Elizabeth L Sampson

Dementia in the acute hospital: prospective cohort study of prevalence and mortality

BACKGROUND Increasing numbers of people will die with dementia, many in the acute hospital. It is often not perceived to be a life-limiting illness. AIMS To investigate the prevalence of dementia in older people undergoing emergency medical admission and its effect on outcomes. METHOD Longitudinal cohort study of 617 people (aged over 70). The main outcome was mortality risk during admission. RESULTS Of the cohort, 42.4% had dementia (only half diagnosed prior to admission). In men aged 70-79, dementia prevalence was 16.4%, rising to 48.8% of those over 90. In women, 29.6% aged 70-79 had dementia, rising to 75.0% aged over 90. Urinary tract infection or pneumonia was the principal cause of admission in 41.3% of the people with dementia. These individuals had markedly higher mortality; 24.0% of those with severe cognitive impairment died during admission (adjusted mortality risk 4.02, 95% CI 2.24-7.36). CONCLUSIONS The rising prevalence of dementia will have an impact on acute hospitals. Extra resources will be required for intermediate and palliative care and mental health liaison services.

Dementia prevention, intervention, and care

Acting now on dementia prevention, intervention, and care will vastly improve living and dying for individuals with dementia and their families, and in doing so, will transform the future for society. Dementia is the greatest global challenge for health and social care in the 21st century. It occurs mainly in people older than 65 years, so increases in numbers and costs are driven, worldwide, by increased longevity resulting from the welcome reduction in people dying prematurely. The Lancet Commission on Dementia Prevention, Intervention, and Care met to consolidate the huge strides that have been made and the emerging knowledge as to what we should do to prevent and manage dementia. Globally, about 47 million people were living with dementia in 2015, and this number is projected to triple by 2050. Dementia affects the individuals with the condition, who gradually lose their abilities, as well as their relatives and other supporters, who have to cope with seeing a family member or friend become ill and decline, while responding to their needs, such as increasing dependency and changes in behaviour. Additionally, it affects the wider society because people with dementia also require health and social care. The 2015 global cost of dementia was estimated to be US

Clinical practice with anti-dementia drugs: A revised (third) consensus statement from the British Association for Psychopharmacology:

818 billion, and this figure will continue to increase as the number of people with dementia rises. Nearly 85% of costs are related to family and social, rather than medical, care. It might be that new medical care in the future, including public health measures, could replace and possibly reduce some of this cost.

A systematic review of the scientific evidence for the efficacy of a palliative care approach in advanced dementia

The British Association for Psychopharmacology coordinated a meeting of experts to review and revise its previous 2011 guidelines for clinical practice with anti-dementia drugs. As before, levels of evidence were rated using accepted standards which were then translated into grades of recommendation A–D, with A having the strongest evidence base (from randomised controlled trials) and D the weakest (case studies or expert opinion). Current clinical diagnostic criteria for dementia have sufficient accuracy to be applied in clinical practice (B) and both structural (computed tomography and magnetic resonance imaging) and functional (positron emission tomography and single photon emission computerised tomography) brain imaging can improve diagnostic accuracy in particular situations (B). Cholinesterase inhibitors (donepezil, rivastigmine, and galantamine) are effective for cognition in mild to moderate Alzheimer’s disease (A), memantine for moderate to severe Alzheimer’s disease (A) and combination therapy (cholinesterase inhibitors and memantine) may be beneficial (B). Drugs should not be stopped just because dementia severity increases (A). Until further evidence is available other drugs, including statins, anti-inflammatory drugs, vitamin E, nutritional supplements and Ginkgo biloba, cannot be recommended either for the treatment or prevention of Alzheimer’s disease (A). Neither cholinesterase inhibitors nor memantine are effective in those with mild cognitive impairment (A). Cholinesterase inhibitors are not effective in frontotemporal dementia and may cause agitation (A), though selective serotonin reuptake inhibitors may help behavioural (but not cognitive) features (B). Cholinesterase inhibitors should be used for the treatment of people with Lewy body dementias (both Parkinson’s disease dementia and dementia with Lewy bodies), and memantine may be helpful (A). No drugs are clearly effective in vascular dementia, though cholinesterase inhibitors are beneficial in mixed dementia (B). Early evidence suggests multifactorial interventions may have potential to prevent or delay the onset of dementia (B). Though the consensus statement focuses on medication, psychological interventions can be effective in addition to pharmacotherapy, both for cognitive and non-cognitive symptoms. Many novel pharmacological approaches involving strategies to reduce amyloid and/or tau deposition in those with or at high risk of Alzheimer’s disease are in progress. Though results of pivotal studies in early (prodromal/mild) Alzheimer’s disease are awaited, results to date in more established (mild to moderate) Alzheimer’s disease have been equivocal and no disease modifying agents are either licensed or can be currently recommended for clinical use.

