Person-centered care for older people with dementia in the acute hospital.

INTRODUCTION: Patients with dementia (PWDs) are often subjected to enforced dependency and experience functional decline and emotional distress during hospital stay. Person-centered care (PCC) with specialized psychosocial interventions, minimally obtrusive medical care, and physical restraints-free practice holds potential to improve patient outcomes. We evaluate the effectiveness of an acute hospital dementia unit (Care for Acute Mentally Infirm Elders [CAMIE]) that adopts a PCC protocol. METHODS: Prospective naturalistic cohort study whereby PWDs in the CAMIE unit (n = 170) were compared with a control group in usual care wards (n = 60) over 6 months. Assessments included patient demographics, dementia type and stage, comorbidities (Charlson's Comorbidity Index), acute illness severity, Well-Being, Ill-Being, functional status (Modified Barthel Index), agitation levels (Pittsburgh Agitation Scale), and quality of life (EuroQoL), assessed on admission and discharge. Multivariate analysis of covariance examined the effect of CAMIE versus usual care on pre-post outcomes. RESULTS: CAMIE patients showed statistically significant greater gains in Modified Barthel Index function and Well-Being, decreased Ill-Being and agitation, and greater improvement in EuroQoL index score (effect size: Δ = 0.18) after adjusting for baseline differences that translated to a quality-adjusted life years gain of 0.045, assuming stability over 3 months. Estimating added cost of CAMIE stay over usual care at SGD 1500 (USD 1040) for average length of stay of 15 days per patient, the incremental cost-effectiveness ratio fell within the threshold for cost-effectiveness at USD 23,111. DISCUSSION: PCC for PWDs in acute hospitals not only improves clinical outcomes for patients but is also cost-effective. The results support the adoption of PCC on a wider scale for better care of PWDs.

Unmarried patients with early cognitive impairment are more likely than their married counterparts to complete advance care plans.

BACKGROUND: Patients with early cognitive impairment (ECI) face the prospect of progressive cognitive decline that impairs their ability to make decisions on financial and personal matters. Advance care planning (ACP) is a process that facilitates decision making on future care and often includes identifying a proxy decision maker. This prospective study explores factors related to completion or non-completion of ACP in patients with ECI. METHODS: Patients with ECI (n = 158, M age = 76.2 ± 7.25 years) at a memory clinic received psycho-education and counseling on the importance of ACP and followed-up longitudinally for up to 12 months to ascertain if ACP had been completed. Univariate and logistic regression were used to analyze factors related to completion and non-completion of ACP. RESULTS: Seventy-seven patients (48.7%) were initially willing to consider ACP after the counseling and psycho-educational session but only 17 (11.0%) eventually completed ACP. On logistic regression, patients who were single were 8.9 times more likely to complete ACP than those who were married (p = 0.007). Among those initially willing to consider ACP, factors impeding completion of ACP included patient (48.0%), process (31.0%), and family factors (21.0%). CONCLUSIONS: As unmarried patients may not have immediate family members to depend on to make decisions, they may perceive ACP to be more important and relevant. Understanding the barriers to ACP completion can facilitate targeted interventions to improve the uptake of ACP.

Creative Music Therapy in an Acute Care Setting for Older Patients with Delirium and Dementia.

BACKGROUND/AIMS: The acute hospital ward can be unfamiliar and stressful for older patients with impaired cognition, rendering them prone to agitation and resistive to care. Extant literature shows that music therapy can enhance engagement and mood, thereby ameliorating agitated behaviours. This pilot study evaluates the impact of a creative music therapy (CMT) programme on mood and engagement in older patients with delirium and/or dementia (PtDD) in an acute care setting. We hypothesize that CMT improves engagement and pleasure in these patients. METHODS: Twenty-five PtDD (age 86.5 ± 5.7 years, MMSE 6/30 ± 5.4) were observed for 90 min (30 min before, 30 min during, and 30 min after music therapy) on 3 consecutive days: day 1 (control condition without music) and days 2 and 3 (with CMT). Music interventions included music improvisation such as spontaneous music making and playing familiar songs of patient's choice. The main outcome measures were mood and engagement assessed with the Menorah Park Engagement Scale (MPES) and Observed Emotion Rating Scale (OERS). RESULTS: Wilcoxon signed-rank test showed a statistically significant positive change in constructive and passive engagement (Z = 3.383, p = 0.01) in MPES and pleasure and general alertness (Z = 3.188,p = 0.01) in OERS during CMT. The average pleasure ratings of days 2 and 3 were higher than those of day 1 (Z = 2.466, p = 0.014). Negative engagement (Z = 2.582, p = 0.01) and affect (Z = 2.004, p = 0.045) were both lower during CMT compared to no music. CONCLUSION: These results suggest that CMT holds much promise to improve mood and engagement of PtDD in an acute hospital setting. CMT can also be scheduled into the patients' daily routines or incorporated into other areas of care to increase patient compliance and cooperation.

Advance care planning in people with early cognitive impairment.

BACKGROUND/AIM: People with early cognitive impairment (ECI), comprising mild cognitive impairment and early dementia face the risk of diminished mental capacity with progressive disease. Advance care planning (ACP) is advocated as a means to uphold the autonomy of individuals and enable them to express their wishes for the future while they still possess mental capacity. This study aims to explore the perspectives of patients with ECI regarding ACP, and in particular, understand their reasons for resistance. METHOD: Consecutive patients undergoing a counselling service for persons with ECI who fulfilled inclusion criteria (Mini Mental State Examination score ≥18, Global Clinical Dementia Rating (GCDR)=0.5 or 1 were recruited. Demographic and clinical data was collected and the detailed documentation in the case records of the counselling sessions was subjected to a thematic analysis. Differences between patients who were willing to engage in ACP and those who declined were also analysed. RESULTS: 93 patients (mean age 76, 60.2% female) were recruited of which 38.7% chose to engage further in ACP discussions. GCDR was the only factor that emerged significant on bivariate analysis for willingness to engage in ACP (t (79)=2.191, p<0.05, two-tailed) whereby milder CI was associated with a greater likelihood of ACP engagement. Among those who declined ACP, three main themes emerged from the thematic analysis. The majority deferred decision-making to their families. Some perceived ACP as irrelevant or unnecessary, and displayed avoidance and denial during ACP discussions. CONCLUSIONS: A large proportion of patients with ECI decline ACP discussions and the reasons are influenced by personal values, coping behaviours and sociocultural norms. These findings have important implications for practice.