The CMS Manual Systems section F329 states “Each resident’s drug regimen must be free from unnecessary drugs.” Despite this regulatory statement, studies have found that as many at 53% of dementia patients took at least 1 unnecessary medication. This percentage increases as the patient transitions into hospice care where the goal is patient comfort.
The most common unnecessary drugs are Cholinesterase inhibitors such as Aricept and Namenda. Studies have shown that—at best—there are moderate benefits in patients with mild to severe dementia, and minimal benefits at end-stage disease (score of FAST 7). Along with moderate benefits with these medications come a number of adverse reactions. Common adverse reactions include bleeding, nausea and vomiting, dizziness, and headaches. There is also an increase in hospitalization over placebo for syncope (31.5% vs 18.6%), bradycardia (6.9% vs 4.4%) and hip fractures (22.4% vs 19.8%). Why then would we keep a patient with the primary goal of comfort on medications that are not only unnecessary but possibly harmful as well.
Many practitioners and family members are fearful of discontinuing these medications because they believe the patient will decline faster. However, one recent study researched what would happen if dementia medications were discontinued and then restarted and found minimal declines in behavior and function. It also found that, once dementia medications were restarted, the caregivers saw no benefit of continuation.
In hospice, where comfort is the primary goal, unnecessary medications should be discontinued, especially Cholinesterase Inhibitors (e.g., Aricept) and Namenda. Discontinuing these medications will not only benefit the patient with a decreased pill burden and quality of life, but will also reduce the chance of hospitalization.
- Park-Wyllie, Laura Y., et al. “Cholinesterase inhibitors and hospitalization for bradycardia: a population-based study.” PLoS Med 6.9 (2009): e1000157.
- Gill, Sudeep S., et al. “Syncope and its consequences in patients with dementia receiving cholinesterase inhibitors: a population-based cohort study.” Archives of Internal Medicine 169.9 (2009): 867-873.
- Tjia, Jennifer, et al. “Use of medications of questionable benefit in advanced dementia.” JAMA internal medicine 174.11 (2014): 1763-1771. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r22soma.pdf