Presentation on theme: "Palliative Care in Dementia"— Presentation transcript:
1 Palliative Care in Dementia Mike WalkerJune 2012
2 Palliative Care in Dementia 3 Topics Dementia is a terminal condition with no prospect of recovery before deathPain symptomsAgitation
3 Dementia is a terminal condition Quality of life can be improvedIt always ends in deathBy tradition we have not treated it in a palliative way – we have tended to treat behaviour and search for cureTime of death very hard to predict (even more than in physical conditions!). But this can prevent palliative approach.Systems often require a “terminal” diagnosis (esp cancer)
4 Carer’s issues “bereavement before death” But stress of being carer at the same timeCarers for people with mental health problems (inc depression and dementia) more stressed than other carers (on average)
5 PEG TubesMedian survival 1 month1 year survival 10%
8 Husebo et al. BMJ 2011Nursing home residents with dementia and agitation (not known pain)Stepwise pain relief, paracetamol -> morphine -> buprenorphine patch -> pregabalinVs placeboSignificant benefit on agitation and behaviour scores
9 Mental Capacity MCA 2005 Always specific to individual question But likely to be lacking in severe dementiaProfessionals must act in “Best Interests” – this is deliberately undefined
10 Advanced Decision (to refuse treatment) Under MCA 2005If this is life-sustaining treatment decision must be in writing, signed and witnessed and specify that life may be at risk
11 Memantine Dr W: “I find it has very few side effects” Carer: “and how would you know?”
12 Double EffectWe accept that control of pain in terminal illness may be associated with severe life-threatening side effectsSymptoms of dementia are often behaviouralCompare the furore over 4% per annum increased mortality with anti-psychotics in dementiaWhose best interests?
13 Agitation in terminal illness RisperidoneHaloperidolBoth the above have a high quality RCT evidence base for behaviour in dementiaBoth potent4% per annum increased mortality – relevant?Still start with lowest doses!
14 Agitation in the last days and hours of life - NCPC guidelines Look for treatable causeMidazolamLevomepromazineHaloperidol if psychotic symptoms
15 Co-ordination of carePatient often known to my team with advanced dementiaOOH services and A+E don’t know patientConfusion assumed to be acute unless otherwise provenFalls + other minor issues lead to admissionSometimes the only way of accessing social care – but burden on health
16 General hospital admission 3 questions in Stewarts:Resus?General Hospital Transfer?Any treatment at all?Recommended answer – no no yesWith proviso to reduce pain and maintain dignity may need high-tech – eg #NOF
17 The real worldMany services find it hard to do nothing without very explicit direction often from doctor. Including:AmbulanceCare HomesPsychiatric wards