CHICAGO — Elderly persons shown a video depiction of advanced Alzheimer's are less likely to opt for life-prolonging care, compared with those who listen to a verbal description.
A multicenter, prospective trial randomized 200 community-dwelling adults aged at least 65 years (mean 75 years) to one of two interventions and then compared their preferences for advanced care if they were in a state of dementia. In all, 106 participants listened to a standardized verbal description of stage 7 Alzheimer's, which is the final stage of the disease when individuals lose the ability to speak or respond to their environment, and ultimately their ability to control movement. The other 94 participants listened to the verbal description and viewed a 2-minute video of a real patient with features of stage 7 Alzheimer's and her family. (The video can be viewed online at www.ACPdecisions.com.)
Among those hearing only the verbal description, 68% preferred comfort care, 17% chose limited care, 13% wanted care that would prolong their life, and 2% were uncertain.
Among those receiving both the verbal narrative and the video, 87% preferred comfort care, 8% chose limited care, 4% desired life-prolonging care, and 1% were undecided, Dr. Angelo E. Volandes said at the annual meeting of the American Geriatrics Society.
“Most patients don't have experience with advanced disease,” he said. “Video may promote preferences for comfort care by providing more realistic expectations of dementia.”
Dr. Richard Payne, a neurologist and director of the Institute on Care at the End of Life at Duke University in Durham, N.C., agreed that videos are a “much more powerful way of giving people insight into what their health condition might be than you can ever describe on a piece of paper or discuss verbally.”
Video presentations of advanced dementia could also help patients and families to sort through the emotions and practicality involved in the decision-making process, said Dr. Marwan Sabbagh, the chief medical-scientific officer and director of clinical research at Banner-Sun Health Research Institute, Sun City, Ariz.
Videos “would be a useful tool in planning with eldercare attorneys, long-term care insurance companies, and facilities that provide such care,” Dr. Sabbagh added, noting that “neurologists could provide feedback in the decision-making process but would not likely be the primary presenters of the video or the primary drivers of the discussion.”
Neither Dr. Payne nor Dr. Sabbagh was involved in the study.
The participants' preferences for care also appeared more stable when made with the assistance of video. After 6 weeks, 27 (29%) of 94 participants interviewed in the verbal group changed their preferences, compared with only 5 (6%) of 84 participants in the video group. The difference between groups was statistically significant, said Dr. Volandes, an internal medicine physician with Massachusetts General Hospital and Harvard University Medical School, both in Boston. Comfort care was significantly more likely to be selected as the new preference (86%) in the verbal group, whereas the percentage choosing this option remained constant in the video group.
“The use of innovative videos in end-of-life decision-making and advance care planning discussions is relatively new,” Dr. Volandes said in an interview. “Further work and studies are needed to examine the implementation of these videos in clinical practice before they can become the standard of care for advance care planning.”
Dr. Payne suggested that although “more things like this need to be done to enhance patient understanding of their medical conditions and their options in the future,” they should not be limited to only patients. “We should include the universe of people who are going to help the patients make these decisions.”
He cautioned that the videos need to be shown at appropriate times because “you can also scare people into inappropriate decisions if you show images that are the worst-case scenarios because that may not be indicative of what the future would look like for that particular patient. I would think you'd need a range of scenarios depicted in the videos from best-case to worst-case.”
Dr. Volandes acknowledged that the study did not use real patients with a dementia diagnosis, and did not include Hispanics or Asians, although he said that similar findings have been observed in his previous research with Hispanics.
The convenience sample, selected from two primary care and two geriatric clinics, was 58% female, 29.5% African American, and had a score of 7 or higher on the Short Portable Mental Status Questionnaire. Overall, 68% of the verbal group and 73% in the video group had a 9th-grade or higher level of health literacy on the Rapid Estimate of Adult Literacy in Medicine test.
The use of video in advance care planning has been evaluated in surrogate decision makers with similar results, Dr. Volandes said.
Dr. Volandes, who received a new investigator award for his work by the American Geriatrics Society, disclosed no conflicts of interest for himself or his associates. The study was sponsored by the Alzheimer's Association, John A. Hartford Foundation, and the Foundation for Informed Medical Decision Making.
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