Martin Blanchard

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.

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

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.

Clinical Effectiveness of Individual Cognitive Behavioral Therapy for Depressed Older People in Primary Care A Randomized Controlled Trial

CONTEXT In older people, depressive symptoms are common, psychological adjustment to aging is complex, and associated chronic physical illness limits the use of antidepressants. Despite this, older people are rarely offered psychological interventions, and only 3 randomized controlled trials of individual cognitive behavioral therapy (CBT) in a primary care setting have been published. OBJECTIVE To determine the clinical effectiveness of CBT delivered in primary care for older people with depression. DESIGN A single-blind, randomized, controlled trial with 4- and 10-month follow-up visits. PATIENTS A total of 204 people aged 65 years or older (mean [SD] age, 74.1 [7.0] years; 79.4% female; 20.6% male) with a Geriatric Mental State diagnosis of depression were recruited from primary care. INTERVENTIONS Treatment as usual (TAU), TAU plus a talking control (TC), or TAU plus CBT. The TC and CBT were offered over 4 months. OUTCOME MEASURES Beck Depression Inventory-II (BDI-II) scores collected at baseline, end of therapy (4 months), and 10 months after the baseline visit. Subsidiary measures were the Beck Anxiety Inventory, Social Functioning Questionnaire, and Euroqol. Intent to treat using Generalized Estimating Equation and Compliance Average Causal Effect analyses were used. RESULTS Eighty percent of participants were followed up. The mean number of sessions of TC or CBT was just greater than 7. Intent-to-treat analysis found improvements of -3.07 (95% confidence interval [CI], -5.73 to -0.42) and -3.65 (95% CI, -6.18 to -1.12) in BDI-II scores in favor of CBT vs TAU and TC, respectively. Compliance Average Causal Effect analysis compared CBT with TC. A significant benefit of CBT of 0.4 points (95% CI, 0.01 to 0.72) on the BDI-II per therapy session was observed. The cognitive therapy scale showed no difference for nonspecific, but significant differences for specific factors in therapy. Ratings for CBT were high (mean [SD], 54.2 [4.1]). CONCLUSION Cognitive behavioral therapy is an effective treatment for older people with depressive disorder and appears to be associated with its specific effects. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN18271323.

Abuse of people with dementia by family carers: representative cross sectional survey.

Objective To determine the prevalence of abusive behaviours by family carers of people with dementia. Design Representative cross sectional survey Setting Community mental health teams in Essex and London. Participants 220 family carers of people newly referred to secondary psychiatric services with dementia who were living at home. Main outcome measure Psychological and physical abuse (revised modified conflict tactics scale). Results 115 (52%, 95% confidence interval 46% to 59%) carers reported some abusive behaviour and 74 (34%, 27% to 40%) reported important levels of abuse. Verbal abuse was most commonly reported. Only three (1.4%) carers reported occasional physical abuse. Conclusions Abusive behaviour by family carers towards people with dementia is common, with a third reporting important levels of abuse and half some abusive behaviour. We found few cases of physical or frequent abuse, although those with the most abusive behaviour may have been reluctant to report it.

The determinants of family carers' abusive behaviour to people with dementia: Results of the CARD study

BACKGROUND Although dementia and elder abuse prevention are political priorities, there are no evidence-based interventions to reduce abuse by family carers. We have limited understanding of why some family carers, but not others in similar circumstances, behave abusively. We aimed to test our hypothesis, that more anxious dementia carers report more abusive behaviours, and dysfunctional coping strategies and carer burden mediate this relationship. METHOD We interviewed 220 family/friend dementia carers from Essex and London Community Mental Health Teams. We used the revised Modified Conflict Tactics Scale to measure abuse. RESULTS More anxious and depressed carers reported more abuse; this relationship was mediated by using dysfunctional coping strategies and higher burden. Abuse was predicted by: spending more hours caring, experiencing more abusive behaviour from care recipients and higher burden. LIMITATIONS This was a cross-sectional study so we cannot confirm directions of causality. While many carers were willing to report abusive actions, some may not have been and our numbers may be an underestimate. CONCLUSION Anxious and depressed carers are particularly likely to report abusive behaviour when asked. Testing interventions directed at reducing carer anxiety, depression or changing unhelpful coping strategies, and/or reducing care recipient aggression where possible, is a logical and urgent next step.

