Wednesday, February 27, 2008
The Archives of Internal Medicine published a significant study regarding antibiotic use in the elderly authored by Dr. D'Agata and Dr. Mitchell from Beth Israel Deaconess. In their article, they review the antibiotic usage in 214 (mostly white, female and over 80yo) nursing home residents with advanced dementia, defined as very severe cognitive impairment, minimal communication, dependent eating/toileting, bowel/bladder incontinence, and inability to walk. This study was part of a larger study called CASCADE (Choices, Attitudes and Strategies for Care of Advanced Dementia at the End-of-Life). (Take that cardiologists with all your fancy acronyms!)
The mean number of antibiotic courses per resident was 4 (range 1-20!), and about 66% of the 214 received at least one course with the majority of residents receiving a course within the 14 days prior to death, indicating the effectiveness of antibiotics to cure an infection in advanced dementia may be limited. This multi-center prospective cohort is probably the best study to demonstrate the limited efficacy of antibiotics in patients with advanced dementia.
The study did not have data representing success of treatment for each course, which makes hampers clinical relevance. If we had information that indicated say 80% of the UTI's were cured, but only 35% of respiratory infections improved or similar info, we could have more informed discussions with staff and family. Also this article does not have information on symptom improvement, since antibiotics may have improved symptoms (although data in elderly says this is not a major effect), but that would be difficult to get workable objective data from someone who by inclusion criteria cannot communicate.
Despite this information, one cannot conclusively make an across the board declaration that patients with advanced dementia should never get antibiotics. We don't yet know what the outcomes might be for those that had antibiotics withheld. There is a general understanding that fever and likely infections are a common pathway towards death for advanced dementia patients. The optimal strategy is not yet clear, and these issues must be decided on an individual basis with open discussions of goals of care. But this study may help nursing home staff, and hospice and palliative medicine staff make more judicious use of a minimally efficacious treatment, that as a secondary gain could potentially help public health by decreasing antibiotic resistance in the community. I would imagine this second point is a bit more challenging to ethically justify. Autonomy versus Distributive Justice...en garde!
Interestingly the CDC is debating on how to advocate influenza immunization of all school age children to protect the children, but also to decrease influenza deaths/infections in the older community. The CDC are not necessarily advocating we "treat the children to save the elderly." So it is interesting this Archives of Internal Medicine study could be spun as "Don't treat the elderly to save the children." I realize I am making broad generalizations, but it is interesting the eerie similarities between the two circumstances. The editorial for this article is highly recommended as well.
(Thanks to Pallimed reader Maria F for the tip!)
D'Agata, E., Mitchell, S.L. (2008). Patterns of Antimicrobial Use Among Nursing Home Residents With Advanced Dementia. Archives of Internal Medicine, 168(4), 357-362. DOI: 10.1001/archinternmed.2007.104
I have had so many things crossing my desk that I have wanted to share, that I have to clear some of these out.
For our chaplain readers, you may be interested in the recent Religious Landscape Survey by the Pew Forum on Religion and Public Life. The site has some good demographic maps to look at the different faith communities in the US and by states. The full report is here. The media's take on this has been focused on how people change religions more often.
The British Medical Journal recently published a clinical review on treatment of adult depression. Dr. Shock (a blogger) reviews it nicely. Obviously the article is not focused on palliative medicine, but a good general background on current views on depression management (and not just pharmacological management). But before you prescribe that Prozac, a recent study (free pdf) in PLoS Medicine suggests that antidepressants may be no better than placebo. James Hrynyshyn at Island of Doubt has a nice blog post summarizing the study and the drug-placebo controversy.
Thomas LeBlanc and Amy Abernathy (of PC-FACS) explore research in hospice patients in an ethics forum for American Medical News. A good conversational review on a desperately needed area.
And finally with the recent movie "The Bucket List" about making a list of things to do before you die comes this very helpful blog post about priorities in life and how to 'manage' your bucket list.