Sex-Specific Differences in End-of-Life Burdensome Interventions and Antibiotic Therapy in Nursing Home Residents With Advanced Dementia

Stall, Nathan M.; Fischer, Hadas D.; Fung, Kinwah; Giannakeas, Vasily; Bronskill, Susan E.; Austin, Peter C.; Matlow, Jeremy N.; Quinn, Kieran L.; Mitchell, Susan L.; Bell, Chaim M.; Rochon, Paula A.

doi:10.1001/jamanetworkopen.2019.9557

Cited by 31 publications

(31 citation statements)

References 67 publications

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“…Alternatively, a palliative care physician might have been involved in situations involving complicated goals of care discussions if discordance in care plans existed between patients with dementia or their caregivers and their treating physicians. Previous work has shown a concerning rate of potentially burdensome interventions delivered in acute care settings near the end of life in this vulnerable population, especially for those who live in nursing homes 35859. In our study, 72% of patients who died from dementia lived in a nursing home.…”

Section: Discussionmentioning

confidence: 65%

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Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study

Quinn

Stukel

Stall

et al. 2020

BMJ

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Abstract Objective To measure the associations between newly initiated palliative care in the last six months of life, healthcare use, and location of death in adults dying from non-cancer illness, and to compare these associations with those in adults who die from cancer at a population level. Design Population based matched cohort study. Setting Ontario, Canada between 2010 and 2015. Participants 113 540 adults dying from cancer and non-cancer illness who were given newly initiated physician delivered palliative care in the last six months of life administered across all healthcare settings. Linked health administrative data were used to directly match patients on cause of death, hospital frailty risk score, presence of metastatic cancer, residential location (according to 1 of 14 local health integration networks that organise all healthcare services in Ontario), and a propensity score to receive palliative care that was derived by using age and sex. Main outcome measures Rates of emergency department visits, admissions to hospital, and admissions to the intensive care unit, and odds of death at home versus in hospital after first palliative care visit, adjusted for patient characteristics (such as age, sex, and comorbidities). Results In patients dying from non-cancer illness related to chronic organ failure (such as heart failure, cirrhosis, and stroke), palliative care was associated with reduced rates of emergency department visits (crude rate 1.9 (standard deviation 6.2) v 2.9 (8.7) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.85 to 0.91), admissions to hospital (crude rate 6.1 (standard deviation 10.2) v 8.7 (12.6) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.86 to 0.91), and admissions to the intensive care unit (crude rate 1.4 (standard deviation 5.9) v 2.9 (8.7) per person year; adjusted rate ratio 0.59, 95% confidence interval 0.56 to 0.62) compared with those who did not receive palliative care. Additionally increased odds of dying at home or in a nursing home compared with dying in hospital were found in these patients (n=6936 (49.5%) v n=9526 (39.6%); adjusted odds ratio 1.67, 95% confidence interval 1.60 to 1.74). Overall, in patients dying from dementia, palliative care was associated with increased rates of emergency department visits (crude rate 1.2 (standard deviation 4.9) v 1.3 (5.5) per person year; adjusted rate ratio 1.06, 95% confidence interval 1.01 to 1.12) and admissions to hospital (crude rate 3.6 (standard deviation 8.2) v 2.8 (7.8) per person year; adjusted rate ratio 1.33, 95% confidence interval 1.27 to 1.39), and reduced odds of dying at home or in a nursing home (n=6667 (72.1%) v n=13 384 (83.5%); adjusted odds ratio 0.68, 95% confidence interval 0.64 to 0.73). However, these rates differed depending on whether patients dying with dementia lived in the community or in a nursing home. No association was found between healthcare use and palliative care for patients dying from dementia who lived in the community, and these patients had increased odds of dying at home. Conclusions These findings highlight the potential benefits of palliative care in some non-cancer illnesses. Increasing access to palliative care through sustained investment in physician training and current models of collaborative palliative care could improve end-of-life care, which might have important implications for health policy.

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Section: Discussionmentioning

confidence: 65%

“…Patients nearing the end of life often have high rates of costly healthcare, including emergency department visits and admissions to hospital, which could be avoidable 1. These potentially burdensome interventions are associated with poor quality of life 12345678. Consequently, the demand for palliative care is rapidly growing.…”

Section: Introductionmentioning

confidence: 99%

Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study

Quinn

Stukel

Stall

et al. 2020

BMJ

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“…Sex affects the etiology, pathological symptoms, and therapeutic outcomes of several neurologic diseases. Initial studies suggested that AD prevalence is higher in women than in men, and the median age of death among women with advanced dementia is higher than that among men, but females live longer than males because of fewer comorbidities [9][10][11]. Sex also influences the effect of AD risk factors.…”

