Palliative care and advanced dementia: trajectory of hospitalized elderly people in their last 48 hours of life
10.15343/0104-7809.202145413423
Keywords:
Elderly. Advanced dementia. End of life care. Palliative care.Abstract
This study aimed to analyze the last 48 hours of life of hospitalized elderly with advanced dementia and the profile of care over the 5 years analyzed. This is a retrospective cross-sectional study, through the analysis of electronic medical records of patients participating in the study, who died between January 1, 2013 and December 31, 2017. 328 medical records were analyzed in the defined period and 97 met the inclusion criteria. Ninety-three patients (95.9%) had records of advance directives of their wills, 73.2% were female, with a mean age of 88.7 years, 52.6% of deaths occurred in an apartment or infirmary, in the latter 48h of life, 64.9% were on an enteral diet, 28.9% were breathing by mechanical ventilation, 51% were using antibiotics, and 86.6% were prescribed fixed analgesia; however, 19% had a record of uncontrolled pain. Over the 5 years of observation, there were changes in the following aspects: reduction of deaths in the intensive care unit (60% vs. 36.4%), decrease in the use of tube feeding (87% vs. 32%), in the use of mechanical ventilation (53% vs. 18%); the use of central venous catheter (47% vs. 27%); the use of permanent urinary catheter (27% vs. 5%), and the presence of pressure injuries (87% vs. 45%). It is concluded that in the 5 years of analysis a palliative trend in care was characterized by the reduction of procedures considered invasive, in the last 48 hours of life, in patients with advanced dementia.
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References
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29. Lee Y-F, Hsu T-W, Liang C-S, Yeh T-C, Chen T-Y, Chen N-C, et al. The Efficacy and Safety of Tube Feeding in Advanced Dementia Patients: A Systemic Review and Meta-Analysis Study. Journal of the American Medical Directors Association. 2021; 22 (2):357–363. DOI: 10.1016/j.jamda.2020.06.035
30. Koopmans R, Van der Sterren KJMA, Van der Steen JT. The ‘natural’ endpoint of dementia: death from cachexia or dehydration following palliative care? Int J Geriatr Psychiatry. 2007; 22: 350–355. DOI: 10.1002/gps.1680
31. Chou HH, Tsou MT, Hwang LC. Nasogastric tube feeding versus assisted hand feeding in-home healthcare older adults with severe dementia in Taiwan: A prognosis comparison. BMC Geriatrics. 2020; 20 (1):1–8. DOI: 10.1186/s12877-020-1464-9
32. Aminoff B, Adunsky A. Dying dementia patients: Too much suffering, too little palliation. Am J Hosp Palliat Care. 2005; 22 (5):344-8. DOI: 10.1177/104990910502200507.
33. Jaul E, Meiron O, Menczel J. The Effect Of Pressure Ulcers On The Survival In Patients With Ad-vanced Dementia And Comorbidities. Experimental Aging Research, 2016; 42: 382–389. DOI: 10.1080/0361073X.2016.1191863
34. Jaul E, Barron J, Rosenzweig JP, Menczel J. An overview of co-morbidities and the development of pressure ulcers among older adults BMC Geriatrics, 2018; 18:305. DOI: 10.1186/s12877-018-0997-7
35. Miller SC, Lima JC, Looze J, Mitchell SL. Dying in U.S. nursing homes with advanced dementia: how does health care use differ for residents with, versus without, end-of-life Medicare skilled nur-sing facility care? J Palliat Med. 2012; 15 (1):43-50. DOI: 10.1089/ jpm.2011.0210
36. Givens JL Jones RN, Shaffer ML, Kiely DK, Mitchell SL. Survival and comfort after treatment of pneumonia in advanced dementia. Arch Intern Med. 2010; 170:1102–1107. DOI: 10.1001/archinternmed.2010.181
37. Eisenmann Y, Golla H, Schmidt H, Voltz R and Perrar KM. Palliative Care in Advanced Dementia. Front. Psychiatry, 2020; 11: 699. DOI: 10.3389/fpsyt.2020.00699
38. Higginson IJ, Finlay I, Goodwin DM, Edwards AGK, Douglas HR, Norman CE, et al. “Do Hospital-Based Palliative Teams Improve Care for Patients or Families at the End of Life?” Journal of Pain and Symptom Management. 2002; 23 (2):96–106. DOI: 10.1016/ S0885-3924(01)00406-
39. Kucmanski LS, Zenevicz L, Geremia DS, Madureira VSF, Silva TG, Souza SS. Alzheimer’s desease: challenges faced by family caregivers. Rev. bras. geriatr. Gerontol. 2016; 19 (6):1022-1029. DOI: 10.1590/1981-22562016019.150162.
2. IBGE. Tábuas de Mortalidade por sexo e idade – Brasil, Grandes Regiões e Unidades de Federação - 2010. Rio de Janeiro: IBGE; 2013.
