Psychotropic drug treatment for agitated behaviour in dementia:what if the guideline prescribing recommendations are not sufficient? A qualitative study

BACKGROUND: Agitation is a common challenging behaviour in dementia with a negative influence on patient's quality of life and a high caregiver burden. Treatment is often difficult. Current guidelines recommend restrictive use of psychotropic drug treatment, but guideline recommendations do not always suffice. OBJECTIVE: To explore how physicians decide on psychotropic drug treatment for agitated behaviour in dementia when the guideline prescribing recommendations are not sufficient. METHODS: We conducted five online focus groups with a total of 22 elderly care physicians, five geriatricians and four old-age psychiatrists, in The Netherlands. The focus groups were thematically analysed. RESULTS: We identified five main themes. Transcending these themes, in each of the focus groups physicians stated that there is 'not one size that fits all'. The five themes reflect physicians' considerations when deciding on psychotropic drug treatment outside the guideline prescribing recommendations for agitated behaviour in dementia: (1) 'reanalysis of problem and cause', (2) 'hypothesis of underlying cause and treatment goal', (3) 'considerations regarding drug choice', (4) 'trial and error' and (5) 'last resort: sedation'. CONCLUSION: When guideline prescribing recommendations do not suffice, physicians start with reanalysing potential underlying causes. They try to substantiate and justify medication choices as best as they can with a hypothesis of underlying causes or treatment goal, using other guidelines, and applying personalised psychotropic drug treatment

Should medical assistance in dying be extended to incompetent patients with dementia? : research protocol of a survey among four groups of stakeholders from Quebec, Canada

Background: Alzheimer's disease and related disorders affect a growing number of people worldwide. Quality of life is generally good in the early stages of these diseases. However, many individuals fear living through the advanced stages. Such fears are triggering requests for medical assistance in dying (MAiD) by patients with dementia. Legislation was recently passed in Canada and the province of Quebec allowing MAiD at the explicit request of a patient who meets a set of eligibility criteria, including competence. Some commentators have argued that MAiD should be accessible to incompetent patients as well, provided appropriate safeguards are in place. Governments of both Quebec and Canada are currently considering whether MAiD should be accessible through written requests made in advance of loss of capacity. Objective: Aimed at informing the societal debate on this sensitive issue, this study will compare stakeholders' attitudes towards expanding MAiD to incompetent patients with dementia, the beliefs underlying stakeholders' attitudes on this issue, and the value they attach to proposed safeguards. This paper describes the study protocol. Methods: Data will be collected via a questionnaire mailed to random samples of community-dwelling seniors, relatives of persons with dementia, physicians, and nurses, all residing in Quebec (targeted sample size of 385 per group). Participants will be recruited through the provincial health insurance database, Alzheimer Societies, and professional associations. Attitudes towards MAiD for incompetent patients with dementia will be elicited through clinical vignettes featuring a patient with Alzheimer's disease for whom MAiD is considered towards the end of the disease trajectory. Vignettes specify the source of the request (from the patient through an advance request or from the patient's substitute decision-maker), manifestations of suffering, and how close the patient is to death. Arguments for or against MAiD are used to elicit the beliefs underlying respondents' attitudes. Results: The survey was launched in September 2016 and is still ongoing. At the time of submission, over 850 respondents have returned the questionnaire, mostly via mail. Conclusions: This study will be the first in Canada to directly compare views on MAiD for incompetent patients with dementia across key stakeholder groups. Our findings will contribute valuable data upon which to base further debate about whether MAiD should be accessible to incompetent patients with dementia, and if so, under what conditions

Association of Vulnerability Screening on Hospital Admission with Discharge to Rehabilitation-Oriented Care after Acute Hospital Stay

Background The short Dutch Safety Management Screening (DSMS) is applied at hospital admission of all patients aged >70 years to assess vulnerability. Screening of four geriatric domains aims to prevent adverse outcomes and may support targeted discharge planning for post-acute care. We explored whether the DSMS criteria for acutely admitted patients were associated with rehabilitation-oriented care needs. Methods This retrospective cohort study included community-dwelling patients aged ≥70 years acutely admitted to a tertiary hospital. We recorded patient demographics, morbidity, functional status, malnutrition, fall risk, and delirium and used descriptive analysis to calculate the risks by comparing the discharge destination groups. Results Among 491 hospital discharges, 349 patients (71.1%) returned home, 60 (12.2%) were referred for geriatric rehabilitation, and 82 (16.7%) to other inpatient post-acute care. Non-home referrals increased with age from 21% (70–80 years) to 61% (>90 years). A surgical diagnosis (odds ratio [OR]=4.92; 95% confidence interval [CI], 2.03–11.95), functional decline represented by Katz-activities of daily living positive screening (OR=3.79; 95% CI, 1.76–8.14), and positive fall risk (OR=2.87; 95% CI, 1.31–6.30) were associated with non-home discharge. The Charlson Comorbidity Index did not differ significantly between the groups. Conclusion Admission diagnosis and vulnerability screening outcomes were associated with discharge to rehabilitation-oriented care in patients >70 years of age. The usual care data from DSMS vulnerability screening can raise awareness of discharge complexity and provide opportunities to support timely and personalized transitional care