INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2002; 17: 681–682.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/gps.670

RESEARCH LETTER

Influenza vaccination of people with dementia in long-staywards in the United Kingdom: What is going on?

Paul Reynolds*, Caroline Linton and Nicholas Warner

Department of Old Age Psychiatry, St Cadocs Hospital, Caerleon, Wales

We carried out a survey in order to determine currentpractice concerning the vaccination of patients withdementia, on long-stay wards, with the influenza vac-cine. The Department Of Health’s policy (CMO et al.,2000) for influenza vaccination for 2000/2001 is thatthe vaccination should be offered to all persons overthe age of 65 years as well as those of any age withspecified physical illnesses and in long-stay residen-tial and nursing homes or other long-stay facilities.This policy has not changed to date.

Studies have shown that influenza vaccinationleads to cost effective reduction in morbidity and mor-tality in such individuals (Ahmed et al., 1995;Govaert et al., 1994; Gross et al., 1995).

Although people with dementia on long stay hospi-tal wards are theoretically included in the criteria forinfluenza vaccination, an awareness of local varia-tions led us to look at wider practice.

METHOD

In September 2000 all Consultant Old Age Psychia-trists in the UK were identified from a list providedby the Royal College of Psychiatrists. Questionnaireswere sent to all asking whether or not the consultantwas the Responsible Medical Officer for patients ofthis population and if so for how many such patientswere they responsible. The consultant was asked if he/she was aware of any local Trust policy for the vacci-nation of these patients against influenza and, if so,requested to briefly outline the policy. If a trust policywas not in place, consultants were asked how manysuch patients they routinely vaccinated. Questions

then followed to try to identify specific factors thatmight influence their decision as to whether to vacci-nate or not—these included: age of patient, stage ofdementia, physical frailty or co-existent medical diag-noses and relatives’ views.

RESULTS

Of the 372 Consultants circulated, 71.5% (266)replied. Less than half of the responding consultantswere aware of any trust policy, although some statedthat they followed the national policy for influenzaimmunisation. 28% stated that they vaccinated allpatients with dementia on long-stay wards; 16%vaccinated none (see Table 1). The vast majority ofrespondents (75–80%) replied that consideration ofage, stage of dementia, physical frailty and co-exis-tent medical diagnoses were not important in the deci-sion. Almost a quarter (22%) attached extremeimportance to relatives’ opinions, 37% said impor-tant, whereas 7% stated they were unimportant.

DISCUSSION

Although not specifically explored in this survey,several ethical issues are raised. If unable to consentto vaccination, how and by whom should the issue bedecided? Should such patients, with a limited qualityof life, be vaccinated against influenza? If suchindividuals are vaccinated, is it for the purpose of pro-tecting them or those in their environment, or both?

Sachs (1994) in his article describing some preli-minary considerations about the ethics of preventivecare for patients with dementia, emphasises:

* the goals of care for the individual patient,* the clinical state and prognosis of the individual

patient,Received 3 July 2001

Copyright # 2002 John Wiley & Sons, Ltd. Accepted 30 January 2002

*Correspondence to: Dr P. Reynolds, Department of Old AgePsychiatry, St Cadocs Hospital, Lodge Road, Caerleon, SouthWales, NP16 1XQ, UK.

* the characteristics of the screening test or pre-ventive measures (their benefits and burdens), and

* consideration of whether one would treat acondition if it were not prevented.

He goes on to describe three different goals of care:

* life prolongation,* some limitations on life prolonging treatment with

weighing of treatment benefits and burdens, and* palliation.

He argues that when palliation is the goal of care,vaccines and cancer screening tests are no longerappropriate parts of the care plan. He does state laterhowever, ‘that vaccines are different from other kindsof preventive treatment because of the concept of herdimmunity’, noting that ‘one may carry out vaccina-tions to provide some benefit to the community at riskand not just the individual patient’.

In the case of the individual with dementia in along-stay ward, death is not imminent on admission,yet the prognosis is for further progression of the ill-ness over an unspecifiable time-span, eventuallyresulting in death. Vaccination against the ‘flu’ is

not burdensome in this population. When consideringvaccination of such an individual the clinician mustbear in mind that the patient is residing in a commu-nity at risk. It could be argued that, in this group, it isnot paradoxical to vaccinate against influenza even ifit would be considered inappropriate to treat the indi-vidual (other than palliatively) should they contractinfluenza or secondary infection.

CONCLUSION

The survey highlights considerable variation in prac-tice and attitudes in the United Kingdom and raisesseveral ethical issues. There is a need for local proto-cols to achieve uniformity of practice in line withDepartment Of Health guidelines.

REFERENCES

Ahmed AH, Nicholson KG, Nguyen-Van-Tam JS. 1995. Reductionin mortality associated with influenza vaccination during 1989–90 epidemic. Lancet 346: 591–595.

Chief Medical Officer. 2000. ‘Influenza immunisation’ letter fromthe Chief Medical Officer, the Chief Nursing Officer, the ChiefPharmacist and the GPC. 1 August 2000.

Chief Medical Officer. 2000. ‘Influenza immunisation’ letter fromthe Chief Medical Officer, the Chief Nursing Officer, the ChiefPharmacist Wales. 4 August 2000.

Govaert TME, Thijs CT, Masurel N, Sprenger MJ, Dinant GJ,Knottnerus JA. 1994. The efficacy of influenza vaccination inelderly individuals. A Randomised double-blind placebo-controlled trial. JAMA 272: 1661–1665.

Gross PA, Hermogenes AW, Sacks HS, Lau J, Levandowski RA.1995. The efficacy of the influenza vaccine in elderly persons:a meta-analysis and review of the literature. Ann Intern Med123: 519–527.

Sachs GA. 1994. Flu shots, mammograms, and Alzheimer’sdisease: ethics of preventive medicine and dementia. In Alzhei-mer Disease and Associated Disorders, Vol. 8, No. 1. RavenPress Ltd: New York; 8–14.

Table 1. Responses to the question. ‘If there is no trust policy,what proportion of patients with dementia on long-stay wards doyou routinely vaccinate?’

Percentage long-stay patients Percentage of old ageroutinely vaccinated. psychiatrists.

100 27.675–99 3850–74 8.625–49 3.71–24 6.1

0 16

682 p. reynolds et al.

Copyright # 2002 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2002; 17: 681–682.