Antimicrobial use among demented in nursing homes
Source: D'Agata E, Mitchell SL. Patterns of antimicrobial use among nursing home residents with advanced dementia. Arch Intern Med 2008; 168:357-362.
By Carol A. Kemper, MD, FACP, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Palo Alto, CA; Associate Editor for Infectious Disease Alert, published by AHC Media; Atlanta.
Researchers from Harvard Medical School examined antibiotic use in a group of elderly, demented patients residing in 21 nursing homes in the Boston area, focusing on the weeks prior to death. All of the patients were severely impaired, incontinent, unable to feed themselves, and could not ambulate without assistance. They couldn't speak or could speak only a little. Data on medical conditions and antibiotic use were collected for a total of 214 patients during an 18-month period. During the study, 99 patients died.
In these 99 subjects, an average of four courses of antibiotics was administered during the study period, most of which was parenteral administration. Two-thirds of the patients received at least one course of antibiotics. In the two weeks prior to death, 42% received antibiotics, although the indications for use were not always clear. Many patients simply had fever.
Patients who died in their last two weeks of life were seven times more likely to receive antibiotics in the last two weeks of their life compared with the preceding two months. Side effects were common, such as discomfort at the IV site or diarrhea.
The authors expressed concern regarding a lack of data supporting antibiotics as an end-of-life measure to extend life. Antibiotic use in such circumstances might not only be futile, but costly, and might result in frequent side effects and discomfort. It also contributes to rates of bacterial resistance, especially in nursing homes, where resistant organisms are common.
It is my frequent experience that families agreeing to comfort care measures for a family member or loved one often agree to dispense with various interventions but, nonetheless, request that "antibiotics be continued," despite a reasonable course of therapy or sometimes well after it is apparent they no longer are effective. The hospitalists at our facility refer to this as "ordering health care from a menu of options." The psychology or emotion behind this request is mystifying. Patients and families should be informed that the use of IV antibiotics is as significant an intervention (or more so) than blood tests or radiographic studies. Our society allows people to succumb to cancer but has lost the concept of allowing people to succumb to infection. Families should be educated that infection represents a good death and is an expected and common outcome for a demented, institutionalized older person.
Researchers from Harvard Medical School examined antibiotic use in a group of elderly, demented patients residing in 21 nursing homes in the Boston area, focusing on the weeks prior to death.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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