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a Geriatric Department, Geneva University Hospitals, Switzerland
Jean-Pierre Michel, Geriatric Department, Geneva University Hospitals, CH-1226 Thonex, Geneve, Switzerland E-mail: jean-pierre.michel{at}Hcuge.ch.
Many clinicians with different training and practice are involved in the care of persons with dementia. Whereas neurologists and psychiatrists focus their attention on the early phase of dementia, geriatricians and palliative care specialists are particularly involved at the end of demented patients' lives. To summarize the progress of knowledge in this field, it seems possible to answer four fundamental questions.
When? Several longitudinal studies of cohorts of demented and nondemented patients showed clearly that dementia is a risk factor for early death. There are no survival differences between Alzheimer's and Lewy body disease patients. Patients with vascular dementia have the worst prognosis. These results need to be analyzed with consideration of associated comorbidity, types and intensity of care, and dementia treatment.
Why? Studies conducted on the basis of death certificates appear to be biased. A large autopsy study performed in the geriatric department of Geneva University Hospital showed no difference existed in immediate causes of death between demented and nondemented hospitalized old patients. On the other hand, cardiac causes are significantly more frequent in vascular dementia than in Alzheimer's disease or mixed dementia patients.
How? Deaths of demented patients raise a lot of ethical considerations. It is always difficult to know demented patients' awareness of the end of life. It is really difficult to accompany these patients, with whom communication is essentially nonverbal. During this delicate phase of the end of life, how can formal health professionals help the family members who are afraid of both death and dementia?
And after? Suffering of family members and caregivers has to be strongly considered. This goal includes the improvement of our communication skills with the patient, and the facilitation of interdisciplinary exchanges with the caregiver's team and with the family members to allow acceptance of the death.
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| Journals of Gerontology Series B: Psychological Sciences and Social Sciences | |
