The clinical course of advanced dementia.
The clinical course of advanced dementia.
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DOI：
10.1056/nejmoa0902234
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发表时间：
2009-10-15
期刊：
影响因子：
--
通讯作者：
Hamel MB
中科院分区：
文献类型：
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作者：
Mitchell SL;Teno JM;Kiely DK;Shaffer ML;Jones RN;Prigerson HG;Volicer L;Givens JL;Hamel MB
在美国，痴呆症是导致死亡的主要原因之一，但作为一种绝症却未得到充分认识。老年痴呆症患者的临床过程尚未得到很好的描述。我们在22家养老院对323名患有晚期痴呆症的养老院居民和他们的医疗保健代理进行了18个月的跟踪调查。收集数据，描述居民的生存、临床并发症、症状和治疗，并确定代理对晚期痴呆患者居民预后和预期临床并发症的了解。在18个月的时间里，54.8%的居民死亡。肺炎的概率为41.1%；发热发作，52.6%；85.8%的人有饮食问题。在调整了年龄、性别和病程后，肺炎患者的6个月死亡率为46.7%；发热发作，44.5%；还有饮食问题，占38.6%。令人痛苦的症状，包括呼吸困难（46.0%）和疼痛（39.1%），是常见的。在生命的最后3个月，40.7%的居民至少接受过一次繁重的干预（住院、急诊室就诊、肠外治疗或管饲）。代理人了解晚期痴呆的不良预后和临床并发症的居民在生命最后3个月进行繁琐干预的可能性要比代理人不了解的居民低得多（调整优势比为0.12；95%可信区间为0.04至0.37）。肺炎、发热发作和饮食问题是晚期痴呆患者的常见并发症，这些并发症与6个月的高死亡率相关。在这类患者中，令人痛苦的症状和繁重的干预措施也很常见。拥有了解预后和临床病程的医疗代理的患者在接近生命结束时可能会接受较少的积极护理。
Dementia is a leading cause of death in the United States but is underrecognized as a terminal illness. The clinical course of nursing home residents with advanced dementia has not been well described. We followed 323 nursing home residents with advanced dementia and their health care proxies for 18 months in 22 nursing homes. Data were collected to characterize the residents’ survival, clinical complications, symptoms, and treatments and to determine the proxies’ understanding of the residents’ prognosis and the clinical complications expected in patients with advanced dementia. Over a period of 18 months, 54.8% of the residents died. The probability of pneumonia was 41.1%; a febrile episode, 52.6%; and an eating problem, 85.8%. After adjustment for age, sex, and disease duration, the 6-month mortality rate for residents who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%. Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last 3 months of life, 40.7% of residents underwent at least one burdensome intervention (hospitalization, emergency room visit, parenteral therapy, or tube feeding). Residents whose proxies had an understanding of the poor prognosis and clinical complications expected in advanced dementia were much less likely to have burdensome interventions in the last 3 months of life than were residents whose proxies did not have this understanding (adjusted odds ratio, 0.12; 95% confidence interval, 0.04 to 0.37). Pneumonia, febrile episodes, and eating problems are frequent complications in patients with advanced dementia, and these complications are associated with high 6-month mortality rates. Distressing symptoms and burdensome interventions are also common among such patients. Patients with health care proxies who have an understanding of the prognosis and clinical course are likely to receive less aggressive care near the end of life.