Hebrew SeniorLife researcher finds

Practice has implications for emergence and spread of antimicrobial resistance

An article co-authored by Susan L. Mitchell, M.D., M.P.H., of Hebrew SeniorLife’s Institute for Aging Research reports that nursing home residents with advanced dementia are frequently prescribed antibiotic medications, especially during the two weeks before death. This practice raises concerns about the end-of-life care of individual patients dying with advanced dementia, as well as the emergence of antimicrobial resistance. The paper appears in the February 25 issue of the Archives of Internal Medicine.

“The extensive antibiotic use demonstrated in this study is concerning given the lack of demonstrable benefits and the potential burdens of treatment in this terminally ill population for whom the goal of care is often palliation,” write study authors Susan L. Mitchell, M.D., M.P.H., of Hebrew SeniorLife’s Institute for Aging Research, and Erika D’Agata, M.D., M.P.H., of Beth Israel Deaconess Medical Center. “Moreover, we believe that the widespread use of antibiotics in advanced dementia may pose a potential public health risk through the emergence of antibiotic resistance.”

Nearly 70 percent of the 5 million Americans with dementia—a progressive decline in cognitive function due to damage or disease in the brain beyond what is expected in normal aging—will live in a nursing home during the final stage of their disease. Recurrent infections and fevers typically occur during this stage; therefore, nursing home residents with advanced dementia are at high risk for exposure to antibiotic medications. Exposure to drugs, however, can lead to the emergence of antibiotic-resistant bacteria, which are associated with higher mortality rates and more frequent and prolonged hospitalizations.

The researchers followed 241 residents with advanced dementia from 21 Boston-area nursing homes who were recruited for a study called Choices, Attitudes and Strategies for Care of Advanced Dementia at End-of-Life (CASCADE), a five year study funded by the National Institutes of Health. The primary goal of the CASCADE study is to describe the multiple facets of the end-of-life experience for nursing home dementia patients and their families. As one component of this larger study, the use of antimicrobial medications (drugs that kill or inhibit the growth of bacteria) among these residents every 3 months for 18 months or until their death.