Developing neuropalliative care for sporadic Creutzfeldt-Jakob Disease

ABSTRACT We aimed to identify targets for neuropalliative care interventions in sporadic Creutzfeldt-Jakob disease by examining characteristics of patients and sources of distress and support among former caregivers. We identified caregivers of decedents with sporadic Creutzfeldt-Jakob disease from the University of California San Francisco Rapidly Progressive Dementia research database. We purposively recruited 12 caregivers for in-depth interviews and extracted associated patient data. We analysed interviews using the constant comparison method and chart data using descriptive statistics. Patients had a median age of 70 (range: 60–86) years and disease duration of 14.5 months (range 4–41 months). Caregivers were interviewed a median of 22 (range 11–39) months after patient death and had a median age of 59 (range 45–73) years. Three major sources of distress included (1) the unique nature of sporadic Creutzfeldt-Jakob disease; (2) clinical care issues such as difficult diagnostic process, lack of expertise in sporadic Creutzfeldt-Jakob disease, gaps in clinical systems, and difficulties with end-of-life care; and (3) caregiving issues, including escalating responsibilities, intensifying stress, declining caregiver well-being, and care needs surpassing resources. Two sources of support were (1) clinical care, including guidance from providers about what to expect and supportive relationships; and (2) caregiving supports, including connection to persons with experience managing Creutzfeldt-Jakob disease, instrumental support, and social/emotional support. The challenges and supports described by caregivers align with neuropalliative approaches and can be used to develop interventions to address needs of persons with sporadic Creutzfeldt-Jakob disease and their caregivers.


Introduction:
Prion diseases such as sporadic Creutzfeldt-Jakob disease (sCJD) are rare but devastating in their rapid progression to serious disability, profoundly impacting patients and their family caregivers [1]. sCJD is the most common form of human prion disease, with about 400 cases of sCJD in the USA annually [2]. Prion diseases develop when a cellular protein in the nervous system is misfolded and aggregates. Prion diseases occur through multiple mechanisms -spontaneously (e.g., sCJD); genetically, through autosomal dominant mutations in the prion protein gene (PRNP); and acquired/infectious, such as through exposure to contaminated surgical equipment used previously on a person who unknowingly had CJD. Persons with sCJD and their caregivers experience a high burden of suffering due to the patient's rapid loss of cognition, coordination, control of motor function and general bodily-function [3]. In about 90% of persons with sCJD, death typically occurs within one year (4.4 to 14 months) of symptom onset [4,5], with a correct and clear diagnosis often coming about 2/3 of the way through the disease course [6]. This leaves persons with sCJD and caregivers little time to prepare for end-of-life care. Given the current lack of disease-altering treatments for sCJD, appropriate care focuses on symptom management and promoting quality of life for both persons with sCJD and their caregivers [7,8].
Neuropalliative care is an emerging subspeciality and an interdisciplinary approach to reducing suffering and improving quality of life for persons with neurological Supplemental data for this article can be accessed here illnesses and caregivers [9,10]. Palliative care approaches include symptom management, emotional and spiritual support, and guidance about treatment decisions. There is international consensus around the importance of palliative care for persons with longer-course dementia syndromes [11]. Little is known, however, about utilizing palliative care to address needs in rapidly progressing dementias (RPDs), with limited literature on palliative care in prion disease [8,[12][13][14]. In sCJD, management is difficult because the rapid decline results in the degree and type of symptoms occurring within a few months of onset that are comparable to advanced stages of other neurodegenerative dementias that progress over many years [7,8,15,16], Caregivers and families typically need help managing distress about treatment decisions, especially those with implications for life-extension (e.g. tube feeding) [8,12,14,17]. We are only aware of one study, by Ford et al. (2018), that has specifically focused on caregivers' struggles to manage symptoms of persons with sCJD [7]. We aimed to expand on Ford et al.'s work by using a mixed methods study informed by a palliative care framework [18] to comprehensively explore a range of both challenges and sources of support among caregivers of persons who died from sCJD. To our knowledge, this is the first in-depth description of palliative care needs associated with sCJD. Our findings highlight opportunities to add palliative care approaches and tools into regular neurology care for prion disease, and opportunities to improve prion-specific care among palliative care and hospice clinicians. These insights may be applicable to other rare diseases or to longer-course neurodegenerative diseases as well.