End of life care for community dwelling older people with dementia: an integrated review

To review the evidence for end‐of‐life care for community dwelling older people with dementia (including those resident in care homes).

Palliative assessment and advance care planning in severe dementia: An exploratory randomized controlled trial of a complex intervention

Patients with advanced dementia often receive poor end-of-life care. We aimed to design and pilot a palliative care and advance care plan (ACP) intervention. Patients had undergone emergency hospital admission and had severe dementia. The intervention consisted of a palliative care patient assessment which informed an ACP discussion with the carer, who was offered the opportunity to write an ACP for the person with dementia. Carer–patient dyads were randomized to ‘usual care’ or the intervention. Carer-related outcome measures included the Kessler Distress Scale, Decision Satisfaction Inventory, Client Satisfaction Questionnaire and the Euroqol-5D, measured at baseline, six weeks, six months and three months after bereavement. The Satisfaction with End of Life Care in Dementia Scale was completed if the patient died. The 32 patient participants were physically frail and in the advanced stages of dementia: 62% had pressure damage to the skin, all needed feeding assistance and 95% were in pain. Nearly 50% died during the six-month follow-up period. Carers were difficult to recruit during acute admission; 33 patients and carers entered the study (22 intervention arm; 11 control arm). Only seven carers made ACPs. The care planning discussion was well received, but few carers wrote an ACP, despite intensive support from an experienced nurse specialist. Advance care planning is, in theory, a necessary intervention for people with severe dementia; the reluctance of carers to write plans needs to be explored further.

Challenges to improving end of life care of people with advanced dementia in the UK

The end of life care received by patients with advanced dementia and their carers is of increasing importance as the incidence of dementia is set to rise in the next 30 years. Currently, inappropriate admissions to hospital are common in the UK and patients are less likely to be referred to palliative care services, receive less pain control but undergo more invasive interventions compared to their cognitively intact counterparts. Patients and families are seldom informed of the terminal nature of dementia and advance care planning discussions are rare. The aim of this study was to improve the understanding of end of life care needs for this patient group and their carers, and to use this information to devise an intervention to improve care. Qualitative data were obtained from relatives of 20 patients with advanced dementia admitted to an inner London teaching hospital acute National Health Service (NHS) Trust and 21 health care professionals involved in their care. Framework analysis was used to analyse the transcripts. The results showed that participants’ understanding of dementia and its likely progress was poor. Provision of information regarding the future was rare despite high information needs. Attitudes regarding end of life care were often driven by the participant’s illness awareness. These attitudes served to guide the decision making process and appear to be a major barrier to the provision of more appropriate care. Implications for patient care are discussed and suggestions for future interventions are made.

Older adults' attitudes to death, palliative treatment and hospice care:

Background: Cancer patients who receive care from specialist palliative care services in the UK are younger than those who do not receive this care. This may be explained by agerelated differences in attitudes to end-of-life care. Objective: To determine the relationship between age and i) attitudes to death and preparation for death; and ii) knowledge about, and attitudes to, cancer and palliative care. Design: Interviews with older people, using a novel questionnaire developed using nominal groups. Main comparisons were made between people aged 55-74 with those aged 75 years and over. Setting: General practices in London. Subjects: 129 people aged 55-74 and 127 people aged 75 years or over on the lists of general practitioners. Methods: A cross-sectional survey to determine knowledge and experience of hospice care; preparation for end-of-life; and attitudes to end-of-life issues. Results: Participants were knowledgeable about specialist palliative care and almost half had some indirect contact with a hospice. People aged <74 were less likely than younger participants to want their doctor to end their life in a terminal illness. Although they believed death was easier to face for older people, they did not believe that younger people deserved more consideration than older people when dying, or that they should have priority for hospice care. Education, social class, hospice knowledge and anxiety about death had little influence on overall attitudes. Conclusions: The relative under-utilization of hospice and specialist palliative care services by older people with cancer in the UK cannot be explained by their attitudes to end-of-life issues and palliative care.

Survival of people with dementia after unplanned acute hospital admission: a prospective cohort study

To examine the effect of dementia on longer term survival after hospital admission, and to assess whether dementia is an independent predictor of mortality. This information is vital for the provision of appropriate care.