September 24, 2014
Many Dementia Patients in Nursing Homes Receive Nonbeneficial Drugs

Worcester, MA—At what point should patients with terminal illnesses stop receiving maintenance drugs and other medications?

Consensus remains elusive, according to a new study finding that more than half of nursing home residents with advanced dementia still receive medications, primarily to treat their cognitive issues and to lower cholesterol. The report was published recently in JAMA Internal Medicine.

Background in the study, led by researchers from the University of Massachusetts Medical School in Worcester, notes that the Institute of Medicine recommends clinicians minimize interventions in patients with life-limiting disease and instead focus on maximizing quality of life.

To examine the use of chronic disease medications in patients with advanced dementia and calculate the costs of those prescribing patterns, researchers used a long-term care pharmacy database. They found that, of the 5,406 nursing home residents with advanced dementia, 53.9% received at least one medication of questionable benefit.

“Despite standards of care that call for minimizing interventions that are unnecessary or provide little benefit in order to focus on interventions that optimize quality of life, polypharmacy remains common in this population,” the authors write. “Several factors suggest that polypharmacy in this population should be minimized. First, swallowing and eating difficulties make giving medication burdensome and difficult for the residents and the nursing home staff. Second, adverse drug effects (ADEs) are common in patients with dementia, yet ADEs are difficult to detect by clinicians because these patients have difficulty expressing the symptoms they feel Third, this population has frequent clinical complications associated with a high risk of six-month mortality, and the time to benefit from many medications exceeds this life expectancy.”

Use of the questionable medications varied by region; the percentage ranged from 44.7% in the Mid-Atlantic census region to 65 in the West South Central census region, according to the study.

Most commonly prescribed were the dementia therapies, cholinesterase inhibitors (36.4%) and memantine hydrochloride (25.2%). About 22.4% of the advanced dementia patients were still receiving cholesterol-lowering medications.

Researchers found that the likelihood of receiving medications of questionable benefit was lower for patients with eating problems, a feeding tube, a do-not-resuscitate order, or in who had enrolled in hospice.

Yet, living in a nursing home with a greater than 10% prevalence of feeding-tube use was associated with a greater likelihood of being prescribed questionably beneficial medications compared with those residents who lived in nursing homes where the use of feeding tubes was 5% or less.

The average 90-day cost for a medication of questionable benefit was $816 and accounted for 35.2 % of the total average 90-day medication expenditures for patients with advanced dementia.

“Our findings have important implications because the use of prescription medications in patients with advanced illness presents a burden to the health care system and to patients,” the authors conclude.

In a related commentary, Greg A. Sachs, M.D., of Indiana University School of Medicine and Eskenazi Health, Indianapolis, suggests the article should be read “not just by clinicians who care for patients with advanced dementia and nursing home residents. The article contributes to the literature and practice in two important ways.”

“First, the study’s strengths advance our understanding of medication prescribing practices for nursing home residents with advanced dementia. Second, the work … is part of the ‘Less is More’ series in this journal and addresses the American Board of Internal Medicine Foundation’s Choosing Wisely campaign and other initiatives aimed at curtailing the use of non-beneficial and potentially harmful medications, tests and treatments. This article should cause all clinicians to reconsider their prescribing practices and other decision making for a broad population of patients late in life,” Sachs concludes.

U.S. Pharmacist Social Connect