Signs of Advanced Dementia
Signs that someone has advanced dementia:
The Palliative Approach to End of Life Care for People with Advanced Dementia
Planning Good Palliative Care Involves
Why is End of Life Care Planning So Hard for Dementia?
How Can We Improve Care Planning and Decision-Making?
Prognostic Indicators for Advanced Dementia
Prognostic indicators are signs, symptoms, concurrent illnesses/co-morbidities that aid in identification of people with advanced dementia who are likely in the last months/weeks/days of life that need supportive and palliative care. This is inherently difficult, but if we are better able to predict those people with advanced dementia who are in the final year of life there is good evidence that we are more likely able to deliver well-coordinated, high quality end of life care.
The following are recognized prognostic indicators for advanced dementia:
What factors contribute to functional decline?
In the last months, ambulatory ability is likely to be lost – the person with dementia cannot walk without personal assistance. In the last weeks of life, the ability to sit up without assistance is likely to be lost e.g. requires arm rests or he/she will fall over. In the last days, it is likely the person will lose the ability to smile and to hold their head up independently.
2. Continence–Bladder Function in Advanced Dementia
The person does not know/remember the steps related to using the toilet/bathroom
A person with advanced dementia will usually become completely incontinent of both urine and faeces in the final months.
What happens to eating and drinking in someone with advanced dementia?
What Are the Signs of Dysphagia (swallowing impairment)?
People will have difficulty swallowing oral medication and will need to have tablets crushed/converted to a syrup or given in another way. e.g. transdermal patch for pain relief
4. Consciousness –
People with advanced dementia will become increasingly sleepy and in the last months of life will likely be sleeping more than 50% of the day.
Levels of Consciousness of The Person with Advanced Dementia
|LEVEL OF RESPONSE
|LEVEL OF STIMULATION
|Eye opening or change in facial expression
|Speech or voices
Sleep Patterns in Someone with Dementia
5. Physical Symptoms
Physical Symptoms – recurring falls, recurring aspiration pneumonia, chest infections, and UTIs +/- delirium, and worsening pressure areas are all signs that a person is in the last months or weeks of their life.
People with advanced dementia lose the ability to communicate with words. In the last months of life, they have limited verbal language i.e. says 6 words or less and may pace, cry out, or scream. If English is the person’s second language, the person may revert to their first language due to loss of English. In the last weeks of life, the person may have no verbal language, may only make sounds, may cry out or scream, may be resistive to care, increased social withdrawal likely, and make limited eye contact. In the last days of life, crying out may cease, resistiveness to care may decrease, there may be complete social withdrawal with eyes closed, or they may have a blank stare.
The coexistence of two or more disease processes
E.g. dementia and diabetes
8. Concurrent illnesses
Common concurrent illnesses include:
Infection and Advanced Dementia
Assessment, Treatment and Management of Physical Symptoms,
Nutrition, and Hydration
Eating and drinking for a person with dementia are other common concerns for family and carers. These issues are complex for all members of the care team as well. It is important to have a fundamental understanding that the reduction in oral intake is a symptom of the disease dementia.
Managing nutrition and hydration involves assessing the cause. If there are simple treatable causes, these should be pursued first, for example ill-fitting dentures. Artificial nutrition and hydration are a more invasive intervention that can cause pain as well as other medical difficulties and there is consensus that this treatment does not improve outcomes for people with end stage dementia. Allowing a person to stop eating and drinking is a comfortable way for the person to die.
Good nutritional care requires an individualized approach that includes early recognition of weight loss and the identification and management of likely causes e.g. adverse medication effects, poor oral health, or depression. This careful attention to assessment and management of a person’s nutritional requirements improves quality-of-life.
Providing oral foods and fluid, even in small amounts, is preferable to using more invasive enteral e.g. Nasogastric or PEG feeding methods. However, a dysphagia assessment is essential to provide direction for oral feeding. The care team member assisting with eating should be seated at eye-level with the person and take time to establish and maintain a relationship with that person to create an atmosphere that is conducive to feeling relaxed. This approach to eating enhances the person’s nutritional intake and improves his / her social well-being. Recommendations regarding fluid therapy that are based on an ongoing assessment of each person’s circumstances, including their treatment preferences and their family’s, improve the satisfaction with the care that is provided.
Regular presentation of fluids that include strategies such as a colourful beverage cart, verbal prompting, or complying with the person’s preferences will increase the amount of oral fluid intake for those able to have oral hydration. Frequent small sips of fluids can reduce the person’s sensation of thirst and oral discomfort that is associated with dehydration.