Dementia: Causes, Symptoms, and Management Overview
V
IDEOS
The bookcase analogy
Pathophysiology/causes/symptoms
https://www.youtube.com/watch?v=v5gdH_Hydeshttps://www.youtube.com/watch?v=kkvyGrOEIfA
undefined
D
EMENTIA
Dr Uma Narayanan
W
HAT
WOULD
YOU
LIKE
TO
LEARN
IN
THIS
SESSION
?
O
VERVIEW
OF
THE
SESSION
Diagnosis
Risk factors
Types of dementia
Case studies
Management
What’s new
Dementia and driving: role plays
W
HAT
IS
DEMENTIA
?
W
HAT
IS
DEMENTIA
?
‘Dementia describes a clinical syndrome that
encompasses difficulties in memory, language
cognitive processing and behaviour that leads to
impairment in activities of daily living’
(BMJ2015;350;h029)
P
ROBLEMS
S
TAGES
OF
D
EMENTIA
I
NCIDENCE
5% people over 65 are affected
20% of people over 80
Prevalence expected to double by 2040
Estimated 50% undiagnosed
Contributes 1 in 4 hospital admissions
Health and social cost more than stroke, heart
disease and cancer combined
Only 50% of people affected are diagnosed!
R
ISK
FACTORS
Alcohol
Smoking (AD)
Obesity
Hypertension
Head injury
Educational
stimulation
Age
Learning disability
Sex
Modifiable risk
Non-modifiable risk
T
YPES
OF
DEMENTIA
W
HEN
TO
SUSPECT
Family concerned and patient denies any
memory problem
“Head turning sign”
D
IAGNOSIS
OF
D
EMENTIA
National Dementia Strategy encourages early
diagnosis
Dementia does not fulfil criteria for population
screening
Case finding in high-risk groups, which are...
>60 with CVD, DM, COPD, obesity, alcohol, smoking
>40 with Down’s syndrome
>50 with learning disability
Patients with neurodegenerative diseases
Any patient who presents with memory loss
Dementia Enhanced Service 2015/2016
D
IAGNOSIS
•
Primary Care
-History (Carer assessment)
-Examination (Cognitive Assessment)
-Blood screen
•
Referral to Old Age Psychiatry
-Neuropsychological testing
-Imaging (MRI, CT)
-Sub-type differentiation
A
SSESSMENT
T
OOLS
MMSE (Gold Standard, 8mins)
6 CIT (for GPs, 90% sensitive, 100% specific,
3-4mins)
GP-COG (for GPs, 4mins)
www.patient.co.uk
(e-copy/printable)
GP-COG
Takes less than 4 minutes
Multicultural population.
Freely available
85% sensitive and 86% specific.
Score <4 indicates cognitive impairment and 5-6-
indeterminate needing informant questionnaire.
GP-COG
(B
RODALY
ET
AL
. JAGS 2002;
50:530-534)
Name and address:
for subsequent recall test
Time/Orientation:
what is the date?
Clock Drawing –
mark in numbers; mark hands
to show 11:10
Information:
Can you tell me something that
has happened in the news recently?
Recall:
What was the name and address I asked
you to remember?
R
EFERRAL
TO
MEMORY
CLINIC
Prepare the ground
Ideas, concerns... What do you think this might
be?
Discuss possible diagnosis, exploring the “D
“word.
Highlight complexity of diagnostic process.
C
ASE
STUDIES
C
ASE
1
A 72 year old man presents in the GP surgery
with his daughter. She says that he is getting
forgetful and on occasions has phoned her in the
middle of the night asking her when she is
coming to take him shopping. He was widowed 5
years previously and is a retired policeman. She
says that she is worried that he may be
developing Alzheimer’s.
C
ASE
2
An 80 year old lady attends the surgery with her
daughter. You have seen her previously at home
when you attended her husband with a chest
infection. The daughter says that she has lost
weight and isn’t eating. She has also been found
by neighbours wandering in the street on one
occasion and seemed disorientated. The lady
herself has no recollection of that event and
denies that there is a problem with her eating.
She says she feels fine and doesn’t want anyone
making a fuss…after all, everyone forgets things
as they get older, don’t they?
