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Chapter 17 - Palliative Care in Dementia

Issues and Evidence

from Section 3 - Approaches to Management

Published online by Cambridge University Press:  12 September 2020

Julian C. Hughes
Affiliation:
University of Bristol
Philippa Lilford
Affiliation:
Severn Deanery, University of Bristol
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Summary

Intimations of death often cause symptoms or syndromes of mental or emotional disorder, of which anxiety and depression are the most common. It is entirely appropriate, therefore, for mental health services to be involved with those who care for the dying in whatever setting. Old age psychiatrists have recognized their more direct role in caring for dying patients for many years., And some years ago a particular impetus emerged behind the notion of palliative care in dementia., This followed the early research by Ladislav Volicer and his colleagues in the dementia special care unit (DSCU) as part of the Geriatrics Research Education and Clinical Center at the E.N. Rogers Memorial Veterans Hospital in Bedford, Massachusetts. Since then there has been a burgeoning both in the field and in the literature. Gradually, different sorts of ways to provide palliative care for people with dementia have also emerged.

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Publisher: Cambridge University Press
Print publication year: 2020

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References

Barraclough, J. ABC of palliative care. Depression, anxiety, and confusion. Br Med J 1997; 315: 13651368.Google Scholar
Spiess, JL, Northcott, CJ, Offsay, JD, Crossett, JH. Palliative care: something else we can do for our patients. Psychiatr Services 2002; 53: 15251526, 1529.Google Scholar
Black, D, Jolley, D. Slow euthanasia? The deaths of psychogeriatric patients. Br Med J 1990; 300: 13211323.CrossRefGoogle ScholarPubMed
Black, D, Jolley, D. Deaths in psychiatric care. Int J Geriatr Psychiatry 1991; 6: 489495.CrossRefGoogle Scholar
Addington-Hall, J. Positive Partnerships: Palliative Care for Adults with Severe Mental Health Problems. National Council for Hospice and Specialist Palliative Care Services, 2000.Google Scholar
Hughes, JC, Robinson, L, Volicer, L. Specialist palliative care in dementia. Br Med J 2005; 330: 5758.CrossRefGoogle ScholarPubMed
Volicer, L, Rheaume, Y, Brown, J, et al. Hospice approach to the treatment of patients with advanced dementia of the Alzheimer type. JAMA 1986; 256: 22102213.CrossRefGoogle Scholar
Volicer, L. The development of palliative care for dementia. Ann Palliat Med 2017; 6: 302305.CrossRefGoogle Scholar
Hughes, JC, Jolley, D, Jordan, A, Sampson, EL. Palliative care in dementia: issues and evidence. Adv Psychiatr Treat 2007; 13: 251260.Google Scholar
World Health Organization (2002). WHO Definition of Palliative Care. Available via: www.who.int/cancer/palliative/definition/en/ (last accessed 22 October 2019).Google Scholar
McInerney, F, Doherty, K, Bindoff, A, et al. How is palliative care understood in the context of dementia? Results from a massive open online course. Palliat Med 2018; 32: 594602.CrossRefGoogle Scholar
Addington-Hall, J. Reaching Out: Specialist Palliative Care for Adults with Non-Malignant Disease. Occasional Paper 14. National Council for Hospice and Specialist Palliative Care Services, 1998.Google Scholar
Sampson, EL, Gould, V, Lee, D, Blanchard, MR. Differences in care received by patients with and without dementia who died during acute hospital admission: a retrospective case note study. Age Ageing 2006; 35: 187189.CrossRefGoogle ScholarPubMed
