95% of people do not want prolonged morbidity with dementia.
70% of people do not want to live even with mild dementia.
Tell people if they have dementia or Alzheimer’s – so they can plan to do things that they may do what they always have wanted and to make future health plans. Support patients after giving them the news.
"Agism" – get rid of the old and suppress elderly, since they represent what we do not want to become
Drug Issues (Ethical Issues)
Brain Supplements
Ginko Biloba – antioxidant, may relieve mild dementia
Vitamin E – prevent heart disease and boost immune function
DHEA – may boost learning tasks
Estrogen – may help normal brain function, improve both verbal and visual memory
Aricept (Cholinesterase inhibitor) – can help early on in the disease, but very expensive; may improve condition so that patient recognizes condition and put themselves in situations which are dangerous. Have to look at whole situation. Patient may suffer more if made aware of situation. – for Alzeihmer’s Disease
Highest rate of depression among caretakers of Alzheimer’s – people with dementia will die after caretaker – do these supplements help caretakers? – are we just prolonging agony?
New anti-dementia compounds are promising, but should not be prescribed without attention to individual cases.
Genetic Testing
No predictive genetic test, unless you are in 5% with early onset familial Alzheimer’s – mutation on chromosome 14 (presenilin 1) or 1 (presenilin 2) or APOE-4 allele gene (all of these are vague tests)
Except for autosomal dominant early-onset families, genetic testing in asymptomatic individuals is unwarranted. Use of APOE genetic testing as a diagnostic adjunct in patients already presenting with dementia may prove useful but it remains under investigation. The premature introduction of genetic testing and possible adverse outcomes are to be avoided.
End of Life Issues
The best thing to do with patients is to be emotionally with the patient.
By 2040, we may be living into the mid-80’s; right now 2 out of 5 will get AD with first degree relative; if life expectancy is extrapolated to mid 80’s 1 in 2.
68% of Kevorkian’s patients had a neurodegenerative disease
After a patient loses the ability to naturally eat and drink, it is ethical to withhold artificial nutrition and hydration.
Patients’ families should be reassured that the patient will die in two weeks, and that dehydration has sedating effects that ensure a more peaceful dying.
Studies have shown a longer life and quality of life without feeding tubes for people with severe cognitive impairment
Prevent aspiration pneumonia and dyphagia
Use morphine if there is a question of pain in dehydration or starvation