title: Severe dementia and adverse outcomes of nursing home-acquired pneumonia: evidence for mediation by functional and pathophysiological decline.
abstract: OBJECTIVE
  To assess whether the severity of dementia is related to unfavorable outcomes of nursing home-acquired pneumonia and how this relationship is mediated.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  Psychogeriatric wards of 61 nursing homes in the Netherlands.
  
  
  METHODS
  Dementia severity and the possible mediators swallowing disturbance, aspiration, insufficient food intake, weight loss, and dehydration were measured and related to the following outcomes: death (rate), cure rate, and increase in discomfort at the onset of pneumonia.
  
  
  METHODS
  Demented patients (n = 374) treated with antibiotics for pneumonia.
  
  
  RESULTS
  Dementia severity was independently related to death rate within the first week after pneumonia (hazard rate ratio = 3.0 for the most severely demented quartile versus the least demented quartile, 95% confidence interval (CI) = 1.1-8.3) and to 3-month mortality (odds ratio (OR) 2.5, 95% CI = 1.1-5.4). The latter relation was in part mediated by aspiration and weight loss (OR dementia severity adjusted for these mediators declined from 2.5 to 1.9, 95% Cl = 0.8-4.3). Dementia severity was not related to cure rate within 2 weeks nor to an in-crease in discomfort after 3 days compared with before the pneumonia.
  
  
  CONCLUSIONS
  The functional and pathophysiological consequences of progressive dementia account in part for increased 3-month mortality after pneumonia. Mid-term mortality is expected to be high only in the most severely demented patients and in less severely demented patients who aspirated or who lost weight. Implications for end-of-life decision-making and effectiveness of preventive and curative interventions are discussed.
authors.affiliation: Department of Nursing Home Medicine, Institute for Research in Extramural Medicine (EMGO Institute), VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands. j.vandersteen@vumc.nl
authors.forename: Jenny T
authors.initials: JT
authors.lastname: van der Steen
authors.forename: Marcel E
authors.initials: ME
authors.lastname: Ooms
authors.forename: David R
authors.initials: DR
authors.lastname: Mehr
authors.forename: Gerrit
authors.initials: G
authors.lastname: van der Wal
authors.forename: Miel W
authors.initials: MW
authors.lastname: Ribbe
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003428:Cross Infection / Q000209:etiology*; D003704:Dementia / Q000150:complications* / Q000503:physiopathology*; D005260:Female; D006707:Homes for the Aged; D006801:Humans; D008297:Male; D008875:Middle Aged; D009735:Nursing Homes; D011014:Pneumonia / Q000209:etiology*; D011446:Prospective Studies; D012720:Severity of Illness Index