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Study characterizes clinical course of advanced dementia

Wednesday, October 28 2009 | Comments

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What's This? According to a recent analysis of nursing home residents with advanced dementia, this stage of the disease is often characterized by complications, such as pneumonia, which are associated with high 6-month mortality rates, and distressing symptoms, such as pain and dyspnea. In addition, the data suggest that patients with advanced dementia frequently undergo burdensome interventions with unclear clinical benefits, although such interventions are less likely in residents with health care proxies who understand the prognosis of the disease.

The study evaluated the clinical course of elderly patients with advanced dementia. Data were obtained from the CASCADE trial, a prospective cohort study that included 323 nursing home residents with advanced dementia and their health care proxies. Follow-up lasted 18 months.

During the study period, 54.8% of the seniors died, and the probability of death within 6 months was 24.7%.

The probability of >=1 episode of an eating problem was 85.8%, of a febrile episode, 52.6%, and of pneumonia, 41.1%. The adjusted 6-month mortality rates after developing these conditions were 38.6%, 44.5%, and 46.7%, respectively. The death rates for the residents with these conditions were substantially higher than for those without the conditions.

Distressing symptoms occurred in many of the residents as well: dyspnea for >=5 days per month (46.0%), pain for >=5 days per month (39.1%), stage II or higher pressure ulcers (38.7%), agitation (53.6%), and aspiration (40.6%). Among the residents who died, the proportion that experienced any of these complications (other than agitation) increased as death approached.

During the last 3 months of life, 40.7% of the residents underwent >=1 burdensome intervention, including hospitalization, an emergency department visit, parenteral therapy, or tube feeding.

Just 22.3% of the residents were referred to hospice care, and only 18.0% of the health care proxies said they had been given prognostic information from a physician.

In adjusted analyses, the residents whose proxies believed the patient had <6 months to live and understood the expected clinical complications of the resident's condition were significantly less likely to undergo burdensome interventions during the last 3 months of life as compared with the residents whose proxies did not have this knowledge (adjusted odds ratio, 0.12; 95% CI, 0.04-0.37). The likelihood of intervention was not associated with receipt of physician counseling. (Mitchell SL, et al. N Engl J Med 2009;361:1529-1538.)

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