Journal Article:

NEJMcp1412652

Summary:

Daniel DeMarco                                  Journal Article Assignment          Rotation #8: Long Term Care

Advanced Dementia

Susan L. Mitchell, M.D., M.P.H.

New England Journal of Medicine

What is Dementia?:

• Defined as “a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning”
• Clinicians have described “Advanced Dementia” as patients with a Stage 7 on the Global Deterioration Scale (Ranges from 1-7 with increasing number indicating increased severity). Features include:
  • Profound memory deficits
  • Inability to recognize family members
  • Minimal verbal abilities
  • Inability to ambulate independently
  • Inability to perform any ADLs
  • Urinary and fecal incontinence

Epidemiology:

• 2010: Estimated 600K Americans with ALZ disease died
• 2011: ALZ Disease is 6^th leading cause of death in U.S.
• 2014: 5 million persons in U.S. affected by ALZ Disease, estimated to approach 14 million by 2050

Complications of Advanced Dementia:

• Clinical course of the disease outlined in Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life (CASCADE) study
  • Median survival: 1.3y
  • Most common complications: (1) eating problems, (2) febrile episodes, (3) pneumonia
• Eating problems
  • Oral dysphagia, pharyngeal dysphagia, inability to feed oneself, refusal to eat
    • May be addressed conservatively – small meals, hand feeding versus more aggressively – tube feeding; a Cochrane review showed that tube feeding does not improve survival, quality of life, nutrition, functional status, prevention of aspiration, or prevention/healing of pressure injuries; consider using decision-support tools for proxies
  • Infections
    • Urinary or respiratory particularly common
      • Overprescribing of antimicrobials; clinical dilemma about when to start antibiotics in patients with + UA/Urine Culture
      • 6-month all-cause mortality in patients with advanced dementia that suffered from pneumonia is 50%; CASCADE study – patients with advanced dementia and pneumonia – treatment with antimicrobials extended life an average of 273d longer, though discomfort was greater than those who did not receive antimicrobials

Life Expectancy:

• Estimations are difficult. As such, access to palliative care should be determined based on desire for comfort care, not based on estimations of life expectancy/prognosis

Planning for Decision Making:

• Family/Friends/Health Care Proxies must be informed about the course of the disease, potential complications, and the importance of advanced care planning (including DNR/DNI and other advance directives, particularly do-not-hospitalize orders)
  • Providers should discuss how proxies should function as surrogates
• Guide treatment decisions using goals of care (A prospective study revealed that in cases of advanced dementia, 90% of proxies stated that comfort was the goal of care)

Caring for Patients with Advanced Dementia (Palliative and Hospice Care):

• Pain often underrecognized/undertreated in this population; make palliative care/hospice care referrals where available
• In patients with agitation, nonpharmacologic approaches are preferred to other options (like antipsychotics), which can increase risk of death and have other untoward effects
• Reassess the medication regimen: continue medications that align with the goals of care. D/C those of questionable benefit

Improvement and the Future of Care:

• Improve education for patients, families/friends/proxies; improved engagement in advanced care planning; improvement in selecting interventions consistent with goals of care

Summary:

• Goal directed care; thorough understanding of risks versus benefits