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

From Science to Smartphones: Boosting Memory Function One Press at a Time

Eva Svoboda, PhD,^1,2 Gillian Rowe, PhD,^1,2 Kelly Murphy, PhD,^1,2
1Neuropsychology and Cognitive Health Program, Baycrest Centre, Toronto, ON.
²Department of Psychology, University of Toronto, Toronto, ON.

Abstract
Memory problems can be devastating as they limit independent functioning and disrupt social, family, and occupational roles. One form of remembering, prospective memory - remembering to attend to a task or event in the future—is particularly vulnerable to disruption. Fortunately memory is not a singular ability and patients can learn to compensate for memory difficulties by using preserved memory systems. Combining smartphone technology with appropriate training techniques has been shown to be effective in supporting prospective memory function even in individuals with amnesia. We have evidence that such technology may be used in a similar fashion to promote memory in mild cognitive impairment with the aim of delaying or preventing dementia onset. Even in dementia, memory training or support in forming new habits and routines which tap into preserved memory systems can be effectively used to help patients learn new names, reduce repetitive questions and remain oriented to the present. The best prevention is early intervention. Older adults presenting with memory complaints, no matter how mild, should be directed to maintain, reestablish, or institute habits of organization and written reminders, both to support current memory functioning and to preserve functional independence into the future should their concerns turn out to be the early manifestations of a neurodegenerative condition.
Keywords: amnesia, technology, dementia, mild cognitive impairment, memory intervention.

Palliative and Therapeutic Harmonization (PATH): A New Model for Decision-Making in Frail Older Adults

Paige Moorhouse, MD MPH FRCPC, and Laurie Mallery MD FRCPC, Division of Geriatric Medicine, Dalhousie University, Halifax Nova Scotia

www.pathclinic.ca

Abstract
As the population ages, advances in medical technology paradoxically result in the accumulation of multiple chronic health conditions—known as frailty. Despite increasing numbers of frail older adults, healthcare systems have not been designed to meet the challenges associated with caring for this patient population. This article describes the characteristics of health systems that exacerbate the complex issues associated with caring for those who are frail and reviews one possible model, known as PATH—Palliative and Therapeutic Harmonization, as a way to respond to these system challenges.
Keywords: frailty, care planning, dementia, knowledge translation, health program.

Neural Plasticity and Cognitive Reserve

Zahra Bardai, BSc, MD, CCFP, MHSc, FCFP, Community Family Physician, Lecturer, University of Toronto, Assistant Clinical Professor (Adjunct), Department of Family Medicine, McMaster University, Hamilton, ON.

Abstract
Neural plasticity in the context of normal aging and dementia can be evaluated on a number of levels. Traditionally there has been much focus on cellular dysfunction, which is evidenced by the plaques and tangles that are the hallmarks of Alzheimer type dementia. Now, more than ever, there is an emerging spotlight on the preservation of functional levels despite failing cognition be it from normal aging, mild cognitive impairment (MCI) or diagnosed dementia. Neural plasticity can be viewed as the complex interaction between the neurons' electrical, biochemical and physical structure and the individual's behavioural, psychological and sociological activities.¹ This article will briefly review the neurobiology of cognition and the sequence of events that lead to its demise. The remainder of this review concentrates on tangible, evidence based strategies to uphold clinical cognition through the aging process.
Keywords: neural plasticity, aging, dementia, cognition, neurons.

…there were neurons in her head, not far from her ears, that were being strangled to death, too quietly for her to hear them. Some would argue that things were going so insidiously wrong that the neurons themselves initiated events that would lead to their own destruction. Whether it was molecular murder or cellular suicide, they were unable to warn her of what was happening before they died.

-Still Alice
Lisa Genova

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

When to Have the Critical Conversation? Issues in Planning for Persons with Dementia and their Caregivers

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

Of the many challenges that face families when looking after their older loved ones, of the most difficult is deciding on end-of-life decisions. The accepting or rejecting artificial nutrition and hydration, apparently life-saving antibiotic intervention for an aspiration pneumonia or urinary tract infection or the implementation of theoretically life-saving cardio-pulmonary resuscitation are among the many decisions that substitute decision-makers, who are often close family members, have to make. More often than not, these types of decisions are required in urgent situations where a time-consuming deliberative process that might be expected for a well-thought out decision to be reached is not possible because of the pressures of the potentially fatal clinical situation. Proper preparation for such eventualities usually requires time and thought that includes exploration of personal values and wishes in what ideally should occur during conversations between older loved ones at risk of or in the throes of dementia when discussions might still take place. These revealing communications must occur with those that are responsible for making these very personal and potentially life-altering clinical decisions.

Helping Families Worried About Developing Dementia

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

One of the challenges faced by those of us who practice geriatric medicine or through another specialty is helping family members understand the hodgepodge of medical literature especially as it is reported by internet/Google searches rather than careful reviews of the peer reviewed literature. Even in the latter there is a wide range of opinions which even for physicians sometimes presents a challenge in how we make our recommendations. This is especially the case when dealing with dementia.
Keywords: dementia, burden, stress, fear, guilt, families.

Cognitive Decline and Dementia Risk in Type 2 Diabetes

Liesel-Ann Meusel¹, PhD, Ekaterina Tchistiakova^2,3, BSc, William Yuen^4,5, BSc, Bradley J Macintosh^2,3, PhD, Nicole D Anderson^1,6, PhD, and Carol E Greenwood^4,5, PhD
¹Rotman Research Institute, Baycrest Centre, Toronto, ON. ²HSF Centre for Stroke Recovery, Sunnybrook Research Institute, Toronto, ON. ³Department of Medical Biophysics, Faculty of Medicine, University of Toronto, Toronto, ON.
⁴Kunin-Lunenfeld Applied and Evaluative Research Unit, Baycrest Centre, Toronto, ON. ⁵Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON. ⁶Departments of Psychology and Psychiatry, University of Toronto, Toronto, ON.

Abstract
Type 2 diabetes mellitus is increasingly common, and previously unrecognized complications are emerging; namely, cognitive impairment and dementia. The mechanisms that link these factors together are still unknown, but likely result from the interplay of several variables, including vascular change, poor glycemic control, inflammation, and hypothalamic pituitary adrenal overactivity. At present, it is still too early to propose best practices related to the management of diabetes-induced cognitive change. All things considered, however, patients should be aware that proper management of metabolic and vascular complications may minimize the adverse effects of type 2 diabetes on cognitive function and quality of life.
Keywords: type 2 diabetes, cognition, dementia, vascular, metabolic.