Jolley, D, Baxter, D. Mortality in elderly patients with organic brain disorder enrolled on the Salford Psychiatric Case Register. Int J Geriatr Psychiatry 1997; 12: 11741181.3.0.CO;2-K>CrossRefGoogle ScholarPubMed
Mitchell, SL, Kiely, DK, Hamel, MB. Dying with advanced dementia in the nursing home. Arch Intern Med 2004; 164: 321326.Google Scholar
Aminoff, BZ, Adunsky, A. Their last 6 months: suffering and survival of end-stage dementia patients. Age Ageing 2006; 35: 597601.Google Scholar
McCarthy, M, Addington-Hall, J, Altmann, D. The experience of dying with dementia: a retrospective study. Int J Geriatr Psychiatry 1997; 12: 404409.Google Scholar
Mitchell, SL, Teno, JM, Kiely, DK, et al. The clinical course of advanced dementia. N Engl J Med 2009; 361: 15291538.CrossRefGoogle ScholarPubMed
Sampson, EL, Candy, B, Davis, S, et al. Living and dying with advanced dementia: a prospective cohort study of symptoms, service use and care at the end of life. Palliat Med 2018; 32: 668681.Google Scholar
Sampson, EL, Blanchard, MR, Jones, L, Tookman, A, King, M. Dementia in the acute hospital: prospective cohort study of prevalence and mortality. Br J Psychiatry 2009; 195: 6166.CrossRefGoogle ScholarPubMed
Sampson, EL, Ritchie, CW, Lai, R, Raven, PW, Blanchard, MR. A systematic review of the scientific evidence for the efficacy of a palliative care approach in advanced dementia. Int Psychogeriatr 2005; 17: 3140.CrossRefGoogle ScholarPubMed
Sampson, EL. Palliative care for people with dementia. Br Med Bull 2010; 96: 159174.Google Scholar
van der Steen, JT. Dying with dementia: what we know after more than a decade of research. Journal of Alzheimer’s Disease 2010; 22: 3755.CrossRefGoogle ScholarPubMed
Shega, JW, Levin, A, Hougham, GW, et al. Palliative excellence in Alzheimer care efforts (PEACE): a program description. J Palliat Med 2003; 6: 315320.Google Scholar
IN-PEACE clinical trial details available via: https://clinicaltrials.gov/ct2/show/NCT03773757 (last accessed 22 October 2019).Google Scholar
Shega, JW, Sachs, GA. Offering supportive care in dementia: reflections on the PEACE programme. In Supportive Care for the Person with Dementia (eds. Hughes, JC, Lloyd-Williams, M, Sachs, GA): 3344. Oxford University Press, 2010.Google Scholar
Hughes, JC, Lloyd-Williams, M, Sachs, GA. The principles and practice of supportive care in dementia. In Supportive Care for the Person with Dementia (eds. Hughes, JC, Lloyd-Williams, M, GA Sachs): 301307. Oxford University Press, 2010.Google Scholar
Hughes, JC, Jordan, A, Ransom, P, et al. Palliative care and dementia: consensus in North Tyneside. Eur J Palliat Care 2010; 17: 9295.Google Scholar
van der Steen, JT, Radbruch, L, Hertogh, CM, et al. White paper defining optimal palliative care in older people with dementia: a Delphi study and recommendations from the European Association for Palliative Care. Palliat Med 2014; 28: 197209.CrossRefGoogle ScholarPubMed
Poole, M, McLellan, E, Bamford, C, et al. End of life care: a qualitative study comparing the views of people with dementia and family carers. Palliat Med 2018; 32: 631642.Google Scholar
van der Steen, JT, Dekker, NL, Gijsberts, M-JHE, Vermeulen, LH, Mahler, MM, The BA-M. Palliative care for people with dementia in the terminal phase: a mixed-methods qualitative study to inform service development. BMC Palliative Care 2017; 16: 28. Available via: doi 10.1186/s12904-017–0201-4 (last accessed 25 October 2019).Google Scholar
Bamford, C, Lee, RP, McLellan, E, et al. What enables good end of life care for people with dementia? A multi-method qualitative study with key stakeholders. BMC Geriatr 2018; 18: 302. Available via: https://doi.org/10.1186/s12877-018-0983-0 (last accessed 20 October 2019).Google Scholar
