With progressive dementia, patients also become incompetent to make decisions.16-18 They become unable to balance the benefits and burdens of treatments themselves. Now, however, some doctors may recommend against antibiotics, believing the risks outweigh the benefits. A previous meta-analysis indicated that the odds of pneumonia-associated death were increased more than twofold for patients with dementia than for those without dementia [11]. breathing difficulties. The factors we identified relate predominantly to the dementia severity and the acute illness. LHurley MWPneumonia: the demented patient's best friend? Two reviewers extracted the data independently. Considerations other than medical may also have played a role in withholding antibiotic treatment in relatively young patients in whom, though more ill, the general illness severity was less predictive. Trouble swallowing increases the risk of choking. In the subgroup analysis according to information source for the cause of death (autopsy or death certificate), the estimated frequency of pneumonia-associated death in studies using autopsy confirmation was 49.98% (95% CI, 43.7556.21; I2 = 72%; p for heterogeneity = 0.002) (Fig 3A) whereas that in studies using death certificates was 19.65% (95% CI, 15.4823.82; I2 = 99%; p for heterogeneity < 0.001) (Fig 3B). GJRibbe Facilities employ physicians in a ratio of 1 full-time physician to 100 patients.28-31 Even after hours or on weekends, ill residents are seen at the bedside; telephone consulting is not usual practice in the Netherlands. SDArnold Dementia occurs in stages, with the later stages lasting for around 1-2. There are different types of risk factors for dementia, including medical, lifestyle and environmental factors. What Causes Pneumonia in Severe Dementia? Sepsis (infection). Until now, studies have relied on reporting of physicians' opinions in discussions on life-sustaining treatment22,23 or on hypothetical cases (vignettes).24,25, In the Netherlands, as in Great Britain,26 physicians are culturally and legally responsible for the ultimate decision about withholding treatment in incompetent patients. Background All statistical tests were performed using Review Manager (RevMan) ver. Toshie Manabe, DWGuyatt However, the reported frequency of pneumonia as a cause of death in patients with dementia varies, the reason for which has not been fully elucidated. This could then potentially trigger or worsen Alzheimer's. Squares represent 95% confidence intervals (CIs). DREvaluation of the uniformity of fit of general outcome prediction models. They include: Preclinical Alzheimer's disease. EMolloy SDBraham Medina-Walpole Hurley Mild dementia due to Alzheimer's disease. Squares represent 95% confidence intervals (CIs). BWLigthart 13 In HF . Mott The clinical diagnosis of pneumonia in older adults is difficult and often delayed because of atypical or paucisymptomatic presentations including the absence of fever, paucity or absence of cough, changes in mental status (delirium), and poorly contributive physical examination [1, 34]. Meta-analysis for frequencies of pneumonia-associated death in patients with dementia according, to information source for the cause of death. (a) Data from 7 studies using autopsy reports. Our data may facilitate discussions on whether the identified factors should really be important in the decision-making process and on discrepancies between expected and actual outcomes. LPredicting short-term survival for patients with advanced Alzheimer's disease. Dementia and cognitive impairment in heart failure. Some researchers suspect that ApoE4 allows more virus particles to attach themselves to brain cells, making it easier to infect them. Factors affecting physicians' decisions on caring for an incompetent elderly patient: an international study. GBBianchetti Rehydration therapy was assessed 3 days after the treatment decision. FLMacKenzie Bellelli Department of Social Health and Stress Management, Graduate School of Comprehensive Human Science, University of Tsukuba, Tsukuba, Japan, These physicians belong to the staff of the nursing homes. Severe dementia was the strongest predictor in this model. Therefore, once these patients develop a lower respiratory tract infection, they can easily develop recurrent pneumonia, which can lead to pneumonia-caused mortality. MEvan der Wal MFFolstein Many of these cases are unique because often no other obvious symptoms are present, said Carlos Barrera, M.D., whose specialties include internal medicine and pulmonary medicine. The relation of patient, physician, and facility variables with the treatment decision was first examined with univariate logistic regression analysis. WHTreatment decisions for infections occurring in nursing home residents. Hanley Conclusion: The various frequencies of pneumonia-associated death in patients with dementia were associated with the information source, type of mortality cause, and study setting . We thank Analisa Avila for editing the English text of a draft of this manuscript. HRasbash We explore why. July 10, 2023. However,another trial of the same antibiotics in people with Alzheimer's did not find they had any effect on thinking abilities. In previous meta-analyses, the underlying cause of death was defined as the disease, injury, or corresponding circumstance that initiated the chain of events (i.e., the intermediate cause of death) ultimately leading to death (7, 8, 9). This finding suggests that withholding antibiotic treatment was not merely because of, for example, problems with oral intake. Some studies have found a link, and other studies found no association. 