Kim Wrigley & Elaine HorganEnd of Life Care and Dementia

“You matter because you are you. You matter to the last moment of your life and we will do all we can, not only to help you die peacefully, but to live until you die.”

Dame Cicely Saunders

1912 - 2005

What is Dementia ?Dementia is:

A syndrome characterised by the death of cells in crucial areas of the brain

Known to affect memory, speech and language, comprehension, motor skills, judgement and orientation.

A progressive condition from which a cure is not currently possible

An age related condition

Caused by more than 70 diseases of which Alzheimer's, Vascular and Lewy Body are the most common.

Often insidious and gradual and has a median duration 6-8 years

May present initially as depression or anxiety

Eventually affects all ADL’s leaving the person totally dependant on others

Dementia Subtypes

• Alzheimer’s disease changes the chemistry and structure of the brain causing brain cells to die. It has a long slow progression.

• Vascular dementia is caused by a series of small strokes or small vessel disease which affect the supply of oxygen to the brain. It can cause communication problems, stroke like symptoms and acute confusion.

• Dementia with Lewy bodies is caused by tiny spherical protein deposits that develop inside the nerve cells of the brain. Hallucinations, parkinsonian tremor and fluctuating abilities are characteristic.

Who is affected by dementia?

Approximately 750,000 people in the UK currently. Of theseapproximately 18,000 are under 65 years of age.

1 in 20 over 65

1 in 5 over 80

Alzheimer’s type dementia makes up 55% of all cases

Where do people with dementia live and die

•New research suggests that over half (54%) of all people with dementia in the UK are resident in care homes with most people dying in long term care or hospitals

•Approximately 19% of people with dementia die at home

•It is estimated that approximately 100,000 people with dementia die each year in the UK

Challenges in the last year of life

• Physical and mental decline• Behavioural and psychological symptoms• Prognostic uncertainty• Ethical and Legal issues• Nutrition and hydration• Symptom Assessment / control• Diagnosing dying• Discontinuation and conversion of medication• Pathway drugs / administration (risk assessment)• Prolonged dying phase• Bereavement support• Resources• Education• Communication skills training• Engagement with other Services

The North West End of Life Care Model

Last Days of Life First Days after Death

1 year1 year

Advancing disease Bereavement

6 months

1 2 3 5

The North West End of Life Care Model

4

Death

Increasing decline

Uncertainty in prognosis

• It is very difficult to assess when a person stops living with dementia and starts dying from it

• Developing methods of predicting the approach of death would enable better planning of care, particularly in moving from actively treating to the palliative care approach

• Prognostic indicators guidance are recommended such as are seen in the Gold Standards Framework

GSF Prognostic indicators - Dementia

• Unable to walk without assistance, and

• Urinary and faecal incontinence, and

• No consistently meaningful verbal communication, and • Unable to dress without assistance • Barthel score <3

Plus any one of the following:

10% weight loss in the previous six months without other causes, pyelonephritis or UTI,Serum albumin 25 g/l, Severe pressure scores eg stage III / IV, Recurrent fever, Reduced oral intake, Weight loss, Aspiration pneumonia

Illness trajectories

Cancer

Dementiaand

decline

A

B

C

Organ

failure

Sudden death

Common Symptoms

Below are examples of the most common symptoms experienced by people who have dementia:

1, 65% experience pain2, 60% experience confusion3, 80% experience fatigue4, 60% experience depression5, 70% experience incontinenceFaull and Woof 2002

Non Pharmacological and Therapeutic Responses

• Reality Orientation• Validation Therapy• Reminiscence therapy• Aromatherapy• Multi sensory stimulation• Music/Dance• Animal assisted therapy• Massage

Principles of good practice when working with the person with dementia

Individually tailored care plans

Life story work

Person centred work

Accurate and thorough assessment

Safe prescribing/administration of neuroleptic drugs (including discontinuation)

Skilled and knowledgeable workforce

Good quality training and education for all staff

Palliative care?

“Palliative care is an approach that improves the quality of life of the patient and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”

(WHO 2002)

Signs and behaviours that suggest a patient with dementia is dying

(Regnard and Hockley 2003)

•Deteriorating day by day or faster •Increasingly drowsy or comatose •Increasingly bed – bound •Peripherally cyanosed and cold •Taking increasingly little food, fluid or oral medication •Altered breathing pattern

Liverpool Care Pathway Management of care in the last days / hours of life

• Aim to transfer hospice care more widely

• Specialist Palliative Care teams lead the training

• Once implemented-empowers generalists to care for the dying patient

• Can be transferred to non cancer patients

Criteria for use of the LCP

All possible reversible causes for current condition have been considered:

The multiprofessional team has agreed that the patient is dying, and two of the following may apply:-

The patient is bedbound Semi-comatose

Only able to take sips of fluid No longer able to take tablets

Research

• Patients with end stage dementia had a number of symptoms for which they did not receive effective palliative care-analgesia was infrequently used, dying phase not recognised and some people given antibiotics inappropriately in last days of life.

Lloyd-Williams and Payne, 2002

NICE Clinical Practice Guideline Dementia 2006

• Health and social care professionals should incorporate a palliative care approach from the time of diagnosis until death for people with dementia

• They should consider physical, psychological, social and spiritual needs to maximise the quality of life of the person with dementia and their family

• Palliative care professionals, other health and social care professionals and commissioners should ensure that people with dementia who are dying have the same access to palliative care services as those with dementia

• Primary care teams should ensure that the palliative care needs of people with dementia who are close to death are assessed and that the resulting information is communicated within the team and and with other health and social care staff

Key points• All professionals need to be aware of and be able to

manage dementia as a significant co-morbidity in a range of conditions

• Sharing knowledge, expertise and skills between different professional groups for patient benefit

• The incidence and prevalence of dementia is increasing with the ageing population so we need to address this now

• Unpaid carers still deliver much of the care for people with dementia

• Palliative care models developed for people with cancer may well not be appropriate for those with dementia

Dementia is rising up the agenda

• DOH National Strategy for dementia (2007)

• Everybody's Business CSIP (2005)

• Raising the standard Royal College of Psychiatry (2006)

• NICE Dementia service Guideline (2006)

• Improving Services and Support for People With Dementia National Audit Office (2007)

“And in the end, it’s not the years in your life that count. It’s the life in your years.”

• Abraham Lincoln.

References

• www.goldstandardsframework.nhs.uk• www.lcp-mariecurie.org.uk• www.cancerlancashire.org.uk/ppc • www.alzheimers.org.uk• www.endoflifecare.nhs.uk • www.alzheimers-research.org.uk • www.northwest.nhs.uk/healthierhorizons • Hughes.J.C, (2006) Palliative care in Severe Dementia, MA Healthcare Limited

• NICE and SCIE. (2006) Dementia Supporting people with dementia and their carers in health and social care. London. National Collaborating Centre for Mental Health

• Small, N; Froggatt,K and Downs, M. (2007) Living and Dying with Dementia Dialogues about Palliative care London Oxford University Press

• Mental Capacity Act 2005

• Alzheimer’s Society (2008) Home from Home. London

Thank You

Mrs Kim Wrigley – End of Life Care Lead (Greater Manchester)Kim.wrigley@northwest.nhs.uk

Miss Elaine Horgan – Enhanced Care FacilitatorElaine.horgan@northwest.nhs.uk

Mrs Sue Mcainsh – Project ManagerSue.mcainsh@northwest.nhs.uk

Project Leads:

Chris Mullen – Workforce Project Director and Nurse Advisor.   Hilary Compston – Associate Network Director Palliative Care

(GMCCN)