Friday, September 12, 2014

Use of Medications of Questionable Benefit in Advanced Dementia

Advanced dementia is characterized by severe cognitive impairment and complete functional dependence. Patients’ goals of care should guide the prescribing of medication during such illness. Medications that do not promote the primary goal of care should be minimized.

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.

Design, Setting, and Participants
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.

Main Outcomes and Measures
Use of medication deemed of questionable benefit in advanced dementia based on previously published criteria and mean 90-day expenditures attributable to these medications per resident. Generalized estimating equations using the logit link function were used to identify resident-and facility-related factors independently associated with the likelihood of receiving medications of questionable benefit after accounting for clustering within nursing homes.

Of 5406 nursing home residents with advanced dementia, 2911 (53.9%) received a least 1 medication with questionable benefit. Cholinesterase inhibitors (36.4%), memantine hydrochloride (25.2%), and lipid-lowering agents (22.4%) were the most commonly prescribed. 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, accounting for 35.2% of the total average 90-day medication expenditures for residents with advanced dementia who were prescribed these medications.

Conclusions and Relevance
Most nursing home residents with advanced dementia receive medications with questionable benefit that incur substantial associated costs.

I thought you might like to look at a medical abstract. It is generally a one page summary. The full study contains all the statistical analysis and references. This one ran 14 pages and was published this week in JAMA (Journal of the American Medical Association). Most of my blogs come from health news articles written about such studies. JAMA published this study as one entry in their ongoing series entitled “Less is More”. It is a worthwhile attempt to reeducate physicians about common excesses in current medical care.

Of note, the drugs of “questionable benefit” are just plain contraindicated in patients with advanced dementia. They have absolutely no benefit to the patient and the guidelines that clearly recommend against the use of these drugs have been well publicized within the medical community. The use of the meds in this patient population is negligent and those physicians prescribing these meds are guilty of malpractice.

Why would any physician attempt to lower cholesterol in an elderly patient with advanced dementia? The only answers I can come up with are ignorance and a complete lack of concern for the patient. The next logical question is why are these facilities and physicians allowed to continue to treat anyone? I don’t have an answer to that question.

Indiscriminate drug prescribing occurs throughout the health care industry in America, and to a lesser extent throughout the world. This study, like the studies on antibiotic use, must be a catalyst to change the way we approach health care. “Thumbs Up” to JAMA for publishing this study and for their ongoing series “Less is More”.

Source: JAMA Internal Medicine –September 8, 2014

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