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Alzheimer's, Dementia & Mental Health

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.”


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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 minimized.

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 medication expenditures.

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 commonly prescribed.

There were reasons to adjust the analysis for some special considerations that lowered the likelihood of receiving these medications, including:

 ● 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.

Note: This report was published by JAMA Internal Medicine online September 8, 2014

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