ABSTRACT
In this article we approach the concept of paradoxical lucidity (LP) (an unexpected, spontaneous, significant and relevant episode of communication or connection) in persons with advanced dementia. The existence of LP could change the paradigm of dementia as a degenerative, chronic, progressive and irreversible disease (where neuronal death plays the leading role), towards a model where functional deficits of neuronal networks acquire importance, which raises new potentially reversible therapeutic and rehabilitative possibilities. We analyze the ethical consequences that these episodes may have with respect to the implicated persons (patients, caregivers and professionals in charge of their care) and try to answer the following question: Do persons with advanced dementia continue to maintain their personal identity despite suffering cognitive impairment so severe?. The LP indicates that this is possible. In this work we make a transversal outline of the different concepts and theories of personal identity in these patients, from different areas of knowledge (philosophy, psychology, neuroscience).
ABSTRACT
Behavioural and psychological symptoms of dementia affect in a great way quality of life of both patients and their caregivers, which increases the risk of patient institutionalisation when such symptoms are poorly controlled. One of the drugs that are used for controlling behavioural and psychological symptoms of dementia (BPSD) is aripiprazole. This narrative review aims to solve three basic questions. Is aripiprazole useful for the management of these symptoms? Does aripiprazole play a substantial role regarding safety and efficacy, compared with the other pharmacological options available for the same purpose? Has aripiprazole gained importance in treatment regimens of these symptoms, in current clinical practice? We conclude that aripiprazole is effective to manage BPSD. Moreover, it has shown a good safety profile compared with other antipsychotics in advanced disease and frail patients. Thus, aripiprazole has gained importance in current management algorithms for dementia patients mainly due to its efficacy regarding rapid control of agitation and aggressiveness.
Subject(s)
Antipsychotic Agents , Dementia , Aggression , Antipsychotic Agents/therapeutic use , Aripiprazole/therapeutic use , Dementia/drug therapy , Humans , Quality of LifeABSTRACT
Introduction: Continuous positive airway pressure (CPAP) therapy remains the standard treatment for obstructive sleep apnea. However, its proven effect is useless if the patient does not tolerate the treatment. The electrical stimulation approach has been investigated for several decades now and it seems that the implantable devices for invasive electrical stimulation of hypoglossal nerve are viewed as effective with some of them already approved for human use.Areas covered: in this review, we intent to summarize the existing records of noninvasive stimulation in sleep apnea to make the scientific community aware of the details before deciding on its future. We believe that this is a battle still to fight and more could be done bearing in mind the safety of this method.Expertopinion: noninvasive electrical stimulation has been left behind based on few, small and inconsistent studies using different stimulation parameters. These studies are difficult to compare and to draw conclusions.Electrical stimulation is a field for research in the treatment of obstructive sleep apnea, with many aspects still to be discovered, and which may become a therapeutic alternative to the use of CPAP in certain patients.
Subject(s)
Electric Stimulation Therapy , Sleep Apnea, Obstructive , Continuous Positive Airway Pressure , Electric Stimulation , Humans , Hypoglossal Nerve , Muscles , Sleep Apnea, Obstructive/diagnosis , Sleep Apnea, Obstructive/therapyABSTRACT
La estenosis aórtica (EA) es la valvulopatía más frecuente en el anciano. El tratamiento es el reemplazo valvular bien por cirugía abierta o en los casos de pacientes de alto riesgo quirúrgico o inoperables mediante transcatheter aortic valve implantation (TAVI). Sin embargo, alrededor del 40% de los ancianos tratados con TAVI presentan malos resultados por falta de mejoría clínica o muerte. Esta revisión analiza los aspectos no cardiológicos de los pacientes con EA que pueden ayudar a responder a 3 preguntas clave: 1) ¿la sintomatología que presenta el paciente se debe exclusivamente a la EA o existen otros factores o comorbilidades que puedan justificarla o acrecentarla?; 2) ¿qué posibilidades de mejoría del estado de salud y calidad de vida tiene el paciente si se hace el reemplazo valvular?, y 3) ¿en qué medida podemos disminuir el riesgo de que el reemplazo sea fútil? (AU)
Aortic stenosis (AS) is the most frequent valve disease in the elderly population Treatment is valve replacement either by open surgery, or in the case of patients at high surgical risk, by TAVI (Transcatheter Aortic Valve Implantation). However, almost 40% of patients who have undergone TAVI show poor health outcomes, either due to death or because their clinical status does not improved. This review examines the non-cardiac aspects of patients with AS, which may help answer three key questions in order to evaluate this condition pre-surgically: 1) Are the symptoms presented by the patient exclusively explained by the AS, or are there other factors or comorbidities that could justify or increase them?, 2) What possibilities for improvement of health status and quality of life has the patient after the valve replacement?, and 3) How can we reduce the risk of a futile valve replacement? (AU)
Subject(s)
Humans , Male , Female , Aged , Aged, 80 and over , Aortic Valve Stenosis/epidemiology , Aortic Valve Stenosis/prevention & control , Aortic Valve Stenosis/surgery , Transcatheter Aortic Valve Replacement/methods , Transcatheter Aortic Valve Replacement/trends , Quality of Life , Aortic Valve Stenosis/complications , Frail Elderly/statistics & numerical data , Comorbidity , Polypharmacy , Delirium/complications , Neurocognitive Disorders/epidemiologyABSTRACT
Aortic stenosis (AS) is the most frequent valve disease in the elderly population Treatment is valve replacement either by open surgery, or in the case of patients at high surgical risk, by TAVI (Transcatheter Aortic Valve Implantation). However, almost 40% of patients who have undergone TAVI show poor health outcomes, either due to death or because their clinical status does not improved. This review examines the non-cardiac aspects of patients with AS, which may help answer three key questions in order to evaluate this condition pre-surgically: 1) Are the symptoms presented by the patient exclusively explained by the AS, or are there other factors or comorbidities that could justify or increase them?, 2) What possibilities for improvement of health status and quality of life has the patient after the valve replacement?, and 3) How can we reduce the risk of a futile valve replacement?
Subject(s)
Aortic Valve Stenosis/diagnosis , Aortic Valve Stenosis/surgery , Aged , Aortic Valve Stenosis/complications , HumansABSTRACT
Las personas mayores son uno de los grupos poblacionales de mayor riesgo de reacción adversa a medicamentos (RAM). Su prevalencia media en el anciano es del 30%. La demencia no es un factor de riesgo independiente de RAM pero, sin embargo, es la principal situación que favorece y multiplica todos los factores de riesgo (polifarmacia, comorbilidad, prescripción inadecuada, interacción medicamentosa, edad avanzada y adherencia terapéutica). Se exponen recomendaciones revisadas y consensuadas para prevenir las RAM en las personas mayores, a la vez que las propias de las personas con demencia en relación con el manejo de la comorbilidad y de los síntomas cognitivos, psicológicos y conductuales(AU)
The elderly are one of the groups at greatest risk for adverse drugs reactions (ADR). The mean prevalence of these reactions in this population is 30%. Dementia is not an independent risk factor of ADR, but is the main condition that increases all risk factors (polypharmacy, comorbidity, inappropriate prescribing, drugdrug interactions, advanced age, and treatment adherence). The present article discusses revised and consensual recommendations for the prevention of ADR in the elderly, as well as recommendations specifically for dementia patients in relation to the management of comorbidity and cognitive, behavioral and psychological symptoms(AU)
Subject(s)
Humans , Male , Female , Aged , Pharmaceutical Preparations/adverse effects , /epidemiology , Dementia/complications , /prevention & control , Risk Factors , Comorbidity , PolypharmacyABSTRACT
The elderly are one of the groups at greatest risk for adverse drugs reactions (ADR). The mean prevalence of these reactions in this population is 30%. Dementia is not an independent risk factor of ADR, but is the main condition that increases all risk factors (polypharmacy, comorbidity, inappropriate prescribing, drug-drug interactions, advanced age, and treatment adherence). The present article discusses revised and consensual recommendations for the prevention of ADR in the elderly, as well as recommendations specifically for dementia patients in relation to the management of comorbidity and cognitive, behavioral and psychological symptoms.
Subject(s)
Dementia/drug therapy , Drug-Related Side Effects and Adverse Reactions/prevention & control , Aged , Algorithms , HumansABSTRACT
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Subject(s)
Humans , Delirium/diagnosis , Delirium/therapy , SyndromeABSTRACT
OBJECTIVES: To evaluate and identify factors determining survival in elderly patients with advanced dementia. METHODS: A prospective, follow-up, observational analysis in a cohort of 67 community-based patients aged 65 years or older with dementia defined by DSM-IV and stage 7A or above on the FAST scale. Data were recorded on socio-demographic variables, FAST, Katz index, language, swallowing ability, diet, nutritional status (from anthropometric and laboratory data), associated diseases and medical complications during the previous 12 months. Survival was analyzed by the Kaplan-Meier method. Prognostic factors for survival were identified by the Cox proportional hazards regression model. RESULTS: The median follow-up was 832 days. The mean age was 82.2+/-6.7 years and 92.5% were women. A comorbid condition was present in 71.6%, most frequently hypertension (22.4%). A clinical event had occurred in 52 (77.6%) patients during the previous year (pneumonia, urinary infection, stroke, pressure sore, dehydration, sepsis or others). A total of 25 (37.3%) patients died. The mean survival was 676 days (95% confidence interval, 600-752 days). Cox proportional hazards model showed that independent prognostic factors for mortality were having pneumonia within the previous year (RR:3.7; p=0.001), a permanent nasogastric tube (RR:3.5; p=0.003) and serum albumin values below 3.5 g/dL (RR:2.9; p=0.028). CONCLUSIONS: In patients with advanced dementia, hypoalbuminemia and pneumonia are strongly and positively associated with mortality. Artificial nutrition via a nasogastric tube reduces survival in these patients.