Results
Eight of 12 persons who died from sCJD had participated in a 2-day clinical research visit and 4 with limited contact with the RPD study team had been admitted to the UCSF inpatient neurology service (Table 1). Median age at first UCSF visit was 70 years old (range 60-86). All patients met UCSF, European 2009, and European 2017 diagnostic criteria for probable sCJD and included of a variety of molecular subtypes [15,19,20]. The median disease duration was 14.5 months (range ; onset to UCSF visit was 8 months (range ; and first UCSF visit to death was 2.5 months (range 0-26), indicating participants were a median of ¾ through their disease course at their visit. Of the 8 research patients, median assessments scores were consistent with moderate to severe dementia and moderate dependence for activities of daily living (ADLs); although less quantitative data was available on the four inpatients, they were typically more impaired (e.g. median time from diagnosis to death was 1 month [range 0-4) for those admitted to inpatient services versus 5 months (range 1-27) for research visit participants).
Caregivers were interviewed a median of 22 months (range  after the death of the patient and had a median age of 59 (range 45-73; Table 1). Threequarters were the patient's spouse; half self-identified as female (50%); most had a college degree or postgraduate education (75%). Below we summarize themes within the challenges, supports, and recommendations shared by caregivers (Figure 1), providing examples in the text as well as in Tables 2-6.

Sources of challenge and distress
We identified 3 major categories of challenges and distress -nature of disease, clinical care, caregiving.

Nature of sCJD
Distinguishing features of sCJD -its rarity, rapidity, potential transmissibility, and gravity -consistently appeared across respondents' narratives as independent challenges and as compounding factors (Table 2). sCJD's rarity meant caregivers encountered a lack of information, expertise, treatment options, and trials, causing protracted diagnostic journeys and inappropriate care.
Challenges related to the rapidity of the disease included the pace of functional decline: 'you suddenly find that at every plateau you upgrade your skills to deal with that plateau and when they fall off that plateau with another function going, it is like you're not expecting it' (c4). One caregiver described their father using a cane for only 10 days before requiring a walker, and then moving to a wheelchair in two months (c7). Caregivers also described correspondingly rapid changes to family and social systems, such as their need to quickly take on legal and medical decisionmaking responsibilities (c2).
Challenges related to the gravity of the disease included loss of almost all ADLs, difficult behavioural symptoms (e.g., hallucinations, panic/fear, wandering: 'all of a sudden she got really hallucinating and being really afraid of things and it just started snowballing from there' (c6)) and assured fatality.
A few caregivers described challenges related to transmissibility: the potential that prions, the misfolded proteins causing sCJD, could be transmitted to others. Some believed that their loved one was treated differently, or rejected from facilities, because of transmissibility concerns. One caregiver said that a funeral  [38]. For inpatients who were only seen in the UCSF clinical wards (and did not participate in the more extensive 2-day research visit), more limited data was extracted from their EPIC electronic health record and (if available) from the UCSF MAC databases. Sources of diagnostic information included brain tissue pathology, cerebrospinal fluid (CSF) biomarkers of neuronal cell injury (i.e.14-3-3 Western blot, total-tau and neuron specific protein levels [45]), CSF RT-QuIC analysis [41], our internal review of brain MRI(s), and prion protein gene (PRNP) analysis (done through the US National Prion Disease Pathology Surveillance Center, Cleveland, OH) [42]. Missing data: age at time of visit (n = 1); educational level (n = 1); MRC prion rating scale (n = 1); CDR scale (n = 1); NPI (n = 1); GDS scale (n = 3 because scale could not be administered due to patient factors); MRI (n = 1); RT-QuIC test (n = 1); brain autopsy (n = 1 because family refused).
2 Demographic data on caregivers were self-reported in a survey completed after the interview [19,35]. We recruited caregivers from lists of main contacts for patients in the UCSF MAC RPD database who had died from sCJD at least 3 months but no more than 3 years previously. One caregiver refused the demographic survey. 3 Race/ethnicity data collected to report per funder requirements. Caregiver data was self-reported and categorized based on NIH reporting categories. 4 "Onset' as identified by the treating neurologist in the patient file at the earliest symptom we could identify based on available medical records and/or the medical history obtained during our research visits 5 Date of 'diagnosis" at which sCJD became the leading and most likely as identified by the treating neurologist in the patient file (could have been at UCSF or elsewhere), based on own assessment, reports from other physicians send to neurologist or highlighted by caregiver or patient during UCSF visit. 6 Mini-Mental State Examination (MMSE) total score range: 0-30, with higher scores indicting more normal cognition 7 Barthel Index total score range: 0-100, with lower scores suggesting greater dependency on activities of daily living 8 Medical Research Council (MRC) prion disease rating scale 4 , total 0-20, with lower scores indicating worse function 9 Clinical Dementia Rating (CDR) scale Sum of Boxes (SOB) score (addition of all subtotals), total score range: 0-18, with higher scores indicating more impairment 10 Neuropsychiatric Inventory questionnaire (NPI) composite score, total score range 0-36, with higher scores indicating more severe neuropsychiatric symptoms 11 Geriatric Depression Scale (GDS) Long Form scale, total score range: 0-30, higher scores (> = 14/30 concerning for depression) indicating screening positive for depression. 12 Sources of diagnostic information included brain tissue pathology, cerebrospinal fluid (CSF) biomarkers of neuronal cell injury (i.e.14-3-3 Western blot, total-tau and neuron specific protein levels [45]), CSF RT-QuIC analysis [41], our internal review of the brain MRI(s), and prion protein gene (PRNP) analysis (done through the US National Prion Disease Pathology Surveillance Center, Cleveland, OH) [42] 13 PRNP (prion protein gene) codon 129 genotypes of sCJD are MM: homozygous for methionine; MV: heterozygous for methionine and valine and VV: homozygous for valine. 14 The one patient with inadequate quality MRI was positive for 14-3-3, total Tau (>4,000 pg/mL), RT-QuIC, and brain tissue pathology testing. 15 The patient whose family refused autopsy had negative 14-3-3 and total Tau, but a positive MRI, and RT-QuIC, meeting UCSF, European 2009, and European 2017 probable sCJD criteria [15].
