Advanced Stages Of Dementia Research Articles

"Mr. Smith Has No Mealtimes": Minimal Comfort Feeding for Patients with Advanced Dementia.

While Comfort Feeding Only is appropriate for patients with advanced dementia, its emphasis on assiduous hand-feeding that may prolong life for years fails to accommodate the preferences of those who do not want to continue living with this illness. Some have proposed advance directives to completely halt the provision of oral nutrition and hydration once a person has reached an advanced stage of dementia. However, these directives may fail to address patients' discomfort, caregivers' obligations, or current care and regulatory standards when patients reside in facilities. In response to these dilemmas, we introduce Minimal Comfort Feeding (MCF). Rather than offering food and liquids proactively as with Comfort Feeding Only, caregivers provide nutrition and hydration only in response to signs of hunger and thirst. While further study is required to define and negotiate challenges in operationalizing this approach, MCF provides a framework that resolves competing ethical and clinical considerations in caring for those with advanced dementia.

Evaluation of ChatGPT’s responses to information needs and information seeking of dementia patients

Many people in the advanced stages of dementia require full-time caregivers, most of whom are family members who provide informal (non-specialized) care. It is important to provide these caregivers with high-quality information to help them understand and manage the symptoms and behaviors of dementia patients. This study aims to evaluate ChatGPT, a chatbot built using the Generative Pre-trained Transformer (GPT) large language model, in responding to information needs and information seeking of such informal caregivers. We identified the information needs of dementia patients based on the relevant literature (22 articles were selected from 2442 retrieved articles). From this analysis, we created a list of 31 items that describe these information needs, and used them to formulate 118 relevant questions. We then asked these questions to ChatGPT and investigated its responses. In the next phase, we asked 15 informal and 15 formal dementia-patient caregivers to analyze and evaluate these ChatGPT responses, using both quantitative (questionnaire) and qualitative (interview) approaches. In the interviews conducted, informal caregivers were more positive towards the use of ChatGPT to obtain non-specialized information about dementia compared to formal caregivers. However, ChatGPT struggled to provide satisfactory responses to more specialized (clinical) inquiries. In the questionnaire study, informal caregivers gave higher ratings to ChatGPT's responsiveness on the 31 items describing information needs, giving an overall mean score of 3.77 (SD 0.98) out of 5; the mean score among formal caregivers was 3.13 (SD 0.65), indicating that formal caregivers showed less trust in ChatGPT's responses compared to informal caregivers. ChatGPT’s responses to non-clinical information needs related to dementia patients were generally satisfactory at this stage. As this tool is still under heavy development, it holds promise for providing even higher-quality information in response to information needs, particularly when developed in collaboration with healthcare professionals. Thus, large language models such as ChatGPT can serve as valuable sources of information for informal caregivers, although they may not fully meet the needs of formal caregivers who seek specialized (clinical) answers. Nevertheless, even in its current state, ChatGPT was able to provide responses to some of the clinical questions related to dementia that were asked.

Relationship between Depressive Symptoms, Caregiver Strain, and Social Support with Dementia Grief in Family Caregivers.

Background and Objectives: Dementia grief in family caregivers of people with dementia refers to grieving prior to the death of the care recipient. It is related to psychosocial risk factors that may have a negative impact on the health of these family caregivers. This study aimed to describe the relationship between depressive symptoms, caregiver strain, and social support with dementia grief in family caregivers of people with dementia. Materials and Methods: A descriptive correlational cross-sectional study was conducted. A total of 250 family caregivers of people with dementia participated. Dementia grief was the main variable, and depressive symptoms, caregiver strain, and social support were assessed. Additionally, socio-demographic data were collected. Descriptive statistics were calculated, and a bivariate correlation analysis and a multiple linear regression analysis were performed for dementia grief. Results: Higher scores for dementia grief were found in women, in family caregivers of patients at advanced stages of dementia, and in family caregivers with a low level of education. High levels of depressive symptoms and caregiver strain and low levels of social support indicated greater intensity of dementia grief. Depressive symptomatology was the variable with the greatest influence on dementia grief. Caregiver strain and social support also related to dementia grief, but to a lesser extent. Conclusions: In family caregivers, depressive symptoms, caregiver strain, and social support are related to the intensity of dementia grief, with a greater influence of depressive symptoms. Moreover, being female, having a low level of education, and caring for a care recipient at an advanced stage of dementia are factors associated with increased dementia grief. Concerning study limitations, the sample was restricted, belonging to a specific region of Spain and to a Provincial Federation of associations. It is necessary to exercise caution in generalizing results due to the sociodemographic and geographical characteristics of the sample.

