Lower respiratory infections (LRI) may be the immediate cause of death for as many as 1/3 of nursing home residents and for 50-70 percent of those with dementia. When an LRI develops in nursing home residents with advanced dementia, clinicians and families face difficult decisions concerning whether to use antibiotics or simply to provide supportive care. Coincidental but simultaneous prospective cohort studies of LRI outcomes in the Netherlands and in Missouri provide a unique opportunity to compare the consequences of different approaches to treating nursing home residents with LRI -- the Netherlands treating many more residents with palliative care only. The investigators propose a combined analysis of the two data sets to: (1) describe care of and mortality from LRI in nursing home residents in Missouri and the Netherlands; (2) determine whether the distinct treatment approaches for nursing home-acquired LRI in Missouri and the Netherlands account for survival differences between the two locations; and (3) for nursing home residents with advanced dementia who develop an LRI, to investigate the effect of treatment with or without antibiotics on complications, mortality, and 90-day Activities of Daily Living (ADL) status. Both studies prospectively collected extensive data on nursing home residents who were identified as having an LRI. Follow-up assessments of survivors in both studies lasted at least 90 days. From the many measures common to both data sets, a risk model for mortality will be developed. This model will be used to control for resident-level factors in subsequent analyses. Analyses will test the impact of treatment, facility-related, and nationality effects after controlling for other variables in multivariable logistic regression models. Using the patient-level risk model to stratify residents, analyses will also explore national differences in treatment and mortality in the high mortality-risk stratum. Finally, mortality, treatment, complications (e.g., new decubitus ulcers), and 90-day decline in ADL status will be examined in residents with advanced dementia. Findings will aid our understanding of how different approaches to managing infections in severely impaired nursing home residents affect both short and intermediate outcomes. This may help to inform national debate on appropriate care at the end of life.
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