C
ASE
3
A 62 year old man who works in a call centre
presents to the GP surgery on his own. He says
that he is forgetting things and that it is making
it difficult to do his job. He has had to write down
his computer password (against company policy)
as he cannot remember it and has on occasions
had to ask his supervisor to help him to log on at
the beginning of a shift. He feels down and very
worried about it as his brother who is 10 years
older developed Alzheimer’s disease at about the
same age and this was preceded in his brother by
a bout of depression. The patient has suffered
with depression about one year ago.
E
ARLY
D
IAGNOSIS
B
ENEFITS
:
•
Relief;
•
End to uncertainty;
•
Label for symptoms;
•
Better understanding;
•
Focus on positive;
•
Cognitive and coping skills training;
•
Drug treatments;
•
Psychosocial support;
•
Family support;
•
Autonomy;
•
Advanced planning and financial planning
D
ISADVANTAGES
:
•
Distress;
•
Depression;
•
Social isolation;
•
Lack of cure;
•
Stigma;
•
Wrong diagnosis;
•
Negative effect on function;
•
Invalid role
EARLY DIAGNOSIS( BMJ 2013)
Evidence suggests most people prefer to know!
Advance care planning can reduce inappropriate
hospital admissions towards end of life.
D
EMENTIA
–
POST
DIAGNOSTIC
SUPPORT
( 2013-
ALZHEIMERS
SOCIETY
)
40% lost friends
48% said they were a burden to family.
19% burden to friends
61% felt lonely
77% felt anxious/ depressed.
D
EMENTIA
CARE
PLAN
– POST
DIAGNOSTIC SUPPORT(
DES
)
General physical, mental and social review.
Medication review/ side effects of medications.
Advance care planning and DNAR
Communication and co-ordinating arrangements
for future.
Identifying carers/ consent to share information.
D
EMENTIA
- CARE PLAN (
DES
)
Post diagnostic support
- Review understanding of diagnosis and
provide written information
- Information – Alzheimer’s Society, local
memory cafe
- Practical support: cognitive
training/rehabilitation
- Psychological therapy: difficulty adjusting
to diagnosis
-Discuss medico-legal issues eg. Driving
-Information regarding financial and legal
advice
C
ARER
SUPPORT
(BMJ 2011)
Carers of People with Dementia: higher
‘burden’
More mental health problems
Worse physical health
Living bereavement
NDS: Implement carers strategy
Assess main carer’s needs as well as
patient
Educational resources for carers
www.carersuk.org
NICE suggesting health checks for
dementia carers for QOF 2014/2015
T
REATMENT
Pharmacological
(NICE)
Cholinesterase
inhibitors
Memantine
Non-pharmacological
Cognitive stimulation
therapy (NICE)
Environmental
interventions
Clinical interventions
Cognitive symptoms
BPSD
T
REATMENT
(
CONTD
.)
DTB 2014:
currently no intervention that cures
or alters long-term progression of dementia
All drugs have modest efficacy in treating
cognitive function/ADL/behaviour
NNT= 12
NNH=12
No evidence that one drug is more effective than
others
T
REATMENT
(
CONTD
.)
Acetyl cholinesterase inhibitors (for mild-
moderate AD):
Donepezil
Galantamine
Rivastigmine
Memantine (for moderate-severe AD)
Combination of treatments have shown
conflicting results
Rivastigmine has shown modest benefits in Lewy
Body, Parkinson’s and Vascular dementia
(unlicensed)
No benefit in MCI
M
ANAGEMENT
OF
B
EHAVIOURAL
& P
SYCHOLOGICAL
S
YMPTOMS
IN
D
EMENTIA
(BPSD)
BPSD
Behavioural
•
restlessness
•
physical aggression
•
screaming, agitation
•
wandering
•
sexual disinhibition
•
shadowing
BPSD
Psychological
•
anxiety
•
depressed mood
•
delusions
•
hallucinations
BPSD occurs in up to 90% people with
dementia
BPSD
More common as dementia progresses
Approach should be broad, biopsychosocial
approach.
May need to try several management options
Most cases are self limiting.
So, non-pharmacological/ short term
pharmacological approach is safe and effective.
