Palliative care in dementia

The main goals of care in progressive dementias (Alzheimer's disease, vascular dementia, dementia with Lewy bodies, and fronto-temporal dementia) are maintenance of quality of life, dignity, and comfort. Three main areas are important for quality of life in individuals with dementia: meaningful activity, medical issues, and behavioral symptoms. Meaningful activities should be provided even in advanced dementia because there is no evidence that it progresses to persistent vegetative state. They should be individualized and prevent isolation of patients in their rooms or placement of patients in corridors. It is important to distinguish behavioral symptoms that occur when the patient is solitary (agitation and apathy) and when the patient interacts with others (most commonly rejection of care). Behavioral symptoms of dementia should be first managed by non-pharmacological strategies: meaningful activities for agitation and apathy and modification of caregiving strategies for rejection of care. Depression is an important risk factor for both of these syndromes and should be treated even in advanced dementia. In individuals with advanced progressive dementia, management of chronic medical problems should be modified, cardiopulmonary resuscitation is not indicated, transfer to a hospital for treatment of intercurrent infections may not be indicated, antibiotic treatment is less effective and not necessary to maintain comfort, and tube feeding does not provide any benefit but poses a burden for the patient. Food refusal may be managed by diet modification, antidepressants, or dronabinol administration, and aspiration may be minimized by diet modification and some medications.