Most Nursing Home Residents with Advanced Dementia Get Medications With Questionable Benefits and Substantial Costs

According to a new AHRQ-funded study, more than half of nursing home residents with advanced dementia – a terminal illness marked by severe cognitive impairment and functional dependence – continue to receive medications that may not help them, but incur substantial financial cost. The study and abstract, “Use of Medications of Questionable Benefit in Advanced Dementia,” were published in the November 2014 issue ofJAMA Internal Medicine. An analysis of more than 5,400 residents at 460 facilities (using 2009-2010 data) found that nearly 54 percent of residents received at least one medication of questionable benefit. The average 90-day expenditure for medications with questionable benefits was $816. This accounts for 35.2 percent of the total average 90-day medication costs for residents with advanced dementia who were prescribed common medications with questionable benefits.

2014 Nov 1;174(11):1763-71. doi: 10.1001/jamainternmed.2014.4103.

Use of medications of questionable benefit in advanced dementia.

Tjia J1, Briesacher BA2, Peterson D3, Liu Q4, Andrade SE3, Mitchell SL5.

Author information

Abstract

IMPORTANCE:

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

OBJECTIVES:

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 questionablebenefit after accounting for clustering within nursing homes.

RESULTS:

Of 5406 nursing home residents with advanced dementia, 2911 (53.9%) received at least 1 medication with questionable benefit (range, 44.7% in the Mid-Atlantic census region to 65.0% in the West South Central census region). Cholinesterase inhibitors (36.4%), memantine hydrochloride (25.2%), and lipid-lowering agents (22.4%) were the most commonly prescribed. In adjusted analyses, having eating problems (adjusted odds ratio [AOR], 0.68; 95% CI, 0.59-0.78), a feeding tube (AOR, 0.58; 95% CI, 0.48-0.70), or a do-not-resuscitate order (AOR, 0.65; 95% CI, 0.57-0.75), and enrolling in hospice (AOR, 0.69; 95% CI, 0.58-0.82) lowered the likelihood of receiving these medications. High facility-level use of feeding tubes increased the likelihood of receiving these medications (AOR, 1.45; 95% CI, 1.12-1.87). The mean (SD) 90-day expenditure formedications with questionable benefit was $816 ($553), accounting for 35.2% of the total average 90-day medication expenditures for residents withadvanced dementia who were prescribed these medications.