Survival and comfort after treatment of pneumonia in advanced dementia.
BACKGROUND
Pneumonia is common among patients with advanced dementia, especially toward the end of life. Whether antimicrobial treatment improves survival or comfort is not well understood. The objective of this study was to examine the effect of antimicrobial treatment for suspected pneumonia on survival and comfort in patients with advanced dementia.


METHODS
From 2003 to 2009, data were prospectively collected from 323 nursing home residents with advanced dementia in 22 facilities in the area of Boston, Massachusetts. Each resident was followed up for as long as 18 months or until death. All suspected pneumonia episodes were ascertained, and antimicrobial treatment for each episode was categorized as none, oral only, intramuscular only, or intravenous (or hospitalization). Multivariable methods were used to adjust for differences among episodes in each treatment group. The main outcome measures were survival and comfort (scored according to the Symptom Management at End-of-Life in Dementia scale) after suspected pneumonia episodes.


RESULTS
Residents experienced 225 suspected pneumonia episodes, which were treated with antimicrobial agents as follows: none, 8.9%; oral only, 55.1%, intramuscular, 15.6%, and intravenous (or hospitalization), 20.4%. After multivariable adjustment, all antimicrobial treatments improved survival after pneumonia compared with no treatment: oral (adjusted hazard ratio [AHR], 0.20; 95% confidence interval [CI], 0.10-0.37), intramuscular (AHR, 0.26; 95% CI, 0.12-0.57), and intravenous (or hospitalization) (AHR, 0.20; 95% CI, 0.09-0.42). After multivariable adjustment, residents receiving any form of antimicrobial treatment for pneumonia had lower scores on the Symptom Management at End-of-Life in Dementia scale (worse comfort) compared with untreated residents.


CONCLUSIONS
Antimicrobial treatment of suspected pneumonia episodes is associated with prolonged survival but not with improved comfort in nursing home residents with advanced dementia.
Givens
Jane L
JL
Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA. JaneGivens@hrca.harvard.edu
Jones
Richard N
RN
Shaffer
Michele L
ML
Kiely
Dan K
DK
Mitchell
Susan L
SL
D000203:Activities of Daily Living; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D016001:Confidence Intervals; D003704:Dementia / Q000150:complications* / Q000401:mortality; D004333:Drug Administration Routes; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008134:Long-Term Care; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D016017:Odds Ratio; D011014:Pneumonia / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D011446:Prospective Studies; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents