Advances in Alzheimer's Disease Management

CHAPTER 7: Ethical and clinically humane end-of-life care for those living with dementia
by Michael Gordon

Editors:
Serge Gauthier, McGill University, Montreal, Quebec, Canada
Pedro Rosa-Neto, McGill University, Montreal, Quebec, Canada
Publisher: Future Medicine
Reviewed by: Michael Gordon, MD, MSc, FRCPC, FACP, FRCPEdin

It is always a pleasure to be able to discuss a new book to a receptive audience when I believe the book has something special to offer. When it comes to reviewing books outside the realm of medicine or the medical sciences, reviews often are reflective of the personal and aesthetic views of the reviewer. There are many books written for professional readers on the fringe of medical science that deal with non-clinical aspects of medicine and many that have translated important medical concepts to the lay audience and others in the form of memoirs and novels of the personal and historical type that add a great deal to the general wealth and richness of medicine and the associated medical sciences.

To undertake an academic text book is always a daunting task. Generally if experts and specialists in the field cannot write such a book without the help of others and currently the idea of editors securing experts to write the relevant chapters is a well-accepted methodology for achieving that goal. That being said it becomes the responsibility of the editors to make sure that those that they recruit to write the relevant chapters have the academically sound and clinically and research-based capability of doing so and on top of that have the writing skills to achieve their goal. Moreover, for the chapters to hang together in one strives to have some degree of congruence in the writing approaches and styles, while at the same time promoting the particular capabilities of the writers of each chapter. At the end it is hoped that the chapters hang together into a whole that attracts the reader and provides a perspective on the subject and each of its varied components that would be hard to achieve if the reader decided to explore each of the subject chapters separately without the benefit of them being collated, edited and reference into one easily accessible book.

I am therefore pleased and honoured to not only present the book to subscribers of HealthPlexus.net, Advances in Alzheimer’s Disease Management edited by Serge Gauthier and Pedro Rosa-Neto but to have been one of the contributors. At a time when the knowledge surrounding Alzheimer’s disease and other dementias is on the one hand expanding rapidly from the scientific perspective, for the practicing physician and patient living with dementia and their families, the challenges seems to be overwhelming. There seems to be a huge disconnect between the understanding and scientific progress of the causes in many domains of enquiry and the actual clinical impact that all this new knowledge currently has that physicians in the front lines of care can utilize clinically.

In medicine however, one never knows what key will be the one that opens the door we are all looking to enter. At any given time all we can do is to try and figure out using the best clues and evidence available to know what secrets lay behind that door. The readily accessible E-book format in which Advances in Alzheimer’s disease management is produced allows for a relatively low cost alternative to the usual costs of hard copy texts. The content of the book covers all the main challenging concepts and recommended or best-practices as they exists currently. Obviously in time, perhaps a very short time, some of these will change but for those in the field we all know that many of the concepts and practices have not changed in many years.

The table of contents includes the following subjects by the authors listed next to the chapter titles, with mine at the end. I have been given permission to reproduce my chapter, Ethical and clinically humane end-of-life care for those living with dementia on the HealthPlexus.net website so that subscribers can get a taste of the e-book itself.

1) Genetics of Alzheimer’s disease by Jayashree Viswanathan, Hilkka Soininen & Mikko Hiltunen;
2) Diagnosis of Alzheimer’s disease by Pedro Rosa-Neto, Jared Rowley, Antoine Leuzy, Sara Mohades, Monica Shin, Marina T Dauar and Serge Gauthier
3) Available symptomatic antidementia drugs by Marie-Pierre Thibodeau and Fadi Massoud
4) New drugs under development for Alzheimer’s disease by Lezanne Ooi, Kirubakaran Shanmugam, Mili Patel, Rachel Debono and Gerald Münch
5) Management of agitation and aggression: controversies and possible solutions by Clive Ballard and Anne Corbett
6) Guidelines for the diagnosis and treatment of Alzheimer’s disease by Serge Gauthier and Christopher JS Patterson
7) Ethical and clinically humane end-of-life care for those living with dementia by Michael Gordon

