Pneumonia and other infections are a common complication of dementia. Often, pneumonia is listed as the cause of death rather than the dementia itself. The question comes with each infection – treat or not to treat? The answer to this question leads to another question. What is the ultimate care goal: quality of life or quantity of life?
Studies show that 50% of dementia patients pass away within six months of a pneumonia infection. The CASCADE study followed 300 dementia patients living in a nursing home. During the observation period, there were 225 episodes of pneumonia. Of those episodes, 91% were treated with antibiotics and 9% were not. The study found that the antibiotic group survived an average of 273 days longer than the non-antibiotic group. However, that same “quantity” group had a lower quality of life as measured by scores on the Symptom Management at End-of- Life in Dementia scale. With limited evidence that antibiotics help with dyspnea, swallowing difficulties that force the use of alternate and painful routes of administration and a greater likelihood of hospitalization, is it any wonder that quality of life decreases? That is without even discussing possible adverse reactions such as nausea, vomiting, diarrhea, light sensitivity, yeast infections and the risk of Clostridium Difficile.
Second to pneumonia, urinary tract infections (UTIs) are the next most commonly treated infections in dementia patients. The Society for Healthcare Epidemiology of America (SHEA) has pinpointed UTIs as the most common reason for antibiotic misuse, which is due to a number of factors in this population. Most dementia patients will test positive for bacteriuria yet show no signs of infection like fever or lethargy. Communication is difficult with late-stage dementia patients and incontinence is so common in the elderly making discerning classic UTI symptoms nearly impossible. Is it any wonder then that as many as 67% of nursing home patients are colonized with drug resistant organisms? Symptoms such as a low grade fever, night sweats or sudden mental status changes should be observable before a UTI is diagnosed and treatment is considered. See decision tree below.
Antibiotic use in hospice is a controversial issue. Are they life sustaining treatments that should no longer be covered or are they comfort measures which should be covered? Whichever side a person leans, studies have shown that although antibiotics may increase quantity of life, the quality of that life is subpar. If quantity is the goal, be sure of an infection by verifying with signs and symptoms, not solely on culture alone, before starting antibiotics. Unnecessarily treating an infection is not only detrimental to the patient but to everyone because of the development of drug resistant organisms.
Agata, E. D., Loeb, M. B. and Mitchell, S. L. Agata, E., Loeb, M., & Mitchell, S. (2013). Challenges in Assessing Nursing Home Residents with Advanced Dementia for Suspected Urinary Tract Infections. Journal Of The American Geriatrics Society, 61(1), 62-66. doi:10.1111/jgs.12070
Mitchell SL, Kiely DK, Jones RN, Prigerson H, Volicer L, Teno JM. Advanced Dementia Research in the Nursing Home: The CASCADE Study. Alzheimer disease and associated disorders. 2006;20(3):166-175.
Caring for the Patient With End-Stage Dementia | Managed Health Care Connect Caring for the Patient With End-Stage Dementia | Managed Health Care Connect. (2017). Managedhealthcareconnect.com. Retrieved 2 June 2017, from http://www.managedhealthcareconnect.com/article/caring-patient-end-stage-dementia
Palliative care of patients with advanced dementia Palliative care of patients with advanced dementia. (2017). Uptodate.com. Retrieved 2 June 2017, from http://www.uptodate.com/contents/palliative-care-of-patients-with-advanced-dementia
Saliba, W., Nitzan, O., Chazan, B. and Elias, M. Saliba, W., Nitzan, O., Chazan, B., & Elias, M. (2015). Urinary tract infections in patients with type 2 diabetes mellitus: review of prevalence, diagnosis, and management. Diabetes, Metabolic Syndrome And Obesity: Targets And Therapy, 129. doi:10.2147/dmso.s51792