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

People nearing the end of life oftenreceive medications they may no longer need, and that's trueeven in nursing homes, researchers say.

Nearly 9,300 Ontario nursing home residents with dementiareceived at least one medication of questionable benefit duringthe last year of life, a study found. And nearly half of theseresidents received potentially unnecessary drugs in the weekbefore they died.

"It's really important to look at these medications on anongoing basis and to determine if these medications are stillthe right medications for the individual, and to reevaluate thisespecially as new situations arise, study leader Dr. PaulaRochon told Reuters Health by phone.

"For example, in situations where the person has advanceddementia, it's important to, at that point in time, look at whatare the things that the person is being (prescribed) and tothink how are these contributing to improving quality of lifeand to review the medications with that kind of lens in mind," said Rochon, who is a researcher at the Institute for ClinicalEvaluative Sciences and Women'sCollege Hospital in Toronto.

About one in three nursing home residents in the studydidn't see any specialists during the last year of life. But,having assessments by a neurologist or psychiatrist during thatyear was associated with less use of questionable medications,she and her colleagues found.

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Medications may be considered problematic for severalreasons, including if there is concern about harmful druginteractions; if there are unacceptable demands, or pill burden,associated with taking medications; and if medications are usedto treat side-effects of other medications, contributing to aprescribing cascade, the researchers write in the Journal ofthe American Geriatrics Society. Furthermore appropriatemedication discontinuation can reduce unnecessary healthcarecosts."

Specifically, the study team looked at medication use forOntario nursing home residents who had advanced dementia anddied between 2010 and 2013.

Questionable benefits

Medications were considered to be of questionable benefit ifthey had been defined as never being appropriate for patientswith advanced dementia according to the Ontario Drug BenefitFormulary.

The researchers identified 9,298 nursing home residents withadvanced dementia who had received at least one such drug in theyear before they died. About 86 per cent had received medicationsof questionable benefit during the last four months of life, and45 per cent were given those medications during the final week oflife.

The most commonly prescribed medications of questionablebenefit included antidementia drugs and cholesterol-loweringmedications, followed by blood thinners and sex hormones.

Rochon said some of the medications with questionablebenefit could possibly be harmful in certain situations.

For example, she said, cholinesterase inhibitors, which aresometimes used to treat Alzheimer's disease, are associatedwith some modest benefit, but they do potentially have side-effects that might be important, including loss of appetite orGI upset.

In general, family physicians provide the majority of carefor individuals with advanced dementia, the authors note.

Rochon said it's important to work with primary care doctorsand 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 shouldfocus on things that make people feel better, and minimizeanything that might cause or be related to symptoms that mightlead to discomfort, said Rochon.

The caregiving team and the decision-makers for thatresident should be involved in evaluating the individual'squality of life and helping to determine the goals of care, saidRochon.

"That's the opportunity to look at things like themedications that are being given and determine are theycontinuing to add a benefit or not, and then making decisionsabout how to proceed on that basis,"she said.