Should patients with advanced dementia receive the influenza (flu) vaccine and pneumococcal (pneumo) vaccine?

Influenza and Pneumococcal Vaccination in Patients with Advanced Dementia

Patients with advanced dementia should receive both influenza and pneumococcal vaccines to reduce morbidity and mortality from respiratory infections, despite their advanced cognitive impairment. 1, 2

Rationale for Vaccination

Patients with advanced dementia are at increased risk for:

• Higher morbidity and mortality from respiratory infections 2
• Complications from influenza and pneumococcal disease 2
• Bacteremia from pneumococcal infection with mortality rates up to 50% 1

Influenza Vaccination Recommendations

• Annual influenza vaccination is strongly recommended for all patients with advanced dementia 1
• Timing: Ideally administered in September through November in North America, but vaccination is beneficial anytime during flu season 1
• Type: For patients ≥65 years (which includes most advanced dementia patients), high-dose or adjuvanted influenza vaccine is preferred over standard-dose vaccine 1
• Administration: Can be given simultaneously with pneumococcal vaccine at different anatomic sites 1, 3

Pneumococcal Vaccination Recommendations

• Pneumococcal vaccination is strongly indicated for patients with advanced dementia 1
• For adults ≥65 years:
  • PCV13 (pneumococcal conjugate vaccine) should be administered first
  • PPSV23 (pneumococcal polysaccharide vaccine) should be given 6-12 months after PCV13 1
• If previously received PPSV23, administer PCV13 at least 12 months later 1

Benefits of Vaccination

1. Reduced mortality: Antimicrobial treatment and preventive vaccination are associated with prolonged survival in nursing home residents with advanced dementia who develop pneumonia 4

2. Reduced hospitalization: Influenza vaccination can reduce hospitalization for pneumonia by 29-32% in older adults 1

3. Potential cognitive benefits: Recent evidence suggests influenza vaccination may be associated with reduced risk of dementia progression, with a 31% reduction in dementia risk observed in vaccinated individuals 5, 6

Practical Considerations

• Timing: Avoid vaccination during moderate to severe acute illness with fever; minor illnesses with or without fever are not contraindications 3
• Consent: Obtain consent from healthcare proxy or surrogate decision-maker
• Documentation: Document vaccination in medical record and provide information to caregivers
• Setting: Vaccination can be administered in long-term care facilities, outpatient settings, or during hospital discharge 1

Contraindications and Precautions

• Absolute contraindications:

  • History of severe allergic reaction (anaphylaxis) to previous doses or vaccine components 3
  • For influenza vaccine: anaphylactic hypersensitivity to eggs or egg products 1

• Precautions:

  • History of Guillain-Barré syndrome within 6 weeks of previous influenza vaccination 1
  • Moderate to severe acute illness with fever (defer until symptoms resolve) 3

Implementation Strategies

• Use standing orders in long-term care facilities to ensure vaccination 1
• Identify and label medical records of patients who should receive vaccination 1
• Document offer of vaccination and receipt or refusal in medical record 1
• Consider vaccination at hospital discharge for patients with unreliable outpatient follow-up 1

Common Pitfalls to Avoid

1. Underutilization: Patients with dementia are often less likely to receive influenza or pneumococcal vaccines despite their increased risk 2

2. Misconceptions about efficacy: Some providers may incorrectly assume vaccines are not beneficial in advanced dementia patients

3. Concern about discomfort: While vaccination may cause mild local reactions, the benefits of preventing serious respiratory infections significantly outweigh these minor discomforts

4. Delayed vaccination: Don't wait for the "perfect time" - vaccinate during any healthcare encounter during the appropriate season

By following these evidence-based recommendations, healthcare providers can help reduce the burden of respiratory infections in this vulnerable population and potentially improve both survival and quality of life.