M
ANAGEMENT
OF
BPSD
C
ONTRIBUTORY
F
ACTORS
P
hysical (infection, pain, constipation)
A
ctivity-related (washing, dressing)
I
atrogenic (drug side-effects)
N
oise (loud environment)
Exclude delirium
N
ON
-P
HARMACOLOGICAL
T
REATMENT
Environment
Safe environment for wandering
Calm
Pets
Behaviour therapy
Reminiscence therapy
Music therapy
Train staff
P
HARMACOLOGICAL
TREATMENTS
SSRI drugs reduce agitation
Sertraline
Citalopram
Trazodone
Mirtazapine (second line drug)
Anti-convulsants
Carbamazapine
Gabapentine
Lamotrigine
Topiramate
Avoid benzos and long-term sedating anti-
histamine
P
HARMACOLOGICAL
TREATMENTS
(C
ONTD
.)
Anti-psychotics in BPSD: CSM warning to
AVOID PRESCRIBING
Increase risk of stroke
Increase mortality
NEVER
IN LEWY BODY/PARKINSON’S
Low dose risperidone only licensed option for
short-term use for severe psychosis, agitation and
aggression in moderate-severe AD
W
HAT
’
S
N
EW
?
New drug:
latrepirdine (Dimebon?)
Dementia-DES
MCI (Mild Cognitive Impairment)
Vitamin B and mild cognitive impairment (VITA
Cog)
Anti psychotics in dementia (BMJ 2012)
Analgesia in BPSD (DTB summary)
Anti depressants in Alzheimers (Lancet 2011)
Move from secondary to primary care
MCI
Impaired memory for age and education but with
preservation of general cognitive function
Increased risk of developing dementia (5-10%)
25-30% recover/improve
No evidence that drugs reduce progression
Cognitive stimulation effective at delaying
progression
VITACOG study: Vitamin B (folic acid, B12 and
B6)
Improves memory scores
I
NFORMATION
PROVISION
Alzheimer’s Society
www.alzheimers.org.uk
E
NHANCE
KNOWLEDGE
DH/RCGP e-learning for Health
Care of older people
2 dementia modules
www.e-lfh.org.uk/projects/egp
D
EMENTIA
F
RIENDS
Alzheimer’s Society programme
Changing public perception of dementia
Learning about what it is like to live with
dementia
Turning that understanding into action
Can then volunteer to be a Champion and
encourage others to learn more about dementia
OTHER BITS
Advanced decisions
Advanced statements
LPA
Driving and Demntia
Mental capacity
A
DVANCED
D
ECISIONS
One aspect of planning ahead
Gives opportunity to make decisions about
specific treatments that the patient may or may
not want to receive in the future
e.g. Can refuse life-sustaining treatments or
blood transfusions
An advanced decision is legally binding
Need to fulfil certain requirements
Should be valid and applicable
W
HAT
CAN
AN
ADVANCED
DECISION
NOT
DO
?
Demand specific treatment
Refuse basic care
Refuse offering of food/drink by mouth
Refuse measures designed to maintain comfort
i.e. painkillers
Refuse treatment for a mental disorder under
Mental Health Act
Ask for anything that is against the law
H
OW
TO
MAKE
AN
ADVANCED
DECISION
Can use a form or write in own words
Can be verbal but recorded on medical records by a
professional
Content can be simple or complex
The record should have:
Clear note of treatments
Details about the witness
Whether health professionals have heard the decision
Talk to GP to make one
May wish to consult a solicitor
Make copies for GP, hospital, relatives, close friends
Review regularly
A
DVANCED
S
TATEMENTS
Not the same as an advanced decision
Not legally binding
Can be verbal or written
General statement about wishes and views for
the future (not specific treatments)
e.g. where to live, type of care, support received, food
preferences, personal care, religious/ spiritual needs
Should be taken into account by health and social
care professionals when making decisions about
care or treatment
L
ASTING
P
OWER
OF
A
TTORNEY
Legal tool that allows patient to appoint someone
to make a decision on their behalf
(same person can fulfil both roles)
LPA (
CONTD
.)
Has to be registered with OPG (Office of the
Public Guardian)
Can make one if:
Over 18
MUST have mental capacity to make the decision
Any adult can be an LPA (usually a relative or a
friend)
Complete an LPA form (separate forms for the
two types) which needs a signature to certify
mental capacity (signature can be from
doctor/social worker/solicitor)
Sign the form in front of a witness
L
PA
(
CONTD
.)
LPA is invalid if– not registered, attorney dies,
applicant dies( will takes over).
If applicant has a valid advance decision then
attorney must follow.