director said: 'Oh, you have Creutzfeldt, well we'll come get her but we're going to direct bury her because we can't embalm her' (c6), contrary to the family's wishes and accepted medical practice [21][22][23].

Clinical care
Caregivers reported many challenges and sources of distress related to clinical care, clinicians, or health systems (Table 3). Almost all experienced extensive challenges in obtaining a diagnosis, often attributed sCJD's rarity. Caregivers evinced frustration at doctors' dismissal of early symptoms and at making multiple clinic trips in pursuit of a diagnosis. Clinicians' ack of sensitivity in disclosing this terminal diagnosis caused distress: 'it didn't seem like there was a lot of concern on their end' (c10). The lack of clear prognostic information to inform planning also was a common problem. Caregivers conveyed distress at many clinicians' lack of expertise in sCJD: 'I don't think we ever saw anybody [prior to UCSF] . . . who had any idea about what this disease was or how it progressed or how to deal with someone that had it' (c10). Caregivers suggested this led to unsuitable care, including inappropriate or harmful medication or care plans ill-suited to an RPD.
Gaps in clinical support were a challenge. Particularly in hospitals or facilities, caregivers felt they needed someone present to help or advocate for the patient: 'We were there 24/7 because . . . [staff] probably wouldn't have come around or known that he wet the bed' (c2). Caregivers were extremely distressed if clinicians no longer helped them ('abandoned' them; c12) after suspected diagnosis or enrolling patients in hospice.
Caregivers described distress at end-of-life care and post-death support. Hospice sometimes delayed enrolment because they did not understand how rapid the decline would be in sCJD. Though predominantly perceived as helpful, as detailed below, hospice care was also insufficient: '[The hospice nurse] was really great, but she was spread so thin . . . and could not come regularly' (c4). Hospice staff did not always know or learn about sCJD, sometimes misinterpreting symptoms, such as treating myoclonus, pyramidal or extrapyramidal symptoms as pain and managing the patient  Figure 1. Summary of findings and implications for intervention targets.
This figure summarizes qualitative analysis of interview data from former caregivers of patients who died from sporadic Creutzfeldt-Jakob disease (sCJD). We identified 3 major categories of challenges and distress -nature of disease (blue box), clinical care (red box), caregiving (gold box). We also identified 2 major categories of support related to clinical care (purple box, reflecting that both the nature of the disease and clinical care are at play) and caregiving (gold box). Opportunities to improve care are organized into clinical (purple) and caregiving (gold) categories, and reflect what caregivers said helped, what they recommended or wished for, and researcher recommendations on how to address challenges as reported in the discussion of the manuscript. Each box summarizes the major themes within each category of challenges, supports, or opportunities. more like 'somebody with cancer' (c7). Challenges did not end upon the patient's death -delays and administrative hurdles with body handling, funeral home and autopsy arrangements, pathological and genetic results were common issues.

Caregiving
Caregiving challenges spanned the disease course and post-death (Table 4). Respondents described difficulty accepting the diagnosis or prognosis of sCJD, which sometimes interfered with fulfiling caregiving or decisionmaking roles. Caregivers took on new roles as advocates and decision-makers: 'I found it very difficult having no knowledge of this and trying to get educated on it in a short period of time' (c5). Caregiving intensified quickly, often involving major lifestyle changes. Several respondents took leaves from work and/or moved in with their loved one. ADL help was hard on both parties, from patients not accepting help, to the new caregiving role preventing them to simply 'be' with their loved one. Table 2. Sources of challenge and distress related to the nature of sCJD; quotes from interviews with bereaved caregivers (n = 12).