For those interested in ordering the book, this can be done through the following links:
The direct URL for the book is:
http://www.futuremedicine.com/doi/book/10.2217/9781780840840
For those who are interested in finding more information about the book/our e-book series, the email address is:
info@futuremedicine.com
For those who wish to place an order, the email is:
sales@futuremedicine.com

A Message From the Editor

D’Arcy Little, MD, CCFP, FRCPC
Medical Director, JCCC and HealthPlexus.NET

As children rush to be on time for school and we fall back into our regular routines it can only mean that sadly this is the end of a beautiful, hot summer. Did I make you feel nostalgic? Don’t worry because we’re pleased to bring you the next edition of the Journal of Current Clinical Care. In this issue, we offer some articles expanding on themes from recent issues, as well as important new topics.

Doctors Kelly Murphy and Angela Troyer, from the Baycrest Centre in Toronto, describe an approach to the recognition of early dementia in clinical practice. They remind us that cognitive impairment is common, with approximately one in 11 older adults suffering some form of dementia. In the early state of the disease, where intervention has the most potential to reduce the disease burden on patients, families and society, the clues may be quite subtle.  The authors review not only the current diagnostic criteria, but also practical early warnings signs of dementia and various screening tools available.

Dr. Michael Gordon’s blog Plants are Good for the Soul Including for those Living with Dementia reminds us that to witness the growth of a plant, affirms for many that there is a meaning to life, and anything that gives life meaning is a worthwhile endeavor.

Also from the Baycrest Centre in Toronto, Doctors Svoboda, Rowe, and Murphy review the fact that different types of memory can be affected to a different extent in cognitive impairment. Episodic memory, the memory that allows us to remember events and details specific to a time and place are often affected early in the course of cognitive impairment, and procedural memory, the memory that underlies automatic or repeated skills is often preserved. They review their research into the use of devices, such as smart phones, which can be used as an external memory aid to overcome episodic memory impairment by using intact procedural memory, and thus and maintaining independence.

As a radiologist, I am frequently reminded that the incidence of small renal masses (SRMs) has risen steadily over time. The lesions are often incidentally detected on CT and ultrasound. Drs. Yap, Alibhai, and Finelli from the University Health Network in Toronto review a practical approach to the diagnosis and management of SMRs.  Although SMRs are a heterogenous group, consisting of both benign and malignant diseases, approximately 80% of incidentally-detected lesions are still malignant—most often a subtype of renal cell carcinoma. Imaging has some limitations in the accurate characterization of lesions as benign or malignant, and the increasing role of image-guided percutanous renal biopsy has increased.  Treatment of such lesions is now tailored to the individual patient, depending on disease characteristics, comorbidity, and patient preference.  Various types of therapies available are reviewed, including surgery, ablative therapy, and active surveillance.

In the case study for the Dermatology Educational Resource, Dr. Francesca Cheung focuses on cutaneous larva migrans, a parasitic infection caused by percutaneous penetration and subsequent migration of the larvae of hookworm.

The potentially severe and even fatal complications of acute tonsillitis, if left untreated, are reviewed by Dr. Shenoy of  the Campbellton Regional Hospital in New Brunswick.  Tonsillitis is an inflammation of the tonsils most commonly caused by a viral or bacterial infection, although more unusual organisms are also reviewed.  Most often, bacterial tonsillitis is treated with antibiotics on the basis of a positive throat culture, however, the reasons for a false negative result are reviewed.  The treatment of the infection and reasons for treatment failure are also reviewed.

I hope you enjoy adding this edition of the Journal to your end of summer reading list.  As always, your comments are welcomed.

A Serpiginous Lesion on the Foot

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Cutaneous larva migrans is a parasitic infection caused by percutaneous penetration and subsequent migration of the larvae of hookworm. The tracks are commonly raised, erythematous, serpiginous, and pruritic. Cutaneous larva migrans is diagnosed based on its clinical characteristics. It is a self-limiting condition because larvae eventually die in humans without being able to infest new hosts. Treatment is used to shorten the disease course, control the intense pruritus, and prevent the risk of secondary infection. Topical thiabendazole is the treatment of choice for mild and localized condition. Systemic treatment such as albendazole, mebendazole, and ivermectin are used in widespread cases or cases recalcitrant to topical treatment.
Keywords: cutaneous larva migrans, parasitic infection, hookworm, Ancylostoma braziliense, thiabendazole.

