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Study: Treat dementia differently

Wednesday, July 05, 2000

By Lindsey Tanner, The Associated Press

CHICAGO (AP) - Doctors often fail to acknowledge the final stages of Alzheimer's disease and other forms of dementia as a terminal illness and subject patients to invasive procedures when providing comfort care would sometimes be more appropriate, research suggests.

The findings, reported in today's Journal of the American Medical Association, indicate that patients suffering from the degenerative neurological condition are often treated for other problems as though the dementia itself was not terminal. That oversight affects the quality of their final months of life, researchers suggested.

The research could have broad implications for the estimated 1.8 million people nationwide with end-stage dementia. Patients in the final stages of dementia can't talk or recognize family members, frequently can't walk and must rely on others for daily care.

Alzheimer's disease, which affects more than 4 million Americans, is the leading cause of dementia.

The study compared treatment given to dementia-free elderly patients and those with end-stage dementia who were hospitalized for either hip fractures or pneumonia - two common ailments in the elderly. Those with end-stage dementia were found to be at least four times more likely to die within six months.

But the dementia patients were given the same degree of invasive treatment, such as daily blood tests, X-rays and catheters, as patients without dementia, the authors reported.

The study was conducted at an unidentified hospital in New York.

A treatment model developed 14 years ago recognized end-stage dementia as terminal and recommended hospice care, focusing on easing discomfort rather than invasive treatment. But the new study suggests "this concept has yet to gain acceptance," Dr. Don Riesenberg of the Binghamton Veterans Affairs Clinic in Binghamton, N.Y., wrote in a JAMA editorial.

Riesenberg said the study underscores the importance of living wills. Doctors should discuss treatment wishes with family members or patients before they become incapacitated to decide on care and "whether the standard of care for hospitalized patients is appropriate for patients with severe dementia," he said.

"A few minutes spent can save a world of suffering," Riesenberg said.

The authors looked at 97 patients age 70 and older with hip fractures and 119 with pneumonia, treated between September 1996 and March 1998. About half in each group had end-stage dementia.

Among hip-fracture patients, morphine doses were more than twice as high in the non-dementia patients. And only 9 (24 percent) of the 38 end-stage dementia patients, "who often are unable to communicate the presence of pain," had standing orders for other painkillers such as acetaminophen, the authors wrote.

The authors theorized that doctors withheld painkillers out of the mistaken assumption that the patients weren't in pain.

Dr. R. Sean Morrison, an assistant professor at Mount Sinai School of Medicine and the study's lead author, said it was unclear whether the hip fractures or the pneumonia hastened the dementia patients' deaths because dementia alone is terminal.

There were no plans recommending palliative (comfort) care rather than life-prolonging care for any of the dementia patients. For 90 percent of them, there also was no evidence that any discussion about treatment goals or withholding life-sustaining care had taken place.

The authors said they were not recommending that life-sustaining treatment or even all invasive tests be withheld from all end-stage dementia patients.

"At a minimum, what we're advocating is that the benefits and burdens of ... burdensome hospital treatments be carefully evaluated" for patients who have "a very limited prognosis," Morrison said.

On the Net: American Geriatrics Society:

Alzheimer's Association:

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