Article Reviews
The Clinical Course of Advanced Dementia
by Neil Orford - Biography
15th Nov, 2009
The clinical course of advanced dementia
The Paper
Title: The clinical course of advanced dementia
Authors: Mitchell S.L, Tenp J.M, Kiely D.K, Shaffer M.L, et al
Journal: NEJM 2009 Oct 15;361(16):1529-38
Overview: An 18-month, multi-center, prospective study of 323 nursing home residents with advanced dementia.
Participants: From Choices, Attitudes and Strategies for Care of Advanced Dementia at the End-of-Life (CASCADE) study, a prospective cohort nursing home study. Recruited Feb 2003 – Aug 2007
Inclusion; >60 yrs age, Cognitive Performance Scale 5 or 6 (uses five variables from Minimum Data Set, intact cognition =0, severe = 6, 5 corresponds to 5.1 on MMSE), LOS > 30 days in facility
Data collected; Sociodemographic, health, clinical complication, distress symptoms, burdensome interventions, hospice use
Results
· 1763 met screening criteria, 572 (32.4%) eligible
· Interventions in 3/12 prior to death; hospitalised 12%, parenteral therapy 30%, ED 7.3%, any of these 41%
· Reason for hospital: Pneumonia 68.2%, other infection 13.6%, heart failure 9%, hip fracture 4.5%, dehydration 4.5%
Discussion
· High mortality associated with advanced dementia, similar to metastatic breast cancer, stage IV CCF. Highest if infections and eating problems. Therefore advanced dementia is terminal illness
· In 3 months prior to death many have burdensome interventions
Reviewer’s summary
A well designed observational study describing the poor prognosis of advanced dementia. From a critical care perspective, it highlights the issue of potential “burdensome interventions” being requested or administered to a population that may not benefit from them. With an ageing population and predictions that dementia will increase accordingly, it is a timely reminder that a considered approach needs to be taken to the elderly, demented, nursing home cared for patient.