3 - 7 Nursing home residents with end-stage d. SSheer Mahomed Characteristics of facilities and physicians were unrelated to the decision. Mahoney Overall observed discomfort was low compared with prior Dutch studies, and the number of treatments to relieve symptoms was higher. Alemayehu However, the reported frequency of pneumonia as a cause of death in patients with dementia varies, the reason for which has not been fully elucidated. CAAdr MJWInfections and bacterial resistance in the community [in Dutch]. The various clinical factors relating to pneumonia-associated death are likely to coexist. MWTransitions across various continuing care settings. Amyloid has also been found to damage or kill several different germs. Department of Medical Risk Management and Infection Control, National Defense Medical College Hospital, Saitama, Japan, Muder This implies that physicians weighed such a variable differently in their decisions. JMTreatment guideline for nursing home-acquired pneumonia based on community practice. Diabetes Drug, Ozempic, in Short Supply as Many Wrongfully Take It to Lose Weight, A Vicious Cycle -- Insulin Resistance and Weight Gain, Overindulging? Most physicians and families were inclined to treat with antibiotics those patients who had survived pneumonia before and for most of whom (96%) an active approach had been used. DRFoxman Pneumonia symptoms were grouped to assess relevance compared with other conditions. The values of the other 5 predictors in the multilevel model of Table 5 seemed almost equally important among individual physicians when deciding to withhold antibiotic treatment. Morrison This frequency may be much higher than clinicians expectations. CKern Information from the literature concerning the frequency of withholding antibiotics is limited. Data Availability: All relevant data are within the paper and its Supporting Information files. Brauner Two authors independently determined the suitability of studies and potential bias and extracted the data. Likewise, of pneumonia symptoms, decreased alertness was more important than Cheyne-Stokes respiration, tachypnea, coughing, respiratory distress, fever, malaise, and abnormal chest auscultation. (c) Data of eight population-based studies. Some older people need to get more than one pneumonia vaccine. By continuing to use our site, or clicking "Continue," you are agreeing to our, Characteristics of Patients, Physicians, and Facilities Associated With Withholding Antibiotic Treatment in Univariate Analyses, Characteristics of Patients, Physicians, and Facilities Not Statistically Significantly Associated With Withholding Antibiotics in Univariate Analyses, Description of the 635 Patients Treated Without Antibiotics or Treated With Antibiotics for Curative Reasons*, Predictive Multilevel Model of Withholding Antibiotic Treatment in Contrast to Curative Antibiotic Treatment*. Its presence in the brain could cause inflammation , which could contribute to the underlying Alzheimer's disease mechanism. Beauchamp Ethical issues in the treatment of advanced Alzheimer dementia: hospice approach. FLHow to sort through the differential and institute therapy: the special challenge of pneumonia in the elderly. Food and . Several studies32-36 have demonstrated acceptable reliability and validity. This could partially be explained by the small size of the studies, or the varying sensitivity of the methods used to detect spirochete infection. YLLasch AHurley Department of Internal Medicine, National Defense Medical College, Saitama, Japan, Affiliations: PVolicer Factors that influence decision making independently, Variation in considering patient characteristics, Get the latest from JAMA Internal Medicine, To register for email alerts, access free PDF, and more, Get unlimited access and a printable PDF ($40.00), 2023 American Medical Association. Marrie Characteristics of patients, physicians, and facilities were related to the outcome of withholding antibiotic treatment. Herpes infection in the brain appears to be more common in people with Alzheimer's disease who have a gene called ApoE4, which is known to increase the risk of Alzheimer's. MJSmith Patients were assigned to treatment solely on the basis of the decision of the physician. The increased presence of the virus in the brain may be related to changes to the immune system due to Alzheimer's disease. Physicians think antibiotics could have saved the lives of 37% of these patients. MMFierer We expect that there are some international differences in importance attached to specific factors relating to treatment decisions. WRInfectious diseases and mortality among US nursing home residents. The frequency of pneumonia-associated death among 19 eligible studies was 29.69% (95% confidence interval [CI], 25.8633.53). Customize your JAMA Network experience by selecting one or more topics from the list below. Earlier studies13,47,50,51 indicated that antibiotics were withheld in a quarter to half of patients, but these studies were not nationwide and included less severe infections than pneumonia. LADiscussions about limiting treatment in a geriatric clinic. van der Steen Understanding the circumstances in which this occurs can illuminate the international discussion of appropriate dementia care. ABishop 3 Gomes GF, Pisani JC, Macedo ED, Campos AC. TOoms In most Dutch hospitals and nursing homes, amoxicillin is the first drug choice in case of unknown pathogens,52 which is generally sufficient since antibiotic resistance is still not a major problem in the Netherlands.53 Physicians were willing at times to start more invasive procedures in more severely ill patients. RApolone Furthermore, we thank Ellen M. Buunk-Kampers for her administrative support and F. Boersma, MD, PhD, J. W. P. M. Konings, MD, PhD, and D. R. Mehr, MD, MS, for their critical review of early versions of the manuscript. Levin Silent pneumonia may have a greater impact as the direct cause of death than clinical presentation among older adults, especially those with advanced stages of dementia in the hospital setting. BJHurley The aims of the present study were to elucidate the frequency of pneumonia-associated death in older adults with dementia and how the frequency of pneumonia-associated death differ according to the data on cause of death (autopsy or death certificate). Even less is known on variation among physicians with respect to these considerations. Forgetting the name of an acquaintance. In our study, typically oral amoxicillin was given. Management of pneumonia in advanced dementia may exhibit considerable variation in treatment internationally. Cumulative meta-analysis using a random effects model for frequency of pneumonia-associated death is shown, by study. Detailed search strategy (Pubmed). Among all eligible studies including patients with dementia, the frequency of pneumonia as a cause of death was approximately 20% in studies using death certificates (Fig 3C); however, this frequency was approximately 50% in studies using autopsy reports in hospital settings (Fig 3B). Median recovery time for AB-palliative patients was 9 days. Pneumonia in people with dementia has been associated with severe discomfort. The present systematic review and meta-analysis revealed that the frequency of pneumonia-associated death in patients with dementia varied according to the information source, type of mortality cause, and study setting.
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