Making decisions for people with dementia who lack capacity: qualitative study of family carers in UK.

BACKGROUND Patients with dementia often receive poor end-of-life care, with inadequate pain control and without access to the palliative care services that patients with cancer are offered. This has been identified as an area of need in recent UK. Government reports and by the Alzheimers Society (UK). Our objective was to perform a systematic review of the scientific literature regarding the efficacy of a palliative care model in patients with dementia. METHODS A systematic review was carried out to identify controlled trials that investigated the efficacy of palliative care in patients with dementia. Data sources included were Medline, EMBASE, PsycINFO, CINAHL, British Nursing Index, AMED, Cochrane Database of Systematic Reviews, Web of Science, Cochrane Central Register of Controlled Trials, International Standard Randomised Controlled Trial register, the NHS Economic Evaluation Database and the System for Information on Grey Literature in Europe. Other data was sourced from hand searches of papers identified on electronic databases and review articles. RESULTS The search identified 30 review articles, but only four papers were eligible for full appraisal and only two of these met the full criteria for inclusion. These papers gave equivocal evidence of the efficacy for a palliative model of care in dementia. CONCLUSION Despite the increased interest in palliative care for patients with dementia there is currently little evidence on which to base such an approach. This may in part be due to the ethical difficulties surrounding such research, prognostic uncertainty in clinicians and the lack of clear outcome measures for patients who are unable to express their needs or wishes. Further systematic research is urgently needed to educate an important and developing area of clinical practice.

In vivo detection of microglial activation in frontotemporal dementia.

Objective To identify common difficult decisions made by family carers on behalf of people with dementia, and facilitators of and barriers to such decisions, in order to produce information for family carers about overcoming barriers. Design Qualitative study to delineate decision areas through focus groups and complexity of decision making in individual interviews. Setting Community settings in London. Participants 43 family carers of people with dementia in focus groups and 46 carers who had already made such decisions in individual interviews. Results Family carers identified five core problematic areas of decision making: accessing dementia related health and social services; care homes; legal-financial matters; non-dementia related health care; and making plans for the person with dementia if the carer became too ill to care for them. They highlighted the difficulties in making proxy decisions, especially against active resistance, and their altered role of patient manager while still a family member. Families devised strategies to gain agreement in order to ensure that the person with dementia retained dignity. Conclusions The following strategies helped with implementation of decisions: introducing change slowly; organising legal changes for the carer as well as the patient; involving a professional to persuade the patient to accept services; and emphasising that services optimised, not impeded, independence. To access services, carers made patients’ general practice appointments, accompanied them to the surgery, pointed out symptoms, gained permission to receive confidential information, asked for referral to specialist services, and used professionals’ authority to gain patients’ agreement. End of life decisions were particularly difficult. They were helped by knowledge of the person with dementia’s previous views, clear prognostic information, and family support. Information sheets to help carers to overcome barriers to proxy decision making have been developed; their impact in practice has yet to be evaluated.