Impact of playful objects on wellbeing, emotions and engagement in patients with dementia and post-stroke cognitive impairment

Stroke is a major public health concern, and finding ways to support the wellbeing and emotional regulation of stroke patients with post-stroke cognitive decline or dementia is vitally important. HUG™ was developed to be used as a psychosocial intervention to reduce anxiety and provide comfort and pleasure to those with cognitive impairment. The aim of the ludic artefacts using gesture and haptics evaluation and making playful objects for wellbeing, emotional regulation and engagement for dementia post-stroke cognitive impairment (LAUGH EMPOWERED PSCI) study, a 2-year collaborative project between the NHS and Sunrise Senior Living, is to improve the lives of older people living with advanced stages of dementia and those living with post-stroke cognitive impairment (PSCI). Post-intervention qualitative data were gathered from NHS health professionals (n=20) via a series of interviews. A qualitative interpretive grounded practical theory methodology underpinned by a ‘compassionate design’ approach was used to analyse qualitative interviews. Two key themes were identified: evidence of improvement in patient care, and difficulties and negative responses to using HUG™ (patient and staff), with respective sub-themes also identified. Findings from this study reveal that HUG™ can be used successfully in a hospital context to improve patient wellbeing and reduce anxiety. Although not every patient who received a HUG™ responded positively, the device did have a significant positive impact on the quality of life and care of those who did. It is clear from this research that, although HUG™ is not the right solution for every patient, it is a useful alternative to prescribed medication for some patients who are anxious and distressed.

Diagnostic Challenge of an Advanced Stage Dementia Case

Diagnostic Challenge of an Advanced Stage Dementia Case

Anti-dementia drugs: what is the evidence in advanced stages?

Dementia is a major public health concern due to its increasing prevalence, substantial caregiver burden, and high financial costs. Currently, the anti-dementia drugs aim only at a symptomatic effect. The subject of prescribing these drugs in advanced stages is a matter of considerable debate, with different countries making distinct recommendations. In this review article, we analyzed the evidence regarding cognitive and functional outcomes, adverse events, health-related costs, and caregiver burden in patients with advanced Alzheimer disease (AD) and mixed dementia. We included 35 studies. Most studies are heterogeneous, focus exclusively on AD, and show small benefits in terms of cognitive and functional scales. The overall evidence seems to suggest a benefit in introducing or maintaining anti-dementia drugs in patients with advanced dementia, but clinical meaningfulness is difficult to ascertain. The issue of costs and caregiver burden is significantly underexplored in this field but also seems to favor treatment continuation, despite a reduced overall effect. The decision of introducing or withdrawing anti-dementia drugs in advanced stages of dementia should be individualized. Future studies with homogeneous designs and outcomes are warranted.

Implementation of an Advance Care Planning Intervention in Nursing Homes: An International Multiple Case Study.

The inability of individuals in the advanced stage of dementia to communicate about preferences in care at the end-of-life poses a challenge for healthcare professionals and family carers. The proven effective Family Carer Decision Support intervention has been designed to inform family carers about end-of-life care options available to a person living with advanced dementia. The objectives of the mySupport study were to adapt the application of the intervention for use in different countries, assess impact on family satisfaction and decision-making, and identify costs and supportive conditions for the implementation of the intervention. A multiple-case study design was chosen where the nursing home was the case. Nursing homes were enrolled from six countries: Canada, Czech Republic, Italy, Netherlands, Republic of Ireland, and United Kingdom. Seventeen cases (nursing homes) participated, with a total of 296 interviews completed including family carers, nursing home staff, and health providers. Five themes relevant to the implementation of the intervention were identified: supportive relationships; committed staff; perceived value of the intervention; the influence of external factors on the nursing home; and resource impact of delivery. There is a commonality of facilitators and barriers across countries when introducing practice innovation. A key learning point was the importance of implementation being accompanied by committed and supported nursing home leadership. The nursing home context is dynamic and multiple factors influence implementation at different points of time.

