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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

A systematic review of the scientific evidence for the efficacy of a palliative care approach in advanced dementia

EL Sampson, CW Ritchie, R Lai, PW Raven, and MR Blanchard.

Review published: 2005.

CRD summary

This review assessed the efficacy of palliative care models in patients with dementia. The authors concluded that there is currently little evidence on which to base any conclusions. Given the limited evidence identified, the authors' cautious conclusions are likely to be reliable.

Authors' objectives

To assess the efficacy of a palliative care model in patients with dementia.

Searching

MEDLINE, EMBASE, PsycINFO, CINAHL, the British Nursing Index, AMED, Web of Science and SIGLE were searched from inception to October 2003. The third quarter of the Cochrane Database of Systematic Reviews, Cochrane CENTRAL Register, ISRCTN Register and NHS EED were searched in 2003. The search terms were reported and no language restrictions were applied. Several relevant journals were handsearched, and the references of retrieved papers and reviews were checked.

Study selection

Study designs of evaluations included in the review

Only controlled trials were eligible for inclusion in the review.

Specific interventions included in the review

Studies that involved the adoption of a palliative care model, or the adoption of clinical guidelines promoting the use of palliative care, were eligible for inclusion. Palliative care was defined using the World Health Organization's definition. Specific interventions in the review included a Dementia Special Care Unit (DSCU) compared with traditional long-term care (TLTC) and a palliative care approach compared with non-palliative care in the acute hospital setting.

Participants included in the review

Studies were eligible if they included participants aged over 18 years with a diagnosis of dementia. The diagnosis of dementia for those included in the review was either not stated or was made using the American Psychiatric Association's DSM III-R criteria.

Outcomes assessed in the review

No specific inclusion criteria relating to the outcomes were described. The included studies assessed: comfort; mortality; the use of medical resources; the length of hospital stay; transfers to the acute medical setting; and the prescription of antibiotics and analgesia.

How were decisions on the relevance of primary studies made?

One reviewer screened the titles of potentially relevant studies and excluded studies if it were clear that they did not relate to dementia or palliative care. The abstracts of the remaining studies were then screened by the same reviewer and a second reviewer independently assessed their relevance.

Assessment of study quality

The authors did not state that they formally assessed validity. Some aspects of validity were mentioned in the text: blinding, description of the intervention and comparability of the treatment groups.

Data extraction

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction. The extracted data included the diagnostic criteria for dementia employed in the studies and whether the palliative care intervention was defined.

Methods of synthesis

How were the studies combined?

The two studies included in the review were combined in a narrative.

How were differences between studies investigated?

The authors did not state how differences between the studies were investigated.

Results of the review

Two studies (n=263) met all of the inclusion criteria and were included in the review: one was a randomised controlled trial (RCT; n=99) and one was a prospective cohort study with a comparison group (n=164). Two other studies (n=70) did not formally meet the inclusion criteria as they were not controlled: one was a description of a care programme and one was the description of the adoption of guidelines. Data on these two studies were extracted but were not included in the synthesis.

In the RCT, the treatment groups were similar with respect to baseline disease severity and demographic characteristics, all patients entered were accounted for, and the outcome assessor was blinded to the treatment groups. In the cohort study, the treatment groups differed at baseline and researchers were not blinded to the treatment group.

The RCT found that, compared with non-palliative procedures, a palliative care intervention in an acute general hospital setting had no influence on mortality, site of discharge, length of hospital stay, number of readmissions, use of non-palliative procedures, do-not-resuscitate orders and antibiotic use. Patients in the intervention group were significantly more likely to have an overall palliative care plan (P=0.008).

The cohort study found that TLTC patients received significantly more analgesia, antibiotics, intravenous therapy, hypnotics and anxiolytics than DSCU patients (P<0.05). DSCU patients also experienced significantly less discomfort, and fewer were transferred to acute medical settings than TLTC patients. DSCU patients had a higher mortality rate than TLTC patients (hazard ratio 2.2).

Cost information

The cohort study reported that the costs of medication, radiology and laboratory procedures were significantly less in the DSCU group than in the TLTC group (P<0.05).

Authors' conclusions

There is currently little evidence on which to base the use of palliative care for patients with dementia.

CRD commentary

The review question was clear in terms of the interventions, participants and study designs of interest. The authors searched several relevant sources without language restrictions, as well as sources of unpublished data, thus minimising the possibility of language and publication bias. The first stage of selecting studies for the review may have been susceptible to some level of reviewer bias and error. There were no details of the methods used to extract the data from the included studies, so it is not known whether any steps were taken to reduce the possibility of error or bias. It was not reported if the validity of the included studies was formally assessed, although some aspects of quality were discussed. The narrative synthesis was appropriate for the small number of studies. Given the limited evidence that was identified, the authors' cautious conclusions are likely to be reliable.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that further systematic research is urgently needed to inform clinical practice, as currently there is limited evidence, due in part to ethical difficulties and a lack of clear outcome measures.

Bibliographic details

Sampson E L, Ritchie C W, Lai R, Raven P W, Blanchard M R. A systematic review of the scientific evidence for the efficacy of a palliative care approach in advanced dementia. International Psychogeriatrics 2005; 17(1): 31-40. [PubMed: 15945590]

Indexing Status

Subject indexing assigned by NLM

MeSH

Aged; Dementia /psychology /therapy; Humans; Palliative Care /methods; Severity of Illness Index

AccessionNumber

12005000069

Database entry date

31/08/2006

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 15945590

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