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Many with advanced dementia getting drugs of uncertain benefit

April 8, 2017

The use of medications that have questionable benefits for patients in the terminal stages of dementia is widespread, and continues even in the final days before death, a new Canadian study has found.

The study showed that 45% of nursing home residents with dementia who received at least one medication of questionable benefit within the last year of life continued to get these drugs in the last week before death.

This is despite recommendations to reduce aggressive and burdensome interventions in these patients.

“We need to think carefully about people with advanced dementia and try to focus our thinking on how we can optimize quality of life in this group,” study author Paula A. Rochon, MD, a geriatrician and scientist at Women’s College Research Institute and the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada, told Medscape Medical News.

“One of the pieces we focus on when you’re reflecting on quality of life is medication use and how to make sure that the medications are being used in a manner that is as appropriate as possible.”

The study was published online March 29 in the Journal of the American Geriatrics Society.

Never Appropriate

An expert panel of geriatricians has concluded that medications of questionable benefit (MQBs) — those that have limited benefit, are associated with unnecessary risks, or both — are never appropriate at the end of life, the authors write. The panel identified cholinesterase inhibitors (eg, donepezil, rivastigmine, and galantamine), as one MQB class.

Dr Rochon and her colleagues used linked databases to identify Ontario nursing home residents aged 66 years and older with dementia who died between June 1, 2010, and March 31, 2013, and who were prescribed at least one MQB in the year before death. Like other Canadian provinces, Ontario has a universal healthcare system where residents aged 65 years and older have access to most prescription medications.

MQBs included lipid-lowering agents (eg, statins and fibrates), antiplatelet agents excluding aspirin, antidementia drugs (these were exclusively cholinesterase inhibitors because the Ontario Drug Benefit plan does not cover memantine), sex hormones, hormone antagonists, leukotriene inhibitors, cytotoxic chemotherapy agents, and immune modulators.

The study included 9298 patients. Overall, 86.3% received at least one MQB in the last 120 days of life. The largest drop in prescribing of these drugs occurred at the very end of life — from 65.9% in the last 2 weeks to 45.0% in the last week.

“There is a recognition, to some extent, that when people are getting worse, there may be less of a role for these medications,” said Dr Rochon. “But we need to start backing that up and thinking about this at a much earlier stage.”

Of those who received any MQB in the last 120 days of life, the most common drug classes prescribed were cholinesterase inhibitors (63.6%), lipid-lowering agents, almost all of which were statins (47.8%), antiplatelet agents (17.7%), and sex hormones (2.1%).

Cholinesterase inhibitors generally have only a modest benefit and are associated with side effects, such as nausea, vomiting, and anorexia. “They are the kind of drugs you might use more in the milder and moderate stages of dementia to try to prevent progression,” said Dr Rochon.

“When people are already at very advanced stages of dementia, and close to the end of life, you have to question what is the benefit of these medications. You need to think about how this could be impacting the person and whether it’s really something that’s required or is part of the goal of maintaining quality of life.”

When stratified by Cognitive Performance Scale score, 56.0% of patients with a score of 5 (severe cognitive impairment) and 49.4% with a score of 6 (very severe cognitive impairment) received MQBs in the last week of life, the study found.

MQB use in the last 7 days of life was associated with taking a moderate number (5 to 14) of drugs per day, severe (vs very severe) cognitive impairment, fewer signs and symptoms of health instability, and not being hospitalized in the last 120 days of life. Residents with moderate physical and cognitive impairment were more likely than those with more advanced disease to use MQBs in the last 7 days of life.

The authors noted that almost a third of the residents in the study did not see a physician specialist in the last year of life. This is important, they said, because an assessment by a neurologist or psychiatrist is associated with lower risk of being dispensed an MQB in the last week of life.

But for Dr Rochon, the “bigger issue” is raising awareness “more broadly” among all providers. “To me, that’s the big opportunity.”

Use of questionable medications in patients with late-stage dementia is part of the overall issue of “problematic polypharmacy” in which patients get more drugs than they need, said Dr Rochon.

One way to potentially intervene to reduce unnecessary use of medications in patients with end-stage dementia is to introduce regular medication reviews, said Dr Rochon.

Regular Review

Ruth Drew, director of family and information services, Alzheimer’s Association, agreed that physicians should regularly review the drugs patients with end-stage dementia are taking.

Although the use of MQBs among these patients “is certainly something that should be looked at,” such use is “not terribly surprising,” Drew told Medscape Medical News.

“A person may have been taking these medications for a long period of time and the nursing staff is just following the doctor’s orders. If a doctor is not regularly seeing patients and re-evaluating their list of medications based on where they are in the disease process, it would be easy for this to happen.”

Drew pointed out that medical staff don’t always know when a nursing home resident is in the last week or last month of their life.

However, she added, they do know that a person has an advanced dementia such as Alzheimer’s disease.

“At the point where the person meets criteria for hospice care, the medical team should shift to a palliative approach by asking what’s going to make this person most comfortable, what makes the most sense now.”

This work was supported by a grant from the Canadian Institutes of Health Research (CIHR) Institute of Nutrition, Metabolism, and Diabetes and a grant from the CIHR Institute of Aging. This study was supported by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. The authors have no disclosed no relevant financial relationships.

J Am Geriatr Soc. Published online March 29, 2017. Abstract

http://wb.md/2oSBdzH

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