Optimising Online Peer Support for People with Young Onset Dementia.

People with Young Onset Dementia (YOD) can be hesitant to engage with online peer support. This work aims to explore (1) why people are hesitant to engage in online peer support, (2) how to get more people involved in online peer support, and (3) what makes online peer support work well. Nine interviews with people with YOD were conducted on MS Teams. Participants were recruited through purposive sampling. Data were analysed thematically. Reasons for being hesitant to engage with online peer support include being unsure what to expect and concerns about seeing others in more advanced stages of dementia. Additionally, it can be difficult to identify groups that suit one's needs and interests. Group facilitators of online peer support groups should provide a detailed description of their group so that people can better assess whether the group would suit them. The insights obtained from this study will be used to develop a Best Practice Guidance on online peer support for people with YOD. Moreover, the findings can be useful for further research exploring how to support people with dementia in general in accessing online health and social care services.

Understanding interaction in problematic dementia and social care encounters: Protocol for a micro-level study combining video-ethnography and Conversation Analysis (CA).

It is well established that the actions and behaviour of dementia care workers are fundamental to the wellbeing of the people they care for. Not only do they deal with basic healthcare needs, but they also perform a vital psycho-social function by providing-through their regular presence-an underlying continuity for residents. This has been shown to improve well-being, particularly for those in the advanced stages of dementia. It has also been suggested that there are additional psycho-social benefits of such contact which can directly influence the need for anti-psychotic medication. However, unlike most other healthcare and medical settings, the specialised and often difficult interactions that dementia care workers handle every day have not yet been the subject of detailed micro-level analysis. This is particularly significant because much of the impact that care-workers have relates to the way in which they interact with the people they care for. Not having a clear understanding of how their interactions 'work' at the micro-level-particularly ones that are specific to dementia care settings, and that care workers report to be difficult or challenging-means that any training interventions that are developed may not resonate with their real-world experience, and ultimately run the risk of failing. This video-based observational study aims to provide a detailed micro-exploration of problematic and challenging interactions involving care-workers and people living with dementia. The study is based in the UK and will involve up to 20 dementia care staff and 60 people living with dementia. Fieldwork will be conducted in 5 dementia care home and community-based dementia day care settings using naturalistic observational methods (primarily video-ethnography). Data will be analysed using Conversation Analysis (CA).

Efficacy of therapeutic intervention with NanoBEO to manage agitation and pain in patients suffering from severe dementia: a pilot clinical trial.

An estimated 57.4 million people live with dementia worldwide, with the social burden of the disease steadily growing. Despite the approval of lecanemab and ongoing trials, there is still a lack of effective and safe treatments for behavioral and psychological symptoms of dementia (BPSD), which affect 99% of patients. Agitation is one of the most disabling BPSD, with a cross-sectional prevalence of ≥50% in nursing homes, and refers to help-seeking behavior in response to various sources of discomfort, among which pain is a crucial component. This pilot phase of the BRAINAID (NCT04321889) trial aimed to assess the effectiveness of the patented nanotechnological device NanoBEO in older (≥65 years) people with severe dementia. This randomized placebo-controlled trial, with quadruple masking that involved all operators and participants, followed the SPIRIT and CONSORT statements. A total of 29 patients completed the trial. The patients were randomly allocated in a 1:1 ratio to the NanoBEO or placebo group, and the corresponding product was applied on both arms once daily for 4weeks, with a 4-week follow-up period. The primary endpoint was efficacy against agitation. The secondary endpoints were efficacy against agitation at follow-up and efficacy against pain. Any adverse events were reported, and biochemical analyses were performed. The NanoBEO intervention reduced the frequency (28%) and level of disruptiveness of agitated behaviors. The effect on frequency was statistically significant after 2weeks of treatment. The efficacy of NanoBEO on agitated behaviors lasted for the entire 4-week treatment period. No additional psychotropic drugs were prescribed throughout the study duration. The results after 1week of treatment demonstrated that NanoBEO had statistically significant analgesic efficacy (45.46% improvement in pain intensity). The treatment was well tolerated. This trial investigated the efficacy of NanoBEO therapy in managing agitation and pain in dementia. No need for rescue medications was recorded, strengthening the efficacy of NanoBEO in prolonged therapy for advanced-stage dementia and the usefulness of the intervention in the deprescription of potentially harmful drugs. This study provided a robust rationale for the application of NanoBEO in a subsequent large-scale pivotal trial to allow clinical translation of the product. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT04321889.

