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IS5.03: Advance care planning in dementia
S6
Invited symposia / European Geriatric Medicine 5S1 (2014) S1–S15
for masses, tone, and prostate in men. The neurologic evaluation includes evaluation of sacral cord integrity. Vaginal mucosa should be evaluated for severe atrophy, and the pelvic exam includes evaluation for pelvic organ prolapse with straining. Urinalysis is recommended (haematuria and glycosuria in diabetics). Although frail elderly may have a higher prevalence of post void residual (PVR), PVR testing can be limited to patients with diabetes, previous urinary retention or elevated PVR, recurrent urinary tract infections, severe constipation, complex neurologic disease, pelvic organ prolapse, prior anti-incontinence surgery, medications that decrease detrusor contractility, persistent or worsening urgency UI despite treatment, known poor detrusor contractility or outlet obstruction. A clinical cough (stress) test may be helpful in patients with stress UI symptoms. Bladder diaries are helpful to determine whether urine volume and timing contribute to increased frequency or nocturia. A 3-day diary entails recording the time and volume of all voids and UI episodes. Routine urodynamic testing is not necessary. Such testing should be reserved when considering invasive treatment, when the etiology of UI is unclear and diagnosis would change management, or when empiric treatment has failed. Cystoscopy is necessary for haematuria or pelvic pain. IS4.06 Management of urinary incontinence in an aging population C.M.M. Everaert Ghent University Hospital, Ghent, Belgium Lower urinary tract symptoms (LUTS) are common, affect quality of life and exert a major influence on health and independence in aging men and women. An estimated 45% of the worldwide population was affected by at least one LUTS in 2008 and this number is estimated to increase by 18% by 2018 (2.3 billion individuals). Despite this epidemiological imperative, the multifactorial etiology of LUTS is still poorly understood in this heterogeneous aging population. In the management of urinary incontinence we have to differentiate the different types of incontinence, mixed incontinence, multifactorial incontinence and comorbidities influencing the management of incontinence. Nocturnal polyuria, impaired bladder sensation and detrusor underactivity, obstruction, cognition, side-effects and complications and functional dysfunction receive little clinical and research attention. Nevertheless, these conditions do influence the clinical presentation and the management of lower urinary tract disorders. We will discuss a flowchart dealing with the above mentioned confounding factors and relate it to the management of incontinence with bladder training, physiotherapy, drugs and surgery.
SIG palliative care. Advance care planning: a cornerstone of preference based geriatric medicine
Methodology: Qualitative study in 38 older patients at the end of life and 21 family members in Flandres Belgium together with a literature review on the topic. Results: Most of the older patients are willing to discuss their wishes and preferences at the end of life. ACP is experienced as a shared decision making process with their physicians and family members. One of the important conditions to start planning is the acceptance of the nearing death. Personal experiences and fears, the need for control, trust in family and physicians will determine if older patients proceed to ACP. The role of the family member is embedded in existing relationships and is influenced by the demand of the patient and by the amount of responsibility the family want to take. The latter is dependent on identical factors as those influencing ACP in the older patient population. Conclusion: To obtain a sustained and solid advance care plan in an older patient population, the health care giver should take into account the existing relationships in families, the acceptance of the nearing death, the personal experiences and the need for control in patient and family. IS5.03 Advance care planning in dementia E.L. Sampson University College London, London, United Kingdom Advance care planning (ACP) has been defined as a process “that usually takes place in anticipation of a future deterioration of a person’s condition, between that person and a care worker”. It appears a simple and pragmatic intervention to help people consider what their preferences for care in the future might be and subsequently ensure they are respected. The number of people diagnosed with dementia is increasing, the condition may significantly shorten life expectancy and concerns have been raised about the quality of end of life care people with dementia receive. Concurrently, the dementia care agenda across the world has shifted towards earlier and timelier diagnosis. It has been suggested that one benefit of diagnosis is that it allows the person to plan for their future care whilst they still have capacity. In this symposium I will highlight how dementia presents particular challenges for ACP. I will review the barriers and facilitators found in the literature on ACP and also introduce concepts such as “response shift”. I will describe some of the challenges to implementing ACP at service and system level such as costs and differing forms of documentation. I will also suggest ways in which ACP can become a meaningful, rather than “tick box” process and how it could be better embedded in day to day practice. I will consider “the misleading simplicity of advance directives”, but also how, through accepting complexity and uncertainty, ACP can improve care and outcomes for people with dementia and their families. IS5.04 Advance care planning in older patients with progressive organ failure J.A. Janssen1 , M.A. Spruit1 , J.M.G.A. Schols2 , E.F.M. Wouters3 CIRO+, Horn, The Netherlands; 2 Maastricht University, Maastricht, The Netherlands; 3 Maastricht University Medical Centre, Maastricht, The Netherlands 1
IS5.01 Perspectives from patients and families on ACP N. Van den Noortgate University Hospital Ghent, Belgium Background and Aims: Advance Care Planning (ACP) can enhance patient-centered care and reduce medical treatments. However only a minority of older patients has an advance care plan at the end of life. To review the main barriers and facilitators for patients and families in planning end of life care.
