current problems*
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2. Pain Pain is under recognized and under treated in dementia patients. Impaired communication (particularly difficulties with recall, interpretation of sensations and verbal expression) reduces ability to express pain and for attendants to recognize it. A growth of interest in pain assessment tools  Self-report scales (mild to moderate dementia who can still communicate), PAIN-AD scales for all stages Palliating dementia: current problems*
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2. Pain (WHO pain ladder, 2006) Non-pharmacological interventions may be used to relieve pain, e.g., massage, exercise, application of heat, or cooling packs. Relaxation techniques or giving the chance to rest and music therapy and presence of other persons may reduce pain Palliating dementia: current problems*
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3. Infections or fevers** For a variety of reasons, including impaired immunological responses and immobility, people with advanced dementia are vulnerable to infections Pneumonia remains a common cause of death; urinary infections become the second leading cause of infection in dementia Use of antibiotics for respiratory infections is very common and can improve survival of people with advanced dementia. However, for urinary infection there was no improved survival When patients are thus very close to death a natural concern is that antibiotics might simply delay death but leave the patient open to further suffering from decubitus ulcers or other consequences of very advanced inanition Palliating dementia: current problems*
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4. Artificial nutrition and hydration** In dementia there is a loss of appetite, a loss of the experience of hunger and of the need for a routine of regular meals Dyspraxia and sequencing problems may cause difficulties with the process of feeding; swallowing problems become increasingly noticeable In more severe stage, aspiration pneumonia becomes a concern  consideration of using NGT or percutaneous endoscopic gastrostomy, however evidence is lacking for its efficacy and infection prevention Palliating dementia: current problems*
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Palliating dementia: current problems* 5. Access to specialist palliative care Patients with dementia are less likely to be referred to palliative care teams, prescribed fewer palliative care medications and are infrequently referred or denied access to hospice care 6. Care planning Patients with dementia are less likely to have advance care planning than those with terminal cancer: advance directives (including withholding tube feeding), “Do not resuscitate” orders, and “Do not hospitalise” instructions More likely to experience uncomfortable or aggressive intervention at the end of life: blood tests, intravenous therapy, arterial blood gases and feeding tubes
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Palliating dementia: current problems* 7. Neuropsychiatric symptoms Agitation (51-71%) and apathy, depressive and behavioral symptoms are common symptoms in the course of the disease Neuropsychiatric symptoms were associated with lower quality of life and unmet needs as pain and social needs were associated with verbally agitated behavioral symptoms Non-pharmacological interventions tailored to the individual may be more appropriate to treat behavioral symptoms, e.g., aromatherapy, massages of hand, or foot can be effective. Presence of a carer and being in interaction with others and individualized interventions may help to reduce symptoms like agitation, aggression, apathy, anxiety
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When to deliver palliative care for dementia patients? Prognostic indicators have been developed to help identify patients with dementia who are likely to be in the last year of life and require palliative and supportive care
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How to deliver palliative care to dementia patients
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GSF The Gold Standards Framework, a programme developed primarily for use in primary care based on the 7 C's: communication, coordination, control of symptoms, continuity, continued learning, carer support, and care of the dying. The emphasis on anticipatory care (to reduce crises and inappropriate admissions) and the transfer and communication of information to out‐of‐hours services are particularly important.
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Goals of care for patients in the dying phase
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THANK YOU