Care needs assessment of older adults with dementia in a semi-rural district in Vietnam: A community-based cross-sectional study.

The increasing needs of people living with dementia (PLWD) in Vietnam present an enormous public health challenge. Vietnam is an understudied country, and little is known regarding the overall unmet needs of caregivers or the demographic risk factors associated with unmet caregiving needs. This study aimed to determine the burden of unmet care needs of community-dwelling PLWD and identify sociodemographic risks associated with unmet care needs. A cross-sectional study in a rural area facing urbanisation in Hanoi, Vietnam recruited PWLD-caregiver dyads with multistage sampling. We utilised the Camberwell Assessment of Need for the Elderly (CANE) instrument to evaluate care needs across four domains. Caregivers rated PLWD needs, with higher scores indicating greater unmet needs. The Mann-Whitney test was employed for comparing two groups, while the Kruskal-Wallis test was used for comparisons involving more than two groups in the analysis, and a P-value of less than 0.05 was considered statistically significant. Among 90 PLWD participating in the study, the overall mean care needs score was 11.6 ± 4.3, with only 16.2% of PLWD having their care needs met. Environmental and physical needs were more frequently met than psychological or social needs. Only 48.0% and 43.9% of environmental and physical needs were met respectively, and a meagre 20.9% and 23.6% for psychological and social needs. Unmet care needs were more frequent for PWLD who were female, single or divorced, had lower monthly household income, or who were in more advanced stages of dementia, as indicated by Clinical Dementia Rating scores ≥1. Unmet needs for PWLD are common. Increased caregiver education, resources, and services in Vietnam are urgently required to improve the quality of life for this population.

Caregiver Accounts of Lucid Episodes in Persons With Advanced Dementia.

Paradoxical lucidity is defined as an instance of unexpected lucid behavior in a person who is assumed to be noncommunicative due to a progressive and pathophysiologic dementing process. To inform studies of the prevalence, characteristics, and impact of these behaviors, this interview study examined caregivers' experiences of witnessing paradoxical lucidity. Participants were family caregivers of persons living with advanced dementia caused by a neurodegenerative disease producing significant impairments in communication. Semistructured interviews elicited the caregivers' experiences of plausible lucid episodes. Data analysis used a thematic analysis approach. Most caregivers reported at least 1 episode of lucidity. Episodes were typically brief. Most involved utterances, but nonverbal behaviors were also common. The mental capacities associated with these behaviors included recognition, awareness of surroundings, recognizing others' emotions, and goal-directed behavior. Most caregivers' reactions were positive. Episodes did not lead to changes in major medical decisions but instead to efforts to either modify or reinforce daily caregiving efforts. Episodes of lucidity were common, a finding seen in other studies. If prevalence studies confirm this, the qualifier "paradoxical" should be eliminated. The caregivers' familiarity with the person living with dementia allowed them to attribute meaning to subtle behaviors that might not otherwise be detected or considered lucid. Clinicians who care for persons with advanced-stage dementia should routinely ask caregivers about episodes of lucid communication and their emotional reactions.