Theme Exemplar quote for challenges related to the nature of sCJD Rarity Lack of information, treatment or trials 'it's a lonely thing because unlike breast cancer, you know, everybody knows about it and everybody's fighting for it but this, nobody knows about it and there's not enough funding for it but it's out there so it is a lonelier battle to fight than some of the other big diseases' (c6) Difficult to obtain diagnoses because of rarity 'I came down for his appointment and we went to the emergency room and they said -they treated him for kind of like stroke symptoms and stuff and they said, "No, there's nothing," . . . they let him go and I wasn't happy with it and I argued with the staff and I said, "Something's wrong." And they said, "Sorry, we can't help you." And I said, "Well I'd like for him to be admitted into the hospital . . . And I want a battery of tests run on him." And they said, "There's really nothing we can do, he's passed everything, we don't see anything wrong." And I said, "Well look at his leg, look at him walk." And they said, "Well, he says it's because of a knee that he should have had reconstructed." And I said, "Well, no . . . What do I need to do here?" And they said, "You have to get with your general practitioner and then he has to actually tell you that you need . . .
[and] will get you into be able to see doctors in the . . . emergency room, it'll get him past the emergency room." And I said, "But I don't think we can wait for this, he's falling almost every day." MSPKR: And so I stayed at my parents' house for a few days until we could get this appointment with his general practitioner.' (c7) Difficult to find care from clinicians/facilities with sCJD experience The hospital in [town] and the nursing home had never had anybody with that disease which is why most nursing homes were reluctant to take her." (c1) Rapidity Speed of functional decline 'So, his symptoms right away were a memory thing and throwing up, and it was boom, boom, boom. His gait -he couldn't walk anymore. He was upright, and all the sudden he was hunched over, and he'd have to hold onto walls and tables to walk.' (c2) Changes to family and social systems 'So after that day when we were talking to him about "Where's your trust?" it was kind of questionable, and we only had a certain window to sign that medical directive to maybe have a say in the hospice care or even the autopsy for [Health Center 2], because we had to make decisions like that, and who was going to be the lead person, and who was going to be in charge? And so, we only had a small window to sign that medical directive, and it never got signed, so [sister1] was kind of I guess in charge even though nobody ever stated it' (c2) 'it's amazing how fast they change from that really capable hard-working amazing person to this person that's not really there. I don't think people realize how fast it changes.' (c6) Gravity Profound symptoms and functional losses 'It wasn't even safe. She was in a very small, tiny house that had huge drop-offs. She had fallen several times and nearly broken her leg because she was left alone, and so the more I observed and watched that I got to a point where I took it out of her hands, but by that time [patient] had quit walking. She wasn't able to walk anymore, and her boyfriend knew that he couldn't take care of her at that point, and he took her to the hospital because she was unable to walk, and at that point she remained in the hospital.' (c1) Difficult behavioural symptoms 'when . . . I really saw how the auditory and visual hallucinations [patient] was having I knew we were in bigger trouble.' (c5) 'Periodically he would have these bouts of real anger still at the household help that they were stealing from him, that they had come and it started becoming clear to me that he was confused about where he was, that initially I said, "They're not here, you are in [city1]," but he would be quite agitated.' (c4) Assured fatality 'She began to get worse and before she lost her ability to communicate she told me how scared she was.
