Treatment strategy and risk of functional decline and mortality after nursing‐home acquired lower respiratory tract infection: two prospective studies in residents with dementia

Abstract

SUMMARYBackground Although lower respiratory tract infections (LRI) cause considerable morbidity and mortality among nursing home residents with dementia, the effects of care and treatment are largely unknown. Few large prospective studies have been conducted. Methods We pooled data from two large prospective cohort studies in 61 Dutch nursing homes and 36 nursing homes in the state of Missouri, United States. We included 551 US residents and 381 Dutch residents with dementia and LRI. Main outcome measures were 3-month mortality and decline in activities of daily living (ADL) function after 3 months compared with pre-illness status. Using multivariable multinomial logistic regression to control for confounding, we assessed associations of restraint use and antibiotic type (oral compared with parenteral), with outcomes of lower respiratory tract infection (LRI). Survival without ADL decline was the reference category. Results After multivariable adjustment, restraint use was associated with ADL decline (OR 1.9, 95% CI 1.1-3.3). Oral antibiotics were not associated with 3-month mortality (OR 0.83; 95% CI 0.56-1.2). Severe dementia was the strongest independent predictor of decline; mortality was most strongly associated with male gender. Conclusions Among Dutch and US nursing home residents with dementia and LRI, restrained residents suffered more decline. Parenteral antibiotic treatment was not associated with better outcome in residents at low to moderate risk of mortality. Aggressive treatment strategies may provide little benefit for the majority of nursing home residents with dementia and LRI.

Discomfort in dementia patients dying from pneumonia and its relief by antibiotics

“…Including discomfort at t0 in our analyses, we adjusted for a large number of potential confounders of associations of treatment with discomfort shortly before death. Post-hoc pooling of data of large observational studies has been shown to be a powerful method to detect treatment effects, including effects of type of antibiotic treatment on mortality [10,19,20]. The studies conducted were large and well representative of the Netherlands, but associations with antibiotics were assessed mainly in the context of the Pneumonia Study in the late 1990s, when few treatments were provided to relieve symptoms in the Netherlands [11] and also in the US [21].…”

Factors Associated With Time to Identify Physical Problems of Nursing Home Residents With Dementia

“…At least 45% have musculoskeletal, genitourinary and/or ear, nose and throat disorders, with 48% of people at moderate stages and 69% at the severe stage of dementia having genitourinary disorders 3. Pneumonia is the leading cause of death with six month mortality rates reported at 36.4% to over 50% 4,5. These problems are discomforting and are associated with increased use of costly acute care services 6.…”

A prospective study of the effect of nursing home residency on mortality following hip fracture

“…Medical comorbidities (e.g. dementia, pneumonia) have been used as predictors of mortality 9,10 but accurate measurement of comorbidities is hampered by different grades of severity of disease, multiplicity of diseases, and the interplay between various comorbidities 11,12 …”