title: Dying with advanced dementia in long-term care geriatric institutions: a retrospective study.
abstract: OBJECTIVE
  The aim of this study is to describe the last month of life of severely demented elders in long-term care institutions, and the clinical decisions in the management of their end-of-life events.
  
  
  METHODS
  Retrospective exploratory study.
  
  
  METHODS
  Seven Italian long-term care institutions with more than 200 beds.
  
  
  METHODS
  One hundred forty-one patients with advanced (FAST stage = 7c) dementia (Alzheimer disease, vascular, other kinds of dementia, severe cognitive impairment).
  
  
  METHODS
  Diagnosis, Mini-Mental State Examination, cause of death. Data were collected from clinical and nursing records referring to the last 30 days of life: symptoms and signs, intensity and incidence, treatments (antibiotics, analgesics, anxiolytics, antidepressants, artificial nutrition/hydration, and use of restraints); the last 48 hours: cardiopulmonary resuscitation attempts and life-sustaining drugs.
  
  
  RESULTS
  Patients were given antibiotics (71.6%), anxiolytics (37.1%), and antidepressants (7.8%). Twenty-nine patients (20.5%) were tube- or percutaneous endoscopic gastrostomy (PEG)-fed. Most patients (66.6%) were also parenterally hydrated (72 intravenously, 15 by hypodermoclysis). Some form of physical restraint was used for 58.2% (bed-rails and other immobilizers). Almost half of the patients had pressure sores. In general, attention to physical suffering was fairly good, but during the last 48 hours a number of interventions could be considered inappropriate for these patients: tube feeding (20.5%), intravenous hydration (66.6%), antibiotics (71.6%), and life-sustaining drugs (34.0%).
  
  
  CONCLUSIONS
  Some indicators imply a less than optimal quality of care (restraints, pressure sores, psychoactive drugs, and the lack of documentation of shared decision-making) and suggest that far advanced demented patients are not fully perceived as "terminal."
authors.affiliation: Department of Public Health and Microbiology Faculty of Medicine and Surgery, Turin University, Turin, Italy. digiulio@marionegri.it
authors.forename: Paola
authors.initials: P
authors.lastname: Di Giulio
authors.forename: Franco
authors.initials: F
authors.lastname: Toscani
authors.forename: Daniele
authors.initials: D
authors.lastname: Villani
authors.forename: Cinzia
authors.initials: C
authors.lastname: Brunelli
authors.forename: Simona
authors.initials: S
authors.lastname: Gentile
authors.forename: Patrizia
authors.initials: P
authors.lastname: Spadin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003704:Dementia / Q000401:mortality*; D005260:Female; D005851:Geriatric Nursing; D006801:Humans; D007558:Italy; D008134:Long-Term Care; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D012189:Retrospective Studies; D013727:Terminal Care / Q000379:methods*