BACKGROUND:Older people with multimorbidities are projected to be the main recipients of palliative care in the coming decades. However, because their specific palliative care needs are poorly understood and service response is underdeveloped, older people with multimorbidity are less likely to receive palliative care. Innovative specialist palliative care services are developing to address this gap, but with little underpinning evidence. Therefore the aim of this paper is to describe the clinical characteristics, symptoms and other concerns of older people with multi-morbidity referred to a new community palliative care service; and to explore possible implications for service delivery by comparing this service population with people receiving standard community-based specialist palliative care.METHODS:Cross-sectional study comparing routinely collected demographic, clinical, and point-of-care patient-level outcomes data [Phase of Illness, Australia-modified Karnofsky Performance Status (AKPS) and Integrated Palliative care Outcome Scale] across an innovative palliative service-Bromley Care Coordination (BCC) with patients in the standard specialist community palliative care (SC). Composite case studies of BCC patients provide more in-depth illustration of results.RESULTS:Compared with patients who received Standard Care, patients seen by BCC were more often female, older and with a non-malignant diagnosis (16% cancer in BCC versus 72% cancer in SC). Patients across the two services had a similar symptom profile at first contact in the pairwise complete case analysis. SC patients reported more frequently pain, nausea, vomiting, constipation, anxiety and family concern, and BCC patients reported more frequently mobility concerns. Functional status was lower for BCC patients on entry into the service (AKPS 40 median versus SC AKPS of 50). BCC patients stayed longer in each phase of illness (56 days median versus SC 41 days), with a more unpredictable subsequent phase.CONCLUSIONS:The population of older people with multimorbidity has not been routinely recognized as having specialist palliative care needs. However, this evaluation shows that, at first contact, the symptoms and concerns across both service populations was surprisingly similar. Nevertheless, patterns of symptoms may differ between populations over time. Longitudinal prospective data are needed to examine these changes overtime, and the relationship with multimorbidity.

Dementia is common and becoming commoner. In developed countries the number of people with dementia is doubling every 20 years as a result of an aging population. In developing countries the situation is even worse as their life expectancy is catching up rapidly with richer nations. This has important economic and social consequences for the state, but also huge personal implications for people with dementia and their carers....

Subject Clinical Medicine Neurology Communication Skills Pain Medicine Pharmacology Palliative Medicine Series Oxford Specialist Handbooks in End of Life Care

Extract Introduction It is important in advanced dementia to use a high index of suspicion but also common sense when managing a physical illness. Chronic pre-morbid conditions which often sit alongside the dementia still need to be managed to maintain control, though rationalization of medication with regular review is important. Acute problems can benefit from prompt intervention, but in every case the human cost of the intervention in relation to the benefit for the individual should be carefully considered from all perspectives ( Chapter 13). Carers and family may have more insight into the impact of treatments on a person who is unable to decide for themselves than health care professionals, and so their views are at the core of informing the decision-making process. ... Optimizing physical abilities every day Most people with advanced dementia are unable to let others know that their physical abilities have deteriorated, and so carers and health care professionals have to be alert to possible changes and have a system that involves a schedule of review. Optimizing the following physical dimensions is crucial to reduce the likelihood of an intercurrent illness developing. Key things that must be dealt with include:

Extract Introduction YOD refers to dementia with an onset before the age of 65. It is rare but presents major challenges. AD represents only 30% of all YODs, including some cases with a strong autosomal dominant inheritance. There is a broader range of conditions that cause dementia in the young, which may be difficult to diagnose. Clinical features, and other effects of the illness, may be different from the effects in older people, both in terms of the dementia itself and its effect on the person with dementia, family, and carers. A dementia affecting someone in their 40s or 50s will have a profound effect on their own and their spouse's employment and financial situation as well as on their family life. Furthermore, YOD often presents with more behavioural problems in fitter, healthier people, increasing the burden of caring. In 2002, the Alzheimer's Society estimated that there were about 18,500 younger people with dementia in the UK.

Extract Complementary therapies What is massage? What is aromatherapy? Complementary therapy in dementia care The ethos and principles of palliative care have been recognized as a template for developing end of life care for people with dementia. Complementary therapy can be included and integrated into such an approach and used as a non-pharmacological intervention. There are some studies on the use of aromatherapy and massage in dementia day care settings2 and the use of aromatherapy to trigger conversation and memory.3 How might massage and aromatherapy help? Benefits Precautions Adaptation of therapies Appropriate use of aromatherapy and massage and patient safety are paramount. The following adaptations are suggested: Adapting the conventional delivery of a therapy is important, and it should be suitable to the person's individual needs. A specifically adapted massage routine, the ‘M’ technique®, has been devised by Dr Jane Buckle for use when a conventional massage technique would not be appropriate. The ‘M’ technique® is a series of stroking movements performed in a set sequence at a set pressure and set pace. It is different from conventional massage and may be suitable when massage is inappropriate. Each movement, identified with a mnemonic name, is repeated three times (see http://www.mtechnique.co.uk\).