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Bedside tests of attention and organized thinking were performed in patients with cognitive impairment or dementia but without delirium, to provide estimates of false positive rates for detecting delirium superimposed on dementia (DSD).
Design and Setting:
This cross-sectional study was conducted in outpatients and institutionalized patients without delirium representing a wide spectrum of severity of cognitive impairments.
Patients with dementia or a cognitive disorder according to DSM IV criteria, after exclusion of (suspected) delirium according to DSM IV criteria.
Tests for inattention and disorganized thinking from the CAM-ICU were assessed.
The sample included 163 patients (mean age 83 years (SD 6; 64% women)), with Alzheimer's disease as most prevalent (45%) diagnosis and a mean MMSE-score of 16.8 (SD 7.5). False positive rates of the test of attention varied from 0.04 in patients with normal to borderline cognitive function to 0.8 in those with severe dementia. The false positive rate of the test of disorganized thinking was zero in the normal to borderline group, increasing to 0.67 in patients with severe dementia. When combining test results false positive rates decreased to 0.03 in patients with MMSE scores above 9.
Use of simple bedside tests of attention and organized thinking for the clinical diagnosis of DSD will result in high rates of false positive observations if used regardless of the severity of dementia. However, if test results are combined they may be useful to exclude DSD in patients with minimal to moderate degrees of dementia, but not in the severe group.
The question of what constitutes a dignified old age has always been a topic of philosophical enquiry. Already in the writings of the stoic philosophers we can find relevant contributions to an ethic of “successful” aging. Seneca, for instance, reflects upon the pleasures of old age in several of his famous “Letters to Lucilius” (Seneca, 1967). However, he also writes about the bad years that may lie ahead and confides to his pupil: “Do not hear me with reluctance as if my statement applied directly to you, but weigh what I have to say. It is this. I shall not abandon old age, if old age preserves me intact for myself, and intact as regards to the better part of myself; but if old age begins to shatter my mind, and pull its various faculties to pieces, if it leaves me, not life, but only the breath of life, I shall rush out of a house that is crumbling and tottering . . .”
Introduction: Although in most developed countries the use of restraints is regulated and restricted by law, the concept of restraint in nursing home care remains ambiguous. This study aims to explore how care professionals and family members of nursing home residents with dementia in the Netherlands experience and define the concept of restraint.
Methods: Individual interviews were held with relatives (n = 7) and key persons (n = 9) in seven nursing homes. We also conducted eight focus group discussions with nursing home staff. In addition, a structured questionnaire was administered to the nurses of participating nursing homes.
Results: In the questionnaire, over 80% of the respondents indicated considering “fixation” (e.g. use of belts) as a restraint and 50 to 70% of the respondents regarded other physical interventions, such as geriatric chairs and bedrails, as restraints. The interviews and focus group discussions show that the residents' perception of the intervention, the staff's intention behind the intervention and concerns of privacy are the criteria used by the respondents in defining an intervention as a restraint.
Conclusions: When trying to diminish restraint use, it is important to be aware of the “local logic” of care practice and to take into account the fact that, for staff and relatives, an intervention is only regarded as a restraint when it is bothering a resident or when an intervention is used for the sole purpose of restricting freedom and/or when interventions invade the privacy of a resident.
Background: Technology has emerged as a potential solution to alleviate some of the pressures on an already overburdened care system, thereby meeting the growing needs of an expanding population of seriously cognitively impaired people. However, questions arise as to what extent technologies are already being used in residential care and how ethically and practically acceptable this use would be.
Methods: A systematic literature review was conducted to explore what is known on the moral and practical acceptability of surveillance technologies in residential care for people with dementia or intellectual disabilities, and to set forth the state of the debate.
Results: A total of 79 papers met the inclusion criteria. The findings show that application and use of surveillance technologies in residential care for vulnerable people generates considerable ethical debate. This ethical debate centers not so much around the effects of technology, but rather around the moral acceptability of those effects, especially when a conflict arises between the interests of the institution and the interests of the resident. However, the majority of articles lack in depth analysis.
Furthermore, there are notable cultural differences between the European literature and American literature whereby in Britain there seems to be more ethical debate than in America. Overall however, there is little attention for the resident perspective.
Conclusion: No ethical consensus has yet been reached, underlining the need for clear(er) policies. More research is thus recommended to determine ethical and practical viability of surveillance technologies whereby research should be specifically focused on the resident perspective.
Background: Although advance directives may seem useful instruments in decision-making regarding incompetent patients, their validity in cases of dementia has been a much debated subject and little is known about their effectiveness in practice. This paper assesses the contribution of advance directives to decision-making in the care of people with dementia, with a special focus on non-treatment directives and directives for euthanasia.
Methods: The relevant problems from the ethical debate on advance directives in cases of dementia are summarized and we discuss how these relate to what is known from empirical research on the validity and effectiveness of advance directives in the clinical practice of dementia care.
Results: The ethical debate focuses essentially on how to respond to the current wishes of a patient with dementia if these contradict the patient's wishes contained in an advance directive. The (very limited) empirical data show that the main factors in medical decision-making in such cases is not the patient's perspective but the medical judgment of the physician and the influence of relatives. Insight into the experiences and wishes of people with dementia regarding advance directives is totally lacking in empirical research.
Conclusions: Ethics and actual practice are two “different worlds” when it comes to approaching advance directives in cases of dementia. It is clear, however, that the use of advance directives in practice remains problematic, above all in cases of advance euthanasia directives, but to a lesser extent also when non-treatment directives are involved. Although generally considered valid, their effectiveness seems marginal. Further empirical research into the (potential) value of advance directives in dementia care is recommended.
Background: Among the general public there is a deep fear of developing dementia, which has led to an increasing number of people “at risk” seeking ways (such as advance directives) to avoid undergoing progressive mental decline. The views of people with dementia are vital in obtaining a real answer to the question of how the disease affects people's lives and whether it actually involves the suffering that so many fear.
Method: A review of the international literature is provided on what is known about living through dementia from the patient's perspective.
Results: A total of 50 papers met the inclusion criteria. The findings of these reviewed papers give insight into the impact of dementia and the ways that those who have it deal with its effects by using different coping strategies. The literature on the perspective of the patient gives no solid support to the widespread assumption that dementia is necessarily a state of dreadful suffering. Although the impact of dementia and the experiences of loss resulting in multiple “negative” emotions cannot be denied, our findings also indicate that people do not undergo the disease passively and use both emotion-oriented and problem-oriented coping strategies to deal with its challenges. The experiences of living through dementia as told by the sufferers appear to yield a more subtle picture than the assumptions made by the general public.
Conclusion: The overview provides a good starting point for improving the adjustment of care to the experience and wishes of people with dementia.
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