If applicant lacks capacity to make an LPA,
option is to apply to court of protection to appoint
a deputy or make a best interest decision( health
and welfare only)
Court appointed deputy may be a relation,
someone who knows applicant well or a
upstanding member of society.
D
RIVING
AND
D
EMENTIA
May be able to continue driving
Must fulfil certain legal requirements
Inform DVLA about diagnosis who then make an
assessment
If unsure, can take a driving assessment
S
TOP
D
RIVING
IF
...
Less confident
Getting lost on familiar roads
Misjudging speed/distance
Straying across lanes or hitting kerbs
Risk of having an accident
Passenger concerns
T
IPS
FOR
ENCOURAGING
PEOPLE
TO
STOP
DRIVING
Acknowledge difficulty
Encourage them to take charge of new transport
arrangement
Set up a taxi account
Pay bills and shop online
Point out benefits of not driving
Saving money on petrol and car insurance
Not having to find parking spaces
Not getting caught in traffic
Public transport can be social
May want to walk which would provide exercise
MENTAL CAPACITY- 2005
Set up to clarify the legal framework around
adult decision making.
Based on five key principles
Also stipulates that a person cannot demand a
treatment or care that is inappropriate but may
refuse treatment or care against medical advice.
M
ENTAL
CAPACITY
-
KEY
PRINCIPLES
Assume capacity unless proven otherwise
Help people to have capacity in all practical ways
before deciding that they do no.
Understand that people with capacity are
entitled to make unwise, unsafe decisions.
Decisions for people without capacity should be in
their best interest.
Capacity is decision and time specific.
C
APACITY
TEST
–
FOUR
POINTS
Understand the information given.
Retain sufficient information to make an
informed decision.
Balance, weigh up and use the information
appropriately.
Communicate their decision.
L
ACKING
M
ENTAL
CAPACITY
-
BEST
INTEREST
DECISIONS
First check validity of any advanced decisions to
refuse treatment and if valid then follow its
requirements.
Identify any power of attorney.
Make best interest decision that seeks to identify
what the persons decision would have been had
they still the capacity to decide.
Take into account any legal constraints
Should not be affected by any preconceptions
based on race, religion, colour.
Clearly document mental capacity and best
interest decisions.
R
OLE
P
LAYS
THANK YOU
Dementia is a clinical syndrome involving memory, cognitive, and behavioral difficulties leading to impairment in daily activities. This session covers diagnosis, risk factors, types of dementia, case studies, management strategies, and the impact of dementia on driving. Learn about the stages, incidence, and modifiable/non-modifiable risk factors associated with dementia.
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Presentation Transcript
VIDEOS The bookcase analogy https://www.youtube.com/watch?v=kkvyGrOEIfA Pathophysiology/causes/symptoms https://www.youtube.com/watch?v=v5gdH_Hydes
DEMENTIA Dr Uma Narayanan
WHAT WOULD YOU LIKE TO LEARN IN THIS SESSION?
OVERVIEW OF THE SESSION Diagnosis Risk factors Types of dementia Case studies Management What s new Dementia and driving: role plays
WHAT IS DEMENTIA? Dementia describes a clinical syndrome that encompasses difficulties in memory, language cognitive processing and behaviour that leads to impairment in activities of daily living (BMJ2015;350;h029)
PROBLEMS Decline in memory Decline in other cognitive functions affecting ADL Challenging behaviour
STAGES OF DEMENTIA Middle stage (MMSE 20 or <) Memory worsens, difficulties with Activities of Daily Living (ADL), Behavioural & Psychological Symptoms in Dementia (BPSD), communication problems, safety risks Diagnosis and early stage Loss of memory, poor judgement, confusion, personality/behavioural changes Late stage Frailty, immobility, swallowing problems, malnutrition, recurrent infections
INCIDENCE 5% people over 65 are affected 20% of people over 80 Prevalence expected to double by 2040 Estimated 50% undiagnosed Contributes 1 in 4 hospital admissions Health and social cost more than stroke, heart disease and cancer combined Only 50% of people affected are diagnosed!