Volicer, L, Collard, A, Hurley, A, Bishop, C, Kern, D, Kanon, S. Impact of special care units for patients with advanced Alzheimer’s disease on patient discomfort and costs. J Am Geriatr Soc 1994; 42: 597603.Google Scholar
Jenkinson, J. Development of a Quality Specialist Continuing Care Service for Older Adults (Unpublished PhD Thesis). King’s College London, 2018.Google Scholar
Tapley, M, Regan, A, Jolley, D. Hospice: putting the heart back into dementia care. J Dement Care 2013; 21: 1415.Google Scholar
Wigan and Leigh Hospice. ‘Hospice in Your Care Home’. Available via: www.wlh.org.uk/hospice-services/hospice-in-your-care-home/ (last accessed 26 October 2019).Google Scholar
St. Cuthbert’s Hospice, Durham, England. ‘Supporting People with Dementia, Their Families and Carers’. Available via: www.stcuthbertshospice.com/215/2/St-Cuthberts-Hospice-Dementia-Support (last accessed 26 October 2019).Google Scholar
Simard, J, Volicer, L. Namaste care and dying in institutional settings. In Supportive Care for the Person with Dementia (eds. Hughes, JC, Lloyd-Williams, M, Sachs, GA): 291299. Oxford University Press, 2010.Google Scholar
Stacpoole, M, Hockley, J, Thompsell, A, Simard, J, Volicer, L. Implementing the Namaste Care Program for residents with advanced dementia: exploring the perceptions of families and staff in UK care homes. Ann Palliat Med 2017; 6: 327339.CrossRefGoogle ScholarPubMed
Scott, S, Pace, V. The first 50 patients: a brief report on the initial findings from the Palliative Care in Dementia Project. Dementia 2009; 8: 435441.CrossRefGoogle Scholar
Treloar, A, Crugel, M, Adamis, D. Palliative and end of life care of dementia at home is feasible and rewarding: results from the ‘Hope for Home’ study. Dementia 2009; 8: 335347.Google Scholar
Bone, AE, Morgan, M, Maddocks, M, et al. Developing a model of short-term integrated palliative and supportive care for frail older people in community settings: perspectives of older people, carers and other key stakeholders. Age Ageing 2016; 45: 863873.Google Scholar
Davies, N, Mathew, R, Wilcock, J, et al. A co-design process developing heuristics for practitioners providing end of life care for people with dementia. BMC Palliat Care 2016; 15: 111.Google Scholar
Hanson, LC, Zimmerman, S, Song, MK, et al. Effect of the goals of care intervention for advanced dementia: a randomized clinical trial. JAMA Intern Med 2017; 177: 2431.CrossRefGoogle ScholarPubMed
Moore, KJ, Candy, B, Davis, S, et al. Implementing the compassion intervention, a model for integrated care for people with advanced dementia towards the end of life in nursing homes: a naturalistic feasibility study. BMJ Open 2017; 7: 115.Google Scholar
Boogaard, JA, de Vet, HCW, van Soest-Poortvliet, MC, et al. Effects of two feedback interventions on end-of-life outcomes in nursing home residents with dementia: a cluster-randomized controlled three-arm trial. Palliat Med 2018; 32: 693702.Google Scholar
Verreault, R, Arcand, M, Misson, L, et al. Quasi-experimental evaluation of a multifaceted intervention to improve quality of end-of-life care and quality of dying for patients with advanced dementia in long-term care institutions. Palliat Med 2018; 32: 613621.Google Scholar
Schonwetter, RS, Han, B, Small, BJ, et al. Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines. Am J Hosp Palliat Care 2003; 20: 105113.Google Scholar
Sachs, G, Shega, J, Cox-Hayley, D. Barriers to excellent end-of-life care for patients with dementia. J Gen Intern Med 2004; 19: 10571063.Google Scholar
Reisberg, B, Sclan, SG, Franssen, E, Kluger, A, Ferris, S. Dementia staging in chronic care populations. Alzheimer Dis Assoc Disord 1994; 8[Suppl 1]: S188S205.Google Scholar