REDUCING HOSPITAL ADMISSIONS FOR PEOPLE LIVING WITH DEMENTIA—RESULTS FROM THE GERMAN DEMWG-STUDY

Abstract People living with dementia (PlwD) have a high risk of being admitted to hospital, especially in advanced stages of dementia – with often severe negative consequences. The DemWG-study therefore aimed to reduce the number of hospital admissions for long-term care dependent PlwD by a complex intervention - including motor and cognitive training for PlwD and education of caregivers and general practitioners. By means of a cluster randomised longitudinal design, data on hospital admissions as well as quality of life, risk of falls, challenging behaviours and cognitive functioning were assessed in 97 shared-housing arrangement (SHA) in Germany with a total of 341 PlwD at baseline and after a 6 months intervention. Results of the of longitudinal data analysis showed a significant decline in hospital admissions for the intervention period and less challenging behaviours. Quantitative and additionally qualitative data were also collected 12 and 18 months after baseline. Caregivers perceived improved social interaction, which in turn has a positive effect on living together in the SHA. Based on the results and in light of the urgent need for easy to implement non-pharmacological and/or psychosocial therapy approaches recommendations for better care and support can be derived and the intervention can be implemented in everyday practice.

EMPOWERING STAFF TO MANAGE MEALTIME DIFFICULTIES AMONG RESIDENTS WITH DEMENTIA: A PILOT STUDY

Abstract People in advanced stages of dementia may experience mealtimes difficulties and depend on others for feeding. This pilot study aimed to evaluate the feasibility, acceptability, and preliminary effects of an educational intervention on mealtime difficulties of people with dementia, in a sample of 16 direct care workers and 9 people with dementia and was conducted in a nursing home. The sessions provided information about dementia, mealtime difficulties, and training on strategies and techniques. Feasibility was assessed through screening, eligibility, consent, retention, completion, and intervention adherence rates; and acceptability through a satisfaction questionnaire. The staff assessment included: burnout, job satisfaction, and knowledge about dementia and mealtime difficulties. In people with dementia, eating and feeding problems, and food intake were assessed. The main findings show that all feasibility rates, except for screening (89%), were excellent (100%). Direct care workers appreciated the intervention and perceived educational and practical benefits, although they reported needing more time to provide better assistance. Burnout levels did not change (mean 58.9 versus 58.6), but job satisfaction showed a positive trend (mean 71 versus 74.5) at the end of the intervention. Knowledge increased 37.5% compared to baseline. EdFED’s score presented slight improvement, while the oral intake of people with dementia increased after the intervention (91.1% versus 98.1%). The intervention was found to be feasible and acceptable. However, the educational intervention content needs improvement, and further studies with robust designs and larger samples are needed to better understand its effects on both direct care workers and people with dementia.

Music and humanoid robots aid in performing daily living activities in people affected with advance stage dementia

AbstractBackgroundAs the disease progresses the ability to perform daily living activities is gradually reduced. As dementia progresses music is one of the last things to go(Foo et al.2017, Beatty et al., 1988). Additionally many studies have shown music to be an effective tool to help people affected with dementia(Baird, & Samson, 2015). In order to help residents in nursing homes to perform their daily living activities we programmed a humanoid robot to sing, perform the daily living activity and instruct the resident to follow them in performing specific daily living activities. The activities that are performed are brushing teeth, washing face, putting on clothes and going from point A to point B.MethodHumanoid robots are programmed to sing the instructions to perform a daily living activity and also act out the activity. The robots are programmed to perform simple activities of daily living that the people affected with dementia are forgetting to perform. The music is composed and lyrics are written by Professors Rudy Perrault and Rachel Inselman.ResultThe robots have been successfully helping people affected with dementia in a short trial. There were three participants chosen for this case study where one person was in the advanced stage of dementia, one person was in the moderate stage of dementia and the third person was in the mild stage of dementia. Each of the participants was able to successfully perform the activities of daily living by mimicking the robots.ConclusionAs soon as the robot started to sing and enact the daily living activity the participants started to move to the music and follow the robot.