And it was hard on me because there was nothing I could do for her, you feel helpless, there's nothing you can do . . . It's horrible way to die, to be trapped in your body like that, to be utterly trapped and she couldn't do anything and I couldn't do anything . . . by the time you do know what you're dealing with it's too late, it's fatal, there's nothing anybody could do' (c1) Transmissibility Impact on how people treated 'Once they learned it was CJD, I noticed that their treatment of him changed. Meaning they were -I started noticing more precautions. They were taking a lot more precautions for themselves. Of course, there's an ability for them to get some kind of contamination, but I told them, "Look, you would have to be, I think, blood or something of the sort." But again, it goes to show some of the, let's call it urban myths that may exist out there from the little of information that paramedics or doctors know of the disease. So, it's almost like there's an unwillingness of them to try to treat a patient that comes to the ER that has CJD.' (c11) Impact on facilities, burial options 'We had a funeral home that said they wouldn't even pick her body up. They would pick her up and they wouldn't direct bury her because they didn't know about it.' (c6) Caregivers experienced intense stress and sacrificed their own wellbeing to care for the person with sCJD 'I really could not believe that . . . I didn't have either a nervous breakdown, a heart attack or something, 'I was upset and angry that if this was the diagnosis, the doctor wasn't as sensitive. We've known him, he's a family doctor for many years, and he's been a friend of the family for many years, but how he gave us the news was sort of, "Look, this is what he has. This is a one-page. And he's going to die from this. He's going to die from this in about six months." And he was very blunt, open, not a pulled you into an office. It was just very blunt.' (c11) Lack of prognostic estimate 'All of this was very scary from the day they said "CJD," because no one could tell me how long I had with my wife, and I would say "Well, am I gonna wake up one day and she's gonna be gone? What am I dealing with here?" And nobody could answer that question, and that was the hardest part of all this, because I felt that death was imminent, and that's a horrible place to be. because the level of stress' (c2). Respondents expressed sadness or anger at the many losses experienced by the patient and worried about their suffering. Caregivers struggled as care needs of the patient surpassed available resources, eventually recognizing their own limits: 'I finally brought somebody in to help me because I couldn't do it anymore on my own' (c3). Obtaining professional caregiving was challenging due to the high cost or limited availability, with some facilities unwilling to care for someone with CJD. Caregivers had 'I was able to do that for maybe a couple of weeks and then I finally brought somebody in to help me because I couldn't do it anymore on my own. I was too worried about him falling, me falling, and the whole nine yards.' (c3) 'So, I feel like just towards the end, and I'll be frank, you become ambivalent, you want him to pass, you don't want to <participant is crying> prolong it, you want him to be comfortable yet it's a very difficult phase, so I made that decision to take him to . . . the long term care' (c4) Limited avenues for other support 'I even had hired help like nurses. We lost one nurse. Another one came in, she was a little bit more negligent. She allowed an infection to develop in his dentures. Like, things that you overlook, I should have known, okay, you can't -If this nurse was not changing out his dentures, might as well leave them out so he doesn't build up food within his dentures. He developed an infection and I don't know if the infection was what killed him, but within two or three days later, he ended up passing away.' (c11) 'Or the caregivers are cleaning him in a way that there's too much moisture and he's not dry enough. So, I had to kind of watch for those things because her examination of him when she came was limited by the time she could budget which I'm sure limited by cost considerations.' (c4) Challenges post-death Final arrangements for decedent 'We had told the hospice people . . . because it is a very rare disease that you need an autopsy to confirm the cause of death or the disease, we want to make sure whatever's written on the death certificate to be correct . . . you want to make sure because it's like important that is it mad cow, is it sporadic, is it genetic. So thank god we caught it in . . . we called the person in charge of the hospice that deals with death certificates and the mortuary and they changed it because it hadn't yet gone through the county yet, and they changed it to I think something encephalitis, and then when the autopsy was finished months later and confirmed that it was sporadic CJD then the death certificate was finalized as sporadic CJD. Caregivers experienced ongoing grief, fatigue, and distress after the patient died: 'it took me a good year to kind of recover from the emotional and physical toll that it took on me' (c4). One compared her experience to posttraumatic stress disorder, noting that aspects of it still 'haunted' her (c9). Reflecting on the caregiving experience, many expressed sadness or cried during the interview.

Sources of support and amelioration
We identified 2 major categories of support -clinical care and caregiving.

Clinical care
Despite challenges, many respondents also experienced clinicians and clinical care as sources of support ( . Guidance about when to seek additional help and the expected disease course, including how to recognize signs of imminent death, helped caregivers feel prepared, take breaks, and feel less guilt. Caregivers valued clinicians' expertise in sCJD, particularly early in the disease journey, when detailed explanations of the disease were helpful. Respondents appreciated expert management of medications and advice about behavioural adaptations to manage sCJD symptoms. Confirming the CJD as sporadic (not genetic) was a source of relief for nearly all.
Sensitive and supportive relationships with clinicians and researchers stood out, such as when clinicians responded quickly and thoroughly: 'I could call her or text her anytime and she would be answering questions for me' (c3). Clinicians and others with prion expertise helped caregivers prioritize self-care: '[Dr. III] himself . . .. advised me strongly to back off from [caregiving], that I would potentially cause harm to myself that could be damaging. So I really appreciated that advice' (c4).
All caregivers reported engaging hospice, sometimes before the diagnosis of CJD. Though some caregivers expressed frustrations with hospice clinicians or the care model (especially lack of continuity), most found hospice helpful for providing hands-on ADL support, breaks, and comfort. They benefited from fast implementation and hospice staff's expertise in recognizing imminent death and appreciated when hospice made effort to learn about sCJD and inquire about respondents' knowledge as sCJD caregivers.

Caregiving
Finally, respondents identified sources that facilitated being a caregiver ( Table 6). They emphasized the benefit of reading or hearing stories from, or connecting with other sCJD caregivers, via YouTube, Facebook, and the CJD Foundation: 'all you want to do is talk to people that have been through it. Because you don't know what to expect' (c7).