Ellis-Smith, C, Evans, CJ, Murtagh, FEM, et al. Development of a caregiver-reported measure to support systematic assessment of people with dementia in long-term care: the integrated palliative care outcome scale for dementia. Palliat Med 2017; 31: 651660.Google Scholar
Ellis-Smith, C, Higginson, IJ, Daveson, BA, Henson, LA, Evans, CJ, BuildCARE. How can a measure improve assessment and management of symptoms and concerns for people with dementia in care homes? A mixed-methods feasibility and process evaluation of IPOS-Dem. PLoS One 2018; 13: e0200240. Available via: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0200240 (last accessed 26 October 2019).Google Scholar
Regnard, C, Huntley, ME. Managing the physical symptoms of dying. In Palliative Care in Severe Dementia (ed. Hughes, JC): 2244. Quay Books, 2006.Google Scholar
Jolley, D, Hughes, J, Greaves, I, Jordan, A, Sampson, E. Seeing patients with dementia through to the end of life. Geriatr Med 2008; (September): 461464.Google Scholar
Zwakhalen, SM, Hamers, JP, Abu-Saad, HH, Berger, MP. Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools. BMC Geriatrics 2006; 6: 3. Available via: https://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-6-3 (last accessed 26 October 2019).Google Scholar
Jordan, A, Hughes, J, Pakresi, M, Hepburn, S, O’Brien, JT. The utility of PAINAD in assessing pain in a UK population with severe dementia. Int J Geriatr Psychiatry 2011; 26: 118126.Google Scholar
Jordan, A, Regnard, C, O’Brien, JT, Hughes, JC. Pain and distress in advanced dementia: choosing the right tools for the job. Palliative Medicine 2012; 26: 873878.Google Scholar
Pieper, MJC, van der Steen, JT, Francke, AL, et al. Effects on pain of a stepwise multidisciplinary intervention (STA OP!) that targets pain and behavior in advanced dementia: a cluster randomized controlled trial. Palliat Med 2018; 32: 682692.Google Scholar
Achterberg, WP, Pieper, MJC, van Dalen-Kok, AH, et al. Pain management in patients with dementia Clin Interv Aging 2013; 8: 14711482.Google Scholar
World Health Organization. ‘WHO’s Pain Relief Ladder’. WHO, 2006. Available via: www.who.int/cancer/palliative/painladder/en/ (last accessed on 26 October 2019).Google Scholar
Kovach, CR, Noonan, PE, Schlidt, AM, et al. The Serial Trial Intervention: an innovative approach to meeting needs of individuals with dementia. J Gerontol Nurs 2006; 32: 1825.Google Scholar
Kovach, CR, Logan, BR, Noonan, PE, et al. Effects of the Serial Trial Intervention on discomfort and behavior of nursing home residents with dementia. Am J Alzheimers Dis Other Demen 2006; 21: 147155.CrossRefGoogle ScholarPubMed
Husebo, BS, Ballard, C, Sandvik, R, Nilsen, OB, Aarsland, D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. Br Med J 2011; 343: d4065.Google Scholar
Husebo, BS, Ballard, C, Cohen-Mansfield, J, Seifert, R, Aarsland, D. The response of agitated behavior to pain management in persons with dementia. Am J Geriatr Psychiatry 2014; 22: 708717.CrossRefGoogle ScholarPubMed
Hughes, JC, Ramplin, S. Clinical and ethical judgement. In Reconceiving Medical Ethics (ed. Cowley, C): 220234. Continuum, 2012.Google Scholar
Fabiszewski, KJ, Volicer, B, Volicer, L. Effect of antibiotic treatment on outcome of fevers in institutionalized Alzheimer patients. Journal of the American Medical Association 1990; 263: 31683172.CrossRefGoogle ScholarPubMed
Hurley, AC, Volicer, BJ, Volicer, L. Effect of fever-management strategy on the progression of dementia of the Alzheimer type. Alzheimer Disease & Associated Disorders 1996; 10: 510.Google ScholarPubMed
