Dementia Patients With Pneumonia - Effectiveness of a Practice Guideline for Optimal Symptom Relief

Highlights

• Pneumonia is common among patients with advanced dementia
• Comfort and maximum relief of symptoms is a primary goal for these patients.
• A recent study analyzes the comfort and survival after treatment of pneumonia patients with advanced dementia

Dementia is a broad term which describes a wide range of symptoms involving a decline in a person’s memory or other thinking skills. Alzheimer’s is the most common type of dementia. Though there are medications that help improve the symptoms temporarily, there is no treatment to stop the progression of dementia. Many of the patients who are in the advanced stages of Alzheimer’s disease need to be cared for in a nursing home setting. They are also prone to various serious infections, primarily pneumonia which could be associated with a lot of discomfort, regardless of whether they are treated with antibiotics or not. It could be quite challenging to treat pneumonia in these patients.

Study

• The researchers of the current study assessed the effectiveness of a practice guideline for optimal symptom relief for dementia patients with pneumonia.
• They conducted a single-blind, multicenter, cluster randomized controlled trial in 32 Dutch nursing homes.
• The trial period was divided into a pre-intervention phase (before randomization) and an intervention phase (after randomization). This was done to allow for adjusting for changes in the outcomes over time. The primary goal of the intervention was to improve patient comfort.
• Outcomes were assessed in the patient level. The main outcome measures were discomfort and symptoms: discomfort (DS-DAT: Discomfort Scale-Dementia of Alzheimer Type), (lack of) comfort (EOLD-CAD: End Of Life in Dementia-Comfort Assessment in Dying), pain (PAINAD: Pain Assessment in Advanced Dementia) and respiratory distress (RDOS: Respiratory Distress Observation Scale).

Observations

• The 229 observers who performed the observations were blind to the residents’ condition, treatments and the intervention. Observation period was limited to 15 days since cure from pneumonia or death were expected by that time.
• Usual care was provided to all nursing homes in a pre-intervention phase. In the intervention phase, matched clusters of homes were randomized to either the control (n = 16) or intervention condition (n = 16).
• 464 episodes of pneumonia were included between January 1, 2012 and May 1, 2015
• Outcomes were obtained for 399 episodes in 367 residents.
• In the remaining 65 episodes, no observations took place, either due to scheduling difficulties or death of the residents soon after diagnosis of pneumonia.
• 87.1% of residents received antibiotic treatment.

Conclusions

• Thus, the practice guideline for optimal symptom relief did not relieve discomfort and symptoms in nursing home residents with dementia and pneumonia. However, discomfort and symptoms decreased gradually throughout the data collection in both the intervention homes and the control homes.
• Discomfort was reportedly low compared to previous studies and it decreased steadily over the course of the study period.

Strengths of the Study

• The study assessed the outcomes on a regular (almost daily) basis.
• The study used four different validated observational instruments to assess the effects of practice guidelines on discomfort and symptoms over time.

Limitations of the Study

• The attending physicians reportedly did not include about 131 episodes in a timely manner, even though they fulfilled the inclusion criteria.
• It was seen that in the 65 of 464 cases which lacked observations, residents often died soon after diagnosis and the results were only based on residents who survived.
• The outcome measures included symptoms that were most burdensome, however they do not necessarily cover all symptoms of pneumonia.
• Residents who were not given antibiotics were relatively less (12.9%), hence subgroup analyses could not be performed.

Further studies are warranted to conclusively prove that an intervention which is directed at awareness of discomfort and regular observations would be more effective than a physician practice guideline.

Reference:

1. Tessa van der Maaden et al; Improving Comfort in People with Dementia and Pneumonia; BMC Medicine 2016

Source-Medindia