Nursing home study finds men with advanced dementia more likely to be hospitalized

The hospital room is seen at St. Michael's Hospital in Toronto on Tuesday, August 13, 2019. A study of nursing home residents with advanced dementia found that men were more likely to be hospitalized, physically restrained, and receive antibiotics and mechanical ventilation than women in the last 30 days of life.The study was conducted by the Toronto-based non-profit research institute ICES and found that men were also more likely to die in an acute care facility, instead of their nursing home. THE CANADIAN PRESS/ Tijana Martin

TORONTO - Researchers say they've discovered profound gender differences in the way Ontario nursing home residents with advanced dementia receive care in their final days — findings they say highlight a stark divide in the way men and women receive care and regard their own deaths.

Doctors with the Ontario non-profit research institute ICES released a study Friday that found male nursing home residents with advanced dementia were more likely to be hospitalized, physically restrained and receive invasive treatment than female residents in the last 30 days of life.

Lead author Dr. Nathan Stall said the data points to gender biases that are known to occur more broadly in health care, in which men are often offered more aggressive treatment than women with similar conditions.

While such interventions might be welcome earlier in life, they are often avoidable and distressing later in life and may not provide comfort if the patient is near death, said Stall, noting that by this point the resident is often frail and cognitively impaired.

"The care should generally be focused at this stage on maximizing quality of life," said Stall.

The study looked at the experiences of 27,243 nursing home residents with advanced dementia who died between June 1, 2010, and March 31, 2015. It was published Friday in the medical journal JAMA Network Open.

Stall said men were 41 per cent more likely to be transferred to an emergency department or hospital, and were 33 per cent more likely to receive antibiotics, the administration of which can be painful for seniors who require it intravenously.

The study also questioned how often antibiotics are appropriate, noting "they are often prescribed in the absence of strong evidence for bacterial infection." The "indiscriminate use of antibiotics in nursing homes" is also linked to the spread of multidrug-resistant organisms, researchers said, posing a "major public health threat."

Researchers suspected unconscious gender biases were at play when it came to delivery of care.

The study cited another paper on people who complained about osteoarthritis, finding that even when presenting similar symptoms, men were more likely to be offered a joint replacement, while women were more likely to be offered physical therapy and supportive therapy.

"We know that men are more likely to be described as 'the fighter' than women are," said Stall. "How does that result in people receiving interventions (at the) end of life?"

The study found that male residents were more likely to die in an acute-care facility, instead of their nursing home, and that overall, only a minority of residents saw a palliative care doctor in the year before death.

Those who did see a palliative care doctor were half as likely to be transferred to an emergency room or hospital, and 25 per cent less likely to receive antibiotics.

Stall said men and women also tend to regard death differently, with women tending to be less afraid of death and more likely to refuse intubation and cardiopulmonary resuscitation at the end of life.

Senior author Dr. Paula Rochon added that women are also more likely to discuss their end-of-life care wishes — something she said should be adopted more broadly by both genders.

"We need to think about these things before people are in that situation so that people can be thoughtful and plan," said Rochon, a geriatric specialist at Women's College Hospital.

While nursing home residents generally have advance directives that specify if they want to be transferred to an acute-care facility, Stall said a resident's wishes aren't always honoured if the directive is unclear, if a family member intervenes, or if nursing staff don't have the capacity or comfort level to provide the palliative care required.

Part of the problem is that many people simply don't perceive advanced dementia as a terminal condition, added Stall, who said he tells patients and family members to consider advanced-care planning when he delivers a dementia diagnosis.

While most people with dementia can be productive in many spheres of their life and make their own decisions, Stall noted that advanced dementia often includes profound memory impairment and the inability to perform most, if not all, of the basic activities of daily living — including grooming, bathing, dressing and feeding.

He said advanced cases should be regarded in the same way as some forms of advanced or metastatic cancer.

"It's a progressive and unfortunately incurable disease," said Stall.

"This knowledge gap ... persists widely in the health-care system and health-care practitioners do not appreciate advanced dementia as the terminal condition that it is."

Family members, especially, need to understand the nature of their loved ones' condition if they want to ensure optimal care, he added.

"This is only a clinical anecdote but when you have a family member at the bedside who's very involved in their life it's much harder for them to let go and they are more likely often to advocate for more aggressive care," said Stall.

"That comes back to, again, the need to educate these family members about the terminal nature of the disease."

In Canada, approximately 564,000 people were living with dementia in 2016, a number that is expected to increase to 937,000 by 2031.

Most people with dementia are older adults, two-thirds of whom are women.

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