van der Steen, JT, Ooms, ME, Ader, HJ, Ribbe, MW, van der Wal, WG. Withholding antibiotic treatment in pneumonia patients with dementia: a quantitative observational study. Archives of Internal Medicine 2002; 162: 17531760.Google Scholar
Clayton, J, Fardell, B, Hutton-Potts, J, Webb, D, Chye, R. Parenteral antibiotics in a palliative care unit: prospective analysis of current practice. Palliative Medicine 2003; 17: 4448.Google Scholar
van der Steen, JT, Ooms, ME, Mehr, DR, van der Wal, WG, Ribbe, MW. Severe dementia and adverse outcomes of nursing home-acquired pneumonia: evidence for mediation by functional and pathophysiological decline. Journal of the American Geriatrics Society 2002; 50: 439448.Google Scholar
van der Steen, JT, Pasman, HRW, Ribbe, MW, van der Wal, G, Onwuteaka-Philipsen, BD. Discomfort in dementia patients dying from pneumonia and its relief by antibiotics. Scand J Infect Dis 2009; 41: 143151.Google Scholar
van der Steen, JT, Lane, P, Kowall, NW, Knol, DL, Volicer, L. Antibiotics and mortality in patients with lower respiratory infection and advanced dementia. J Am Med Dir Assoc 2012; 13: 156161.CrossRefGoogle ScholarPubMed
Ikeda, M, Brown, J, Holland, AJ, Fukuhara, R, Hodges, JR. Changes in appetite, food preference, and eating habits in frontotemporal dementia and Alzheimer’s disease. J Neurol Neurosurg Psychiatry 2002; 73: 371376.Google Scholar
Finucane, TE, Christmas, C, Travis, K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999; 282: 13651370.Google Scholar
Sampson, EL, Candy, B, Jones, L. Enteral tube feeding for older people with advanced dementia (Review). Cochrane Database of Systematic Reviews 2009; Issue 2: Art. No.: CD007209. Available via: www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007209.pub2/full (last accessed 28 October 2019).Google Scholar
Gillick, M. R. (2000) Rethinking the role of tube feeding in patients with advanced dementia. New England Journal of Medicine, 342: 206210.Google Scholar
Hughes, JC, Baldwin, C. Ethical Issues in Dementia Care: Making Difficult Decisions. Jessica Kingsley, 2006.Google Scholar
Low, JA, Chan, DK, Hung, WT, Chye, R. Treatment of recurrent aspiration pneumonia in end-stage dementia: preferences and choices of a group of elderly nursing home residents. Intern Med J 2003; 33: 345349.Google Scholar
The, AM, Pasman, R, Onwuteaka-Philipsen, B, Ribbe, M, van der Wal, G. Withholding the artificial administration of fluids and food from elderly people with dementia: ethnographic study. Br Med J 2002; 325: 13261330.Google Scholar
Hanson, LC, Carey, TS, Caprio, AJ, et al. Improving decision-making for feeding options in advanced dementia: a randomized controlled trial. J Am Geriatr Soc 2011; 59: 20092016.Google Scholar
Conroy, SP, Luxton, T, Dingwall, R, Harwood, RH, Gladman, JR. Cardiopulmonary resuscitation in continuing care settings: time for a rethink? Br Med J 2006; 332: 479482.Google Scholar
Ebell, MH, Becker, LA, Barry, HC, Hagen, M. Survival after in-hospital cardiopulmonary resuscitation. A meta-analysis. J Gen Intern Med 1998; 13: 805816.Google Scholar
Volandes, AE, Abbo, ED. Flipping the default: a novel approach to cardiopulmonary resuscitation in end-stage dementia. J Clin Ethics 2007; 18: 122139.Google Scholar
Seeher, K, Brodaty, H. Family carers of people with dementia. In Dementia (5th ed.) (eds. Ames, D, O’Brien, J, Burns, A): 142160. CRC Press, Taylor Francis Group, 2017.Google Scholar
Hughes, JC. Behaviours that challenge at the end of life. In Understanding Behaviour in Dementia that Challenges: A guide to Assessment and Treatment (2nd ed.) (eds. James, IA, Jackman, L): 280292. Jessica Kingsley, 2017.Google Scholar