Music and humanoid robots aid in performing daily living activities in people affected with advance stage dementia

AbstractBackgroundAs the disease progresses the ability to perform daily living activities is gradually reduced. As dementia progresses music is one of the last things to go(Foo et al.2017, Beatty et al., 1988). Additionally many studies have shown music to be an effective tool to help people affected with dementia(Baird, & Samson, 2015). In order to help residents in nursing homes to perform their daily living activities we programmed a humanoid robot to sing, perform the daily living activity and instruct the resident to follow them in performing specific daily living activities. The activities that are performed are brushing teeth, washing face, putting on clothes and going from point A to point B.MethodHumanoid robots are programmed to sing the instructions to perform a daily living activity and also act out the activity. The robots are programmed to perform simple activities of daily living that the people affected with dementia are forgetting to perform. The music is composed and lyrics are written by Professors Rudy Perrault and Rachel Inselman.ResultThe robots have been successfully helping people affected with dementia in a short trial. There were three participants chosen for this case study where one person was in the advanced stage of dementia, one person was in the moderate stage of dementia and the third person was in the mild stage of dementia. Each of the participants was able to successfully perform the activities of daily living by mimicking the robots.ConclusionAs soon as the robot started to sing and enact the daily living activity the participants started to move to the music and follow the robot.

'There's something they can do': Educating aged care staff about the trajectory of dementia, palliative care and the Namaste Care™ program: A mixed methods study.

To evaluate outcomes of education about the dementia illness trajectory and Namaste Care™ program on aged care staff's knowledge, attitudes, self-perceived skills and competence. A convergent mixed methods research design was adopted to compare the results of quantitative and qualitative data following an education intervention. Nurses and aged care staff (n = 35) undertook 2 × 2 h training sessions over 3 days. Data were collected pre- and post-intervention using three validated surveys. Qualitative data were collected through interviews and a focus group. Thematic analysis was used to generate themes. Quantitative and qualitative data were integrated and compared during interpretation and discussion of the findings. Significant improvements in knowledge, attitudes and skills survey scores from already published data were confirmed by the qualitative findings in this study. Three key themes were derived from the data, comprising dementia-related education and knowledge changes, recognising the benefits of the Namaste Care™ program, and the importance of changing practice. Dementia education using the Namaste Care™ program enabled staff to identify gaps in knowledge and skills within their own practice. Staff perceived that the Namaste Care™ program can be a driver for practice change including palliative care to improve quality of life for people living in the advanced stages of dementia.

Influence of Care Burden-related Factors on Mental Health and Quality of Life of the Caregivers of Dementia Patients

Purpose: To evaluate the care burden of the caregivers of dementia patients and the relationship between anxiety-depression risk and quality of life.
 Methods: This study was conducted with 152 primary caregivers of dementia patients by using “Caregiver Burden Inventory”(CBI), “Hospital Anxiety-Depression Scale” (HADS) and “Short Version of the Quality of Life Assessment Instrument From the World Health Organization” (WHOQOL-BREF).
 Results: Mean age of the caregivers was 49.4±9.0 years; of them, 79.6% were females, 54.6% were graduates of elementary/secondary school. Mean age of dementia patients was 79.8±8.0 years; of them, 55.2% were females, 46.1% had advanced stage dementia and 30.9% had pressure ulcers. High care burden was detected in 101 (66.4%) caregivers, anxiety in 37 (24.3%) and depression in 109 (71.7%). The scores of HAD-A and HAD-D were significantly high (p=0.007, p=0.002) and WHOQOL-Bref score was significantly lower (p=0.001) in caregivers of the patients with pressure ulcers. Scores of CBI, HAD-A and HAD-D were found to significantly increase (p=0.005, p=0.042 and p=0.030, respectively) and WHOQOL-Bref score was found to significantly decrease (p=0.009) as stage of dementia increased. HAD-A and HAD-D scores were detected to increase (p=0.000, p=0.000) and WHOQOL-Bref score was detected to decrease (p=0.000) as CBI score increased. 
 Conclusion: Dementia causes a high care burden for the caregivers. It is of vital importance to facilitate reaching professional support services for reducing care burden that increases with increasing stage, and establishing hospice care institutions for reducing the risk of mental disorders and for improving quality of life of the caregivers.

