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Medical Treatment of Acute Illnesses in End-Stage Dementia

Medical Treatment of Acute Illnesses in End-Stage Dementia Data are presently scarce regarding the prognosis of severely demented patients who develop an acute illness. In general, it is perceived that survival in end-stage dementia following acute illness is very poor. Along this line, a recent survey published in the ARCHIVES on the attitude of Netherland physicians indicates that antibiotic treatment is commonly withheld in severely demented patients affected by pneumonia.1 Similarly, Morrison and Sia2 concluded that given the limited life expectancy of patients with end-stage dementia following acute illnesses and the burdens associated with their treatment, increased attention should be focused on palliation of symptoms and enhancement of comfort rather than on the application of burdensome interventions directed at life prolongation. We would like to contribute to this important issue by presenting data obtained in our Acute Care for the Elderly (ACE)–Medical Unit in Brescia, Italy. We have observed the 6-month survival of inpatients admitted with pneumonia and that of inpatients with acute noninfectious conditions (eg, gastroesophageal bleeding, dehydration, delirium, heart failure, and stroke). For the study's aim, patients were divided into 3 groups: (1) those with absent to moderate cognitive impairment (Mini-Mental State Examination3 score >12); (2) those with severe dementia (Mini-Mental State Examination score ≤12) not bedridden; and (3) those with end-stage dementia (bedridden). The clinical characteristics of the population are reported in Table 1 according to the level of cognitive impairment. View LargeDownload Characteristics and 6-Month Mortality Rate of 1297 Inpatients According to Their Dementia and Disability Status* At 6 months, mortality was 80% for patients with end-stage dementia and pneumonia and 63.6% for end-stage dementia with noninfectious conditions. These data indicate that any medical condition of demented patients increases the risk of death. Under this perspective, the question of withholding therapies by offering only palliative care concerns all severely demented patients affected by pneumonia and those affected by acute conditions sufficiently severe to require hospitalization. It should be also noted that 6 months after hospitalization, a sizable proportion (20%) of end-stage demented patients hospitalized with pneumonia were still alive. Should we be allowed to withhold antibiotic treatment in these patients? Since we were unable to solve this dilemma in our ACE unit, we decided to follow the American Thoracic Society guidelines for the treatment of pneumonia also in patients with advanced dementia. Nevertheless, in providing treatment for specific diseases in severely demented patients we do not imply withholding palliative care for pain and other subjectively distressing conditions. We should reach a level of equilibrium in the management of demented persons with somatic diseases, performing a mix of therapeutic procedures, sometimes subjectively "uncomfortable," and palliative care directed to the well-being of patients. References 1. van der Steen JTOoms MEAder HJRibbe MWvan der Wal G Withholding antibiotic treatment in pneumonia patients with dementia: a quantitative observational study. Arch Intern Med. 2002;1621753- 1760Google ScholarCrossref 2. Morrison RSSiu AL Survival in end-stage dementia following acute illness. JAMA. 2000;28447- 52Google ScholarCrossref 3. Folstein MFFolstein SEMcHugh PR "Mini-Mental State": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12189- 198Google ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Medical Treatment of Acute Illnesses in End-Stage Dementia

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Publisher
American Medical Association
Copyright
Copyright © 2003 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.163.4.496
Publisher site
See Article on Publisher Site

Abstract

Data are presently scarce regarding the prognosis of severely demented patients who develop an acute illness. In general, it is perceived that survival in end-stage dementia following acute illness is very poor. Along this line, a recent survey published in the ARCHIVES on the attitude of Netherland physicians indicates that antibiotic treatment is commonly withheld in severely demented patients affected by pneumonia.1 Similarly, Morrison and Sia2 concluded that given the limited life expectancy of patients with end-stage dementia following acute illnesses and the burdens associated with their treatment, increased attention should be focused on palliation of symptoms and enhancement of comfort rather than on the application of burdensome interventions directed at life prolongation. We would like to contribute to this important issue by presenting data obtained in our Acute Care for the Elderly (ACE)–Medical Unit in Brescia, Italy. We have observed the 6-month survival of inpatients admitted with pneumonia and that of inpatients with acute noninfectious conditions (eg, gastroesophageal bleeding, dehydration, delirium, heart failure, and stroke). For the study's aim, patients were divided into 3 groups: (1) those with absent to moderate cognitive impairment (Mini-Mental State Examination3 score >12); (2) those with severe dementia (Mini-Mental State Examination score ≤12) not bedridden; and (3) those with end-stage dementia (bedridden). The clinical characteristics of the population are reported in Table 1 according to the level of cognitive impairment. View LargeDownload Characteristics and 6-Month Mortality Rate of 1297 Inpatients According to Their Dementia and Disability Status* At 6 months, mortality was 80% for patients with end-stage dementia and pneumonia and 63.6% for end-stage dementia with noninfectious conditions. These data indicate that any medical condition of demented patients increases the risk of death. Under this perspective, the question of withholding therapies by offering only palliative care concerns all severely demented patients affected by pneumonia and those affected by acute conditions sufficiently severe to require hospitalization. It should be also noted that 6 months after hospitalization, a sizable proportion (20%) of end-stage demented patients hospitalized with pneumonia were still alive. Should we be allowed to withhold antibiotic treatment in these patients? Since we were unable to solve this dilemma in our ACE unit, we decided to follow the American Thoracic Society guidelines for the treatment of pneumonia also in patients with advanced dementia. Nevertheless, in providing treatment for specific diseases in severely demented patients we do not imply withholding palliative care for pain and other subjectively distressing conditions. We should reach a level of equilibrium in the management of demented persons with somatic diseases, performing a mix of therapeutic procedures, sometimes subjectively "uncomfortable," and palliative care directed to the well-being of patients. References 1. van der Steen JTOoms MEAder HJRibbe MWvan der Wal G Withholding antibiotic treatment in pneumonia patients with dementia: a quantitative observational study. Arch Intern Med. 2002;1621753- 1760Google ScholarCrossref 2. Morrison RSSiu AL Survival in end-stage dementia following acute illness. JAMA. 2000;28447- 52Google ScholarCrossref 3. Folstein MFFolstein SEMcHugh PR "Mini-Mental State": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12189- 198Google ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Feb 24, 2003

Keywords: dementia

References