September 18th, 2019
The Lown Institute and American Family Physician are collaborating on a series of commentary articles called the “Lown Right Care” series. This series applies the framework of right care — evidence-based, patient-focused, high value care — to common clinical situations. Each article provides an example of a common clinical situation where there there are opportunities to avoid overuse by not doing things, and to improve underuse by incorporating things into routine practice.
In the latest edition in the “Right Care” series, Dr. Nick Bott and Dr. Ann Lindsay from the Stanford University School of Medicine tackle the question, “Why is it difficult to provide the right care to adults with dementia?”
A large part of the problem is the way we view dementia, write Bott and Lindsay. Currently, most clinicians view dementia as just another medical condition, like high blood pressure or diabetes, rather than a condition that affects all other aspects of the patient’s life and health. This is partly a result of our fragmented health care system, in which patients are often seen as a “collection of diseases” rather than a whole person.
“In reality, dementia is a life-limiting terminal illness for the patient, and a life-altering diagnosis for the patient’s family or caregivers,” the authors write. “A diagnosis of dementia should be considered the primary problem under which care for all other problems is considered.” There is no cure for dementia, and generally dementia gets worse over time. This means that patients and family/ caregivers may have to reconsider health goals and treatment decisions. For example, cancer screenings are unlikely to benefit older patients with dementia, and often lead to overtreatment and harm.
Clinicians should also let patients and caregivers know about the increased risk of hospitalization and hospital complications in patients with dementia, so they can take steps to avoid preventable hospitalization whenever possible. Patients and caregivers should make use of alternatives to inpatient hospitalization, such as Hospital At Home (HAH), which delivers medical care at home for common conditions.
Another reason dementia often goes ignored is because clinicians may not know that there are steps they can take to help patients with dementia and their family/caregivers. However, primary care clinicians can change the course of a patient’s health care for the better by helping patients and their families with advanced care planning, reviewing medications, and creating a care plan that focuses on preventing harm.
“A thoughtful pause opens the door for intelligent intervention that is goal congruent and invaluable for reducing complications and preventable morbidity,” write Bott and Lindsay.