Lower Respiratory Infections in Nursing Home Residents With Dementia: A Tale of Two Countries (original) (raw)
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International Journal of Geriatric Psychiatry, 2007
Background Although lower respiratory tract infections (LRI) cause considerable morbidity and mortality among nursing home residents with dementia, the effects of care and treatment are largely unknown. Few large prospective studies have been conducted. Methods We pooled data from two large prospective cohort studies in 61 Dutch nursing homes and 36 nursing homes in the state of Missouri, United States. We included 551 US residents and 381 Dutch residents with dementia and LRI. Main outcome measures were 3-month mortality and decline in activities of daily living (ADL) function after 3 months compared with pre-illness status. Using multivariable multinomial logistic regression to control for confounding, we assessed associations of restraint use and antibiotic type (oral compared with parenteral), with outcomes of lower respiratory tract infection (LRI). Survival without ADL decline was the reference category. Results After multivariable adjustment, restraint use was associated with ADL decline (OR 1.9, 95% CI 1.1-3.3). Oral antibiotics were not associated with 3-month mortality (OR 0.83; 95% CI 0.56-1.2). Severe dementia was the strongest independent predictor of decline; mortality was most strongly associated with male gender. Conclusions Among Dutch and US nursing home residents with dementia and LRI, restrained residents suffered more decline. Parenteral antibiotic treatment was not associated with better outcome in residents at low to moderate risk of mortality. Aggressive treatment strategies may provide little benefit for the majority of nursing home residents with dementia and LRI.
Prognosis is important in decisionmaking in Dutch nursing home patients with dementia and pneumonia
International Journal of Geriatric Psychiatry, 2009
Objective To explore how physicians treating nursing home residents with dementia and pneumonia in the Netherlands consider prognosis in their treatment decision. Methods Survey study with data collected between July 2006 and March 2008. Physicians (n ¼ 69) from 54 nursing homes in the Netherlands completed a questionnaire on symptoms, treatment, and prognosis for their next dementia patient newly diagnosed with pneumonia. They were also asked a general question regarding withholding antibiotic treatment and prognosis. Outcome was assessed at least two months afterwards. Two-week mortality risk if treated with antibiotics was calculated with a validated prognostic score. Results The patients not treated with antibiotics had high (92%) actual 2-week mortality while only 12% of patients treated with antibiotics died. Physicians believed that mortality risk was high in the untreated group and would have been only slightly lower if treated with antibiotics (mean estimated risk 73%), which was higher than predicted from the risk score (42%). In general, three-quarters of physicians considered withholding antibiotics appropriate for mortality risks between 75% and 90%. Conclusions Prognosis is an important consideration when Dutch nursing home physicians make antibiotic treatment decisions for patients with dementia and pneumonia. This suggests they prefer not to treat with antibiotics when to do so is probably futile. Physicians in other countries may hold different views on futility, which should be addressed in larger, crossnational comparative studies.
Alzheimer disease and associated disorders, 2016
We explored how pneumonia and intake problems affect survival in nursing home residents in variable stages of dementia. In a longitudinal observational study (372 residents) with up to 3.5 years of follow-up, we examined relationships between dementia severity, the development of pneumonia, intake problems, and mortality using joint modeling, Cox models, and mediation analyses. Dementia severity was measured semiannually with the Bedford Alzheimer Nursing Severity-Scale (BANS-S). The median BANS-S score at baseline was 13 (range, 7 to 28). Pneumonia occurred in 103 (28%) and intake problems in 126 (34%) of 367 residents with complete registration of pneumonia and intake problems. Compared with dementia severity, incident pneumonia and, even more so, incident intake problems were more strongly associated with mortality risk. Pneumonia and intake problems both mediated the relationship between more severe dementia and mortality. Developing pneumonia and intake problems affects surviva...
Journal of The American Geriatrics Society, 2006
To describe the occurrence and management of suspected pneumonia in end-stage dementia and to identify factors associated with aggressiveness of antibiotic treatment. DESIGN: Retrospective cohort study. SETTING: A 675-bed long-term-care facility in Boston, Massachusetts. PARTICIPANTS: Two hundred forty subjects aged 65 and older who died with advanced dementia between January 2001 and December 2003. Subjects who had suspected pneumonia during the last 6 months of life were identified. MEASUREMENTS: Independent variables included subject characteristics and features of suspected pneumonia episodes. These variables were obtained from medical records. Antibiotic treatment for each episode was determined. Multivariate analysis was used to identify independent variables associated with aggressiveness of treatment. RESULTS: One hundred fifty-four (64%) subjects with advanced dementia experienced 229 suspected pneumonia episodes during the last 6 months of life. Within 30 days of death, 53% of subjects had suspected pneumonia. Antibiotic treatment for the 229 episodes was as follows: none, 9%; oral only, 37%; intramuscular, 25%; and intravenous, 29%. Factors independently associated with more-invasive therapy were lack of a do-not-hospitalize order (adjusted odds ratio (AOR) 5 3.24, 95% confidence interval (CI) 5 2.02-5.22), aspiration (AOR 5 2.75, 95% CI 5 1.44-5.26), primary language not English (AOR 5 2.21, 95% CI 5 1.17-4.15), and unstable vital signs (AOR 5 2.02, 95% CI 5 1.10-3.72). CONCLUSION: Pneumonia is a common terminal event in advanced dementia for which many patients receive parenteral antibiotics. The aggressiveness of treatment is most strongly determined by advance care planning, the patient's cultural background, and clinical features of the suspected pneumonia episode.
