The Role of Emergency Care in Patients with Advanced Dementia

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Kieran Lewis Quinn

Dementia, Emergency Department, Goals of Care


The prevalence of advanced dementia (AD) is expected to increase dramatically over the next few decades.  Patients with AD suffer from recurrent episodic illnesses that frequently result in transfers to acute care hospitals.  The default pathway followed by the emergency physicians, internists and intensivists who see those patients there is prioritize disease-directed therapies over attention to the larger picture of advanced dementia.  While this strategy is desired by many families, some families prefer a different approach.  This essay examines the reason why this phenomenon occurs and offers suggestions for improvement.  Gaps in information and physician workload are important factors, but we argue that until physicians who see patients in emergency departments learn to pause first and ask “Why are we doing this?" they will revert to their comfort zone of ordering tests and therapies that may be unwanted.  A separate emergency palliative care pathway may be one solution.  Shifting the focus back to the larger picture of AD and away from the physiologic disturbance of the moment may alter the trajectory of care in ways that truly respect the wishes of some patients and their families.
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1. Hebert LE, Weuve J, Scherr PA, Evans DA. Alzheimer disease in the United States (2010-2050) estimated using the 2010 census. Neurology. 2013;80(19):1778-1783. doi:10.1212/WNL.0b013e31828726f5.

2. Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA. 2000;284(1):47-52.

3. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538. doi:10.1056/NEJMoa0902234.

4. Chang A, Walter LC. Recognizing dementia as a terminal illness in nursing home residents: Comment on "Survival and comfort after treatment of pneumonia in advanced dementia". Arch Intern Med. 2010;170(13):1107-1109. doi:10.1001/archinternmed.2010.166.

5. Gozalo P, Teno JM, Mitchell SL, et al. End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med. 2011;365(13):1212-1221. doi:10.1056/NEJMsa1100347.

6. Stephens CE, Newcomer R, Blegen M, Miller B, Harrington C. Emergency department use by nursing home residents: effect of severity of cognitive impairment. Gerontologist. 2012;52(3):383-393. doi:10.1093/geront/gnr109.

7. Lamba S, Nagurka R, Zielinski A, Scott SR. Palliative Care Provision in the Emergency Department: Barriers Reported by Emergency Physicians. Journal of Palliative Medicine. 2013;16(2):143-147. doi:10.1089/jpm.2012.0402.

8. Givens JL, Jones RN, Shaffer ML, Kiely DK, Mitchell SL. Survival and comfort after treatment of pneumonia in advanced dementia. Arch Intern Med. 2010;170(13):1102-1107. doi:10.1001/archinternmed.2010.181.

9. Mitchell SL, Miller SC, Teno JM, Kiely DK, Davis RB, Shaffer ML. Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines. JAMA. 2010;304(17):1929-1935. doi:10.1001/jama.2010.1572.

10. Grudzen CR, Stone SC, Morrison RS. The palliative care model for emergency department patients with advanced illness. Journal of Palliative Medicine. 2011;14(8):945-950. doi:10.1089/jpm.2011.0011.