Integrating advance care planning as part of comprehensive geriatric assessment for hospitalised frail elderly patients: findings of a cross-sectional study

INTRODUCTION@#The integration of advance care planning (ACP) as part of the comprehensive geriatric assessment (CGA) of hospitalised frail elderly patients, together with the clinical and demographic factors that determine successful ACP discussion, has not been previously explored.@*METHODS@#A cross-sectional study on patients and family caregivers admitted under the geriatric medicine department of a tertiary hospital was conducted from October 2015 to December 2016.@*RESULTS@#Among 311 eligible patients, 116 (37.3%) patients completed ACP discussion while 166 (53.4%) patients declined, with 62 (37.3%) of the decliners providing reasons for refusal. Univariate logistic regression analysis showed that older age, higher Charlson Comorbidity Index, poorer functional status and cognitive impairment had statistically significant associations with agreeing to ACP discussion (p < 0.05). On multivariate logistic regression analysis, only poorer functional status was significantly associated (odds ratio 2.22 [95% confidence interval 1.27-3.87]; p = 0.005). Among those who completed ACP discussion, a majority declined cardiopulmonary resuscitation (79.3%), preferred limited medical intervention or comfort care (82.8%), and opted for blood transfusion (62.9%), antibiotics (73.3%) and intravenous fluid (74.1%) but declined haemodialysis (50.9%). Decision-making was divided for enteral feeding. Among decliners, the main reasons for refusal were 'not keen' (33.9%), 'deferring to doctors' decision' (11.3%) and 'lack of ACP awareness' (11.3%).@*CONCLUSION@#The feasibility and utility of integrating ACP as part of CGA has been demonstrated. Poorer functional status is significantly associated with successful ACP discussion. Greater public education on end-of-life care choices (besides cardiopulmonary resuscitation) and follow-up with decliners are recommended.

Diagnostic performance of short portable mental status questionnaire for screening dementia among patients attending cognitive assessment clinics in Singapore

<p><b>INTRODUCTION</b>The Short Portable Mental Status Questionnaire (SPMSQ) is a brief cognitive screening instrument, which is easy to use by a healthcare worker with little training. However, the validity of this instrument has not been established in Singapore. Thus, the primary aim of this study was to determine the diagnostic performance of SPMSQ for screening dementia among patients attending outpatient cognitive assessment clinics and to assess whether the appropriate cut-off score varies by patient's age and education. A secondary aim of the study was to map the SPMSQ scores with Mini-Mental State Examination (MMSE) scores.</p><p><b>MATERIALS AND METHODS</b>SPMSQ and MMSE were administered by a trained interviewer to 127 patients visiting outpatient cognitive assessment clinics at the Singapore General Hospital, Changi General Hospital and Tan Tock Seng Hospital. The geriatricians at these clinics then diagnosed these patients with dementia or no dementia (reference standard). Sensitivity and specificity of SPMSQ with different cut-off points (number of errors) were calculated and compared to the reference standard using the Receiver Operator Characteristic (ROC) analysis. Correlation coefficient was also calculated between MMSE and SPMSQ scores.</p><p><b>RESULTS</b>Based on the ROC analysis and a balance of sensitivity and specificity, the appropriate cut-off for SPMSQ was found to be 5 or more errors (sensitivity 78%, specificity 75%). The cut-off varied by education, but not by patient's age. There was a high correlation between SPMSQ and MMSE scores (r = 0.814, P <0.0001).</p><p><b>CONCLUSION</b>Despite the advantage of being a brief screening instrument for dementia, the use of SPMSQ is limited by its low sensitivity and specificity, especially among patients with less than 6 years of education.</p>

The Role of GPs in Helping Caregivers of Persons with Dementia

Caregiver interventions have been shown to reduce caregiver depression, burden of care, and improve their health and quality of life. Caregiver support also benefits the person with dementia (PWD). It is important to recognise that caregivers too need care. Caregivers of PWD are usually middle-aged daughters and sons followed by spouses. Foreign domestic helpers also play a pivotal role in Singapore. Stressors arising from caregiving change at different stages of the disease. As the disease progresses into the advanced stages, stress from having to deal with behavioural problems can lessen as the burden from coping with functional impairments increases. For this reason, caregiver interventions should be stage appropriate. There is a need to work towards creating a positive experience in the GP consultation with the important elements of early diagnosis, providing stage specific information and interventions, and up-to-date information on dementia resources available in the community.

Early Diagnosis of Dementia in the Primary Care Setting

General Practitioners (GPs) play an important role in early detection and initiation of the diagnostic process of dementia. A consideration of barriers and enablers of this process can aid the diagnostic process. Early referral for Specialist evaluation is an important step. The GP can also provide additional advice and support to the patient and caregiver during diagnosis.