Pepersack T
Clinique de Gériatrie, Hôpital Erasme, Bruxelles.
Rev Med Brux. 2010 Sep;31(4):333-41.
Most people in contemporary western society die of the chronic diseases of old age. Whilst palliative care is appropriate for elderly patients with chronic, non-malignant disease, few of these patients access such care compared with cancer patients. That patients dying with dementia have significant health care needs, comparable with cancer patients, is now well established. Yet, their families typically describe poor advance-care planning and an inadequate level of symptom control, with distress associated with pain, pressure sores, constipation, restlessness and shortness of breath. A comparison of people dying with advanced dementia or terminal cancer found that those with dementia were more likely to experience burdensome interventions and restraints and to have had poor advance-care planning. Prognostic models that attempt to estimate survival of >6 months in demented patients have generally poor discrimination, reflecting the unpredictable nature of most nonmalignant disease. However, a number of generic and disease-specific predictor variables were identified that may help clinicians identify older, non-cancer patients with poor prognoses and palliative care needs. Simple, well-validated prognostic models that provide clinicians with objective measures of palliative status in demented patients are needed. Additionally, research that analyses the effect of comprehensive geriatric assessment and geriatric palliative care on psychosocial outcomes in demented patients and their caregivers is needed. Advances care planning and directives making before death allow meeting patient's preferences.
当代西方社会的大多数人死于老年慢性疾病。虽然姑息治疗适用于患有慢性非恶性疾病的老年患者，但与癌症患者相比，这些患者中很少有人能获得此类护理。现已明确，患有痴呆症的临终患者有着与癌症患者相当的重大医疗需求。然而，他们的家人通常表示，临终前护理计划不完善，症状控制水平不足，且伴有疼痛、压疮、便秘、躁动和呼吸急促等痛苦。一项对晚期痴呆症患者或晚期癌症患者的比较发现，患有痴呆症的患者更有可能经历繁重的干预和限制，且临终前护理计划不完善。试图估计痴呆患者生存时间超过6个月的预后模型通常区分能力较差，这反映了大多数非恶性疾病的不可预测性。然而，已确定了一些通用和特定疾病的预测变量，这些变量可能有助于临床医生识别预后不良且有姑息治疗需求的老年非癌症患者。需要简单且经过充分验证的预后模型，为临床医生提供痴呆患者姑息状态的客观衡量标准。此外，还需要开展研究，分析综合老年评估和老年姑息治疗对痴呆患者及其护理人员心理社会结局的影响。生前进行预先护理计划和制定指示有助于满足患者的偏好。
