Preliminary Data from an Advanced Dementia Consult Service:Integrating Research Education and Clinical Expertise

摘要

Hospitalized patients with advanced dementia often receive care that is of limited clinical benefit and inconsistent with preferences. We designed an Advanced Dementia Consult Service and conducted a pre and post pilot study to evaluate it in a Boston hospital. Consults were conducted by geriatricians and palliative care nurse practitioner. They consisted of structured consultation, counseling and provision of an information booklet to the family, and post-discharge follow-up with the family and primary care providers. Patients > 65 admitted with advanced dementia were identified and consults were solicited using pop-ups programmed into the computerized provider order entry (POE) system. In the initial 3-month period, patients received usual care (N=24). In the subsequent 3-month period, consults were provided to patients for whom it was requested (N=5). Data were obtained from the electronic medical record and proxies interviews (admission, 1-month post-discharge). The patients’ mean age in the combined sample (N=29) was 85.4, 58.6% were from nursing homes, and 86.2% of their proxies stated comfort was the goal of care. Nonetheless, their hospitalizations were characterized by high rates of intravenous antibiotics (86.2%), > 5 venipunctures (44.8%), andradiological exams (96.6%). Acknowledging the small sample size, there weretrends towards better outcomes in the intervention group including: higher proxyknowledge of the disease, greater communication between proxies and providers,more advance care planning, lower re-hospitalization rates, and fewer feedingtube insertions after discharge. Targeted consultation for advanced dementia isfeasible and may promote greater engagement of proxies and goal-directed carefor patients after discharge.