Predicting short-term survival for patients with advanced Alzheimer's disease.

OBJECTIVE: The purpose of this study was to develop a statistical model for predicting short term survival in patients with dementia of the Alzheimer type (DAT). DESIGN: A prospective cohort study. SETTING: Three 25-bed intermediate medical care units using a structured approach to patient care management including palliative care options and patients from a second, traditional long-term care setting. PARTICIPANTS: Of 104 patients with advanced DAT monitored for 34 months, 68 patients (97% white male) who had at least one fever episode were included in the model development phase. Data from 71 additional DAT patients with at least one fever episode were used to test the statistical model. MAIN OUTCOME MEASURES: Six-month survival following a fever episode. RESULTS: Older age and higher severity of DAT at the time of the fever episode, palliative care, and hospital admission for long-term care within 6 months prior to the fever were found to be positively associated with likelihood of mortality within 6 months of the fever onset. Adjusted odds ratios for each of these variables were statistically significant. The model performed well in subsequent testing on an independent sample of patients. CONCLUSION: Results provide a formula which can be used to predict likelihood of dying within 6 months following onset of a fever in DAT patients. This statistical prediction is recommended for use in combination with clinical judgment to certify DAT patients for Medicare hospice coverage.

Effect of antibiotic treatment on outcome of fevers in institutionalized Alzheimer patients.

Fever episodes in 104 institutionalized patients with Alzheimer's disease were prospectively evaluated to determine the impact of antibiotic treatment on fever outcomes. During the 34-month observation period, 75 patients developed 172 episodes of fever and 29 patients had no fevers. Patients who developed fevers had more advanced disease than patients who did not. Patients who received diagnostic workup of all fevers and treatment with antibiotics (Antibiotic Group) were compared with patients who received comfort measures only (Palliative Group). The incidence of fever was similar in the Antibiotic and Palliative groups. Survival analysis revealed that, for the more severely affected patients, there was no difference in survival between the groups. Among less severely affected patients, survival was higher for the Antibiotic than the Palliative Group. These results suggest that treatment of fever with antibiotics does not alter the outcome of fever in patients with advanced Alzheimer's disease.

KIE: The object of this study was to compare the effectiveness of antibiotic treatment for fever with a palliative approach in a group of hospitalized patients with Alzheimer's disease. One hundred and four patients were divided into three groups, based on the occurrence of fever and on the treatment strategy used, and observed for 34 months. Those who developed fevers had more advanced disease than those who did not. The incidence of fever was similar for the antibiotic and palliative groups, and for the more severely demented patients in each group there was no difference in survival. Among less demented patients those who received antibiotics had a higher rate of survival than those who received palliative treatment. The authors suggest that these observations should be taken into account by health personnel and family members weighing the benefits and burdens of diagnostic workups and treatments in Alzheimer's patients with fevers.

Hospice approach to the treatment of patients with advanced dementia of the Alzheimer type.

A program that limits the extent of medical treatment in patients with advanced dementia of the Alzheimer type was initiated on an intermediate medical ward. Five levels of care were designed to define options that stress maintenance of patient comfort without striving for a maximal period of survival (hospice approach). An optimal care level for each patient recommended by the staff correlated highly with the severity of dementia, but care levels assigned during meetings of family members with the multidisciplinary team for 40 patients correlated poorly with the staff recommendations and the severity of dementia. Intensive nursing care and comfort measures, which included antipyretics, analgesics, and (if necessary) oxygen and anticholinergics, were provided during the terminal phase. Preliminary results indicate that the mortality did not increase significantly during the first year of this program, although the extent of medical care was limited in all patients, and 62% were not treated with antibiotics if they developed symptoms of pneumonia or urinary tract infection.

KIE: The authors describe the implementation of a program that provides a decision making mechanism for limiting treatment of patients with advanced Alzheimer's disease. The nursing staff and attending physician propose a treatment plan, which is approved or revised at a multidisciplinary team conference with family members. Each decision about patient care is reviewed monthly. During the first year of the program's operation, 40 patients were assigned to treatment options that ranged from withholding resuscitation to withholding non-oral feeding and hydration. Assignment of care levels did not correlate well with the severity of dementia or with staff recommendations. The authors discuss staff reaction, team-family interactions, and the rationale for the various treatments provided. Their preliminary findings indicate that the hospice approach did not significantly increase mortality.