Age and Ageing Advance Access originally published online on April 25, 2007
Age and Ageing 2007 36(5):584-587; doi:10.1093/ageing/afm035
Do we really need palliative care for severe dementia patients?
SIR—The decision about the most appropriate care model for patients affected by severe dementia and acute somatic diseases is a major topic in the discussion regarding hospital processes. With this in mind, we read with interest the editorial by Parker et al. on ‘Acute hospital care for frail older people’ and the paper by Zvi Aminoff and Adunsky recently published in Age and Ageing [1, 2]. We share most of the statements by the authors regarding the care of elderly people in the acute hospital setting. Moreover, we appreciate the attention given to this topic in a period when geriatric wards are under pressure with the general trend to reduce acute hospital beds. In particular, the Italian national agenda is dominated mostly by an emphasis on developing intermediate care and community services for older people [3]. Some acute geriatric wards are closing and others are being converted to departments of ‘low care’ [4]. The remaining geriatric hospital wards have to face the difficult task of caring for a higher number of old patients with an increase in the average level of illness severity and complexity. In order to answer these difficulties we need to define new models of inpatient units. Special acute care units for elderly patient (ACE) like sub-intensive care units for the elderly, stroke units, hip units and delirium units have been developed. Most of them have been shown to be effective for specific clinical conditions. However, for many patients, i.e. those with severe dementia, the effectiveness of hospital admission has not been completely evaluated, and new models of care are in the process of being developed. Among these models, palliative care seems inspired by the most diffused cultural backgrounds.In this framework, we would like to present our data, in order to contribute to the ongoing discussion.
From 1 January to 31 December 2003, there were 1,418 patients who were consecutively admitted to our ward. One hundred and eight patients were under 65 years of age and were excluded from the analysis, and 16 patients were lost at follow-up (n = 16). We report data from 1,310 patients over 65 years old (female = 67.7%, mean age = 79.4 ± 7.8). Our ward is modelled on the US ACE units [5, 6] and 78% of our patients are admitted through the emergency room (ER).
A multidimensional evaluation, including information on demographics, cognitive and affective status, physical health, functional abilities, and social support was performed on the first day after admission using a standard protocol administered by trained geriatricians. Somatic health was evaluated as single chronic diseases, co-morbidity, and physiological severity. Single chronic diseases were measured as presence/absence of individual symptomatic diseases not controlled by therapy. Co-morbidity was computed using the Charlson index, a score for evaluating prognosis based on co-morbid conditions [7]. Physiological severity was computed using the Apache II score that by the Acute Physiology sub-Score (APS), takes into account the degree of abnormality of multiple physiological variables; moreover the Apache II score also takes into account age and chronic coexistent conditions (CHF, COPD, cirrhosis, renal failure, and cancer) [8]. The number of currently administered drugs was also recorded. Cognitive status was evaluated using the Mini Mental State Examination (MMSE) [9], and depressive symptoms with the 15 item Geriatric Depression Scale (GDS) [10]. The GDS was administered only to patients with MMSE >14. Self reported disability in Instrumental Activities of Daily Living (IADL) was assessed asking patients or their proxy (if patients were unable to give an answer, e.g. subjects affected by dementia) to recall their pre-morbid function; Lawton and Brody Scale was adopted [11].
Self-reported disability in basic activities of daily living (BADL) was assessed by the Barthel Index (BI) [12]. For the aim of the study we considered patients with severe dementia and divided them into two groups: patients affected by dementia but not confined to bed, and patients with severe dementia and confined to bed. Patients with severe dementia were those with a MMSE lower than 10. The characteristics of these two groups were compared with all other inpatients. Six-month mortality was the outcome measure of our analysis and was determined by phone calls to relatives or, in their absence, assessed by searching Municipal Death Index records.
Table 1 shows the characteristics of patients according to their mental status.
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Patients with dementia and confined to bed have the worst health status: they have a higher impairment in the APS-APACHE II score, the lowest level of serum albumin, haemoglobin and serum cholesterol, and the highest co-morbidity. Six-month mortality was 64.4, 21.1 and 12.5%, respectively, for patients with dementia and confined to bed, with dementia without being confined to bed, and for the control group.
In Table 2, factors associated with 6-month mortality are shown. Patients with severe dementia (with or without being confined to bed) have an independent association with increased 6-month mortality even when adjusted for all the clinical variables found to be associated with mortality in bivariate analysis. When using the group of patients without severe dementia as the reference group, the RRs and 95% CI of patients with severe dementia but not bedridden, and of patients with severe dementia and bedridden, were respectively 1.7 (1.0–3.1) and 4.6 (2.8–7.6).
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Do we need to adopt a palliative approach for these severely demented patients? Considering that 35% of patients with severe dementia and confined to bed survive for more than 6 months, we may discuss the need to adopt a palliative care model. Certainly this approach in dementia is more complex if compared with that to be adopted in cancer patients whose need of palliative care is more easily understandable. Furthermore, an important task for the ACE Medical Unit may be to select, on the basis of a clinical assessment, patients at immediate (6 months) risk of death and thus appropriate for palliative care, from those who may benefit from clinical interventions aimed at modifying the natural history of specific diseases [13, 14]. In both cases we may contribute toward reducing the patient's level of suffering, and respecting the needs of each person by individualising the care based on an assessment of relevant biological and clinical parameters. Some require palliation, and others need the most advanced technological and pharmacological intervention.
Translating assessment into actions is still more an art than a science [15]. In this perspective, our data support the need to consider the single patient as the target of decisional processes rather than adopting general models valid for the entire ward.
- Need to define prognosis in all geriatric patients.
- Geriatric assessment is the main tool in defining prognosis and guiding therapy.
- Assessment is the main tool when considering palliation or technological and pharmacological intervention.
None
1 Department of Internal Medicine and Geriatrics, Poliambulanza Hospital, Brescia and Geriatric Research Group, Brescia, Italy
2 University Unit, Geriatric Department, Ullevaal University Hospital, Oslo, Norway
* To whom correspondence should be addressed E-mail: renzo.rozzini{at}iol.it; renzo.rozzini{at}poliambulanza.it
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