Introduction: Aims of this longitudinal observational study were to explore the preferences of patients with advanced chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF) or chronic renal failure (CRF) regarding life-sustaining treatments and end-of-life care, changes in these preferences over time, and current status of advance care planning. Methods: 265 clinically stable outpatients with COPD, CHF, or CRF were visited at baseline and every 4 months for 1 year,
Invited symposia / European Geriatric Medicine 5S1 (2014) S1–S15
for masses, tone, and prostate in men. The neurologic evaluation includes evaluation of sacral cord integrity. Vaginal mucosa should be evaluated for severe atrophy, and the pelvic exam includes evaluation for pelvic organ prolapse with straining. Urinalysis is recommended (haematuria and glycosuria in diabetics). Although frail elderly may have a higher prevalence of post void residual (PVR), PVR testing can be limited to patients with diabetes, previous urinary retention or elevated PVR, recurrent urinary tract infections, severe constipation, complex neurologic disease, pelvic organ prolapse, prior anti-incontinence surgery, medications that decrease detrusor contractility, persistent or worsening urgency UI despite treatment, known poor detrusor contractility or outlet obstruction. A clinical cough (stress) test may be helpful in patients with stress UI symptoms. Bladder diaries are helpful to determine whether urine volume and timing contribute to increased frequency or nocturia. A 3-day diary entails recording the time and volume of all voids and UI episodes. Routine urodynamic testing is not necessary. Such testing should be reserved when considering invasive treatment, when the etiology of UI is unclear and diagnosis would change management, or when empiric treatment has failed. Cystoscopy is necessary for haematuria or pelvic pain. IS4.06 Management of urinary incontinence in an aging population C.M.M. Everaert Ghent University Hospital, Ghent, Belgium Lower urinary tract symptoms (LUTS) are common, affect quality of life and exert a major influence on health and independence in aging men and women. An estimated 45% of the worldwide population was affected by at least one LUTS in 2008 and this number is estimated to increase by 18% by 2018 (2.3 billion individuals). Despite this epidemiological imperative, the multifactorial etiology of LUTS is still poorly understood in this heterogeneous aging population. In the management of urinary incontinence we have to differentiate the different types of incontinence, mixed incontinence, multifactorial incontinence and comorbidities influencing the management of incontinence. Nocturnal polyuria, impaired bladder sensation and detrusor underactivity, obstruction, cognition, side-effects and complications and functional dysfunction receive little clinical and research attention. Nevertheless, these conditions do influence the clinical presentation and the management of lower urinary tract disorders. We will discuss a flowchart dealing with the above mentioned confounding factors and relate it to the management of incontinence with bladder training, physiotherapy, drugs and surgery.
SIG palliative care. Advance care planning: a cornerstone of preference based geriatric medicine
Methodology: Qualitative study in 38 older patients at the end of life and 21 family members in Flandres Belgium together with a literature review on the topic. Results: Most of the older patients are willing to discuss their wishes and preferences at the end of life. ACP is experienced as a shared decision making process with their physicians and family members. One of the important conditions to start planning is the acceptance of the nearing death. Personal experiences and fears, the need for control, trust in family and physicians will determine if older patients proceed to ACP. The role of the family member is embedded in existing relationships and is influenced by the demand of the patient and by the amount of responsibility the family want to take. The latter is dependent on identical factors as those influencing ACP in the older patient population. Conclusion: To obtain a sustained and solid advance care plan in an older patient population, the health care giver should take into account the existing relationships in families, the acceptance of the nearing death, the personal experiences and the need for control in patient and family. IS5.03 Advance care planning in dementia E.L. Sampson University College London, London, United Kingdom Advance care planning (ACP) has been defined as a process “that usually takes place in anticipation of a future deterioration of a person’s condition, between that person and a care worker”. It appears a simple and pragmatic intervention to help people consider what their preferences for care in the future might be and subsequently ensure they are respected. The number of people diagnosed with dementia is increasing, the condition may significantly shorten life expectancy and concerns have been raised about the quality of end of life care people with dementia receive. Concurrently, the dementia care agenda across the world has shifted towards earlier and timelier diagnosis. It has been suggested that one benefit of diagnosis is that it allows the person to plan for their future care whilst they still have capacity. In this symposium I will highlight how dementia presents particular challenges for ACP. I will review the barriers and facilitators found in the literature on ACP and also introduce concepts such as “response shift”. I will describe some of the challenges to implementing ACP at service and system level such as costs and differing forms of documentation. I will also suggest ways in which ACP can become a meaningful, rather than “tick box” process and how it could be better embedded in day to day practice. I will consider “the misleading simplicity of advance directives”, but also how, through accepting complexity and uncertainty, ACP can improve care and outcomes for people with dementia and their families. IS5.04 Advance care planning in older patients with progressive organ failure J.A. Janssen1 , M.A. Spruit1 , J.M.G.A. Schols2 , E.F.M. Wouters3 CIRO+, Horn, The Netherlands; 2 Maastricht University, Maastricht, The Netherlands; 3 Maastricht University Medical Centre, Maastricht, The Netherlands 1
IS5.01 Perspectives from patients and families on ACP N. Van den Noortgate University Hospital Ghent, Belgium Background and Aims: Advance Care Planning (ACP) can enhance patient-centered care and reduce medical treatments. However only a minority of older patients has an advance care plan at the end of life. To review the main barriers and facilitators for patients and families in planning end of life care.
Introduction: Aims of this longitudinal observational study were to explore the preferences of patients with advanced chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF) or chronic renal failure (CRF) regarding life-sustaining treatments and end-of-life care, changes in these preferences over time, and current status of advance care planning. Methods: 265 clinically stable outpatients with COPD, CHF, or CRF were visited at baseline and every 4 months for 1 year,