Video Images of Advanced Dementia Help Patients Plan Care

Allison Gandey

June 11, 2009

June 11, 2009 — A short video depicting advanced dementia helped patients identify preferences for future medical care, report researchers. Their work, evaluating a new video decision-support tool, was published May 29 in BMJ.

"Visual images can improve communication of complex health information and inform decision making at the end of life," Angelo Volandes, MD, from Massachusetts General Hospital, in Boston, told Medscape Neurology. "Sometimes the information about clinical realities we are trying to communicate to patients is poorly understood, and we are looking for new ways to help people learn."

In previous studies, the researchers showed that a video decision-support tool for advanced dementia seemed to improve communication and decision making for patients by helping them visualize future health states. But these studies were not well controlled and had significant shortcomings, they point out. In an effort to overcome these problems, investigators conducted this new randomized controlled trial of 200 people.

Randomized Controlled Trial

Participants were 65 years or older and from 4 primary-care clinics. About half of the patients received a verbal narrative describing hypothetical situations and exploring possible goals of care. The other half of patients heard the same narrative and then viewed a short video on a portable computer.

It can be challenging to envision hypothetical future disease states, the researchers note. Descriptions can also be inconsistent among providers, and the degree to which patients understand verbal descriptions can vary.

Dr. Volandes and his team put together a 2-minute video depicting the principal features of advanced dementia. The video shows an 80-year-old female patient with her 2 daughters in a nursing-home setting. The images demonstrate that the patient is unable to respond to their attempts at conversation. The patient is next shown being pushed in a wheelchair. And in the last segment, she is being fed pureed food.

The researchers found that when presented with the possibility of developing advanced dementia, older patients are more likely to choose comfort as the primary goal of care after viewing a video and listening to a verbal description.

Choice of Care for Advanced Dementia

Care Verbal Description (%) Verbal Description and Video (%)
Comfort 64 86
Limited 19 9
Life-prolonging 14 4
Uncertain 3 1

In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio, 3.9; 95% CI, 1.8 – 8.6).

Participants were reinterviewed after 6 weeks. Among those in the verbal group, 29% changed their preferences and only 6% in the video group changed theirs.

"Viewing the video improved knowledge of advanced dementia and enhanced stability of preferences for treatment over time compared with hearing only the verbal narrative," the investigators conclude.

More Study Needed

But did the video improve knowledge or did the information persuade patients and in some way encourage them to opt for comfort care?

Dr. Volandes tells Medscape Neurology that the video was carefully designed to be impartial and help patients make more informed choices. He says the fact that patients' decisions remained consistent over time is further evidence of this.

Were some patients frightened by the depiction of advanced dementia and therefore less likely to choose more aggressive life-prolonging measures? Dr. Volandes says no. "We asked people whether they were comfortable with the video and if they would recommend it for other people, and most said they were comfortable and would suggest that others view it. I think if people were frightened, they might have answered these questions differently."

Elizabeth Gould, director of quality care programs at the Alzheimer's Association, says it is too soon to know if the video decision-support tool is effective.

The Alzheimer's Association contributed funding for the project but was not directly involved in the study. "We very much support planning and helping patients make decisions while they still have the capacity to do so," she said. "It's good to see projects like this geared toward improving health literacy, but it is too early to draw any conclusions."

Dr. Volandes says he agrees that more studies are needed and that video standardization will be key.

The video is available on BMJ.com at http://www.bmj.com/video/care_preferences_dementia.dtl.

Dr. Volandes received funding from the Foundation for Informed Medical Decision Making, the Alzheimer's Association, and the Hartford Foundation. None of the foundations participated in the collection, analysis, or interpretation of the data.

BMJ. 2009;338:b1964. Abstract

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