Ventilator use surges for nursing home residents with dementia

(Reuters Health) - The number of nursing home residents with advanced dementia who get hooked up to breathing machines has roughly doubled in recent years even though this doesn’t appear to help them live longer, a U.S. study suggests.

In 2013, among every 1,000 nursing home residents with dementia who needed to be hospitalized for some reason, 78 were hooked up to mechanical ventilators, compared to just 39 out of 1,000 in 2000, the study found.

Despite this surge, the mortality rate for these patients with mechanical ventilation remained constant at more than 80 percent.

“My concern is the use of intensive care units and mechanical ventilation is like a runaway train where no one is able to hit the stop button and consider: `Is this what this patient wanted? Will this treatment result improved quality of life or only prolong their suffering to inevitable death?’” said lead study author Dr. Joan Teno, a geriatrics researcher at the University of Washington in Seattle.

More than 5 million people in the U.S. alone are currently living with dementia, and by 2050 the condition will result in 1.6 million deaths a year, Teno and colleagues note in JAMA Internal Medicine.

Many of them have Alzheimer’s disease, the most common form of dementia. As their brain function declines over time, they often suffer from personality shifts and a loss of memory and judgment that can make it difficult for them to live independently.

For the current study, researchers analyzed data on about 635,000 hospitalizations for 380,000 nursing home residents with Medicare, the U.S. health insurance for the elderly and disabled.

Most of these patients were female, and they were around 84 years old on average.

They had advanced dementia and had lived in a nursing home for at least four months prior to their hospitalization.

Nearly all of them were bed-bound and unable to eat without help, an analysis of the data from 2013 found. Most of them were spoon-fed a soft diet, while about one in five had feeding tubes.

The proportion of these hospitalized dementia patients admitted to intensive care units (ICUs) rose to 39 percent in 2013 from 17 percent in 2000, the researchers found.

Among the subset of dementia patients with pneumonia and bloodstream infections, the proportion of hospitalizations involving mechanical ventilators increased to about 127 for every 1,000 admissions in 2013 from 45 per 1,000 at the start of the study.

Over time, as hospitals added ICU beds, their use of mechanical ventilation for these patients increased.

For every 10 ICU beds added by hospitals, the odds of mechanical ventilation among hospitalized nursing home patients with advanced dementia increased by 6 percent. When patients had pneumonia or bloodstream infections, the odds climbed by 11 percent.

“As long as it’s easier to access an intensive care unit bed than comprehensive hospice and palliative care services in nursing homes, the trend of increasing use of mechanical ventilation for these individuals is likely to continue,” said Dr. Gary Winzelberg, author of an accompanying editorial.

Limitations of the study include its reliance on data from patients’ hospital bills, which doesn’t show a full picture of their health, the authors note. They authors also counted ICU beds based on voluntary reporting by hospitals, which excludes some facilities.

Still, the findings suggest that patients and families need to have a care plan, if not a “Do-Not-Resuscitate,” or DNR, order, that reflects their preferences and helps reduce aggressive interventions they don’t want at the end of life, Winzelberg, a geriatrics researcher at the University of North Carolina at Chapel Hill, said by email.

“Completion of a living will and/or designating a health care proxy can help ensure that patients’ values are known and respected when dementia deprives them of decision-making abilities,” Winzelberg said.

SOURCE: JAMA Internal Medicine, online October 10, 2016.