title: Pneumonia, Intake Problems, and Survival Among Nursing Home Residents With Variable Stages of Dementia in the Netherlands: Results From a Prospective Observational Study.
abstract: OBJECTIVE
  We explored how pneumonia and intake problems affect survival in nursing home residents in variable stages of dementia.
  
  
  METHODS
  In a longitudinal observational study (372 residents) with up to 3.5 years of follow-up, we examined relationships between dementia severity, the development of pneumonia, intake problems, and mortality using joint modeling, Cox models, and mediation analyses. Dementia severity was measured semiannually with the Bedford Alzheimer Nursing Severity-Scale (BANS-S).
  
  
  RESULTS
  The median BANS-S score at baseline was 13 (range, 7 to 28). Pneumonia occurred in 103 (28%) and intake problems in 126 (34%) of 367 residents with complete registration of pneumonia and intake problems. Compared with dementia severity, incident pneumonia and, even more so, incident intake problems were more strongly associated with mortality risk. Pneumonia and intake problems both mediated the relationship between more severe dementia and mortality.
  
  
  CONCLUSIONS
  Developing pneumonia and intake problems affects survival, and this is not limited to advanced dementia. The occurrence of pneumonia and intake problems are important signals to consider a palliative care approach in nursing home residents with dementia, and an active focus on advance care planning is needed. Future studies should investigate whether this is also relevant for patients in primary care.
authors.affiliation: Departments of *General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research ‡Epidemiology and Biostatistics, VU University Medical Center, Amsterdam †Infectious Diseases, Epidemiology and Surveillance, Centre for Infectious Disease Control §Department of Statistics, Computer Science and Mathematical Modelling (SIM), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.
authors.forename: Simone A
authors.initials: SA
authors.lastname: Hendriks
authors.forename: Martin
authors.initials: M
authors.lastname: Smalbrugge
authors.forename: Arianne B
authors.initials: AB
authors.lastname: van Gageldonk-Lafeber
authors.forename: Francisca
authors.initials: F
authors.lastname: Galindo-Garre
authors.forename: Maarten
authors.initials: M
authors.lastname: Schipper
authors.forename: Cees M P M
authors.initials: CMPM
authors.lastname: Hertogh
authors.forename: Jenny T
authors.initials: JT
authors.lastname: van der Steen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003704:Dementia / Q000175:diagnosis* / Q000453:epidemiology* / Q000523:psychology; D004435:Eating / Q000502:physiology / Q000523:psychology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D009426:Netherlands / Q000453:epidemiology; D009735:Nursing Homes / Q000639:trends*; D011014:Pneumonia / Q000175:diagnosis* / Q000453:epidemiology* / Q000523:psychology; D011446:Prospective Studies; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends