Nursing home residents with dementia often get unneeded drugs at end of life

People nearing the end of life often receive medications they may no longer need, and that's true even in nursing homes, researchers say.
 
Nearly 9,300 Ontario nursing home residents with dementia received at least one medication of questionable benefit during the last year of life, a study found. And nearly half of these residents received potentially unnecessary drugs in the week before they died.
 
"It's really important to look at these medications on an ongoing basis and to determine if these medications are still the right medications for the individual, and to reevaluate this especially as new situations arise, study leader Dr. Paula Rochon told Reuters Health by phone.
 
"For example, in situations where the person has advanced dementia, it's important to, at that point in time, look at what are the things that the person is being (prescribed) and to think how are these contributing to improving quality of life and to review the medications with that kind of lens in mind," said Rochon, who is a researcher at the Institute for Clinical Evaluative Sciences and Women's College Hospital in Toronto.
 
About one in three nursing home residents in the study didn't see any specialists during the last year of life. But, having assessments by a neurologist or psychiatrist during that year was associated with less use of questionable medications, she and her colleagues found.

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Medications may be considered problematic for several reasons, including if there is concern about harmful drug interactions; if there are unacceptable demands, or pill burden, associated with taking medications; and if medications are used to treat side-effects of other medications, contributing to a prescribing cascade, the researchers write in the Journal of the American Geriatrics Society. Furthermore … appropriate medication discontinuation can reduce unnecessary healthcare costs."
 
Specifically, the study team looked at medication use for Ontario nursing home residents who had advanced dementia and died between 2010 and 2013.

Questionable benefits
 

Medications were considered to be of questionable benefit if they had been defined as never being appropriate for patients with advanced dementia according to the Ontario Drug Benefit Formulary.
 
The researchers identified 9,298 nursing home residents with advanced dementia who had received at least one such drug in the year before they died. About 86 per cent had received medications of questionable benefit during the last four months of life, and 45 per cent were given those medications during the final week of life.

 
The most commonly prescribed medications of questionable benefit included antidementia drugs and cholesterol-lowering medications, followed by blood thinners and sex hormones.
 
Rochon said some of the medications with questionable benefit could possibly be harmful in certain situations.
 
For example, she said, cholinesterase inhibitors, which are sometimes used to treat Alzheimer's disease, are associated with some modest benefit, but they do potentially have side-effects that might be important, including loss of appetite or GI upset.
 
In general, family physicians provide the majority of care for individuals with advanced dementia, the authors note.
 
Rochon said it's important to work with primary care doctors and pharmacists, who are experts in the use of drug therapies, to review patients medications on an ongoing basis.
 
Providers caring for patients near the end of life should focus on things that make people feel better, and minimize anything that might cause or be related to symptoms that might lead to discomfort, said Rochon.
 
The caregiving team and the decision-makers for that resident should be involved in evaluating the individual's quality of life and helping to determine the goals of care, said Rochon.
 
"That's the opportunity to look at things like the medications that are being given and determine are they continuing to add a benefit or not, and then making decisions about how to proceed on that basis," she said.