3. Kalache A. The Longevity Revolution: Creating a society for all ages. Adelaide Thinker in Residence 2012-2013. Adelaide: Government of South Australia; 2013.
4. Alzheimer’s disease international. World Alzheimer Report 2015: The Global Impact of Dementia, An analysis of prevalence, incidence, cost & trends. 2015.
5. Spector A, Orrel M. Using a biopsychosocial model of dementia as a tool to guide clinical practice, Intern. Psychoger. 2010; 22(6): 957–965. DOI: 10.1017/S1041610210000840.
6. Souza RK, Barboza AF, Gasperin G, Garcia HD, Barcellos PM, Nisihara R. Prevalência de demência em pacientes atendidos em um hospital privado no sul do Brasil. Einstein. 2020; 18, 1-7. DOI: 10.31744/einstein_journal/2020AO4752
7. Karantzoulis S, Galvin J. Distinguishing Alzheimer’s disease from other major forms of dementia. Expert Rev Neurother. 2011; 11; 1579–1591. DOI: 10.1586/ern.11.155
8. Prince M, Wimo A, Guerchet M, Al G-C, Wu Y-T, Prina M. World Alzheimer Report 2015. The global impact of dementia: an analysis of prevalence, incidence, cost and trends. London: Alzheimer’s Disease International; 2015. Disponível em: https://www.alzint.org/u/ WorldAlzheimerReport2015.pdf
9. Burla C, Camarano AA, Kanso S, Fernandes D, Nunes R. Panorama prospectivo das demências no Brasil: um enfoque demográfico. Ciência & Saúde Coletiva. 2013; 18 (10):2949-2956. DOI: 10.1590/S1413-81232013001000019
10. Todd S, Barr S, Roberts M, Passmore AP. Survival in dementia and predictors of mortality: a revi-ew. Int J Geriatr Psychiatry. 2013; 28(11): 1109-1124. DOI: 10.1002/gps.3946
11. Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State”: practical method for grading the cogni-tive state of patients for the clinician. J Psychiatr Res. 1975; 12 (3):189-198. DOI: 10.1016/0022-3956(75)90026-6
12. Reisberg B. Functional Assessment Staging (FAST). Psychopharmacol Bull. 1988; 24 (4):653-659.
13. Morris J. The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology. 1993;43 (11):2412-2414. DOI: 10.1212/WNL.43.11.2412-a
14. Mitchell SL, Miller SC, Teno JM, Kiely DK, Davis RB, Shaffer ML. Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines. JAMA. 2010; 304(17): 1929-1935. DOI: 10.1001/jama.2010.1572
15. Jayes RL, Arnold RM, Fromme EK. Does this dementia patient meet the prognosis eligibility requirements for hospice enrollment? J Pain Symptom Manage. 2012; 44 (5):750-756. DOI: 10.1016/j.jpainsymman.2012.08.004.
16. Cassel CK, Vladeck, BC. ICD-9 code for palliative or terminal care. N Engl J Med. 1996; 335 (16):1232–1234. DOI: 10.1056/ NEJM199610173351612
17. Fins JJ, Miller FG, Acres CA, Bacchetta MD, Huzzard LL, Rapkin BD. End-of-life decision-making in the hospital: current practice and future prospects. J Pain Symptom Manage. 1999; 17 (1):6-15. DOI: 10.1016/s0885-3924(98)00109-2.
18. Broad J, Gott M, Kim H, Boyd M, Chen H, Connolly MJ. Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics. J Public Health. 2013; 58 (2):257-267. DOI: 10.1007/s00038012-0394-5.
19. Merel S, DeMers S, Vig E. Palliative Care in Advanced Dementia.” Clin Geriatr Med. 2014; 30 (3):469-492. DOI: 10.1016/j. cger.2014.04.004.
20. Hashimie J, Schultz SK, Stewart JT. Palliative Care for Dementia: 2020 Update. Clinics in Geriatric Medicine. 2020; 36 (2): 329-339. DOI: 10.1016/j.cger.2019.11.011
21. BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde Departamento de Ações Programáticas e Estratégicas. Orientações técnicas para a implementação de Linha de Cuidado para Atenção Integral à Saúde da Pessoa Idosa no Sistema Único de Saúde – SUS [recurso eletrônico] / Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Ações Programáticas e Estratégicas. – Brasília : Ministério da Saúde, 2018.
22. Conselho Federal de Medicina (BR). Resolução do CFM número 1995 de 9 de agosto de 2012. Brasília- DF, 2012. Disponível em: http://www.portalmedico.org.br/resolucoes/CFM/2012/1995_2012.pdf.
23. Murphy E, Froggatt K, Connolly S, O'Shea E, Sampson EL, Casey D, et al. Palliative care interventions in advanced dementia. Cochrane Database Syst Rev. 2016; 12 (12):CD011513. DOI: 10.1002/14651858.CD011513.pub2
24. Yumoto Y, Kernohan WG, Morioka N, Ogata Y. International reflections on caring for people with advanced dementia Public Health Nurs. 2019; 36 (2):192-198. DOI: 10.1111/phn.12572.
