Keywords: BPSD, Palliative Care, Continuity of care, deprescribing, LTCF

Background:

The management of advanced dementia in Long-Term Care Facilities (LTCFs) requires shifting from a "curative" to a "palliative" model, focused on comfort and quality of life. The case of Carmela, a 90-year-old patient with vascular dementia with behavioural and psychological symptoms of dementia (BPSD) resistant to common pharmacological and non-pharmacological treatments, multimorbidity (chronic heart disease, atrial fibrillation COPD, CKD), and rapid functional decline, illustrates the complexity of ethical and clinical decision-making challenges in frail patients subject to frequent hospitalizations for acute events and shows the feasibility and efficacy of a palliative approach.

Research questions:

How can BPSD management be integrated with proportionality of care and deprescribing in a context of extreme frailty, while reconciling clinical guidelines with patient well-being and family expectations?

Method:

Case Report

Results:

A multidisciplinary approach was implemented, based on the review of the Individualized Care Plan and clear communication with the caregiver, regarding the patient's irreversible prognosis. The plan included: therapeutic optimization (suspension of edoxaban), BPSD management via the introduction of gabapentinoids, following the failure of commons neuroleptics and benzodiazepines, and off-label use of midazolam. Starting Midazolam resulted in better sleep patterns significantly improving the quality of life for the patient and their caregivers alike The therapeutic alliance with the caregiver led to the acceptance of limits of care, drastically reducing hospitalizations and allowing for the management of acute events within the facility. Discontinuing futile therapies and deprescribing the anticoagulant, balancing hemorrhagic risk with theoretical stroke-preventive role according to guide-lines, were deemed ethically defensible to realign treatment with comfort goals.

Conclusions:

This case report demonstrates that palliative care in LTCFs is a daily clinical and relational skill and a suitable approach to the treatment of resistant BPSD in advanced dementia. Restraint reduction, therapeutic harmonization and avoiding hospitalization are essential tools for reducing delirium and ensuring the well-being of the frail patient.

Points for discussion:

In the context of improving quality of life, to what extent is the deprescribing of anticoagulants considered and implemented for frail patients with comorbid dementia?

To what extent is the use of midazolam considered in the treatment of refractory BPSD in advanced dementia?

How widely practiced and accepted is Palliative Care within Long-Term care facilities ( LTCFs)?