Decadent Summer Reading

D’Arcy Little, MD, CCFP, FRCPC
Medical Director, JCCC and HealthPlexus.NET

The latest issue of The Journal of Current Clinical Care is once again packed with highly informative articles and interactive content.

Drs. Moorhouse and Mallery from the Division of Geriatric Medicine at Dalhousie University in Nova Scotia recognize that as our population ages, patients often develop an accumulation of multiple chronic health conditions—known as frailty. Their article not only describes the features health systems that make caring for such patients difficult, but also reviews a model, known as PATH—Palliative and Therapeutic Harmonization, to respond to these system problems. In my role as a hospital-based radiologist, I see on a regular basis one of their tenets: when older adults present with acute decline in cognition, mobility or function, it is often a sign of underlying medical disease in a frail substrate. As clinicians we can definitely use an approach to this ever-increasing patient population.

Dr. Bardai reviews the role of neural plasticity in the development and the amelioration of cognitive decline. Neural plasticity has been described as a “complex interaction between the neurons’ electrical, biochemical and physical structure and the individual’s behavioural, psychological and sociological activities.” This article reviews the neurobiology of cognition, and the sequence of events that lead to its deterioration, as well as reviewing strategies for maintaining cognitive faculties in the aging process.

Dr. Francesca Cheung, a Family Physician and Senior Editor of the Dermatology Educational Resource reviews a challenging dermatological diagnosis, Granuloma annulare (GA). GA is a benign and usually self-limited skin condition that classically presents as arc-like or annular plaques in a symmetrical and acral distribution with an unknown etiology. The condition is commonly seen in children and young adults and has been described as a paraneoplastic condition.

Drs. Shenoy and Bali describe an approach to the complex problem of the removal of impacted sharp esophageal foreign bodies using a case study.

As part of our Lecture Series, Dr. Robert Madan, the Chief Psychiatrist at Baycrest Geriatric Health Care System at the University of Toronto, gives an engaging talk on Treatment for Behavioral and Psychological Symptoms of Dementia.

Dr. Barry Goldlist sat down for an interview with Dr. Charles Lynde, the Editor-in-Chief of Dermatology Educational Resource.

Our choice of topic to present as an infographic is Lumbar Spinal Stenosis, a condition we review as part of the larger scope of Back Pain for which we are developing a blended CME program that is scheduled for release later this year.

I hope you enjoy the issue as much as I enjoyed reviewing for you. As always, comments and questions are welcomed. I hope you are enjoying the Summer season!

The Launch of the Dermatology Educational Resource: Interview With the Editor-in-Chief Dr. Charles Lynde

Treatment for Behavioral and Psychological Symptoms of Dementia

Dr. Robert Madan is currently the Acting Psychiatrist-in-Chief, Executive Medical Director for the Centre for Mental Health and the Medical Program Director for the Psychiatric Day Hospital at Baycrest.

Learning Objectives
By the end of the session, participants will be able to:
- Describe the problems with pharmacological treatment of behavioral symptoms of dementia;
- Describe a non-pharmacological approach to treating behavioral symptoms of dementia.

Keywords: dementia, behaviour, agitation
 

Later Stage Dementia: Promoting Comfort, Compassion and Care

Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Baycrest Geriatric Health Care System; Professor of Medicine, University of Toronto, Toronto, ON.
 

Learning Objectives

When it comes to dementia much of the focus is related to diagnosis and treatment(s). A terminal phase is not always considered with conditions that cause dementia-but must be to properly plan care.

To address clinical and ethical challenges that face health care providers and families for this population and to provide health care providers with processes by which to address such ethical dilemmas.

Keywords: dementia, caregiving, end-of-life planning

Dermatology Editorial Team Joins HealthPlexus and JCCC

I have the pleasure of introducing the latest edition of the Journal Of Current Clinical Care. As always there are a multitude of noteworthy developments to report and a variety of interesting and clinically relevant topics that are covered in this issue.