Caregivers benefited from instrumental support (e.g. paid caregivers or facilities relieved caregiving burden): 'I did all the heavy lifting at our house . . . When we transferred to the care facility, I felt lighter' (c7). Friends or family also provided ADL, legal or financial help, such as documenting preferences or decision-makers while the patient was still able to make decisions. Many narratives indicated that socioeconomic resources were essential, such as being able to pay for caregiving, having access to state-funded care, and/or having jobs that permitted reduced schedules and lengthy leaves of absence.
Social and emotional support was beneficial. Much of this came from friends and family, e.g., keeping the patient company or reminding (and helping) the caregiver to take a break: 'There wasn't anything to do except support her and everybody was ready, willing and able to sign up' (c5). Some caregivers benefitted resilience-bolstering activities, such as religious practice or exercise. Others found comfort in maintaining close connection to the person with sCJD; one caregiver did 'spa days' for his wife after she was bedbound (c12).

Caregiver recommendations or wishes
Caregivers also identified items that they thought would have been helpful to them or future sCJD caregivers. Though hypothetical, these insights may be useful for intervention development.
Regarding clinical care, some caregivers felt earlier accurate diagnosis and familiarity with sCJD among clinicians, hospice staff, and funeral home directors would have made the experience less difficult. Some recommended that clinics provide resources about expected symptoms and prognosis, what to take care of (e.g., advance care planning), resources (e.g., CJD Foundation, support groups, local hospice organizations), and contact information for expert advice about sCJD management to give facilities, hospices, and funeral homes.
Regarding caregiving, some respondents thought they would have benefited from more self-care and It also allowed me to -after we left to . . . research on my own. And better manage the situation.'(c11) What to expect over time 'He said -now remember, we saw a picture of her MRI. And if you've never even seen an MRI of a brain he pointed out and he said, "This part doesn't function anymore. This part doesn't function anymore. This part. And it will soon become her entire brain that no longer functions," because this disease, for lack of better words, eats it away which is a pretty hard visual. And so she will go from being able to talk and request and feed herself to not being able to feed herself, to the point of not being able to eat' (c5) When to seek more help 'I found a social worker here locally that -she was very instrumental in helping me through the hospice question. And she said -and, again, we agreed that, okay, when this happens and this happens, you need to call me . . .. And then her and I had worked out, "[interviewee], here's what you need to do. When you can't feed her anymore and she's been incontinent," she said, "you need to think about engaging hospice."' (c12) How to identify imminent death 'The hospice did because I told them . . . I want to know what the signs are when she's down to a matter of days, and they told me. They said she won't be able to eat, she won't be able to drink at all, and her sleeping ability will rapidly change, which it did.' (C1) Expertise in sCJD and symptom management Reassurance of expertise ' . . . although the ultimate diagnosis was not what we wanted, but we were with people that knew what they were dealing with and weren't dismissive and they did a much better job caring for our mom and for us.' (c9) Advice on how to manage symptoms, adjust medications 'I got really good help from [the attending physician] himself, the team. I would just email him and say this is what is happening, and they would respond. Even sometimes they recommended change in medication in consultation obviously with the psych doctors here, and at some point they even recommended that most of the medication that he's taking, just stop those medications, like he doesn't need cholesterol control anymore.' (c4) 'It was not only guidance, it was also if you see these symptoms, try to calm him this way. So, for example, we were told about music. We were told about light. We were told cloudy days he's going to go bad. If it's raining outside with the barometric pressure, he's going to be affected. But on a sunny day, take him outside. It was like medicine. You take him outside on a sunny day and he was alive. You would see him attentive.' (c11) Confirmation of variant type 'Well first thing it was I just burst into tears when I found out it was spontaneous and it wasn't genetic because we were again already under so much stress, and then to find out at least it was not genetic was huge.'(c3) Supportive clinical relationships Sensitive, responsive, proactive communication at every stage 'So while they're doing the exams, I'm asking questions. As I'm asking questions, the people doing the exam were very transparent. And that, to me, was very, very valuable . . . It's not like they were trying to withhold information. Any question I asked, "Why is this being done? What's the purpose of this?" . . . Everything was being answered.' (c11) "They [hospice clinicians] told us they were going to do it like a dementia patient because she exhibited lots of signs of dementia. And I don't know if they were really that educated on the actual Creutzfeldt-Jakob but they were amazing for our family, I think we were learning together, it was more like, 'We're all in this together at this point.' And they would ask me, 'You've been through this with your mom for the last year and a half, two years, whatever, so we are really open to what you think is best.' (c6) Prompting caregiver self-care 'I remember at one point in time she had said, "Are you talking to anybody like, you know, a counselor or anything?" And I had said, "You know, I hadn't even thought of it because right now it's just-" Like, you know when you're caring for someone it's' a job and you're, you just want to do a good job and you don't want to leave any stone unturned.' (c7) 'a doctor in one of the emergency rooms and he was able to give me -He sat with me. He started to explore, "Okay, you've been here now twice to this emergency room. You've been to other emergency rooms." . . . He was trying to understand based on my records why was I there. And when I started telling him the story he just said, "Okay. Your issue with your dad is trust." And that's when he said, "You've got to bring in a team. There is such a thing called hospice." But at the same time, he said, "Look, just hire people if you can afford it."' (c11) time connecting with the patient. When asked for recommendations for future sCJD caregivers, respondents echoed these themes: spend more meaningful time with the patient, have more patience with themselves and the patient, connect with other sCJD caregivers, and engage hospice care.

