Advanced Dementia Patients Given Medications of
Questionable Benefit, High Cost
Questionably medications account for more than one
third of their medication expenditures
Nov. 3, 2014 A nationwide study of 5046 patients
with advanced dementia mostly white females and more than half age 85
or older has found that most nursing home residents with advanced
dementia receive medications with questionable benefit that incur
substantial associated costs.
For such residents, questionably beneficial
medications account for more than one third of their medication
expenditures, wrote the authors of the study to be published in JAMA
Internal Medicine, November 3, 2014.
The researcher note that Lower use of questionably
beneficial medications was found among residents with advance directives
who were enrolled in the hospice setting.
Advanced dementia in this study was defined as a
terminal illness characterized by no longer recognizing family,
bedridden and able to speak fewer than five words. Generally, they had
frequent problems with dysphagia and aspiration but received an average
of five to 15 medications daily.
Standards of care require patients goals of care
should guide the prescribing of medication during such terminal illness.
Medications that do not promote the primary goal of care should be
The goal of the researchers, according to lead
author Jennifer Tjia,
MD, MSCE, Department of Quantitative Health Sciences, University of
Massachusetts Medical School, was to estimate the prevalence of
medications with questionable benefit used by nursing home residents
with advanced dementia, identify resident- and facility-level
characteristics associated with such use, and estimate associated
They conducted a cross-sectional study of
medication use by nursing home residents with advanced dementia using a
nationwide long-term care pharmacy database linked to the Minimum Data
Set (460 facilities) between October 1, 2009, and September 30, 2010.
They identified the use of medication deemed of
questionable benefit in advanced dementia based on previously published
criteria and the mean 90-day expenditures attributable to these
medications per resident.
Of 5406 nursing home residents with advanced
dementia, 2911 (53.9%) received at least one medication with
questionable benefit (range, 44.7% in the Mid-Atlantic census region to
65.0%in the West South Central census region).
Cholinesterase inhibitors (36.4%), memantine
hydrochloride (25.2%), and lipid-lowering agents (22.4%) were the most
There were reasons to adjust the analysis for some
special considerations that lowered the likelihood of receiving these
● having eating problems,
● a feeding tube, or
● a do-not-resuscitate order, and
● enrolling in hospice.
High facility-level use of feeding tubes increased
the likelihood of receiving these medications.
The mean 90-day expenditure for medications with
questionable benefit was $816 ($553), accounting for 35.2%of the total
average 90-day medication expenditures for residents with advanced
dementia who were prescribed these medications.
Our findings have important implications at the
policy level, and show that little progress has been made with respect
to meeting the intent of the F329 section of the Nursing Home Reform
Act, which calls for all nursing home residents to be free of
unnecessary medications, the authors write in their conclusion.
This report was published by JAMA Internal Medicine online September 8,
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