Behandeling van pneumonie bij verpleeghuispatiënten met ernstige dementie: terughoudender beleid in Nederland en actiever beleid in de Verenigde Staten naarmate de prognose ongunstiger is

To describe differences in the treatment of pneumonia and in the association of treatment with prognosis in Dutch and American nursing home patients with late-stage dementia.

Design

Prospective studies in the Netherlands and the American state of Missouri.

Method

In 61 Dutch nursing homes and 36 in Missouri, severely demented patients with pneumonia were included in the periods October 1996-July 1998 and August 1995-September 1998 respectively. Data was collected on their state of health, comorbidity, symptoms of pneumonia and treatment aspects such as antibiotic use, hospital admission and relief of symptoms. Comparisons were made between treatments in both countries and between groups of patients with a similar probability of mortality within 2 weeks.

Results

A total of 328 Dutch and 280 American patients were selected. Antibiotics were more frequently withheld in the Netherlands (in 33 of patients) than in Missouri (24). Differences in antibiotic use were more pronounced in patients with a poor prognosis (56 versus 15). Dutch patients were more frequently dehydrated but were less likely to receive rehydration therapy than American patients, with a larger difference in patients with a poor prognosis (2 versus 63). Treatments to relieve symptoms that were provided more often in patients with a poor prognosis (in 20-26) were: oxygen (both countries), and in the Netherlands also opiates, and hypnotics, sedatives or anxiolytics.

Conclusion

In the Netherlands, curative treatment was frequently withheld in patients with severe dementia and pneumonia, and even more frequently when the prognosis was poorer. Conversely, treatment in Missouri was more active in patients with a poor prognosis. Despite more frequent palliative treatment goals in the Netherlands, treatments to relieve symptoms were provided infrequently and inconsistent with this approach. These insights may be helpful for decision-making in the treatment of pneumonia in patients with severe dementia.

Ned Tijdschr Geneeskd. 2007;151:915-9