Invasive mechanical ventilation improves survival among patients hospitalized with dementia, pneumonia

Invasive mechanical ventilation improved 30-day survival in patients with advanced dementia hospitalized with pneumonia compared with noninvasive ventilation, despite lack of 1-year survival benefit and higher health care costs.

“In persons with advanced dementia, [noninvasive ventilation] could potentially be used as a ‘ceiling strategy’ or palliative strategy to avoid the use of [invasive mechanical ventilation],” Joan M. Teno, MD, from the division of general internal medicine at Oregon Health and Science University in Portland, and colleagues wrote in Annals of the American Thoracic Society. “However, the effectiveness of [noninvasive ventilation] in subjects with pneumonia is controversial, with no research focused on the comparative effectiveness of [noninvasive ventilation] and [invasive mechanical ventilation] in persons with advanced dementia.”

Researchers conducted a retrospective cohort study of 27,483 adults aged 66 years and older who were hospitalized with pneumonia or septicemia with pneumonia from 2015 to 2017 and treated with either noninvasive (8.2%) or invasive mechanical ventilation (12.5%). Researchers identified participants with dementia and at least four impairments in daily living activities using Minimum Data Set assessments within 120 days of hospitalization.

Outcomes of interest were 30-day mortality from admission, 1-year mortality and health care costs from initial hospitalization and up to 1 year after discharge.

Researchers used a propensity-matched model to compare invasive vs. noninvasive mechanical ventilation and matched 96.3% of cases with invasive mechanical ventilation.

According to study results, matched cases treated with noninvasive mechanical ventilation demonstrated higher 30-day mortality rates compared with invasive mechanical ventilation cases (58.7% vs. 51.9%; P < .001). However, 1-year mortality was marginally higher among patients with invasive mechanical ventilation compared with noninvasive ventilation (86.5% vs. 85.9%; P > .05).

In addition, researchers reported higher health care costs up to 1 year after discharge among patients treated with invasive mechanical ventilation (adjusted mean = $57,122) compared with noninvasive ventilation ($33,696; P < .001).

“Although discussions regarding the role of hospitalization should occur in prehospital settings among persons with advanced dementia and their surrogates, our results lend credence to a strategy of [noninvasive ventilation] use to allow time for family meetings to discuss the effectiveness of [invasive mechanical ventilation] and clarify patients’ values and goals,” the researchers wrote.