Expert: Paula Damgaard - 7/23/2008

Question
My 85 y/o grandmother suffers from pretty severe alzheimer's, currently she is non-ambulatory.  She has been ambulatory in recent past (1-2 months ago) which was acutally shocking because she had gone through a long phase where she was not.  She did suffer a few falls during this period but CT is clear for signs of injury.  She developed a UTI and was put on cipro on 07-05, this caused her to develop c. diff and she was put on Flaygl on 07-12.  She was then admitted for severe dehydration, diarrhea and UTI on 07-19.  On admit she had a temp of 103 and her WBCs were 23.  Apparntly the c. diff was resistant to the Flaygl and she was placed on Vanco.  She has now been on the Vanco for three days, her temps are low to none however her WBC has elevated and is at 32.5.  The RN reports she eats the best at breakfast and that is only about 30-40% and then will not eat much more than 2-3 bites at other meals.  My first instinct was sepsis however the RN told me her blood cx was no growth at 3 days.  However, I don't think that can tell us much due to the fact that it was drawn after she had been on 14 days of antibiotics.  I also noted that her urine was fairly dark and the RN advised she has an average 275 output per 8 hours.  I wonder if my insticts are correct and she could be septic, and also, I read that c. diff has a pretty high rate of reoccurance.  Is this something we should worry about, especially since it was resistant to the Flaygl this time.  My sister called to inform me her boyfriend who is a RN has assured her that Grandma will be just fine and back in her home soon, I am not convinced of that.  Even without temps, she is still suffering from the UTI, c.diff and dehydration. My father is her DPOA but he really does not understand medical issues or terminology.  Her physician was not available today while I was there (I live in a different area) and I could only get some answers from the RN.  I would really like an honest opinion of her current condition. I work in tissue donation and read medical charts every day so I feel as though I most likely know the course to expect, but since I was unable to visit with her physician for some direct answers I was just wondering if these types of infections will cause her more problems d/t her age, med history, and non-ambulatory state, or if it will just take a bit longer but the Vanco should knock it out.  And the risk of reoccurance, she is a resident in a skilled nursing facility, does this perhaps increase those risks or is there simply a small chance that we make it that far?

Answer
Hi Sarah, I am afraid this is a little out of my league. I am not an expert on infection/antibiotic use.  I have a different mindset then you on this topic it seems.  I am one for not treating pretty severe Alzheimer's patients who have infections.  I am more for giving them quality of life and having them admitted to the hospital and being subjected to all the tests, probing, picking that is done, is not my idea of quality.  

Years ago before we had the Cipros and they Flagyls and Vancos etc, infections were the old people's friends because they would get an infection and die a peaceful death.  Now because we have all of these drugs we give them and give them and end up giving quantity of life rather than quality.  There is no chance that giving them antibiotics will make them come back and be the person that they were and I am sure that if you could ask an elderly person to look ahead in their life if this is what they would have wanted for themselves I am pretty sure they would say no.  

Alzheimer's disease is an ugly thing and there is no pretty ending.  All I can ever counsel anyone on is please make sure you are seeking quality for her rather than quantity.  This disease is a long hard road and everything should be done to make it as easy as possible, not only for the patient but for their spouses/family as well.  

I hope this helps you.  I am sorry for what you all are going through.  Having been there, I know that withholding antibiotics is not an easy decision, but in the long run it is the BEST decision we ever made as a family.