Rage against the Dying of the Light: Geriatrics, Palliative Care, and Dementia

Case based discussion dementia is a chronic illness but not recognized as a terminal illness.

There are really not any good secondary prevention measures. Most people with dementia have symptoms if we look for them.

Treating depression may reverse some of the cognitive decline.

Tertiary Prevention: intensive case management can make a big difference in rate of decline.

Frail elderly have an atypical presentation for many medical problems and delirium can be many things. Need to know the patient’s baseline to make a better assessment.

Older drivers per mile driven have more accidents than younger drivers.

No great tool for assessing driving, can refer for testing but most will not go. Only 9 states have mandatory reporting for driving impairment. Most states have no reporting at all.

Florida is God’s waiting room? I am only reporting what I hear so don’t take it out on me.

Dementia trajectory is gradual slow decline and many of the patients will follow all the trajectories.

Study showing that dementia is a terminal illness and increases mortality from all other causes.

Barriers to good end of life care for dementia: 1. View it as a terminal illness and trajectory is slow over 4-8 years, hospice criteria is not very helpful. 2. Treatment of co-morbid conditions is harder, when do they forgo treatments. 3. Pain management is very hard.

Advanced care planing needs to be done while the patient still has cognitive ability. Health Care proxy more likely to choose aggressive care if they understand it is a terminal illness.

Decision-making capacity should be related to specific decisions, can be determined by any physician and is not the same as competence.

Patients with dementia can make a contribution to decisions about their care.

Advanced directives are not always useful or easy to find. More helpful when families have the discussions before the emergency.

Asking dementia about pain while they are moving is better and use behavioral pain scales.

Palliative care as the restraint police. That is a great analogy.

Take home points: Frank discussion of prognosis can make a big difference in end-of-life care.

Hope this was helpful found it to be fun!

4 thoughts on “Rage against the Dying of the Light: Geriatrics, Palliative Care, and Dementia

  1. Dementia is depressing for patients and families. Carefully assessing for depression and treatment seems clinically to be helpful. You might say that you have depression induced pseudo-dementia superimposed on dementia in many cases.
    Need to remember that the number needed to treat to get a response can be 4 or 5 and therefore looking for response and dose escalation or changing med is just as important as starting the medication.

  2. I really liked the visual the speaker created (at least in my mind) of the geriatric approach to dementia and the palliative medicine approach to dementia. Both good but not always complete.
    Geriatrics: good at identifying syndromes and atypical sx presentations.
    PallMed: good at understanding dementia is a terminal disease.
    Certainly a generalization but enhanced the discussion regarding barriers to excellent end of life care in patients with dementia. Now the trick is getting everyone to attend to the palliative care tasks in dementia while being attentive to the varying symptom presentations.

  3. With regard to the driving issue is if the family will not ride with the patient can be a telling symptom.
    I have found that dementia is still not diagnosed well, mostly secondary to the fear of the disease and not often pulled together until an acute hospitalization occurs which then provides for a palliative care discussion. As a geriatric NP then allows for discussions of trajectory and often to some goal setting. I have found education is the best tool in my kit.

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