Dementia Sufferers at the End Stage and Comorbidities
The prevalence of dementia in the United States has increased as a result of the increases in the numbers of the elderly segment of population. As growing numbers of baby boomers join the retirement ranks and the older old increase as well, the prevalence of dementia can be reasonably expected to increase in the future as well. To determine the characteristics of this population of interest at the end stage of dementia, this paper provides a review of the relevant peer-reviewed and scholarly literature, including why this population is of interest, a description of the salient characteristics of this population, and pressure ulcers as a health issue that affects this population. Finally, a proposal concerning how to address pressure ulcers in end stage dementia patients is followed by a summary of the research and important findings concerning this population of interest in the conclusion.
Review and Discussion
Description of interest in end-stage dementia patients
My interest in this condition is based on extensive professional experience. For the past 17 years, I have worked in a hospice setting where approximately 35% of the patients have end-stage dementia. Although every patient is unique, there are some common features that characterize the end stages of dementia that can provide some indication of the psychophysiological issues that are involved. For example, the end stages of dementia are characterized by the Functional Assessment Staging Tool as (a) some with verbalization restrictions; (b) substantial weight loss; (c) assistance needed for all normal activities of daily living; (d) inability to ambulate or sit without assistance; and (e) propensity to multiple secondary infections including urinary tract infections and pneumonia (Sanders & Swails, 2011). The diagnostic criteria for dementia given in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) are as follows:
Symptoms must include decline in memory and in at least one of the following cognitive abilities:
1) Ability to speak coherently or understand spoken or written language.
2) Ability to recognize or identify objects, assuming intact sensory function.
3) Ability to perform motor activities, assuming intact motor abilities and sensory function and comprehension of the required task.
4) Ability to think abstractly, make sound judgments and plan and carry out complex tasks.
The decline in cognitive abilities must be severe enough to interfere with daily life (cited in Lacey, 2006).
In sum, end-stage dementia is characterized by the loss of communicative abilities, including: (a) verbal abilities and eye contact; (b) difficulty or inability to sit up and hold one's head up; (c) incontinence; and (d) an lack of self-care ability (Lacey, 2006). The majority of the elderly suffering from end-stage dementia also lack interest in food, and more than half experience problems with swallowing (Lacey, 2006). This point is also made by Vitale, Hiner, Ury and Ahronheim (2008) who report that while clinical interventions exist to help mitigate the symptoms that are associated with dementia, the problems with eating and a lack of interest in food in general continue to worsen over time.
Local, regional, national, and global statistics related to end-stage dementia patients
Generally, women in the United States are at higher risk for dementia compared to their male counterparts. According to the Alzheimer's Association, nearly 66% of Alzheimer's sufferers in the United States today are women, with 3.2 million women and 18 million men aged 65 years and older having Alzheimer's disease (2013 Alzheimer's disease facts and figures, 2014, p. 15). In addition, 16% of women age 71 years and older have some type of dementia versus 11% of men of the same age (2013 Alzheimer's disease facts and figures, 2014). There is also significant geographic variation in the treatment of end-stage dementia in the United States today (Vitale et al., 2008).
Identification of a health issue that affects the population of interest
Unfortunately, this population of interest may be at risk of incurring pressure ulcers as the result of therapeutic nihilism, which occurs when practitioners essentially give up any realistic expectation that clinical interventions will have a beneficial effect on the condition eventual outcome "(Sanders & Swails, 2011). This point is also made by Lacey (2006) who emphasizes that many healthcare providers view end-stage dementia as untreatable, a view that is reinforced by a growing body of evidence that many of the rehabilitative and pharmacological interventions used to date have been ineffective in prolong life or contributing to the quality of life of end-stage dementia sufferers.
Furthermore, therapeutic nihilism may become more pronounced during the end stages of dementia when the cognitive impairment has become most acute (Sanders & Swails, 2011). Moreover, there remains a paucity of timely and relevant clinical studies concerning optimal approaches to caring for end-stage dementia patients. In this regard, Casarett and Karlawish (2009) cite the dearth of clinical studies concerning optimal approaches to end-stage dementia management and clinical interventions that are most appropriate for this population. Notwithstanding this lack of knowledge, there are some problems that are characteristic of end-stage dementia that can be addressed directly, including pressure ulcers, which are discussed further below.
Proposal for addressing pressure ulcers in end-stage dementia patients at the tertiary level of prevention
One of the most common problems seen in hospice settings among end-stage dementia patients are pressure ulcers, and the actual incidence of these problems may be far more than has been reported in the relevant literature (Srivastava & Gupta, 2009). In this regard, McGadney-Douglass (2008) reports that a breakdown in skin integrity causes pressure ulcers, a condition that is usually caused by a combination of dementia, incontinence, inadequate nutrition, immobility and other factors commonly associated with this debilitating condition. Not surprisingly, pressure ulcers are a common problem in long-term care facilities as well as hospice settings (Srivastava & Gupta, 2009). Although decreased mobility in general is a contributing factor for pressure ulcer among end-stage dementia patients, their decreased mobility during sleep is particularly problematic. In addition, the suboptimal management of urinary incontinence in hospice setting frequently contributes to pressure ulcers as well (Roehl & Buchanan, 2006).
Preventing pressure ulcers at the tertiary level in this population of interest, though, is a challenging enterprise because the problem tends to worsen with time. For instance, Srivastava and Gupta point out that end-stage dementia sufferers tend to move less and less as their length of stay in a hospice setting increases, thereby exacerbating their vulnerability to forming pressure ulcers. These complex processes combine to place end-stage dementia patients at greater risk for pressure ulcers, and the problem is sufficiently commonplace that it referred to in the medical literature as ectodermic syndrome. Complex problems frequently require complex solutions and the prevention of pressure ulcers to avoid further comorbidities is no exception. For instance, Srivastava and Gupta (2009) recommend that prevention efforts should be implemented for this population to help reduce the incidence of increased comorbities.
There are some evidence-based approaches to treating pressure ulcers at the tertiary level in hospice settings. In this regard, Srivastava and Gupta recommend a multidisciplinary team approach at the tertiary level. The use of a multidisciplinary team approach for the treatment of pressure ulcers at the tertiary level in a hospice setting is congruent with the guidance provided by the World Health Organization that advises palliative care in these settings:
Provides relief from pain and other distressing symptoms;
Affirms life and regards dying as a normal process;
Intends neither to hasten or postpone death;
Integrates the psychological and spiritual aspects of patient care;
Offers a support system to help patients live as actively as possible until death;
Offers a support system to help the family cope during the patients illness and in their own bereavement;
Uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated;
Will enhance quality of life, and may also positively influence the course of illness; is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications (End stage dementia, 2014, para. 2).
Potential impact of proposed intervention
The potential exists for the proposed intervention to prevent the leading cause of death among end-stage dementia patients. Although persistent failure to eat is a common problem among end-stage dementia sufferer, Lacey (2006) points out that the most common cause of death among end-stage dementia suffers are recurring infections. Therefore, by more effectively managing pressure ulcers at the tertiary level, end-stage dementia sufferers may have their lives prolonged and the quality of their lives improved as the result of the multidisciplinary intervention outlined above.
The research showed that end-stage dementia is characterized by the loss of communicative abilities, including verbal abilities and eye contact; difficulties or an inability to sit up and hold the head up; a loss of bladder and bowel control; and a loss of all self-care abilities (Lacey, 2006). The research also showed that women are…