Occurrence and treatment of suspected pneumonia in long-term care residents dying with advanced dementia

OBJECTIVES: To describe the occurrence and management of suspected pneumonia in end-stage dementia and to identify factors associated with aggressiveness of antibiotic treatment. DESIGN: Retrospective cohort study. SETTING: A 675-bed long-term-care facility in Boston, Massachusetts. PARTICIPANTS: Two hundred forty subjects aged 65 and older who died with advanced dementia between January 2001 and December 2003. Subjects who had suspected pneumonia during the last 6 months of life were identified. MEASUREMENTS: Independent variables included subject characteristics and features of suspected pneumonia episodes. These variables were obtained from medical records. Antibiotic treatment for each episode was determined. Multivariate analysis was used to identify independent variables associated with aggressiveness of treatment. RESULTS: One hundred fifty-four (64%) subjects with advanced dementia experienced 229 suspected pneumonia episodes during the last 6 months of life. Within 30 days of death, 53% of subjects had suspected pneumonia. Antibiotic treatment for the 229 episodes was as follows: none, 9%; oral only, 37%; intramuscular, 25%; and intravenous, 29%. Factors independently associated with more-invasive therapy were lack of a do-not-hospitalize order (adjusted odds ratio (AOR)=3.24, 95% confidence interval (CI)=2.02-5.22), aspiration (AOR=2.75, 95% CI=1.44-5.26), primary language not English (AOR=2.21, 95% CI=1.17-4.15), and unstable vital signs (AOR=2.02, 95% CI=1.10-3.72). CONCLUSION: Pneumonia is a common terminal event in advanced dementia for which many patients receive parenteral antibiotics. The aggressiveness of treatment is most strongly determined by advance care planning, the patient's cultural background, and clinical features of the suspected pneumonia episode.