To our knowledge, this prospective cohort study respresents the most rigorous effort to date to examine treatment outcomes of suspected pneumonia in advanced dementia. We found that antimicrobial agents are commonly prescribed (91%) for pneumonia episodes in this cohort. Survival was prolonged among residents who received antimicrobial treatment compared with those who were untreated. At the same time, our findings suggest that treatment with antimicrobial agents does not improve the comfort of residents with advanced dementia who have pneumonia, and more aggressive care may be associated with greater discomfort.
Short of a randomized trial, this study offers several advances over prior work that has examined the outcomes of antimicrobial treatment for suspected pneumonia in end-stage dementia.12–15
First, it is the largest prospective cohort study of NH residents rigorously defined as having advanced dementia conducted to date. Second, it extends earlier research by adjusting for clinical characteristics that are associated with the likelihood of receiving treatment. Finally, it examined residents who received no antimicrobial treatment and compared them with residents who received treatment by different routes. With these approaches, we report, for the first time, a strong association between antimicrobial treatment by any route and improved survival after pneumonia in persons with advanced dementia.
Comfort is often a main goal of care in advanced dementia,27
and it is an important concern when treatment options are being considered. Interventions such as parenteral therapy and hospital transfers can be burdensome for the frail elderly.28
Pneumonia is associated with discomfort in end-stage dementia,15
and some prior studies suggest that antimicrobial use may reduce that discomfort.14,15
Among residents who did not die in the 90 days after a suspected pneumonia episode, we found lower comfort levels in those who received antimicrobial treament compared with no treatment, as well as an association between greater discomfort and more aggressive routes of treatment. Although we cannot distinguish whether the residents’ discomfort was attributable to their pneumonia or to the treatment that they received, our analyses more fully adjusted for markers of episode severity as well as for other conditions and interventions that may cause discomfort compared with prior studies.14,15
High-quality medical decision making requires weighing the risks and benefits of treatment options against the primary goal of care. Taken together, our results suggest that when the most important goal for a resident with advanced dementia is to prolong survival, even if treatment may cause discomfort, then antimicrobial treatment may extend life by as much as 9 months after suspected pneumonia. However, for these residents, providers and family should consider limiting treatment to oral antimicrobial agents (or intramuscular if oral administration is not possible), which appear to achieve the same survival benefit, but with potentially less individual burden and health care costs, compared with more aggressive management approaches (eg, intravenous antimicrobial treatment or hospitalization). On the other hand, our results suggest that for residents with advanced dementia and suspected pneumonia for whom the primary goal of care is comfort, or for whom it is thought that an additional few months of life with advanced dementia will not outweigh the potential burdens of antimicrobial treatment, these agents should be withheld and palliation provided.
This study should be considered in light of certain limitations. First, it is an observational study and not a randomized trial. Therefore, although we used multivariable techniques, it is possible that unmeasured sources of bias or confounding limit the validity of our findings. However, we evaluated potential confounders, including markers of disease severity, resident functional status, measures of comfort care, and advance care planning. Second, suspected pneumonia episodes were identified using NH records. Although strict confirmation of infections was not obtained, our approach represents the real-world practices of treating frail NH residents for whom treatment decisions for infections are often made empirically, without extensive testing to firmly establish diagnostic criteria. However, we note that pneumonia was confirmed in 84% of cases in which a chest radiograph was obtained. While the absolute number of residents who did not receive antimicrobial treatment was relatively small, detectable differences were still found in both the survival and the comfort outcomes among treatment groups. Furthermore, this study did not analyze outcomes related to the use of specific antimicrobial agents; it analyzed only their route of administration. Lastly, the CASCADE study was limited to the Boston area and mostly white residents, and the generalizability of our findings to other geographic areas or racial groups is uncertain. However, the facility and resident characteristics are comparable to similar cohorts nationwide.17
This study’s findings have important implications for practice. The management of infections, especially pneumonia, is one of the common decisions confronting the families and practitioners who are providing care to the growing number of Americans with advanced dementia residing in NHs.16
For these patients, our results indicate that antimicrobial treatment for suspected pneumonia may be a double-edged sword, as it was associated with both survival and discomfort. These observations may help families and providers of residents with advanced dementia align the potential advantages and disadvantages of antimicrobial treatment with their goals of care.