Study couldn't explain why more dementia patients had operation, though families' wishes likely a factor
By Steven Reinberg
MONDAY, July 28, 2014 (HealthDay News) -- People who have dementia and heart rhythm irregularities are more likely to get a pacemaker than people without dementia, new research has found.
In fact, the study of more than 16,000 people found that those with dementia were up to 80 percent more likely to get a pacemaker than those without the memory-robbing condition.
What isn't clear from this study is why folks with dementia are so much more likely to be treated with a pacemaker, said the study's lead researcher, Nicole Fowler, an assistant professor of medicine at the University of Pittsburgh.
Perhaps the more important question, though, is whether some patients with dementia -- a progressive condition without a cure -- should get a pacemaker at all, Fowler said.
"We really need to take into account the whole picture and make sure patients understand the implications of the decisions they are making," she said.
A pacemaker is a device that's surgically implanted in the chest or abdomen with wires that send electrical pulses to the heart to correct abnormal heart rhythms, according to the National Heart, Lung, and Blood Institute. Getting a pacemaker may improve the patient's quality of life, but sometimes it may have no impact on quality, and would only prolong the life of a person with dementia, Fowler said.
Fowler said that cardiologists may only be focused on the patient's heart and may not even know that the patient has dementia unless it is severe and obvious.
"We have to think seriously about the way we provide holistic care to patients with dementia," she said. "I think that if some patients understood the implications of the treatment, they might not choose it for themselves," Fowler said.
The report was published July 28 online in JAMA Internal Medicine.
For the study, Fowler's team collected data on more than 16,000 patients from 33 Alzheimer's disease centers. The participants were seen between September 2005 and December 2011 and added to the National Alzheimer's Coordinating Center Uniform Data Set.
At the start of the study, almost half the of participants had no signs of dementia, 21 percent had a mild dementia and nearly 33 percent had dementia.
The researchers found that people with dementia were older and more likely to be men, and to have heart disease and a history of stroke.
As to why those with dementia and irregular heart rhythms were more likely to get a pacemaker, Fowler speculates that people suffering from dementia typically aren't making medical decisions themselves. "Older adults with dementia often have other people helping them make decisions or making decisions for them," she said.
Or, doctors may treat patients with dementia more aggressively. "There is also evidence to show that family members have a tendency to be more aggressive when patients are seriously ill," Fowler said.
One reason could be that doctors may feel that patients with dementia aren't able to care for themselves, and placing a pacemaker takes away the need for patients to be responsible for medications or comply with other treatments, she said.
Doctors may feel more comfortable choosing conservative treatments in people without dementia because they can provide a more complete medical history, and are better able to care for themselves, she said.
Interestingly, there was no difference in the rates of implanted defibrillators between those with and without dementia, Fowler's group noted. Implanted defibrillators can shock the heart to get it beating regularly again.
Dr. Gregg Fonarow, a professor of cardiology at the University of California, Los Angeles, thinks the decision to use a pacemaker should be based on the patient's heart problem.
"There have been few studies that evaluate whether the presence of various degrees of mental impairment influences clinical decision making in terms of placement of pacemakers," he said.
This new observational study shows that patients with dementia were more likely to receive a pacemaker than patients without mental impairment, but beyond that it doesn't indicate why, he said.
"As there were no data collected on the specific indications for pacemaker, these findings are confusing and further studies are needed," Fonarow said.
Fowler recommended that, in the early stages of dementia, patients discuss their medical wishes with their family and their doctor. This discussion might also include whether or not a patient wants certain medications or to be screened for cancers, she said.
For more information on dementia, visit the Alzheimer's Association.
SOURCES: Nicole Fowler, Ph.D., assistant professor, medicine, University of Pittsburgh; Gregg Fonarow, M.D., professor, cardiology, University of California, Los Angeles; July 28, 2014, JAMA Internal Medicine, online
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