Ventilators overused in ICU patients with dementia

Mechanical ventilation rates increased by 100% in patients with advanced dementia, but these rates were not linked with significant improvement in survival, according to findings published in JAMA Internal Medicine.

Joan M. Teno, MD, MS, from the University of Washington, and colleagues reported that increased mechanical ventilation use was associated with an increased number of beds in intensive care units. Noting that dementia will lead to 1.6 million deaths by 2050, the researchers highlighted the importance in understanding lifesaving treatments vs. treatments that prolong suffering.

“Intensive care units (ICUs) may be an appropriate location of care for some elderly patients, but the role of the ICU in the medical care of persons with advanced dementia raises concerns about whether this care is consistent with informed preferences, has the potential to improve the quality of life and provides increased value from a societal perspective,” Teno and colleagues wrote. “The disease trajectory of advanced dementia is characterized by progressive cognitive and functional impairment, with 86% developing eating problems that often lead to malnutrition; recurrent infections are common and are often accompanied by burdensome patterns of hospitalizations before death.”

The researchers conducted a retrospective cohort study of 380,060 Medicare beneficiaries with advanced dementia admitted between January 2000 and December 2013. They reported a mean patient age of 84.4 years and 635,008 hospitalizations.

Results showed mechanical ventilation rates increased from 39 per 1,000 hospitalizations to 78 per 1,000 hospitalizations from 2000 to 2013 (P < .001).

In addition, patients had greater odds of receiving mechanical ventilation as the number of beds in the ICU increased (adjusted odds ratio per 10 bed increase = 1.06; 95% CI, 1.05-1.07).

Teno and colleagues also found hospitals with the least ICU beds were reimbursed $8,050.24 for each hospitalization and those with the most beds were reimbursed $9,611.89 for each hospitalization (P < .001), but there was no significant difference in mortality at 1 year (64.6% vs. 65.2%; P = 54).

“From 2000 to 2013, the use of mechanical ventilation for hospitalized persons with advanced dementia and severe functional impairment increased without substantial evidence of improved survival,” the researchers wrote. “These hospitalized patients were at higher risk for mechanical ventilation when they were admitted to hospitals that had increased their number of ICU beds. Our results call for reconsideration of the role that the excess supply of ICU beds plays in the ICU admission and subsequent mechanical ventilation of patients with advanced dementia.”

They continued, calling for “a multifaceted approach” in dealing with care intensity for patients with advanced dementia.

“Such an approach will need to align clinical care and financial incentives with patients’ informed preferences and provide the needed education and training for health care professionals to ensure that decisions to use mechanical ventilation in persons with advanced dementia are based on high-quality shared decision-making that incorporates the goals of care of informed patients and their families,” Teno and colleagues concluded.

In an accompanying editorial, Gary S. Winzelberg, MD, MPH, and Laura C. Hanson, MD, MPH, both from the Center for Aging and Health at the University of North Carolina at Chapel Hill School of Medicine, wrote these results “both confirm and contrast” with previous ICU research.

“Quality of care for frail older patients in nursing homes, a majority of whom have dementia, has improved over the past decade because of multiple system-level interventions linking quality of care with financial and regulatory incentives,” they wrote. “In addition, innovations in care such as evidence-based decision aids may help to modify clinician behavior and family understanding. Similar strategies, as well as further research on benefits and harms, may be needed to address the use of mechanical ventilation for persons with advanced dementia.”

Winzelberg and Hanson noted the association of increased use of mechanical ventilation and increased ICU bed availability is an important finding.

They concluded, “As long as it is easier to access an ICU bed than comprehensive hospice and palliative care services in nursing homes, this trend is likely to continue.” – by Chelsea Frajerman Pardes

Disclosure: The authors report no relevant financial disclosures.