Life In The Slower Lane

Here is the structured PICO analysis for the sixty-ninth article you uploaded:

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Full Title (verbatim and exact):

“A systematic review of the effectiveness of advance care planning interventions for people with cognitive impairment and dementia”

Robinson L, Dickinson C, Rousseau N, et al.

Age and Ageing (2012); 41(2):263–269

DOI: 10.1093/ageing/afr148

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Type of Article:

Systematic review (of randomised and non-randomised studies)

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PICO Analysis:

Population:

• People with cognitive impairment or dementia, primarily in nursing home settings
• Four included studies: two from the USA, one from Canada, and one from Australia
• Participants ranged from mild cognitive impairment to moderate/severe dementia
• Mean age across studies: 78–87 years 

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Intervention:

Advance Care Planning (ACP) interventions including:

• Structured ACP education for residents, families, and staff
• ACP facilitation by nurses, social workers, or palliative care teams
• Implementation of advance directive (AD) programs such as Let Me Decide
• Broader interventions incorporating ACP into palliative care or hospital-in-the-home models 

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Comparator:

• Usual care or delayed intervention (in all four studies)
• Some studies used cluster-randomised or non-randomised control designs to compare outcomes

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Outcome:

1. Person-centred outcomes:

• ACP documentation increased significantly in 3 of 4 studies:
  • Greater completion of ADs, especially Let Me Decide directives
  • More documented DNR preferences and refusal of treatments (e.g. CPR, artificial feeding) 
• Patient/family satisfaction with care: only one study measured this; no significant difference found
• Pain assessment improved in one study; no significant improvement in pain treatment delivery 

2. Process outcomes:

• Capacity to participate in ACP: formally assessed in 3 studies; only ~36% of participants had decision-making capacity at the time of intervention
• Timing of ACP was key—often implemented too late in dementia trajectory for meaningful engagement 

3. Health system outcomes:

• Hospitalisation rates:
  • Two studies found significant reductions in hospital admissions in the intervention group
  • One study reported lower hospital costs per patient and fewer emergency transfers 
• Hospice use: One study reported an increase in hospice uptake (4% to 6.8%, p < 0.01)
• Costs: One Canadian study (Molloy et al.) found significant cost savings associated with ACP intervention (CAD $3,490 vs $5,239 per patient) 

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Summary Conclusion:

This systematic review found limited but promising evidence that structured Advance Care Planning (ACP) interventions can improve documentation of care preferences and reduce hospitalisation rates in people with cognitive impairment or dementia. However, methodological weaknesses, small sample sizes, and variability in intervention design limit the generalisability of results. The review emphasises that ACP discussions should occur early in the dementia trajectory, ideally before capacity is lost, and that timely implementation may increase alignment with patient wishes and reduce burdensome care.

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