Family perceptions of wishes of dementia patients regarding end-of-life care
International Journal of Geriatric Psychiatry, 2011
antibiotics did not prolong suffering. However, in our study, antibiotics delayed dying for several days (van der Steen et al., 2009b). Moreover, antibiotics may prolong the dying process in more patients compared to the number of patients who obtain long-term survival. Although it is still unclear if antibiotics reduce suffering in presence of optimal treatment to relieve symptoms, this does show the importance of accurate risk assessment in individual patients for balanced decision-making regarding antibiotic treatment. Finally, the undesirable consequences of antibiotic treatment for the patient (adverse effects) and the society (cost and development of antibiotic resistance) should be considered before antibiotics are used indiscriminately.
Journal of the American Geriatrics Society, 2000
OBJECTIVES: To compare predictors of hospitalization and death in nursing home residents with pneumonia and other lower respiratory infections (LRIs). DESIGN: A nested cohort study. SETTING: Nine nursing homes in southern Ontario. PARTICIPANTS: Three hundred fifty-three nursing home residents with LRIs (enrolled in the control arm of a clinical trial). MEASUREMENTS: Comorbidities, vaccination status, age, health-related quality of life, functional status, and vital statistics were evaluated as potential predictors of hospitalization and mortality at 30 days. RESULTS: Moderate to high disease severity score on a practical severity scale was a strong independent predictor of hospitalization (odds ratio (OR) 5 7.12, Po.001) and mortality (OR 5 5.04, P 5.003). Diagnosis of pneumonia, established using chest radiograph, was also associated with hospitalization (OR 5 2.43, P 5.008) and mortality (OR 52.35, P 5.02). Oxygen saturation (o90%) was a strong independent predictor of hospitalization (OR 5 3.02, P 5.004) but was not a significant predictor of mortality in multivariable analyses. Diagnosis of congestive heart failure (OR 5 2.26, P 5.02) was an independent predictor of hospitalization, whereas receipt of pneumococcal vaccine (OR 5 0.36, P 5.01) and greater functional independence (OR 5 0.92, P 5.02) were negatively associated with hospitalization. CONCLUSION: In nursing home residents with LRI, severity of illness and radiographically confirmed pneumonia are predictive of death and hospitalization. J Am Geriatr Soc 55: 414-419, 2007.
The American journal of hospice & palliative care, 2017
Comfort may be an appropriate goal in advanced dementia. Longitudinal studies on physician decision-making and discomfort assessed by direct observation are rare, and intravenous rehydration therapy is controversial. To assess treatment decisions and discomfort in patients with advanced dementia and pneumonia and to compare by intravenous rehydration therapy, we used data from the observational multicenter Italian End of Life Observatory-Prospective Study On DEmentia patients Care. We analyzed 109 episodes of pneumonia, which involved decisions in 77 nursing home patients with Functional Assessment Staging Tool stage 7. We assessed decisions, decision-making, and treatments every fortnight. Trained observers assessed discomfort with the Discomfort Scale-Dementia Alzheimer Type (DS-DAT). Most decisions referred to treatment with antibiotics (90%; 98 of 109) and intravenous rehydration therapy (53%; 58 of 109), but hospitalization was rare (1%). Selecting decisions with antibiotics, w...
Journal of the American Medical Directors Association, 2016
Objectives: To describe observations of suffering in patients with dementia from the diagnosis of pneumonia until cure or death. Design: Prospective observational study between January 2012 and May 2014. Setting: Dutch nursing homes (32). Participants: Nursing home patients with dementia and pneumonia (n ¼ 193). Measurements: Independent observers performed observations of patients with dementia scheduled 13 times within the 15 days following diagnosis of pneumonia; twice daily in the first 2 dayse to observe discomfort (Discomfort ScaleeDementia of Alzheimer Type; range 0e27), comfort (End Of Life in Dementia-Comfort Assessment in Dying; range 14e42), pain (Pain Assessment in Advanced Dementia; range 0e10), and dyspnea (Respiratory Distress Observation Scale; range 0e16). Results: Observational data were obtained for 208 cases of pneumonia in 193 patients. In 71.2% of cases, patients received 1 or more treatments to relieve symptoms such as antipyretics, opioids, or oxygen; 89.4% received antibiotics. Discomfort was highest 1 day after diagnosis [mean Discomfort Scale-Dementia of Alzheimer Type score 8.1 (standard deviation, SD 5.8)], then declined, and stabilized around day 10 [mean 4.5 (SD 4.1)], or increased in the days preceding death. Observed pain and dyspnea followed a comparable pattern. Discomfort patterns did not differ much between cases treated with and without antibiotics. Conclusions: Pneumonia in patients with dementia involved elevated levels of suffering during 10 days following diagnosis and in the days preceding death. Overall observed discomfort was low compared with prior Dutch studies, and the number of treatments to relieve symptoms was higher. Future studies should examine whether symptoms of pneumonia can be relieved even more, and what treatments are the most effective.