As hinted in my last editorial, I am pleased to welcome Dr. Charles Lynde as Editor-in-Chief for the Dermatology Educational Resource @HealthPlexus and the Journal of Current Clinical Care. Dr. Lynde with the help of his fellow editors Drs. Anne Goodfellow, John Kraft and Francesca Cheung, will spearhead a Dermatology section on www.healthplexus.net and the Journal of Current Clinical Care. For this edition, Shahana Nathwani and Dr. Joseph Lam from the University of British Columbia provide an approach to ‘lumps and bumps’ in the pediatric population. There are a number of conditions that present clinically as ‘lumps and bumps’ in this age group. Some of these follow a benign course and can be safely observed, and others are more concerning and require definitive therapy and may even result in serious complications. A helpful feature of the article is a practice helper tool: A menu of cutaneous lesions in the pediatric population categorized according to colour.

I am also happy to introduce our new department called Infographics. Going forward we will select a topic and present the information and facts in an exciting and visually informative format. In this issue our choice of condition to present as an infographic is Ulcerative Colitis, an important topic for which we are also developing a CME program that is scheduled for release later this year.

Another first that we are introducing in this issue is a Lecture Series department. Dr. Michael Gordon, the Medical Program Director at Baycrest Geriatric Health Care System at the University of Toronto, is one our regular contributors, and is the Editor-in-Chief of our Dementia Educational Resource, gives an engaging talk on Later Stage Dementia and focusing on Promotion of Comfort, Compassion and Care, complete with video and slides.

Also in this issue, Dr. Michael Gordon in his article When to Have the Critical Conversation? Issues in Planning for Persons with Dementia and their Caregivers, uses a poignant family vignette to remind us that as health care providers we should encourage families and our patients to initiate conversations early regarding treatment at the end of life.

Drs. Lovingly Quitania Park and Sarah Tomaszewski Farias from the Department of Neurology at the University of California at Davis review the concept of Functional Limitations Predict Future Decline in Mild Cognitive Impairment (MCI). MCI is a term used to describe a transitional stage between normal aging and dementia. In MCI there are subtle changes in everyday activities that may indicate the presence of an under lying neurodegenerative condition, however patient independence is maintained. The authors review how to assess for cognitive impairment in this population and the prognostic implications of on subsequent conversion to dementia and the rate of progression of dementia.

The effects of caregiver burden are often expressed as a decline in psychological and physical health, as well as an increase in physician visits. In the article, Identifying and Managing Caregiver Burden Among Spouses of Individuals with Parkinson’s Disease Dr. Andrew Johnson et al., examines some of the predictors of caregiver burden, with a specific emphasis on the burden experienced by caregivers of individuals with Parkinson’s disease. Helpful strategies for relieving caregiver burden are also reviewed.

I hope you enjoy this edition of the journal. As always, your comments and questions are welcomed.

The Importance of Healthy Skin

Skin is the body’s largest organ. It acts as a protective layer between the insides and the rest of the world, helps regulate body temperature, acts as a natural filter and is constantly growing. It’s affected by every aspect of our life, by what we eat and the environment. Skin that is healthy is able to resist signs of aging, heals faster and can even stave off potential disease. It often manifests some underlying diseases and when it’s visually altered or damaged can make a profound effect on one’ quality of life.

As the newly appointed Editor-in-Chief for the Dermatology Educational Resource @HealthPlexus and the Journal of Current Clinical Care and with the help of my fellow editors Drs. Anne Goodfellow, John Kraft, and Francesca Cheung, we will solicit, organize and present to you educational materials of relevance to primary care practitioners and specialists alike by asking for contributions from recognized Key Opinion Leaders in the field of Dermatology on evidence-based best practices and treatment options.

In this issue, we are featuring the first article in our dermatology section titled Common Lumps and Bumps in Children: A Colour-coded Differential. Dr. Joseph Lam and Shahana Nathwani examine the many conditions that present as ‘lumps and bumps’ in the pediatric population. While some follow a benign course, others require definitive therapy or carry the potential for serious complications. Their review presents and categorizes common pediatric cutaneous lesions according to colours as a tool to help the general practitioner recognize and remember these lesions.

If you have questions, interested in serving as a contributor or peer-reviewer please reach out to us at contactus@healthplexus.net

I hope you enjoy this issue of the Journal. Feedback and discussion, as always, is welcomed.