RISK FACTORS Modifiable risk Non-modifiable risk Alcohol Smoking (AD) Obesity Hypertension Head injury Educational stimulation Age Learning disability Sex
TYPES OF DEMENTIA Alzheimer s Disease (60%) Vascular Dementia Mixed (AD + Vascular) Parkinson s Disease Dementia Pick s Disease (frontotemporal dementia) Dementia with Lewy bodies
WHEN TO SUSPECT Family concerned and patient denies any memory problem Head turning sign
DIAGNOSIS OF DEMENTIA National Dementia Strategy encourages early diagnosis Dementia does not fulfil criteria for population screening Case finding in high-risk groups, which are... >60 with CVD, DM, COPD, obesity, alcohol, smoking >40 with Down s syndrome >50 with learning disability Patients with neurodegenerative diseases Any patient who presents with memory loss Dementia Enhanced Service 2015/2016
DIAGNOSIS Primary Care -History (Carer assessment) -Examination (Cognitive Assessment) -Blood screen Referral to Old Age Psychiatry -Neuropsychological testing -Imaging (MRI, CT) -Sub-type differentiation
ASSESSMENT TOOLS MMSE (Gold Standard, 8mins) 6 CIT (for GPs, 90% sensitive, 100% specific, 3-4mins) GP-COG (for GPs, 4mins) www.patient.co.uk (e-copy/printable)
GP-COG Takes less than 4 minutes Multicultural population. Freely available 85% sensitive and 86% specific. Score <4 indicates cognitive impairment and 5-6- indeterminate needing informant questionnaire.
GP-COG (BRODALY ET AL. JAGS 2002; 50:530-534) Name and address: for subsequent recall test Time/Orientation: what is the date? Clock Drawing mark in numbers; mark hands to show 11:10 Information: Can you tell me something that has happened in the news recently? Recall: What was the name and address I asked you to remember?
REFERRAL TO MEMORY CLINIC Prepare the ground Ideas, concerns... What do you think this might be? Discuss possible diagnosis, exploring the D word. Highlight complexity of diagnostic process.
CASE STUDIES History Investigations and why you are doing them Examination
CASE 1 A 72 year old man presents in the GP surgery with his daughter. She says that he is getting forgetful and on occasions has phoned her in the middle of the night asking her when she is coming to take him shopping. He was widowed 5 years previously and is a retired policeman. She says that she is worried that he may be developing Alzheimer s.
CASE 2 An 80 year old lady attends the surgery with her daughter. You have seen her previously at home when you attended her husband with a chest infection. The daughter says that she has lost weight and isn t eating. She has also been found by neighbours wandering in the street on one occasion and seemed disorientated. The lady herself has no recollection of that event and denies that there is a problem with her eating. She says she feels fine and doesn t want anyone making a fuss after all, everyone forgets things as they get older, don t they?
CASE 3 A 62 year old man who works in a call centre presents to the GP surgery on his own. He says that he is forgetting things and that it is making it difficult to do his job. He has had to write down his computer password (against company policy) as he cannot remember it and has on occasions had to ask his supervisor to help him to log on at the beginning of a shift. He feels down and very worried about it as his brother who is 10 years older developed Alzheimer s disease at about the same age and this was preceded in his brother by a bout of depression. The patient has suffered with depression about one year ago.
EARLY DIAGNOSIS Benefits Disadvantages
BENEFITS: Relief; End to uncertainty; Label for symptoms; Better understanding; Focus on positive; Cognitive and coping skills training; Drug treatments; Psychosocial support; Family support; Autonomy; Advanced planning and financial planning
DISADVANTAGES: Distress; Depression; Social isolation; Lack of cure; Stigma; Wrong diagnosis; Negative effect on function; Invalid role
EARLY DIAGNOSIS( BMJ 2013) Evidence suggests most people prefer to know! Advance care planning can reduce inappropriate hospital admissions towards end of life.
DEMENTIA POST DIAGNOSTIC SUPPORT( 2013- ALZHEIMERS SOCIETY) 40% lost friends 48% said they were a burden to family. 19% burden to friends 61% felt lonely 77% felt anxious/ depressed.
DEMENTIACAREPLAN POST DIAGNOSTIC SUPPORT(DES) General physical, mental and social review. Medication review/ side effects of medications. Advance care planning and DNAR Communication and co-ordinating arrangements for future. Identifying carers/ consent to share information.
