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No disease-modifying treatments for dementia are available. Sleep disturbance is strongly associated with cognitive impairment. Non-pharmacological treatments targeting sleep may offer an alternative therapeutic approach. We searched PubMed, CINAHL, EMBASE and the Cochrane library for non-pharmacological treatments for sleep disturbance in mild cognitive impairment (MCI) and dementia, published in English from October 1965 to 2018, including all designs, excluding studies of drug therapies. In all, 53 papers representing 48 studies were included. Participant age ranged from 67.3 to 89.4 years. Most studies (79%) had small samples (50 participants, range 1-173) and were conducted in long-term/residential care (62%). The majority (85%) recruited participants with moderate-severe dementia; mean MMSE scores ranged from 0 to 28.3/30. Four studies examined MCI. Light therapy delivered over 1-10 weeks was the most studied stand-alone intervention (n = 27), and the majority (81.5%) of these studies found improvements on objective or subjective sleep measures, though the evidence was inconclusive with significant clinical and methodological heterogeneity. Seven multi-modal intervention studies were identified, all incorporating light exposure, and six of these reported improved sleep. Other interventions included electrotherapy stimulation (n = 4), physical exercises/activities (n = 4), acupressure/acupuncture (n = 3) and mindfulness/cognitive behavioural therapy (n = 3). Those examining MCI utilised different mono-modal approaches. A meta-analysis of data from randomised controlled trials showed a statistically significant (mean difference = 3.44, 95% CI: 0.89-5.99, I

The management of medications in persons with frailty presents challenges. There is evidence of inappropriate prescribing and a lack of consensus among healthcare professionals on the judicious use of medications, particularly for patients with more severe frailty. This study reviews the evidence on the use of commonly prescribed pharmacological treatments in advanced frailty based on a questionnaire of prescribing practices and attitudes of healthcare professionals at different stages in their careers, in different countries. A convenience sample of those attending hospital grand rounds in Ireland, Canada and Australia/New Zealand (ANZ) were surveyed on the management of 18 medications in advanced frailty using a clinical vignette (man with severe dementia, Clinical Frailty Scale 7/9). Choices were to continue or discontinue (stop now or later) medications. In total, 298 respondents from Ireland (n = 124), Canada (n = 110), and ANZ (n = 64) completed the questionnaire, response rate 97%, including 81 consultants, 40 non-consultant hospital doctors, 134 general practitioners and 43 others (nurses, pharmacists, and medical students). Most felt that statins (88%), bisphosphonates (77%) and cholinesterase inhibitors (76%) should be discontinued. Thyroid replacement (88%), laxatives (83%) and paracetamol (81%) were most often continued. Respondents with experience in geriatric, palliative and dementia care were significantly more likely to discontinue medications. Age, gender and experience working in nursing homes did not contribute to the decision. Reflecting the current literature, there was no clear consensus on inappropriate prescribing, although respondents preferentially discontinued medications for secondary prevention. Experience significantly predicted the number and type discontinued, suggesting that education is important in reducing inappropriate prescribing for people in advanced states of frailty.

Advance care planning (ACP), involving discussions between patients, families and healthcare professionals on future healthcare decisions, in advance of anticipated impairment in decision-making capacity, improves satisfaction and end-of-life care while respecting patient autonomy. It usually results in the creation of a written advanced care directive (ACD). This systematic review examines the impact of ACP on several outcomes (including symptom management, quality of care and healthcare utilisation) in older adults (>65years) across all healthcare settings. Nine randomised controlled trials (RCTs) were identified by searches of the CINAHL, PubMed and Cochrane databases. A total of 3646 older adults were included (range 72-88 years). Seven studies were conducted with community dwellers and the other two RCTs were conducted in nursing homes. Most studies did not implement a standardised ACD, or measure the impact on quality of end-of-life care or on the death and dying experience. All studies had some risk of bias, with most scoring poorly on the Oxford Quality Scale. While ACP interventions are well received by older adults and generally have positive effects on outcomes, this review highlights the need for well-designed RCTs that examine the economic impact of ACP and its effect on quality of care in nursing homes and other sectors.

Few case-finding instruments are available to community healthcare professionals. This review aims to identify short, valid instruments that detect older community-dwellers risk of four adverse outcomes: hospitalisation, functional-decline, institutionalisation and death. Data sources included PubMed and the Cochrane library. Data on outcome measures, patient and instrument characteristics, and trial quality (using the Quality In Prognosis Studies [QUIPS] tool), were double-extracted for derivation-validation studies in community-dwelling older adults (>50 years). Forty-six publications, representing 23 unique instruments, were included. Only five were externally validated. Mean patient age range was 64.2–84.6 years. Most instruments n = 18, (78%) were derived in North America from secondary analysis of survey data. The majority n = 12, (52%), measured more than one outcome with hospitalisation and the Probability of Repeated Admission score the most studied outcome and instrument respectively. All instruments incorporated multiple predictors. Activities of daily living n = 16, (70%), was included most often. Accuracy varied according to instruments and outcomes; area under the curve of 0.60–0.73 for hospitalisation, 0.63–0.78 for functional decline, 0.70–0.74 for institutionalisation and 0.56–0.82 for death. The QUIPS tool showed that 5/23 instruments had low potential for bias across all domains. This review highlights the present need to develop short, reliable, valid instruments to case-find older adults at risk in the community.