A systematic review of the prevalence, associations and outcomes of dementia in older general hospital inpatients

Using positron emission tomography and [11C](R)‐PK11195, a marker of “peripheral benzodiazepine sites” that is upregulated on activated microglia during progressive tissue pathology, we show increased binding of [11C](R)‐PK11195 in frontotemporal lobar degeneration in the typically affected frontotemporal brain regions. This implies the presence of an active glial response reflecting progressive neuronal degeneration. It also suggests that increased [11C](R)‐PK11195 binding, previously demonstrated for Alzheimers disease, may occur independently from increased amyloid plaque formation, given that it is not a characteristic feature of frontotemporal lobar degeneration. Ann Neurol 2004;56:894–897

Young onset dementia.

BACKGROUND Older people are commonly admitted to the acute hospital and increasing numbers will have dementia. In this study we systematically reviewed the prevalence, associations and outcomes of dementia in older people in the general hospital, to examine the range of diagnostic tools used and highlight gaps in the literature. METHODS We searched the English language literature using Embase, PsychInfo and Medline. Studies were included if they used validated criteria for diagnosing dementia, involved subjects over the age of 55 years and were set in the general hospital. RESULTS Fourteen papers were identified. Prevalence estimates for dementia in studies with robust methodology were 12.9-63.0%. Less than a third of studies screened for delirium or depression and therefore some subjects may have been misclassified as having dementia. The data were highly heterogeneous and prevalence estimates varied widely, influenced by study setting and demographic features of the cohorts. Patients with dementia in the acute hospital are older, require more hours of nursing care, have longer hospital stays, and are more at risk of delayed discharge and functional decline during admission. CONCLUSIONS When planning liaison services, the setting and demographic features of the population need to be taken into account. Most study cohorts were recruited from medical wards. More work is required on the prevalence of dementia in surgical and other specialties. A wider range of associations (particularly medical and psychiatric comorbidity) and outcomes should be studied so that care can be improved.

Risk factors for incident delirium among older people in acute hospital medical units: a systematic review and meta-analysis

Young onset dementia is a challenging clinical problem with potentially devastating medical and social consequences. The differential diagnosis is wide, and includes a number of rare sporadic and hereditary diseases. However, accurate diagnosis is often possible, and all patients should be thoroughly investigated to identify treatable processes. This review presents an approach to the diagnosis, investigation, and management of patients with young onset dementia, with particular reference to common and treatable causes.

Clinical effectiveness of a manual based coping strategy programme (START, STrAtegies for RelaTives) in promoting the mental health of carers of family members with dementia: pragmatic randomised controlled trial

Background: delirium affects up to 40% of older hospitalised patients, but there has been no systematic review focussing on risk factors for incident delirium in older medical inpatients. We aimed to synthesise data on risk factors for incident delirium and where possible conduct meta-analysis of these. Methods: PubMed and Web of Science databases were searched (January 1987–August 2013). Studies were quality rated using the Newcastle-Ottawa Scale. We used the Mantel–Haenszel and inverse variance method to estimate the pooled odds ratio (OR) or mean difference for individual risk factors. Results: eleven articles met inclusion criteria and were included for review. Total study population 2338 (411 patients with delirium/1927 controls). The commonest factors significantly associated with delirium were dementia, older age, co-morbid illness, severity of medical illness, infection, ‘high-risk’ medication use, diminished activities of daily living, immobility, sensory impairment, urinary catheterisation, urea and electrolyte imbalance and malnutrition. In pooled analyses, dementia (OR 6.62; 95% CI (confidence interval) 4.30, 10.19), illness severity (APACHE II) (MD (mean difference) 3.91; 95% CI 2.22, 5.59), visual impairment (OR 1.89; 95% CI 1.03, 3.47), urinary catheterisation (OR 3.16; 95% CI 1.26, 7.92), low albumin level (MD −3.14; 95% CI −5.99, −0.29) and length of hospital stay (OR 4.85; 95% CI 2.20, 7.50) were statistically significantly associated with delirium. Conclusion: we identified risk factors consistently associated with incident delirium following admission. These factors help to highlight older acute medical inpatients at risk of developing delirium during their hospital stay.