Section: Introductionmentioning

confidence: 99%

The behavioural and neuropathologic sexual dimorphism and absence of MIP-3α in tau P301S mouse model of Alzheimer’s disease

Sun

Guo

Feng

et al. 2020

J Neuroinflammation

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Background: Tau hyper-phosphorylation has been considered a major contributor to neurodegeneration in Alzheimer's disease (AD) and related tauopathies, and has gained prominence in therapeutic development for AD. To elucidate the pathogenic mechanisms underlying AD and evaluate therapeutic approaches targeting tau, numerous transgenic mouse models that recapitulate critical AD-like pathology have been developed. Tau P301S transgenic mice is one of the most widely used mouse models in AD research. Extensive studies have demonstrated that sex significantly influences AD pathology, behavioral status, and therapeutic outcomes, suggesting that studies using mouse models of AD must consider sex-and age-related differences in neuropathology, behavior, and plasma content. Method: We systematically investigated differences in tau P301S transgenic mice (PS19 line) and wildtype littermates of different sex behavioral performance, tau neuropathology, and biomarkers in plasma and brain. Results: Male P301S transgenic mice exhibited significant changes in weight loss, survival rate, clasping, kyphosis, composite phenotype assessment, nest building performance, tau phosphorylation at Ser202/Thr205, and astrocyte activation compared to that of wild-type littermates. In contrast, female P301S transgenic mice were only sensitive in the Morris water maze and open field test. In addition, we characterized the absence of macrophage-inflammatory protein (MIP-3α) and the upregulation of interferon (IFN)-γ, interleukin (IL)-5, and IL-6 in the plasma of P301S transgenic mice, which can be served as potential plasma biomarkers in P301S Tg mice. Male P301S transgenic mice expressed more monokine induced by IFN-γ (MIG), tumor necrosis factor-α (TNF-α), IL-10, and IL-13 than those of female P301S mice. Conclusion: Our findings highlight sexual dimorphism in the behavior, neuropathology, and plasma proteins in tau P301S transgenic AD mice, indicating that the use of male P301S transgenic mice may be more suitable for assessing anti-phosphorylated tau therapeutic strategies for AD and related tauopathies, and the MIP-3α may be a new potential plasma biomarker.

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“…In residents both with and without dementia, men were more likely to receive new medications of questionable benefit prior to death. A previous study has pointed toward sexspecific differences in dementia care, with men more commonly receiving burdensome interventions at the end of life [53]. The differences between men and women may be more related to social contexts than biological phenomena, i.e., gender-based differences in the provision of care or different attitudes toward death [53][54][55].…”

Section: Comparison With Other Studiesmentioning

confidence: 98%

Prescribing medications of questionable benefit prior to death: a retrospective study on older nursing home residents with and without dementia in Germany

Rausch

Hoffmann

2020

Eur J Clin Pharmacol

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Purpose We studied the prevalence of medications of questionable benefit in the last 6 months of life among older nursing home residents with and without dementia in Germany. Methods A retrospective cohort study was conducted on claims data from 67,328 deceased nursing home residents aged 65+ years who were admitted between 2010 and 2014. We analyzed prescription regimens of medications of questionable benefit in the 180-91-day period and the 90-day period prior to death for residents with dementia (n = 29,052) and without dementia (n = 38,276). Factors associated with new prescriptions of medications of questionable benefit prior to death were analyzed using logistic regression models among all nursing home residents and stratified by dementia. Results A higher proportion of nursing home residents with dementia were prescribed at least one medication of questionable benefit in the 180-91-day (29.6%) and 90-day (26.8%) periods prior to death, compared with residents without dementia (180-91 days, 22.8%; 90 days, 20.1%). Lipid-lowering agents were the most commonly prescribed medications. New prescriptions of medications of questionable benefit were more common among residents with dementia (9.8% vs. 8.7%). When excluding antidementia medication, new prescriptions of these medications were more common among residents without dementia (6.4% vs. 8.0%). The presence of dementia (odds ratio [OR] 1.40, 95% confidence interval [95%CI] 1.32-1.48) and excessive polypharmacy were associated with new prescriptions of medications of questionable benefit prior to death (OR 4.74, 95%CI 4.15-5.42). Conclusion Even when accounting for anti-dementia prescriptions, the prevalence of nursing home residents with dementia receiving medications of questionable benefit is considerable and may require further attention.

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Sex-Specific Differences in End-of-Life Burdensome Interventions and Antibiotic Therapy in Nursing Home Residents With Advanced Dementia

Cited by 31 publications

References 67 publications

Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study

Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study

The behavioural and neuropathologic sexual dimorphism and absence of MIP-3α in tau P301S mouse model of Alzheimer’s disease

Prescribing medications of questionable benefit prior to death: a retrospective study on older nursing home residents with and without dementia in Germany

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