Erika D’Agata, MD, MPH, is an associate professor of medicine at Harvard Medical School and is on staff in the Department of Medicine at Beth Israel Deaconess Medical Center in Boston, Massachusetts.
A new study has identified a trend toward the increased prescription of antimicrobials as patients with advanced dementia approach death. Some heath experts wonder whether guidelines ought to be rewritten, given that we know widespread use of antibiotics (a type of antimicrobial) among elderly patients in nursing homes is a factor behind the development of antibiotic-resistant strains of bacteria, which has become a significant public health threat.
Boston researchers examined 214 nursing home residents with advanced dementia for an ongoing, prospective study called Choices, Attitudes and Strategies for Care of Advanced Dementia at the End-of-Life (CASCADE). The researchers analyzed antimicrobial usage among these residents for 18 months or until the residents’ deaths. They found that two-thirds of the residents (66%) received at least one course of antibiotics. During the final eight weeks of life antimicrobials were used to treat infections, including those of the respiratory tract (64%)… urogenital tract (18%)… skin (17%)… and gastrointestinal tract (2%). During the course of the study, nearly half of the patients (99 patients) died and nearly half of those (42%) received antimicrobials within the last two weeks of life. As the residents approached death, researchers noted that the number of antibiotics prescribed increased significantly. The study was published in the February 25, 2008, issue of the Archives of Internal Medicine.
I asked study coauthor Erika D’Agata, MD, MPH, associate professor of medicine at Harvard Medical School, about the study’s implications. She explained that infections are very common among patients with advanced dementia since they typically have multiple comorbidities and are bedridden. These infections are commonly treated with antibiotics, in part because it is a standard medical practice, but also because it’s often what family members want, she said. Dr. D’Agata noted that the study results raise questions about whether they actually help patients feel better or prolong their lives, adding that future studies are planned to learn more.
Antibiotics do play a role in alleviating symptoms from some infections, such as pneumonia, thereby making patients with “end of life infections” more comfortable. Dr. D’Agata acknowledges, however, that it remains unclear if such treatment actually brings greater comfort than would other palliative therapies, such as oxygen and pain-relieving medications.
Patient comfort is a key concern, but we can’t afford to ignore the broad public health risk of antibiotic overuse in nursing home residents with advanced dementia. Dr. D’Agata explained that elderly persons tend to harbor antibiotic-resistant bacteria and are likely to live in nursing homes where antimicrobials are frequently prescribed. “Approximately 70% of persons with dementia will die in nursing homes,” said Dr. D’Agata, so “understanding these prescribing patterns is very important.”
The challenge is to balance compassionate care for people with end of life infections with the need for responsible antibiotic usage. One suggestion for caregivers is to develop an advance directive (a form that lists what treatments a person wants and does not want when he/she is ill and can no longer make decisions) soon after a patient is diagnosed with Alzheimer’s or dementia, keeping in mind the purpose and likely benefit of treatments. If the goal is simply palliative care, different therapies may keep patients comfortable without putting others at risk.