End stage dementia

Question 1

When to discontinue CHEI in end stage dementia?

Answer 1

1. Patient/SDM wants to stop
2. Patient non-adherent
3. Patient is worse (cognitive, function or behaviour)
4. Side effects >benefits
5. Futile treatment (terminally ill)
6. Dementia so advanced that no clinically meaningful benefit to continuing therapy
   *Do not discontinue with active psychosis, agitation or aggression until stabilized unless felt related to start/increase of CHEI dose
   *If they had improvement in BPSD after starting then don’t stop it even if evidence of cognitive or functional decline

Question 2

How to discontinue CHEI in end stage?

Answer 2

1. Taper by 50% q4 weeks
2. After 4 weeks on starting dose, stop
3. Observe over next 1-3 months for observable decline
4. If this occurs then suggest restarting therapy

Question 3

GDS Severe dementia description

Answer 3

7
Verbal abilities lost over this stage
Incontinent
Need assistance with feeding
Lose ability to walk

Question 4

GDS moderately severe description

Answer 4

6
May occasionally forget spouses name
Largely unaware of recent experiences and life events
Require assistance with basic ADLs
May be incontinent
BPSD common

Question 5

Patient with advanced dementia (dysphagia, mumbles only, totally dependent)
What is prognosis/lifespan?

Answer 5

Dementia is a terminal disease
Advanced dementia has a high mortality rate
LTC = median survival is 16 months (GDS 7)
Community = median survival is 20 months

Question 6

Staging tools for dementia

Answer 6

1. Global deterioration scale (cognitive)
2. Functional assessment staging tool (function)
3. Clinical Dementia Rating scale

Question 7

Prognostic tools for dementia in nursing home

Answer 7

1. Advanced dementia prognosis tool (ADEPT)
2. Mitchell Index

Question 8

Reasons against feeding tubes in advanced dementia

Answer 8

Should NOT be recommended
1. Likely increase aspiration
2. Does not prevent/heal pressure ulcers
3. Does not improve nutritional status
4. Does not decrease mortality (may increase)
5. Causes inc oral secretions
6. Site for infection/complication (inc hospital transfers)
7. Likely causes discomfort (agitation, risk of restraints)

Question 9

Alternatives to feeding tubes in end stage dementia

Answer 9

1. Careful hand feeding
2. Liberalize diet to patient preferences
3. Optimize environment (sitting up, dentures)
4. Discontinue unnecessary meds (big pills etc)

Question 10

End of life symptoms/signs in dementia

Answer 10

1. Dysphagia and eating problems
2. Pneumonia
3. BPAD - agitation, pain
4. ADL dependency
5. Place of care/transfers
6. CPR/DNR
7. SDM/POA