An Overview of Dementia Dr Micheal O’Cuill

Consultant Psychiatrist

Longford/Westmeath MHS

Congratulations Palliative Care

•The Economist 6 Oct 2015

•Quality of Death Index

• Ireland 4th in World

•2ND in Europe

Palliative Approach in Dementia

•Why Palliative approach?

Palliative Care WHO

•An approach that improves the quality of life of individuals and their families facing the problems associated with life threatening illness

Palliative Care

Provides relief from pain and other distressing symptoms.

Affirms life, regards dying as a natural process.

Support to live as active a life as possible.

Psychological and spiritual needs addressed.

Neither hasten nor postpone death.

Palliative Care

Family support.

Team approach.

Enhance quality of life.

Applicable early in the course of illness.

Palliative Care Competency Framework 2014

•Knowledge of Principles of PC

•Communication Skills

•Optimise Comfort &Quality of Life

•Care Planning, Collaborative Practice

•Loss, Grief, Bereavement

•Ethics and Professional Practice

Palliative Care Competency Framework 2014

•Recognise when Interventions futile or over-burdensome

•Respecting refusal of interventions

•Advance Directives

•Advance Care Plans

•Self awareness

Dementia Vs Cancer

Cancer

•Wide Age Range

•Initially High Function

•Predictable Course

•Rapid Decline at End

•Have Capacity

Dementia Vs Cancer

Dementia

•Majority over 80yr

•Frequently Low Baseline Function

•Prolonged Course – 8yr

•Incremental Decline

•Impaired Capacity at first contact

Epidemiology

•1% Population

•47,000 people with Dementia

•50% Moderate to Severe

•70% of people in Long Term Care

Treatment

•Currently no disease modifying treatments

•Symptomatic Rx only

•Cognitive features: AChE Inhibitors

•Non Cognitive Symptoms: Memantine

•“Defer/Delay” problems for 9-12 months

Behavioural & Psychological Symptoms of Dementia

•90% patients at some stage

•Main cause of carer stress

•Main reason for Long Term Care

Treatment of BPSD

•Pharmacological- Bad

•Non Pharmacological- Good

•Few clinical trials

•Variable Quality

•Many – no benefit

Drug Treatment of BPSD

•Antipsychotics: Quetiapine, Risperidone

•Antidepressants

•Benzodiazepines

•Anti Epileptics: Carbamazepine, Valproate

Drug Treatment of BPSD

•Increasingly controversial

•All Party Parliamentary Group 2008

•Alzheimer’s Society in UK

•HIQA – “Chemical Restraint”

Treatment of BPSD

Restraint: Not always a bad idea

Antipsychotics and BPSD

•Increased rate of cognitive decline

•Increased mortality

•3 fold increase in CVA: 1% v 0.3%

Antipsychotics and BPSD

•Risk: Benefit balance

•Significant benefit for many patients

•Can reduce falls, neglect, misadventure, malnutrition

•Reduce carer stress

•Delay move into LTC

Delay move into LTC

End of Life Care

•Dysphagia

•Cachexia

•Immobility

•Recurrent Sepsis

End of Life Care

•Dutch Study: 46% families agreed after education that Dementia a disease you can die from

End of Life Care

•Hospital Admissions: Severe Dementia

•6 Month Mortality: 55%

•Quality of Care as good as for other patients

•Receive as many interventions as others

•Lot of uncertainty in predicting

An Irish National Survey of dementia in Long Term Residential Care 2014

•54 Specialist Dementia Units

•13 Refer to Palliative Care

•3 HSE Units routinely transfer dying residents

•4 Others sometimes do

Summary

•Palliative Care approach highly desirable in Dementia Care

•Dementia lends itself to this approach

•Reminder of goals in Dementia Care – tell the Wood from the Trees

•Plenty of scope for improvement along journey and End of Life care

•Universally acknowledged as way forward - why the delay?