Allen, FB, Coleman, PG. Spiritual perspectives on the person with dementia: identity and personhood. In Dementia: Mind, Meaning, and the Person (eds. Hughes, JC, Louw, SJ, Sabat, SR): 205221. Oxford University Press, 2006.Google Scholar
Sapp, S. Spiritual care of people with dementia and their carers. In Supportive Care for the Person with Dementia (eds. Hughes, JC, Lloyd-Williams, M, Sachs, GA): 199206. Oxford University Press, 2010.Google Scholar
Davis, R. My Journey into Alzheimer’s Disease. Tyndale, 1989.Google Scholar
Dinning, L. The spiritual care of people with severe dementia. In Palliative Care in Severe Dementia (ed. Hughes, JC): 126134. Quay Books, 2006.Google Scholar
Hughes, J. Personhood and religion in people with dementia. In Neurology and Religion (eds. Coles, A, Collicutt, J): 149160. Cambridge University Press, 2020.Google Scholar
Jewell, A. (ed.) Spirituality and Personhood in Dementia. Jessica Kingsley, 2011.Google Scholar
Ødbehr, L, Kvigne, K, Hauge, S, Danbolt, LJ. Nurses’ and care workers’ experiences of spiritual needs in residents with dementia in nursing homes: a qualitative study. BMC Nurs 2014; 13: 12. Available via: https://bmcnurs.biomedcentral.com/track/pdf/10.1186/1472-6955-13-12 (last accessed 28 October 2019).Google Scholar
Ødbehr, LS, Kvigne, K, Hauge, S, Danbolt, LJ. Spiritual care to persons with dementia in nursing homes; a qualitative study of nurses and care workers experiences. BMC Nurs 2015; 14: 70. Available via: www.ncbi.nlm.nih.gov/pmc/articles/PMC4693438/pdf/12912_2015_Article_122.pdf (last accessed 28 October 2019).CrossRefGoogle ScholarPubMed
van der Steen, JT, Gijsberts, M-JHE, Hertogh, CMPM, Deliens, L. Predictors of spiritual care provision for patients with dementia at the end of life as perceived by physicians: a prospective study. BMC Palliat Care 2014; 13: 61. Available via: https://bmcpalliatcare.biomedcentral.com/track/pdf/10.1186/1472-684X-13-61 (last accessed 28 October 2019).Google Scholar
Musa, I, Seymour, J, Narayanasamy, MJ, Wada, T, Conroy, S. A survey of older peoples’ attitudes towards advance care planning. Age Ageing 2015; 44: 371376.Google Scholar
Robinson, L, Dickinson, C, Bamford, C, et al. A qualitative study: professionals’ experiences of advance care planning in dementia and palliative care, ‘a good idea in theory but…Palliat Med 2013; 27: 400408.Google Scholar
Sampson, EL, Burns, A. Planning a personalised future with dementia: ‘the misleading simplicity of advance directives’. Palliat Med 2013; 27: 387388.Google Scholar
Hertogh, CM. The misleading simplicity of advance directives. Int Psychogeriatr 2011; 23: 511515.CrossRefGoogle ScholarPubMed
van der Steen, JT, van Soest-Poortvlieta, MC, Hallie-Heierman, M, et al. Factors associated with initiation of advance care planning in dementia: a systematic review. J Alzheimer’s Dis 2014; 40: 743757.Google Scholar
Brazil, K, Carter, G, Cardwell, C, et al. Effectiveness of advance care planning with family carers in dementia nursing homes: a paired cluster randomized controlled trial. Palliat Med 2018; 32: 603612.Google Scholar
Wiggins, N, Droney, J, Mohammed, K, Riley, J, Sleeman, KE. Understanding the factors associated with patients with dementia achieving their preferred place of death: a retrospective cohort study. Age Ageing 2019; 48: 433439.Google Scholar
Dixon, J, Karagiannidou, M, Knapp, M. The effectiveness of advance care planning in improving end-of-life outcomes for people with dementia and their carers: a systematic review and critical discussion. J Pain Symptom Manage 2018; 55: 132150.Google Scholar
Turner, M, Peacock, M. Palliative care in UK prisons: practical and emotional challenges for staff and fellow prisoners. J Correct Health Care 2017; 23: 5665.Google Scholar

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