More consideration needed for medical care of patients with dementia

June 27, 2000

In a "Special Communication" in the June 28, 2000 issue of JAMA, three Chicago physicians use a catastrophic and unanticipated complication of routine medical care to alert physicians that for patients with dementia, every clinical decision requires extensive consideration.

They also argue that as long as patients with dementia are excluded from clinical trials of therapies for common age-related diseases, such as osteoporosis or arthritis, physicians will have insufficient data to make evidence-based recommendations for this rapidly growing group.

"When therapy involves a patient with dementia, the established equations balancing the benefits and burdens of treatment no longer add up," said Daniel Brauner, MD, associate professor of clinical medicine at the University of Chicago and first author of the article. "Besides the usual risk-benefit analysis, physicians need to consider a patient’s ability to comprehend, remember and follow directions, and to recognize and report problems. Treatment choices should also take into account the capacity of each patient’s caregivers to listen, understand and act."

The catastrophe involved a woman in her 80s with mild Alzheimer’s-type dementia who came to the doctor for back pain from a vertebral fracture. Her physician prescribed an osteoporosis medication. Because the drug can irritate the esophagus, patients are told to take it with a cup of water and to sit upright after swallowing it.

The woman recovered well at home and soon resumed her daily activities. Four weeks after starting therapy, however, she was brought to an emergency room for shortness of breath. Her evaluation showed severe damage to her esophagus, presumably caused by the medication. Ulceration had caused rupture of the esophagus and eventual erosion into a major vessel, which led to her death.

Cases like this "raise important questions about the safety of this and other commonly used agents in patients with dementia," note the authors. "These drugs," added Brauner, "have not been systematically tested in this population."

Alzheimer-type dementia is a common chronic disorder, becoming even more prevalent as the population ages, and it frequently coexists with other diseases of aging.

But "far too little attention has been paid to how the presence of dementia should influence the treatment of non-dementia illnesses," said Brauner, "despite the fact that Alzheimer’s can have a profound effect on the risks and benefits of treatment."

Two other vignettes consider other issues raised by a 78-year-old patient with dementia and an abnormal heart rhythm, and the value of screening tests for high cholesterol or colon cancer in a 69-year-old patient with dementia. In both cases, the accepted guidelines conflict with the best interests of the patient--with the burden of routine care clearly exceeding the probable benefits for these specific patients.

Unfortunately, the studies that led to the guidelines excluded patients with dementia. These patients have traditionally been viewed as a vulnerable group and "protected" from participation in clinical studies.

The authors suggest that current efforts to include more women, children and the elderly in clinical trials should be extended to include patients with dementia in low-risk studies of treatments for non-dementia illnesses.

"Until we have compelling data" note the authors, "--and such data may not be forthcoming--we must rely on our experience."

Funding for the study came, in part, from the Greenwall Foundation Interdisciplinary Program in Bioethics. Additional authors include geriatrician Greg Sachs, MD, from the University of Chicago, and palliative-care specialist Cameron Muir, MD, from Northwestern University.

Summary:
A catastrophic complication of routine medical care shows that for patients with dementia every clinical decision requires extensive consideration. The authors argue that as long as patients with dementia are excluded from clinical trials, physicians can’t make evidence-based recommendations for this rapidly growing group.

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