Discussion
This novel study provides an expanded understanding of challenges experienced by caregivers and persons with sCJD and identifies opportunities for improvement. Challenges primarily related to clinical care and ' . . . then they just did everything and ordered the bed was in our home within hours kind of thing. You know, they told us you should get the . . . pad for the bed. I mean, it was just wonderful, that whole part. And we ordered the medications, Lorazepam and morphine to have there when he got home so that if you could -needed to start distributing it. And it was just boom, boom, boom.' (c2) Finding a funeral home to meet sCJD needs 'The funeral home here, they did the autopsy and took her brain and they took care of it and it wasn't a problem like we kept worrying that maybe it was going to be and because of all the considerations for the disease. But it ended up not being a problem at all and it got handled' (c9) Social and emotional support From friends and family members 'almost every day people were coming in and bringing him milkshakes and Frappuccino's and cookies, and just spending time with him . . ..the guys that he played tennis with would come over and . . . they'd roll him over [in his wheelchair] so he could watch a tennis match.' (c3) 'We had a lot of the people that stayed overnight and helped out, so myself and my son, we could get some rest.' (c10) Strategies to maintain connection between caregiver and person with sCJD "I would raise his bed, I would feed him by hand a little bit, I would keep him hydrated, give him water. . . . and again culturally to us that is -we feel a lot of pride and comfortable in being able to take care of somebody to feed them by hand. " (c4) 'I think the best medicine for me was taking care of her. I saw her in a different light. I saw her as a very humble human being that needed me. And I would tell them you have every right to be angry. It's frustrating. And it is heart wrenching that your loved one is going to be taken from you so quickly and there's nothing you can do.' (c6) Promoters of caregiver emotional resilience 'we're a very religious family . . . I really believe there's something after this life and so that was integral in me staying grounded.' (c6) 'They encouraged me to make sure that I take care of myself. So -and I did. . . . I had a bike down here. my sister-in-law would spell me for, you know, an afternoon so I could go ride my bike.' (c12) • List of common symptoms and recommended management strategies [17] (https://memory.ucsf.edu/dementia/ rapidly-progressive-dementias) List of medications to consider using or avoiding [17] (https://memory.ucsf.edu/dementia/rapidly-progressivedementias) Reminders for sensitive disclosure of serious diagnoses Challenge of the diagnostic journey Serious illness communication strategies [24] such as NURSE, [25,26] SPIKES, [46] and/or the Serious Illness Guide [47]. Key principles including whether to disclose at initial or dedicated follow-up appointment, allowing patient/ caregiver to choose who to be present, having enough time to disclose diagnosis and answer questions, and providing written materials Prognostic information, caregiver training, and anticipatory guidance  [20 -23, 7]. Caregivers in our study voiced similar challenges with symptoms, and described broader sources of distress and challenges. Caregivers framed changes in patient function within the larger context of major losses and changes to relationships, life plans, and family roles. We additionally asked about supports to identify factors that ameliorated caregivers' difficulties. Supports were often the inverse of challenges, such as sensitive versus insensitive disclosure of diagnosis and prognosis. Data on sources of distress and support in sCJD facilitates the development of neuropalliative tools and interventions. Table 7 demonstrates how palliative care approaches might be integrated into neurology practice for sCJD and slower-progressing dementia syndromes. For example, neurology trainees can be taught to use serious illness communication strategies [24] for sensitively disclosing a diagnosis of sCJD and asking if patients and caregivers want prognostic information or anticipatory guidance at this time [25,26]. Findings from this study can facilitate improving sCJD-specific care among hospice and palliative care clinicians. Neuropalliative-infused interventions for improving sCJD care will need to be refined with interdisciplinary multi-stakeholder input and tested for utility and effectiveness.
