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Comprehensive Guide to Palliative Care for Dementia Patients

Understand the challenges, symptoms, and holistic needs in providing palliative care for dementia patients, with a case study example. Gain insights into symptom management, end-of-life predictors, and barriers to care. Learn about assessment, diagnosis, and management strategies for better patient outcomes.

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Comprehensive Guide to Palliative Care for Dementia Patients

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  1. Palliative and End of Life Care for patients with Dementia Dr Katharine Thompson Consultant in Palliative Medicine February 2019

  2. Background

  3. Prevalence and Relevance • 1 /3 people >65yrs have dementia • 2/3 are female • Huge rise in numbers (1 million in UK by 2021)

  4. Definition • A syndrome due to disease of the brain • Chronic and progressive nature • Disturbance of multiple higher cortical functions • Memory, thinking, orientation, comprehension, language, judgement • Consciousness is not impaired • Impairment of cognitive function and associated decline in: • Emotional control • Social behaviour • Motivation

  5. Clinical Features of Dementia 3 Clusters: • Neuropsychological • Memory loss, executive function (reasoning/judgement) • Function (ADLs) • Washing, dressing, shopping, driving • Neuropsychiatric - Behavioural and psychological symptoms of dementia (BPSD) • Mood, agitation, hallucinations

  6. Indicators of Advancing Dementia • Unable to walk without assistance • Urinary and faecal incontinence • No consistently meaningful conversation • Unable to manage ADLs • Barthel score <3 Plus any of: • Weight loss • Urinary tract infection • Severe pressure sores, stage 3 or 4 • Recurrent fever • Reduced oral intake • Aspiration pneumonia Predictors of End Stage Dementia • 5-10% weight loss over 1-2 months • Admission to care home

  7. Challenges

  8. Unmet Need Symptom Burden may be similar to: • Cancer • Chronic obstructive pulmonary disease • Advanced heart failure Symptoms: • Anxiety • Agitation • Dysphagia Holistic Need: • Functional • Financial • Existential/Spiritual needs • Carer burden

  9. Barriers to Palliative Care Service • Potential number of service users • Location of care • Social care versus health care • Visibility to secondary care • Lack of prognostic markers • Culture Patient • Unable to articulate symptoms • Behavioural change often multi-factoria Disease • Challenging behavioural and psychological symptoms • Often co-morbidities • Survival is unpredictable • Death may be due to dementia or inter-current illness

  10. Palliation of Symptoms

  11. Symptom Management BPSD: • Depression • Anxiety • Sleep/Wake Cycle Reversal • Hallucinations/Delusions • Agitation Pain Distress

  12. Case Study

  13. Mrs D • 84 year old female • Dementia for several years • Long standing nursing home resident • Slow deterioration over months • Family felt NH unable to meet needs

  14. Recent History Symptoms: • Family felt patient had abdominal pain • Patient unable to articulate this verbally • Wincing, grimacing, drawing legs up intermittently • New agitation/aggression In context of: • Significant weight loss • Not eating • Sleeping more • Mainly bed bound

  15. What would you do? • Assessment • Investigations? • Management • Referral?

  16. Assessment • Patient unable to provide further history Obs: • Hypotensive • Afebrile Examination • Very frail, cachectic • Agitated, tense • Abdominal examination • Grimacing and shouting out • Distended bowel loops – faecal loading • Palpable bladder

  17. Diagnosis?

  18. Diagnosis • Hypotensive • Urinary retention • Constipation In context of rate of change described: • Approaching EOL

  19. Management?

  20. Management Reverse the reversible: • Catheterise • Bowel intervention • Rationalise meds • Anticipatory prescribing

  21. Outcome • Patient died peacefully in the Hospice over 1 week later....could have been in NH

  22. Questions

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