2012 Canadian Consensus Conference on Dementia

On May 4^th and 5^th the fourth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD4) took place in Montreal. First started in 1989, the goal of the conference and its contributors, participants and authors is to review the evidence on various critical aspects of dementia and produce a series of papers summarizing the evidence. After the papers are written by a team of physician experts in the field of study, then are posted on the consensus website and conference participants are invited to add comments, then vote on a series of recommendations which are formulated by the authors, based on the best available evidence that can be gleaned from the English and French language medical literature.

The conference is attended by the papers’ authors, the steering committee of the conference and delegates from across Canada representing as much as possible all the fields addressed by the papers. This resulted in 27 attendees at the Montreal conference, from neurology, geriatric psychiatry, geriatric medicine, care of the elderly family medicine, genetics, neuroimaging and the major organizations that deal with those populations often living with or at risk for dementia that included the Canadian Academy of Geriatric Psychiatry, Canadian Geriatrics Society, College of Family Physicians of Canada and the Alzheimer’s Society.

The topics chosen for the focus of the papers from which evidence was gleaned to formulate the many recommendations were divided into the following categories: Definitions, Pharmacology and Therapeutics, Neuroimaging, Rapidly Progressive Dementia, Liquid Biomarkers, Early Onset Dementia, Knowledge translation in Dementia and Translation into Primary Care. As can be seen from the list, not every conceivable component of dementia care was covered, but those areas that are dependent on a body of literature from which evidence as to the consistency, efficacy and outcomes could be reasonably gleaned were the primary focus of the conference as has been the case in the past. When there was nothing new from the literature, we endorsed previous recommendations. For example, we did not recommend any changes to the laboratory work up for all cases of suspected dementia. There was also recognition that the areas chosen for review have a substantial impact on the practice of dementia-related medical care and public health care policy. All the papers were also explored for the ethical and resource allocation impact of the proposed recommendations.

At the end of each paper presentation by one or more of the authors, the results of the online voting was reviewed. Further, robust and far-reaching discussion of the recommendations often resulted in some modifications of the wording or conclusions. The strength of the recommendations (strong, weak) and levels of supporting evidence (A= most persuasive, B= moderate, C= weakest) resulted in suggestions for practice that were then subjected to the conference participants’ final vote. While most recommendations reached consensus agreement, some were rejected as being inappropriate or not supported by sufficient evidence.

The next step is that the results of the conference and the final recommendations will be submitted to a number of journals directed to the whole spectrum of physicians involved in dementia care. This includes primary care physicians, specialist physicians both community-based and academic, of which the latter often function within the milieu of tertiary level memory and dementia programs and clinics.

After the recommendations are published in the medical literature, HealthPlexus will play an important role in the dissemination and the process of translation of the recommendations into clinical practice with the goal of assisting primary care physicians in the evaluation, investigation, and care of their patients afflicted with the wide range of cognitive impairments, and the caregivers and families who support them. We will endeavour to help family physicians through various modalities of presentations including the possibility of case-based presentations that can be addressed through the lens of the new recommendations so that our HealthPlexus readership can assimilate the new recommendations into the very practical challenges of primary care.

As the editor of the dementia section of HealthPlexus, and member of the steering committee, and ethics consultant to the Consensus conference, I am very pleased that we can play an active role in helping front-line primary care physicians utilize the recommendations of the Conference to guide the every day challenges of their practice.

Michael Gordon, MD, MSc, FRCPC
Editor-in-Chief, Dementia Educational Resource
www.healthplexus.net and the Journal of Clinical Care
and
Member of CCCDTD2012 Steering Committee
Ethics Consultant to the Committee

About Health Plexus:
Comprised of 1000s of clinical reviews, CMEs, bio-medical illustrations and animations and other resources, all organized in the 34 condition zones, our vision is to provide physicians and allied healthcare professionals with access to credible, timely and multi-disciplinary continuing medical education from anywhere and on any media consumption device. The Dementia Educational Resource is the compilation of high quality clinical reviews, online CME programs, library of original visual aids, interviews, roundtable discussions and related conference reports.