Antibiotic Use for Dying Nursing Home Patients with
Advanced Dementia Raises Questions
Frequent use two weeks before death may
endanger other patients
Feb. 25, 2008 - Antibiotics appear to be frequently
prescribed to individuals with advanced dementia in nursing homes,
especially in the two weeks before death, according to a report in the
February 25 issue of Archives of Internal Medicine, one of the JAMA/Archives
journals. An editorial in the issue asks if this is really good for the patients and if it
does not increase risk for the other patients.
More than 5 million Americans have dementia,
according to background information in the article. About 70 percent of
them will live in nursing homes at the end of their lives. Recurrent
infections and fever are common among these patients, who may receive
antibiotics to treat these conditions.
Erika DAgata, M.D., M.P.H., of Beth Israel
Deaconess Medical Center, Harvard Medical School, Boston, and colleagues
studied 214 residents (average age 85.2) with advanced dementia living
in 21 area nursing homes.
The participants underwent an initial assessment
between 2003 and 2006 and then were examined every three months for a
maximum of 18 months. At each evaluation, the number of courses of
antibiotic therapy prescribed since the prior visit was obtained from
facility records.
During an average of 322 days of follow-up, 142
(66.4 percent) participants received at least one course of antibiotics
and the overall average was four courses. Of the 99 (46.3 percent)
residents who died, 42 (42.4 percent) received antibiotics during the
two weeks before their death.
The proportion of residents taking antimicrobials
was seven times greater in the last two weeks of life compared with six
to eight weeks before death, the authors write.
Thirty of the 72 courses (41.7 percent) in the last
two weeks of life were administered intravenously rather than by mouth,
a method that may be uncomfortable for patients with advanced dementia.
This extensive use of antimicrobials and pattern
of antimicrobial management in advanced dementia raises concerns not
only with respect to individual treatment burden near the end of life
but also with respect to the development and spread of antimicrobial
resistance in the nursing home setting, the authors write.
The results support the development of programs
and guidelines designed to reduce the use of antimicrobial agents in
advanced dementia.
Editorial: Antibiotics raise ethical dilemmas that
must be solved individually
The findings in this study require the medical
community to ask whether the extensive use of antibiotics in this
particular patient population is appropriate, taking two factors into
consideration: the benefit to the patient treated and the risk imposed
on other patients, write Mitchell J. Schwaber, M.D., M.Sc., and Yehuda
Carmeli, M.D., M.P.H., of the Tel Aviv Medical Center, Israel, in an
accompanying editorial.
The solution is not to categorically deny
antibiotics to the severely demented elderly, or even to impose limits
on their use or their spectrum as a matter of policy, they continue.
We must, however, begin to consider every decision
to use antibiotics in this population as we would decisions regarding
other treatment modalities, including resuscitation and major surgery.
That is, we must ask whether the interests of the patient are being
served by using antibiotics. We must further ask whether the use of
antibiotics in each specific patient justifies the risk placed on others
by their use.
All such decisions must ultimately be made
individually, based on the medical situation and the expressed wishes of
the patient and family, as well as on the physicians judgment of the
benefits and risks entailed in treating vs. not treating, they
conclude.
Editor's Note: This study was supported by a grant
from the National Institute on Aging, National Institutes of Health.
