Cognitive Issues

Background

Palliative care provision in the context of older age needs to consider some specific issues including confusion, dementia and/or communication difficulties. [2] Mild Cognitive Impairment (MCI) is generally defined as significant memory loss without the loss of other cognitive functions. [7] Cognitive impairment carries an increased risk of mortality. [2] This risk increases with severity of dementia, even though the mechanism for this is not fully understood. [2]

Dementia is an incurable, life-limiting condition. [1] Dementia is the leading cause of cognitive decline and the second leading cause of death and disability in Australia. [1,4] Dementia isn't a specific disease. Instead, it describes a group of symptoms affecting intellectual and social abilities severe enough to interfere with daily functioning. [8] As the community ages, dementia is becoming increasingly common. [1,2] The estimated prevalence of dementia in Australia in 2012 was 353,800 persons, and this is predicted to rise to 900,000 by 2050. [1] It seems that adequate and appropriate end-of-life or palliative care is not as commonly offered to this cohort as it might be to people dying from cancer. [5]

This summary discusses the evidence for palliative care management of older adults with dementia and additional considerations specific to this cohort.
 

Evidence Summary

A palliative approach can be beneficial to older adults dying from non-cancer related conditions including dementia [3,5]. It provides a focus on quality of life, symptom or pain management, concerns for communication and place of care as well as death [8]. 

Symptoms such as depression, agitation, pain, aggression and difficulty with communication are common in end-stage dementia. [8] Management of these symptoms benefits the person and their family. [5,8] Care should be taken to ensure acute symptoms of delirium are diagnosed, which if present with pre-existing dementia, can be hard to distinguish. [6]

Diagnosis of early dementia provides the opportunity for patients and their carers to undertake advance care planning. [2,4] There is consensus that advance care planning can be beneficial for the delivery of appropriate dementia care. [3] End-of-life planning should be initiated before a person’s decision-making capacity becomes impaired or as soon as possible after a diagnosis of dementia. [3-5] The optimal time to initiate these discussions is not clear and can vary across cultures and individuals. [3] Noted in the literature, is the reluctance, unwillingness and difficulty for people to engage in advance care planning, and this is complicated by the difficulty in predicting the trajectory of cognitive decline. [3]

Advance care planning can assist in planning for place of death. Residential aged care is likely to be the place of death for many residents so it is important that staff are able to provide a palliative approach to care. Education on how to provide palliative care in these settings will be important for the quality of life for the person. [5,9]

Aggressive treatment of symptoms and complications such as dysphagia or acute infections like pneumonia are thought not to be congruent with a palliative approach. [5] The majority of the evidence suggests that there is no benefit to the use of feeding tubes; careful hand feeding is preferential and promotes quality of life. [5, 8]  

The decision-making around therapies for medically-assisted nutrition and hydration or antibiotic therapies often falls to the substitute decision-maker of an older adult with cognitively impairment. Documenting care preferences can help these decisions to be made with respect for the person’s wishes and low burden to the family. [4]

Quality Statement

Overall the evidence has been derived from a mix of quantitative and qualitative studies with only one RCT sourced for the review by Hines et al. [5] At best, the level of evidence is moderate but consensus in the evidence is supportive of a palliative care approach for older adults with dementia. There is an opportunity for further research in this domain, particularly identifying optimal timing for end-of-life discussion and how to implement a palliative approach to care in residential and community aged care settings.