Evidence regarding neuropalliative care needs in sCJD may be applicable to other rare and rapidly progressive diseases with no cure, as well as longer-course neurodegenerative diseases. A recent systematic review of factors influencing the provision of palliative care to persons with advanced dementia report similar problems: difficulty managing symptoms, lack of continuity of care, and lack of clinician skill in palliative care (such as sensitive disclosure of information or providing anticipatory guidance) [27]. A systematic review of integration of palliative care into dementia management highlights the importance of discussing disease trajectory and expectations and challenges from suboptimal symptom and medication management [28]. These challenges appeared in our study as well. We are adapting the analytic approach of this sCJD study to our parallel efforts to identify neuropalliative intervention targets for longer-course dementia syndromes [29][30][31].
Limitations of the study include a relatively small sample at one institution, albeit one that recruits study participants nationally (and even globally) for this rare disease. Demographics of participating caregivers suggest that they are well-resourced. Caregivers with fewer resources may encounter more, or more severe, challenges than documented here. Future research should engage larger, more socioeconomically-and globallydiverse populations, and other RPDs that may raise different caregiving challenges. Nevertheless, these novel findings provide foundational data for further research and intervention development.
In summary, this study drew on palliative care frameworks and mixed methods to yield a comprehensive description of challenges, supports, and opportunities to improve care for people with sCJD and their caregivers. Though sCJD is rare and rapidly progressing, the themes uncovered provide a framework for ongoing efforts to improve neuropalliative care for dementia care more broadly.

Methods:
Design: We conducted an exploratory mixed methods study [32] to capture in-depth information about  [33].
Participants and setting: We identified caregivers from the UCSF Memory and Ageing Center (MAC) RPD research programme database, which includes extensive information on individuals who consented to the ongoing use of their data from medical records and/or from research records through an IRB-approved study of RPDs [34]. We purposively sampled caregivers of persons who died with sCJD at least 3 months but no more than 3 years previously to capture variation in degree of interaction with the UCSF MAC RPD research team and to capture variation in clinical presentation through sCJD molecular classification [19,35]. Of 23 candidate caregivers approached before recruitment closed due to COVID-19, 12 agreed to participate.
Data collection: Caregiver interview domains focused on key experiences along the patient's disease trajectory; caregiver activities and quality of life; challenges and sources of distress; and things that did or could have helped them to care for the person with sCJD; and a demographic survey (Appendix). Phone-only interviews were conducted from September 2019 through March 2020 (median 88 minutes, range 41-161). Caregivers provided written consent and agreed to digital recording. Recordings were professionally transcribed.
We extracted demographic and clinical data on patients linked to recruited caregivers from the UCSF MAC RPD and UCSF MAC general research ('LAVA') databases. For patients who participated in a 2-day outpatient research visit, data included assessments of cognition [36] [37],, neuropsychiatric symptoms [38],, function [39] [40],, and disease characteristics (Table 1). For inpatients who were only seen in the UCSF clinical wards (and did not participate in the more extensive 2-day research visit), more limited data was extracted from their EPIC electronic health record and (if available) RPD and LAVA databases. Sources of diagnostic information included brain tissue pathology, cerebrospinal fluid (CSF) biomarkers [41], brain MRI summary, and prion protein gene (PRNP) analysis [42] (Table 1).
Data management and analysis: Patient data were summarized using descriptive statistics. Caregiver data were summarized in structured case summaries that included emergent themes and interviewer reflections. We iteratively reviewed chart data, case summaries, and transcript excerpts throughout data collection to refine analytic approaches and identify preliminary themes.
We employed both deductive and inductive coding to identify themes. Deductive codes reflected concepts from the interview framework: challenges or sources of distress, sources of help, and caregiver recommendations for improvements. Inductive codes reflected meaningful concepts emerging from the interviews (e.g., disease rarity, rapidity, transmissibility). Three authors (KLH, SBG and CSR) iteratively refined codes by double-coding and discussing discrepancies until agreement had been met; KLH applied the updated codebook to all transcripts. Analysis was guided by the constant comparative method [43], which uses iterative comparisons within and between analytic cases. The team maintained an audit trail of methodological and analytic decisions.
• SBG: study conceptualization/design, data acquisition, data interpretation and analysis, drafting/ revising manuscript for content • ABS: study conceptualization/design, data interpretation and analysis, drafting/revising manuscript for content • JG: data acquisition, data interpretation/analysis, drafting/revising manuscript for content • MJT: data acquisition, data interpretation/analysis, revising manuscript for content • CSR: study conceptualization/design, data interpretation and analysis, drafting/revising manuscript for content • MDG: study conceptualization/design, data acquisition, data interpretation and analysis, drafting/revising manuscript for content