DEMENTIA - CARE PLAN (DES) Post diagnostic support - Review understanding of diagnosis and provide written information - Information Alzheimer s Society, local memory cafe - Practical support: cognitive training/rehabilitation - Psychological therapy: difficulty adjusting to diagnosis -Discuss medico-legal issues eg. Driving -Information regarding financial and legal advice
CARERSUPPORT (BMJ 2011) Carers of People with Dementia: higher burden More mental health problems Worse physical health Living bereavement NDS: Implement carers strategy Assess main carer s needs as well as patient Educational resources for carers www.carersuk.org NICE suggesting health checks for dementia carers for QOF 2014/2015
TREATMENT Cognitive symptoms BPSD Pharmacological (NICE) Cholinesterase inhibitors Memantine Non-pharmacological Cognitive stimulation therapy (NICE) Environmental interventions Clinical interventions
TREATMENT (CONTD.) DTB 2014: currently no intervention that cures or alters long-term progression of dementia All drugs have modest efficacy in treating cognitive function/ADL/behaviour NNT= 12 NNH=12 No evidence that one drug is more effective than others
TREATMENT (CONTD.) Acetyl cholinesterase inhibitors (for mild- moderate AD): Donepezil Galantamine Rivastigmine Memantine (for moderate-severe AD) Combination of treatments have shown conflicting results Rivastigmine has shown modest benefits in Lewy Body, Parkinson s and Vascular dementia (unlicensed) No benefit in MCI
MANAGEMENTOF BEHAVIOURAL & PSYCHOLOGICAL SYMPTOMS IN DEMENTIA (BPSD)
BPSD Behavioural restlessness physical aggression screaming, agitation wandering sexual disinhibition shadowing
BPSD Psychological anxiety depressed mood delusions hallucinations BPSD occurs in up to 90% people with dementia
BPSD More common as dementia progresses Approach should be broad, biopsychosocial approach. May need to try several management options Most cases are self limiting. So, non-pharmacological/ short term pharmacological approach is safe and effective.
MANAGEMENTOF BPSD Non- Contributory Factors Pharmacological treatment pharmacological treatment
CONTRIBUTORY FACTORS Physical (infection, pain, constipation) Activity-related (washing, dressing) Iatrogenic (drug side-effects) Noise (loud environment) Exclude delirium
NON-PHARMACOLOGICAL TREATMENT Environment Safe environment for wandering Calm Pets Behaviour therapy Reminiscence therapy Music therapy Train staff
PHARMACOLOGICALTREATMENTS SSRI drugs reduce agitation Sertraline Citalopram Trazodone Mirtazapine (second line drug) Anti-convulsants Carbamazapine Gabapentine Lamotrigine Topiramate Avoid benzos and long-term sedating anti- histamine
PHARMACOLOGICALTREATMENTS (CONTD.) Anti-psychotics in BPSD: CSM warning to AVOID PRESCRIBING Increase risk of stroke Increase mortality NEVERIN LEWY BODY/PARKINSON S Low dose risperidone only licensed option for short-term use for severe psychosis, agitation and aggression in moderate-severe AD
WHATS NEW? New drug: latrepirdine (Dimebon?) Dementia-DES MCI (Mild Cognitive Impairment) Vitamin B and mild cognitive impairment (VITA Cog) Anti psychotics in dementia (BMJ 2012) Analgesia in BPSD (DTB summary) Anti depressants in Alzheimers (Lancet 2011) Move from secondary to primary care
MCI Impaired memory for age and education but with preservation of general cognitive function Increased risk of developing dementia (5-10%) 25-30% recover/improve No evidence that drugs reduce progression Cognitive stimulation effective at delaying progression VITACOG study: Vitamin B (folic acid, B12 and B6) Improves memory scores
INFORMATIONPROVISION Alzheimer s Society www.alzheimers.org.uk
ENHANCEKNOWLEDGE DH/RCGP e-learning for Health Care of older people 2 dementia modules www.e-lfh.org.uk/projects/egp
DEMENTIA FRIENDS Alzheimer s Society programme Changing public perception of dementia Learning about what it is like to live with dementia Turning that understanding into action Can then volunteer to be a Champion and encourage others to learn more about dementia
OTHER BITS Advanced decisions Advanced statements LPA Driving and Demntia Mental capacity
ADVANCED DECISIONS One aspect of planning ahead Gives opportunity to make decisions about specific treatments that the patient may or may not want to receive in the future e.g. Can refuse life-sustaining treatments or blood transfusions An advanced decision is legally binding Need to fulfil certain requirements Should be valid and applicable
