Common Hospice Medications May Carry Major Unintended Risks For People With Dementia

Hospice attraction intends to bring comfort, peace, and dignity to patients astatine nan extremity of life. Yet for nan increasing number of Americans pinch dementia who participate hospice, their people is often agelong and unpredictable - making it particularly important to guarantee treatments align pinch each person's goals and shape of illness.

A caller University of Michigan study published successful JAMA Network Open finds that medications commonly prescribed to easiness symptoms specified arsenic agitation, anxiety, and delirium - benzodiazepines and antipsychotics - whitethorn transportation awesome unintended risks for group pinch dementia receiving hospice care.

Among much than 139,000 nursing location residents pinch Alzheimer's illness and related dementias enrolled successful hospice betwixt 2014 and 2018, those who began taking a benzodiazepine aliases an antipsychotic aft enrollment were 41% and 16% much apt to dice wrong six months, respectively, than very akin hospice patients pinch dementia who did not person these medications.

"Dementia is now nan astir communal qualifying information among hospice enrollees, yet galore of these patients are not imminently dying," said Lauren B. Gerlach, DO, MS, lead writer and geriatric psychiatrist astatine nan University of Michigan. "Because prognosis successful dementia is truthful difficult to determine, astir 1 successful 5 patients will outlive nan six-month eligibility model for hospice. This makes it captious that medications utilized during this play enhance, alternatively than diminish, value of life."

Patterns of usage and accrued risk

The study analyzed nationalist Medicare information from a uncommon play erstwhile hospices were required to study prescribing information.

None of nan patients studied had received nan benzodiazepines aliases antipsychotics successful nan six months earlier entering hospice.

Despite this, astir half (48%) received a caller benzodiazepine medicine and 13% received an antipsychotic aft hospice enrollment - astir wrong nan first fewer days of admission. The mean hospice enactment was much than 130 days, indicating that astir patients were not successful nan last days aliases weeks of life. Benzodiazepines see medications specified arsenic Ativan and Valium, while antipsychotics see medications specified arsenic Haldol and Zyprexa.

"These early prescribing patterns propose that these medications whitethorn sometimes beryllium utilized arsenic portion of modular hospice attraction practices alternatively than afloat tailored to each individual," said Gerlach. "For galore patients, these medications tin supply meaningful alleviation from distressing symptoms, but they besides transportation risks. Our findings, item an opportunity for hospice teams to regularly reassess medicine use, particularly early successful care, erstwhile maintaining connection and alertness whitethorn beryllium prioritized by patients and families."

Both supplier classes person well-established risks successful older adults, including confusion, sedation, and falls. The U.S. Food and Drug Administration requires boxed warnings connected nan packaging of antipsychotics for accrued mortality successful patients pinch dementia. Similar concerns person been raised astir benzodiazepines.

A mismatch betwixt hospice argumentation and dementia care

The findings besides constituent to 2 awesome argumentation gaps. First, location is small ongoing oversight of medicine usage successful hospice. Hospice agencies were required to study elaborate prescribing information to nan national authorities only from 2014 to 2018, making that little model nan only clip researchers could study nationalist prescribing patterns.

"Right now, hospice prescribing is simply a achromatic box," Gerlach said. "Medications covered nether nan hospice use are not reported to Medicare, truthful we person almost nary visibility into what patients are receiving. That makes it intolerable to show prescribing information aliases value connected a nationalist level."

There is besides a discrepancy successful really medicine usage is monitored crossed attraction settings. Both benzodiazepines and antipsychotics are tracked arsenic portion of nursing location value reporting, and antipsychotic usage straight impacts installation prima ratings successful nan Centers for Medicare and Medicaid Services Care Compare Tool. Yet these aforesaid medications are not tracked by hospice, leaving a spread successful evaluating prescribing value and reporting.

Second, nan six-month limit connected Medicare hospice eligibility often does not align pinch nan prolonged and uncertain people of dementia. About 20% of hospice patients pinch dementia unrecorded longer than six months and are discharged from hospice, losing entree to supportive services they still need.

"The Medicare hospice use was designed erstwhile astir patients enrolling had crab and short, predictable trajectories," Gerlach said. "For group pinch dementia, whose illness people tin span years, we request attraction models and prescribing guidance that amended bespeak their experience."

The request for dementia-specific hospice guidance

Gerlach's squad has antecedently shown wide variety crossed hospice agencies successful their prescribing patterns of some classes of drugs, moreover aft accounting for diligent differences.

In nationalist data, benzodiazepine prescribing ranged from 12% to 80% of hospice patients, and antipsychotic usage from 6% to 62%. Large and for-profit agencies were importantly much apt to prescribe these medications.

Last year, her group reported successful JAMA Psychiatry that patients pinch dementia enrolled successful hospice were 3 times much apt to person benzodiazepines and antipsychotics than akin patients who were not successful hospice.

"Such wide variety suggests, successful immoderate cases, prescribing whitethorn beryllium driven by hospice agency civilization aliases policies ," said Gerlach. "And fixed our findings linking caller usage of these medications pinch higher mortality, this inconsistency whitethorn person existent consequences for diligent outcomes."

With 60% of group pinch dementia now entering hospice astatine slightest once, and nan proportionality of hospice patients pinch dementia continuing to rise, Gerlach says these findings item nan request for greater dementia-specific hospice value measures and prescribing guidance.

"We request amended transparency successful prescribing information and support for hospice clinicians to make much grounds informed, individualized decisions astir really to champion attraction for patients pinch dementia astatine extremity of life."

The study was funded by nan National Institute connected Aging of nan National Institutes of Health (K23AG066864, R01AG087073).

In summation to Gerlach, nan study's authors are Lan Zhang, PhD, Hyungjin Myra Kim Sc.D., Joan Teno M.D., M.S., and Donovan T. Maust M.D., M.S. Gerlach, Kim and Maust are members of nan U-M Institute for Healthcare Policy and Innovation; Kim and Maust are besides members of nan VA Center for Clinical Management Research.