Prognosis is important in decisionmaking in Dutch nursing home patients with dementia and pneumonia (original) (raw)
Related papers
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.
Antibiotic Prescribing In Dutch Nursing Homes: How Appropriate Is It?
Journal of the American Medical Directors Association, 2014
Nursing homes antibiotic prescribing urinary tract infection respiratory tract infection a b s t r a c t Objective: To investigate the appropriateness of decisions to prescribe or withhold antibiotics for nursing home (NH) residents with infections of the urinary tract (UTI), respiratory tract (RTI), and skin (SI). Design: Prospective study. Setting: Ten NHs in the central-west region of the Netherlands. Participants: Physicians providing medical care to NH residents. Measurements: Physicians completed a registration form for any suspected infection over an 8-month period, including patient characteristics, signs and symptoms, and treatment decisions. An algorithm, developed by an expert panel and based on national and international guidelines, was used to evaluate treatment decisions for appropriateness of initiating or withholding antibiotics. Results: Appropriateness of 598 treatment decisions was assessed. Overall, 76% were appropriate, with cases that were prescribed antibiotics judged less frequently "appropriate" (74%) compared with cases in which antibiotics were withheld (90%) (P ¼ .003). Decisions around UTI were least often appropriate (68%, compared with 87% for RTI and 94% for SI [P < .001]). The most common situations in which antibiotic prescribing was considered inappropriate were those indicative of asymptomatic bacteriuria or viral RTI. Conclusion: Although the rate of appropriate antibiotic prescribing in Dutch NHs is relatively high compared with previous studies in other countries, our results suggest that antibiotic consumption can be reduced by improving appropriateness of treatment decisions, especially for UTI. Given the current antibiotic resistance developments in long-term care facilities, interventions reducing antibiotic use for asymptomatic bacteriuria and viral RTI are warranted.
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...
Lower Respiratory Infections in Nursing Home Residents With Dementia: A Tale of Two Countries
2000
Purpose: A focus on palliative care for residents with dementia is much more common in Dutch nursing homes than in the United States. We compared treatment and mortality in U.S. and Dutch nursing home residents with lower respiratory infections (LRI), which are often the immediate cause of death in dementia. Design and Methods: We studied two prospective cohorts-a study of pneumonia (n ¼ 706) conducted in 61 psychogeriatric nursing homes throughout the Netherlands and 701 subjects with likely dementia from a study of LRIs in 36 nursing homes in Missouri. Results: Nursing home residents with dementia were more often treated without antibiotics in the Netherlands (23%) than in Missouri (15%). Indicators of severe illness operate in opposite directions: more severe illness is associated with antibiotic treatment in the United States, but with palliative treatment without antibiotics in the Netherlands. Implications: Our findings are consistent with others in indicating problems with transition to palliative care for U.S. nursing home residents with dementia.
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...
Management of Pneumonia in the Nursing Home
CHEST Journal, 2010
Pneumonia is a major cause of morbidity and mortality among nursing home residents. The approach to managing these patients has lacked uniformity because of the paucity of clinical trials, complexity of underlying comorbid diseases, and heterogeneity of administrative structures. The decision to hospitalize nursing home patients with pneumonia varies among institutions depending on staffi ng level, availability of diagnostic testing, and laboratory support. In the absence of comparative studies, choice of empirical antibiotic therapy continues to be based on expert opinion. Validated prognostic scoring models are needed for risk stratifi cation. Pneumococcal and infl uenza vaccination are the primary prevention measures. As of January 2010, Medicare no longer pays for consultation codes; thus, practitioners must instead use existing evaluation and management service codes when providing these services.