Common hospice medications can pose significant unintended risks for people with dementia.

Common hospice medications can pose significant unintended risks for people with dementia.

Hospice care and its challenges

Hospice care aims to provide patients with comfort, peace and dignity at the end of life. For the growing number of Americans with dementia entering hospice care, the journey is often long and unpredictable. Therefore, it is particularly important that treatments are consistent with each person's goals and stage of disease.

A new study from the University of Michigan published inJAMA Network Open, has found that medications commonly prescribed to relieve symptoms such as agitation, anxiety and delirium – benzodiazepines and antipsychotics – can pose significant unintended risks for people with dementia in hospice care.

Study results

Among more than 139,000 nursing home residents with Alzheimer's disease and related dementias admitted to hospice between 2014 and 2018, the odds of dying within six months were 41% higher for those who took a benzodiazepine after admission and 16% higher for those who took an antipsychotic, compared to similar patients who did not receive these medications.

“Dementia is now the most common illness among hospice patients, but many of these patients are not immediately dying forecast Although dementia is extremely difficult to determine, almost one in five patients will live longer than six months and lose access to the hospice services they continue to need. Therefore, it is critical that medications used during this time promote, rather than diminish, quality of life.”

Lauren B. Gerlach, DO, MS, lead author and geriatrician, University of Michigan

Patterns of use and increased risk

The study analyzed national Medicare data from a rare period when hospices were required to report their prescription data.

None of the study participants had received benzodiazepines or antipsychotics in the six months before hospice admission.

Nevertheless, almost half (48%) received a new prescription for benzodiazepines and 13% received a prescription for antipsychotics after hospice admission - most within the first few days. The average length of stay in hospice was more than 130 days, suggesting that most patients were not in the last days or weeks of life. Benzodiazepines include medications such as Ativan and Valium, and antipsychotics include Haldol and Zyprexa.

“These early prescribing patterns suggest that these medications are sometimes used as part of standard practice in hospice care, rather than being completely tailored to each person,” Gerlach said. "For many patients, these medications can provide significant relief from distressing symptoms, but they also carry risks. Our results raise the possibility that hospice teams regularly reevaluate medication use, particularly early in care when communication and alertness of patients and families may be considered a priority."

Both groups of medications have well-established risks in older adults, including confusion, sedation, and falls. The U.S. Food and Drug Administration calls for warnings on antipsychotics because of increased risk of death in patients with dementia. Similar concerns have also been raised about benzodiazepines.

A mismatch between hospice policies and dementia care

The results also point to two major policy gaps. First, there is little ongoing oversight of medication use in hospice. Hospice agencies were only required to report detailed prescribing data to the federal government between 2014 and 2018, making that short period the only one during which researchers could examine national prescribing patterns.

“Right now, hospice prescribing is a black box,” Gerlach said. "Medications covered under hospice coverage are not reported to Medicare, so we have almost no visibility into what patients are receiving. This makes it impossible to monitor the safety or quality of prescribing on a national level."

There is also a difference in monitoring medication use across different care settings. Both benzodiazepines and antipsychotics are tracked as part of nursing home quality reporting, and antipsychotic use directly impacts facilities' star ratings in the Centers for Medicare and Medicaid Services' Care Compare Tool. However, these same medications are not tracked in hospice, leaving a gap in assessing prescribing quality and reporting.

Second, the six-month deadline for Medicare hospice eligibility often does not align with the prolonged and uncertain course of dementia. Approximately 20% of hospice patients with dementia live longer than six months and are discharged from hospice, losing access to supportive services they continue to need.

“Medicare hospice coverage was designed when most admitting patients had cancer and had short-term, predictable progression,” Gerlach said. “For people with dementia, whose disease progression can take years, we need care and prescribing models that better reflect their experiences.”

The need for specific guidelines for hospice care for dementia

Court's team has previously shown that there are large differences between hospice agencies in their prescribing patterns of both drug classes, even when patient differences are taken into account.

In national data, benzodiazepine prescriptions varied between 12% and 80% of hospice patients, and antipsychotic use varied between 6% and 62%. Large and commercial agencies prescribe

used these medications significantly more frequently.

Last year her group reported inJAMA psychiatryfound that patients with dementia who were admitted to hospice were three times as likely to receive benzodiazepines and antipsychotics than similar patients who were not in hospice.

“Such a large variation suggests that in some cases prescribing may be influenced by the culture or policies of the hospice agency,” Gerlach said. “And given our results linking new use of these drugs to higher mortality, this inconsistency could have real consequences for patient outcomes.”

With 60% of people with dementia now entering hospice at least once and the proportion of hospice patients with dementia continuing to rise, Gerlach says these results highlight the need for better, specific quality measures and prescribing guidelines for hospice care in dementia.

“We need more transparency in prescribing data and support for hospice clinicians to make evidence-based, individualized decisions about the best possible end-of-life care for patients with dementia.”

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

In addition to Gerlach, the study's authors include 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 the U-M Institute for Healthcare Policy and Innovation; Kim and Maust are also members of the VA Center for Clinical Management Research.

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