Study suggests antibiotics overused for dying dementia patients

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Harvard University

 

Study suggests antibiotics overused for dying dementia patients

Posted by Elizabeth Cooney

The Boston Globe

February 25, 2008 04:06 PM

 

Elderly patients with advanced dementia are seven times more likely

to receive antibiotics in their last two weeks of life than in the

two months before they die, despite little evidence that the drugs

prolong life or relieve suffering, a Harvard study reports. Overusing

the drugs can contribute to the development of microbes resistant to

antibiotics, a public-health hazard common in nursing homes.

 

Researchers from Harvard Medical School studied more than 214

patients with an average age of 85 in 21 Boston-area nursing homes.

Ninety-nine patients died during the 18-month study, which the

authors say is the first to look at antibiotic prescriptions for

people in the end stages of dementia. All the patients were in such

severe cognitive decline that they could talk little if at all, could

not walk, were incontinent, and needed help with eating.

 

Two-thirds of the patients received at least one course of

antibiotics during the study period, with an average of four courses

being given, authors Dr. Ericka D'Agata and Dr. Susan L. Mitchell

write in the Archives of Internal Medicine. Most patients got the

drugs intravenously, which can be uncomfortable, and some experienced

troubling side effects such as diarrhea.

 

 

In the last two weeks before they died, 42 percent of patients were

on antibiotics, " an extraordinary use of antimicrobials, which

increased dramatically at the end of life, " Mitchell, also of the

Hebrew Senior Life Institute for Aging Research, said in an interview.

 

" Huge amounts of antimicrobials in people who are very, very near the

end of life raise questions both about the individual benefit and

burden and about what is important on a broader level about

preventing antimicrobial resistance, " she said.

 

Fevers and infections are common in people at this stage of dementia,

creating an opportunity for families to be counseled ahead of time

about their goals for care of their loved one at the end of this

terminal disease, Mitchell said. If comfort is the key, symptoms of

pneumonia, the most common infection, can be eased by oxygen or

Tylenol, she said. If postponing death is the hope, there is little

in the medical literature to say that antibiotics help extend life.

 

In contrast, the growth of antibiotic resistance has been widely

documented, especially in long-term care settings. Because antibiotic

exposure is the greatest risk factor for antibiotic resistance,

Mitchell said, treating dying dementia patients with antibiotics may

promote resistance.

 

In an accompanying editorial, Dr. Mitchell J. Schwaber and Dr. Yehuda

Carmeli of Tel Aviv Medical Center argue that using antibiotics in

these patients requires the same degree of ethical deliberation as

avoiding them.

 

" If there is no benefit to the individual patient, the good of the

public health demands that antibiotic use be withheld, " they

write. " We must … begin to consider every decision to use antibiotics

in this population as we would decisions regarding other treatment

modalities, including resuscitation and major surgery. "

 

Alice Bonner, director of clinical quality at the Massachusetts

Extended Care Federation, a nursing-home association, said the study

points out the need for more discussion of advance directives, the

documents that patients and families use to make their wishes known

at the end of life. Antibiotic use in advanced dementia is very

common, she said in an interview, but less often broached in family

meetings than decisions on resuscitation or intubation, both of which

arise less often than antibiotic use.

 

" This is a huge issue that providers -- nurses, physicians, all of us

who work in nursing homes --deal with a lot, " said Bonner, who has

worked as a geriatric nurse practitioner in nursing homes for 20

years. " There's a need for more education around these advanced

directives and end-of-life issues so the public is more knowledgeable

and understands through studies like this that we aren't really

helping patients by doing these things. "

 

 

The Boston Globe

 

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