As people who have dementia develop advanced disease, neurological and functional deterioration predisposes them to lower respiratory tract infection (LRI), including pneumonia, which is often their immediate cause of death. Many question the appropriateness of aggressive care for these patients due to high mortality and the discomfort associated with aggressive care such as feeding tubes and intravenous fluids. Nevertheless, residents with dementia who develop LRI are treated much more aggressively in the United States than similar nursing home patients in the Netherlands. Dutch nursing homes focus on comfort care for these patients, according to a recent study that was supported in part by the Agency for Healthcare Research and Quality (HS08551).
The study found that treatment of nursing home-acquired LRI in Missouri residents involved a larger number of antibiotics, more frequent hospitalization, and a greater use of intravenous antibiotics and rehydration therapy than in Dutch residents with equally severe dementia. Treatment of nursing home residents in Missouri was more aggressive particularly for residents with severe dementia, and intensive interventions were often provided irrespective of severe dementia. On the other hand, Dutch residents, despite severe dehydration, did not receive invasive rehydration procedures. Feeding tubes and restraints, which we know are uncomfortable for cognitively competent individuals, were rare as well. By contrast, in both countries, treatments to relieve symptoms of LRI, such as oxygen, benzodiazepines, and bronchodilators, were provided for only a minority of residents. Dutch mortality rates were higher overall.
These findings are based on analysis of the results of two simultaneous studies of the health status and treatment of 701 nursing home residents from Missouri and 551 residents in the Netherlands who were diagnosed with LRI and dementia.
See "Treatment of nursing home residents with dementia and lower respiratory tract infection in the United States and the Netherlands: An ocean apart," by Jenny T. van der Steen, Ph.D., Robin L. Kruse, Ph.D., M.S.P.H., Marcel E. Ooms, M.D., Ph.D., and others, in the May 2004 Journal of the American Geriatrics Society 52, pp. 691-699.
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