March 21, 2008
People in the most advanced stages of Alzheimer's disease most often live in nursing homes and are prone to respiratory infections, fevers and other ills. Antibiotics are typically prescribed for these patients in their final weeks of life, even though that may not be the best course of treatment, a new study reports.
The study, published in the Archives of Internal Medicine, looked at 214 nursing-home residents with advanced dementia living in the Boston area. The researchers, from Beth Israel Deaconess Medical Center, found that antibiotic use increased the frailer and further advanced the dementia. Two thirds of patients received at least one course of antibiotics during their stay, with many receiving four or more courses of the drugs. Antibiotic use was particularly common during the final weeks of life.
"The proportion of residents taking antimicrobials was seven times greater in the last two weeks of life compared with six to eight weeks before death," the authors write. More than 40 percent of the antibiotics given in the last two weeks of life were administered intravenously rather than by mouth, a method that may be especially uncomfortable for patients with advanced dementia
The findings are important, because experts estimate that some 70 percent of the more than five million Americans with Alzheimer's will live in a nursing home at some point during their illness. Fevers and recurrent infections are common in this group.
Overuse of antibiotics breeds drug-resistant bacteria that can present a serious danger to other residents. Infections from these potent germs do not respond to standard medications and can often prove fatal.
"This extensive use of antimicrobials and pattern of antimicrobial management in advanced dementia raises concerns not only with respect to individual treatment burden near the end of life, but also with respect to the development and spread of antimicrobial resistance in the nursing home setting," the authors continue. The results support "the development of programs and guidelines designed to reduce the use of antimicrobial agents in advanced dementia."
The authors point out that deciding whether to give antibiotics to a loved one with advanced dementia can be a difficult decision. In general, antibiotics are given to cure infectious diseases and prolong life. However, this and earlier observational studies suggest that for many frail patients with terminal Alzheimer's, antibiotics given at the very end of life may be of less value.
Providing comfort and care, without drugs, may achieve more benefits in many of these patients, the authors note.
"We must ask whether the interests of the patient are being served by using antibiotics," write doctors from Tel Aviv Medical Center in an editorial accompanying the study. "We must further ask whether the use of antibiotics in each specific patients justifies the risk placed on others by their use." Once again, the doctors are referring to very advanced cases of dementia and not to people in earlier stages of Alzheimer's.
They note that each decision must be made individually, based on the likely benefits and risks to the individual patient. The individual wishes of patients and their families should also be considered, as well as the treating doctor's judgment, the doctors say.
Erika D'Agata, M.D., M.P.H.; Susan L. Mitchell, M.D., M.P.H.: "Patterns of Antimicrobial Use Among Nursing Home Residents With Advanced Dementia." Archives of Internal Medicine, February 25, 2008, Volume 168(4), pages 357-362.
Mitchell J. Schwaber, M.D., M.Sc.; Yehuda Carmeli, M.D., M.P.H.: "Antibiotic therapy in the Demented Elderly Population: Redefining the Ethical Dilemma" (editorial). Archives of Internal Medicine, February 25, 2008, Volume 168(4), pages 349-350.