ANTICIPATED SUICIDAL AND DEATH IDEATION IN RESPONSE TO AN IMAGINED DEMENTIA DIAGNOSIS

Abstract Alzheimer’s disease and related dementias are prevalent, incurable, and highly impactful diagnoses. Dementias are therefore feared diagnoses. Dementia-related anxiety (DRA) is anxiety about a current or future diagnosis of dementia and the associated complex symptoms. In a mixed methods study, semi-structured interviews were conducted to identify causes of DRA and revealed that numerous adults anticipated suicidal or death ideation if diagnosed with dementia. Fifty cognitively healthy, community-dwelling adults aged 58 to 89 (M = 70.92, SD = 6.08; 64% female) were recruited from a university participant registry and Memory Clinic. Among participants endorsing anticipated suicidal or death ideation, responses ranged from active plans, including interest in physician-assisted suicide, to more passive wishes to hasten death rather than continue to live with dementia. Within reports of both anticipated suicidal and death ideation, subthemes emerged, including the concern about becoming a burden to others in more advanced stages of dementia, the devaluation of life or the self with dementia, and the desire for (and anticipated thwarting of) control and independence. Statements of anticipated suicidal and death ideation were contingent on a future dementia diagnosis and may reflect errors in affective forecasting. Nevertheless, given the prevalence of dementias and older adults’ elevated rates of suicide, the intersection of these two public health issues warrants greater attention and further investigation.

Identifying delirium in advanced dementia in the ECT‐AD clinical trial

AbstractBackgroundDelirium and dementia are common causes of cognitive impairment in older adults and frequently co‐exist. Delirium is associated with poor clinical outcomes when comorbid with dementia. Identifying delirium superimposed on dementia (DSD) is clinically challenging given the overlap in symptoms, including inattention, cognitive impairment, and altered level of consciousness, especially in advanced stages of dementia. Recognition of delirium is also critical in ADRD (Alzheimer’s Disease and Related Dementias) clinical trials for both validity and safety reasons. The ECT‐AD study is one such trial investigating the safety and efficacy of electroconvulsive therapy (ECT) for treatment‐refractory agitation and aggression in individuals with advanced ADRD. Herein we review the Confusion Assessment Method (CAM) for identifying delirium in the ECT‐AD study.MethodInclusion criteria for ECT‐AD are hospitalized individuals diagnosed with ADRD (ages 55–89, MMSE ≤ 15) and refractory agitation/aggression, as measured by the Cohen‐Mansfield Agitation Inventory (CMAI). Procedures for detecting baseline and treatment‐emergent delirium involve a 3‐step approach conducted by raters trained in the CAM, which assesses inattention, disorganized thinking, altered levels of consciousness, and fluctuating mental status. Step 1 involves gathering information from nurse informants regarding the patient’s mental status over the past 24 hours. Step 2 involves collecting observational data through informal patient interaction (e.g., brief conversation). Step 3 is an objective assessment of cognitive status using the Severe Impairment Battery – 8 Item (SIB‐8), while also making qualitative observations about delirium features (e.g., level of consciousness). The rater then codes the CAM and determines delirium status based on these 3 steps.ResultOf our 6 consented subjects, 1 experienced delirium detected by the CAM during the Randomization Phase. The subject received three positive CAMs on consecutive treatment days, citing change in mental status, inability to arouse, restlessness, psychomotor agitation, and swearing. ECT/S‐ECT was held each treatment day and the subject was withdrawn from the Randomization Phase.ConclusionIdentifying DSD is challenging due to overlapping symptoms and the fluctuating nature of delirium. The CAM may be useful in this regard by using a multi‐step approach that incorporates observations from reliable informants, direct patient interactions, and structured cognitive assessments.