Context Little is known about the prognosis of acutely ill patients with en
d-stage dementia or about the type of care that these patients receive. If
their prognosis is poor, then emphasis should be placed on palliative care
for these patients rather than on curative interventions.
Objectives To examine survival for patients with end-stage dementia followi
ng hospitalization for hip fracture or pneumonia and to com pare their care
with that of cognitively intact older adults.
Design Prospective cohort study with 6 months of follow-up.
Setting and Patients Patients aged 70 years or older who were hospitalized
with hip fracture (cognitively intact, n = 59; with end-stage dementia, n =
38) or pneumonia (cognitively intact, n = 39; with end-stage dementia, n =
80) in a large hospital in New York, NY, between September 1, 1996, and Ma
rch 1, 1998,
Main Outcome Measures Mortality, treatments directed at symptoms, and appli
cation of distressing and painful procedures in cognitively intact patients
vs those with end-stage dementia.
Results Six-month mortality for patients with end-stage dementia and pneumo
nia was 53% (95% confidence interval [CI], 41%-64%) compared with 13% (95%
CI, 4%-27%) for cognitively intact patients (adjusted hazard ratio, 4.6; 95
% CI, 1.8-11.8), Six month mortality for patients with end-stage dementia a
nd hip fracture was 55% (95% CI, 42%-75%) compared with 12% (95% CI, 5%-24%
) for cognitively intact patients (adjusted hazard ratio, 5.8; 95% CI, 1.7-
20.4). Patients with end-stage dementia received as many burdensome procedu
res as cognitively intact patients and only 8 (7%) of 118 patients with end
-stage dementia had a documented decision made to forego a life-sustaining
treatment other than cardiopulmonary resuscitation, Only 24% of patients wi
th end-stage dementia and hip fracture received a standing order for analge
sics.
Conclusions In this study, patients with advanced dementia and hip fracture
or pneumonia had a very poor prognosis. Given the limited life expectancy
of patients with endstage dementia following these illnesses and the burden
s associated with their treatment, increased attention should be focused on
efforts to enhance comfort in this patient population.