Assessment of factors that influence physician decision making regarding medication use in patients with dementia at the end of life

Parsons, Carole; McCorry, Noleen; Murphy, Kevin D.; Byrne, Stephen; O’Sullivan, David; O’Mahony, Denis; Passmore, Peter; Patterson, Susan; Hughes, Carmel

doi:10.1002/gps.4006

Cited by 34 publications

(41 citation statements)

References 76 publications

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“…The present findings regarding possible correlates of opinions of whether AH, AT and AN should be administered or not when a patient's life expectancy falls warrant a few comments. These practices are widely used, even in cases with a limited residual life expectancy, even though the benefits are not apparent from the literature . It might be that healthcare providers working in geriatrics tend to administer AT and AN less to patients with a life expectancy limited to a few weeks, because they know more about terminal dementia conditions and the process of dying.…”

Section: Discussionmentioning

confidence: 99%

“…The results of the present study showed that AN creates more ethical dilemmas in clinical management of end life than AH or AT. It remains to be explored whether this option is as a result of a non‐explicit, but wanted, intervention to hasten death, or if this attitude is instead related to the probability that AN leads to more adverse effects …”

Section: Discussionmentioning

confidence: 99%

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Advanced dementia: opinions of physicians and nurses about antibiotic therapy, artificial hydration and nutrition in patients with different life expectancies

Pengo

Zurlo

Voci

et al. 2016

Geriatrics Gerontology Int

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Advanced dementia: opinions of physicians and nurses about antibiotic therapy, artificial hydration and nutrition in patients with different life expectancies

Pengo

Zurlo

Voci

et al. 2016

Geriatrics Gerontology Int

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“…The question of when to discontinue ChEI therapy remains challenging given the lack of general consensus among clinicians [54,55]. ChEIs are frequently prescribed in nursing home residents and at the time of hospice enrollment, with one cross-sectional study of 5406 nursing home residents with advanced dementia finding that ChEIs were the most commonly prescribed drug (36.4 % of patients) [56][57][58].…”

Section: Cholinesterase Inhibitors At the End Of Lifementioning

confidence: 99%

The Use of Cholinesterase Inhibitors Across All Stages of Alzheimer’s Disease

2015

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Current pharmacological therapy for Alzheimer's disease (AD) includes the cholinesterase inhibitors (ChEIs) donepezil, rivastigmine, and galantamine and the N-methyl D-aspartate receptor antagonist memantine. Based on the results of randomized controlled trials and several meta-analyses, ChEIs appear to show modest but statistically significant improvements on several measures, including cognition and global functioning. Given their modest effects, there is a lack of consensus among clinicians regarding issues related to initiation, optimal duration, and discontinuation of ChEI therapy across the spectrum of AD. There is evidence from long-term observational controlled studies that early initiation and persistent exposure to AD therapy lead to delays in nursing home admission and significantly slower rates of cognitive and functional impairment. In the moderate to severe stages of AD, therapeutic trials of higher dose ChEIs and the addition of memantine are recommended for patients who are no longer responding to lower doses. While side effects are generally mild and gastrointestinal in nature, these events can lead to significant morbidity in more susceptible patients with advanced disease. Patients should thus be regularly monitored for any potential serious side effects of ChEI therapy, which also may include syncope and bradycardia. At the terminal stages of AD, such as when patients become hospice eligible, attempts to cautiously discontinue all medications not necessary for quality of life, including AD drugs, should be made.

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“…Furthermore, there were some medications, namely expectorants and tricyclic antidepressants, for which classifications of appropriateness varied widely. This variation may in part be explained by cross-national or cultural differences in prescribing in US and UK jurisdictions but may also reflect the complexity and variability in decision-making regarding medication use at the end of life for patients with advanced dementia and the lack of evidence-based guidance available to guide clinical practice [8,27,41].…”

Section: Discussionmentioning

confidence: 99%

Development and Application of Medication Appropriateness Indicators for Persons with Advanced Dementia: A Feasibility Study

et al. 2014

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USA) for their advice regarding study design. The authors would also like to thank the physicians who participated in the Delphi consensus panel survey, and the residents, their relatives and care home staff who participated in the feasibility study. AbstractBackground: No studies have been conducted in the United Kingdom (UK) context to date which categorise medications in terms of appropriateness for patients with advanced dementia, or which examine medication use in these vulnerable patients.Objectives: To categorise the appropriateness of a comprehensive list of medications and medication classes for use in patients with advanced dementia; to examine the feasibility of conducting a longitudinal prospective cohort study to collect clinical and medication use data;and to determine the appropriateness of prescribing for nursing home residents with advanced dementia in Northern Ireland (NI), using the categories developed.Methods: Three-round Delphi consensus panel survey of expert clinicians, to categorise the appropriateness of medications for patients with advanced dementia (defined as having Functional Assessment Staging [FAST] scores ranging from 6E to 7F). This was followed by a longitudinal prospective cohort feasibility study which was conducted in three nursing homes in NI. Clinical and medication use for participating residents with advanced dementia (FAST scores ranging from 6E to 7F) were collected and a short test of dementia severity administered.These data were collected at baseline and every three months for up to nine months or until death. For those residents who died during the study period, data were also collected within 14 days of death. The appropriateness ratings from the consensus panel survey were retrospectively applied to residents' medication data at each data collection timepoint to determine the appropriateness of medications prescribed for these residents.Results: Consensus was achieved for 87 (90%) of the 97 medications and medication classes included in the survey. Fifteen residents were recruited to participate in the longitudinal prospective cohort feasibility study, four of whom died during the data collection period. Mean numbers of medications prescribed per resident were 16.2 at baseline, 19.6 at three months, 17.4 at six months and 16.1 at nine months respectively. Fourteen residents at baseline were taking at least one medication considered by the consensus panel to be never appropriate, and approximately 25% of medications prescribed were considered to be never appropriate. Postdeath data collection indicated a decrease in the proportion of never appropriate medications and an increase in the proportion of always appropriate medications for those residents who died. Conclusions

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Assessment of factors that influence physician decision making regarding medication use in patients with dementia at the end of life

Abstract: Further research is required into other factors that may impact upon physicians' prescribing decisions for these vulnerable patients and to clarify how the factors examined in this study influence prescribing decisions.

Cited by 34 publications

References 76 publications

Advanced dementia: opinions of physicians and nurses about antibiotic therapy, artificial hydration and nutrition in patients with different life expectancies

Advanced dementia: opinions of physicians and nurses about antibiotic therapy, artificial hydration and nutrition in patients with different life expectancies

The Use of Cholinesterase Inhibitors Across All Stages of Alzheimer’s Disease

Development and Application of Medication Appropriateness Indicators for Persons with Advanced Dementia: A Feasibility Study

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