25. Conselho Federal de Medicina (BR). Resolução do CFM número 1805 de 28 de novembro de 2006. Brasília-DF, 2006. Disponível em: https://sistemas.cfm.org.br/normas/visualizar/resolucoes/BR/2006/1805.
26. Di Giulio P, Toscani F, Villani D, Brunelli C, Gentile S, Spadin P. Dying with Advanced Dementia in Long-Term Care Geriatric Institutions: A Retrospective Study. J Palliat Med. 2008; 11(7): 1023-1028. DOI: 10.1089/jpm.2008.0020
27. Shega JW, Hougham GW, Stocking CB, Cox-Hayley D, Sachs GA. Patients dying with dementia: experience at the end of life and impact of hospice care. J Pain Symptom Manage. 2008; 35: 499-507. DOI: 10.1016/j.jpainsymman.2007.06.011
28. Van Bruchem-Visser RL, Mattace-Raso FUS, Beaufort ID, Kuipers EJ. Percutaneous Endoscopic Gastrostomy in Older Patients with and without Dementia: Survival and Ethical Considerations. J Gastroenterol Hepatol. 2018; 34 (4):736-741. DOI: 10.1111/jgh.14573
29. Lee Y-F, Hsu T-W, Liang C-S, Yeh T-C, Chen T-Y, Chen N-C, et al. The Efficacy and Safety of Tube Feeding in Advanced Dementia Patients: A Systemic Review and Meta-Analysis Study. Journal of the American Medical Directors Association. 2021; 22 (2):357–363. DOI: 10.1016/j.jamda.2020.06.035
30. Koopmans R, Van der Sterren KJMA, Van der Steen JT. The ‘natural’ endpoint of dementia: death from cachexia or dehydration following palliative care? Int J Geriatr Psychiatry. 2007; 22: 350–355. DOI: 10.1002/gps.1680
31. Chou HH, Tsou MT, Hwang LC. Nasogastric tube feeding versus assisted hand feeding in-home healthcare older adults with severe dementia in Taiwan: A prognosis comparison. BMC Geriatrics. 2020; 20 (1):1–8. DOI: 10.1186/s12877-020-1464-9
32. Aminoff B, Adunsky A. Dying dementia patients: Too much suffering, too little palliation. Am J Hosp Palliat Care. 2005; 22 (5):344-8. DOI: 10.1177/104990910502200507.
33. Jaul E, Meiron O, Menczel J. The Effect Of Pressure Ulcers On The Survival In Patients With Ad-vanced Dementia And Comorbidities. Experimental Aging Research, 2016; 42: 382–389. DOI: 10.1080/0361073X.2016.1191863
34. Jaul E, Barron J, Rosenzweig JP, Menczel J. An overview of co-morbidities and the development of pressure ulcers among older adults BMC Geriatrics, 2018; 18:305. DOI: 10.1186/s12877-018-0997-7
35. Miller SC, Lima JC, Looze J, Mitchell SL. Dying in U.S. nursing homes with advanced dementia: how does health care use differ for residents with, versus without, end-of-life Medicare skilled nur-sing facility care? J Palliat Med. 2012; 15 (1):43-50. DOI: 10.1089/ jpm.2011.0210
36. Givens JL Jones RN, Shaffer ML, Kiely DK, Mitchell SL. Survival and comfort after treatment of pneumonia in advanced dementia. Arch Intern Med. 2010; 170:1102–1107. DOI: 10.1001/archinternmed.2010.181
37. Eisenmann Y, Golla H, Schmidt H, Voltz R and Perrar KM. Palliative Care in Advanced Dementia. Front. Psychiatry, 2020; 11: 699. DOI: 10.3389/fpsyt.2020.00699
38. Higginson IJ, Finlay I, Goodwin DM, Edwards AGK, Douglas HR, Norman CE, et al. “Do Hospital-Based Palliative Teams Improve Care for Patients or Families at the End of Life?” Journal of Pain and Symptom Management. 2002; 23 (2):96–106. DOI: 10.1016/ S0885-3924(01)00406-
39. Kucmanski LS, Zenevicz L, Geremia DS, Madureira VSF, Silva TG, Souza SS. Alzheimer’s desease: challenges faced by family caregivers. Rev. bras. geriatr. Gerontol. 2016; 19 (6):1022-1029. DOI: 10.1590/1981-22562016019.150162.
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Published
2021-11-12
How to Cite
Falcão Durão, S., Carréra Campos Leal, M., de Oliveira Marques, A. P., & Gouveia Bezerra, K. M. (2021). Palliative care and advanced dementia: trajectory of hospitalized elderly people in their last 48 hours of life: 10.15343/0104-7809.202145413423. O Mundo Da Saúde, 45, 413–423. Retrieved from https://revistamundodasaude.emnuvens.com.br/mundodasaude/article/view/1194
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