More than half of long-term nursing home residents with advanced dementia are receiving at least one "questionably beneficial medication," according to a new study in JAMA Internal Medicine.
The authors of the study conclude there's a high use of unnecessary, inappropriate drugs for terminally ill dementia patients, whose goal of care should be comfort, not prolonging life.
If this sounds familiar, it's because appropriate end-of-life care is a common theme on this blog. Recently, I reported on a study finding that providing futile care in the intensive care unit could hurt another patient's chances of getting needed treatment.
The study relies on information collected from the prescription-dispensing database of a national long-term care pharmacy that operates in 47 states, according to the report. It assessed the drugs prescribed to 5,406 nursing home residents with advanced dementia between October 1, 2009, and September 30, 2010.
The side effects
The authors explain that current standards of care recommend minimizing unnecessary procedures, so providers can focus on interventions that improve a patient's last days of life.
But this prescription study suggests those guidelines aren't always being followed.
In the Los Angeles Times, Melissa Healy writes that Alzheimer's disease drugs, "which are virtually ineffective in patients with severe dementia, were the questionable medications most commonly given to nursing home patients with advanced disease."
On top of that, the study's authors describe how medication can cause discomfort, or harm, to patients with advanced dementia:
"First, swallowing and eating difficulties make giving medication burdensome and difficult for the residents and the nursing home staff. Second, adverse drug effects are common in patients with dementia, yet (adverse drug effects) 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 6-month mortality, and the time to benefit from many medications exceeds this life expectancy."
Healy notes there's also an economic cost: "The practice of prescribing such drugs "needlessly inflates the cost of caring for patients near the end of life, by an estimated $816 on average every 90 days," she writes.
In an invited commentary in JAMA, Dr. Greg Sachs, who specializes in geriatrics at Eskenazi Health Center for Senior Health in Indianapolis, writes that the study holds big lessons for nursing home providers:
"If nursing home providers were to discontinue just some of these medications, there would be a substantial reduction in staff burden of medication administration, patient burden of taking medications, adverse effects, and costs. As few interventions can simultaneously achieve such outcomes for frail patients with dementia, reviewing medication lists and stopping nonbeneficial drug use should be a top priority for prescribers."
Sachs concludes that more research is needed in this area, particularly with an eye towards developing lists of questionably beneficial medications for people with other serious illnesses.
But, he writes:
"We ought to begin now to incorporate the conceptual framework and decision-making approach into our daily prescribing practices, as well as test and treatment ordering."
Has a loved one with advanced dementia - or another serious illness - been prescribed a medication of questionable benefit? What happened, and what's your reaction? Tell us about it in the comment section below, or e-mail us at Impatient@scpr.org.