Dementia patients frequently on medications with minimal benefit

1. More than half of patients with advanced dementia in this study were on medications of questionable benefit.

2. Patients with chewing or swallowing problems, mouth pain, feeding tubes, do-not-resuscitate (DNR) orders, or enrolled in hospice had lower likelihood of being prescribed a medication of questionable benefit.

Evidence Rating Level: 3 (Average)

Study Rundown: Patients with advanced dementia suffer from a terminal illness characterized by significant cognitive, social, and functional impairment. Goals of care in terminal illness should focus on maximizing comfort and quality of life. Previous studies, though limited, suggest that many patients with advanced dementia may be on medications that fail to address this primary goal and in fact provide minimal benefit. This study defined medications of questionable benefit as those deemed ‘never appropriate’ for use in advanced dementia by a previous consensus of experts.

This study confirms that more than half of long-term nursing home patients (53%) with advanced dementia are prescribed at least one of the medications on that list. Most notably the list includes cholinesterase inhibitors and memantine hydrochloride, medications that are commonly prescribed early in the disease process but have minimal benefit for patients with advanced dementia. The use of such medications is decreased in patients with advance directives enrolled in the hospice setting, and in those who require feeding tubes or have difficulty swallowing. This large cross-sectional study suggests that streamlining medications in accordance with goals of care for patients with advanced dementia is an important issue. One limitation of the study is that the list of medications deemed questionably beneficial was determined by expert consensus. Moreover, the cross-sectional design in this case may over-represent prevalence since dementia is a long duration disease.

Click to read the study in JAMA Internal Medicine

Click to read an accompanying editorial in JAMA Internal Medicine

Relevant Reading: Withholding, Discontinuing and Withdrawing Medications in Dementia Patients at the End of Life

In-Depth [cross-sectional study]: This study used data from the prescription-dispensing database of a long-term care pharmacy. Patients were selected based on having data available between 2009-2010, being greater than 65 years of age, and with a diagnosis of advanced dementia characterized by scores on Mini-Mental State Examination (MMSE). Exclusion criteria were length of stay at care facility less than 90 days, small facilities, and any patients with missing data. 5406 patients met criteria for study.

53.9% of patients (2911 patients) were prescribed at least one medication of questionable benefit during a 90-day observation period. Patients with oral problems had a lower likelihood of being prescribed a questionably beneficial medication, including those with chewing problems, swallowing problems, or mouth pain (adjusted odds ratio [AOR]: 0.68; 95% CI: 0.59-0.78), a feeding tube (AOR: 0.58; 95% CI: 0.48-0.70), a do-not-resuscitate (DNR) order (AOR: 0.65; 95% CI: 0.57- 0.75), and who were enrolled in hospice (AOR: 0.69; 95% CI: 0.58-0.82). Of patients that were on at least 1 questionably beneficial medication, the mean (SD) 90-day drug expenditure was higher, at $2317 ($1357), of which 35.2% was attributable to medications of questionable benefit.

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