Why do clinicians continue medications with questionable benefit in advanced dementia?

A recent study in JAMA Internal Medicine estimated the prevalence of medications with questionable benefit being used by nursing home residents with advanced dementia. This is an important question because significant healthcare resources are utilized in the last 6 months of life. Furthermore, if there is no benefit then the only possible outcomes can be excess cost with or without harm. As the authors note most patients at this stage just want comfort care and maximization of quality of life.

The researchers studied medication use deemed of questionable benefit by nursing home residents with advanced dementia using a nationwide long-term care pharmacy database.  A panel of geriatricians and palliative medicine physicians defined a list of medications that are of questionable benefit when the patient’s goal of care is comfort and included cholinesterase inhibitors, memantine hydrochloride, antiplatelets agents (except aspirin), lipid-lowering agents, sex hormones, hormone antagonists, leukotriene inhibitors, cytotoxic chemotherapy, and immunomodulators.

53.9% nursing home residents with advanced dementia were prescribed at least 1 questionably beneficial medication during the 90-day observation period with cholinesterase inhibitors (36.4%), memantine hydrochloride (25.2%), and lipid-lowering agents (22.4%) being most commonly prescribed. Patients residing in facilities with a high prevalence of feeding tubes were more likely to be prescribed these questionably beneficial medications.

Of only those residents who used at least 1 questionably beneficial medication, the mean (SD) 90-day drug expenditure was higher ($2317 [$1357]; IQR, $1377-$2968 compared to $1815 for all residents), of which 35.2% was attributable to medications of questionable benefit (mean [SD], $816 [$553]; IQR, $404-$1188).

Picture of elderly patient

I think this study demonstrates excess medication usage and excess costs in a population in which costs are already high and for which this added cost is of little benefit. So why are these medications continued in this population? Are physicians unaware of the lack of benefit of these medications in this population? Are they aware but worried that stopping them will make the patient worse? I suspect a little of both is the correct answer.

A major challenge for EBM is getting the E out there. Numerous resources are available but a major step in accessing a resource is recognizing a knowledge deficit. How do you know you don’t know something? Pushing evidence (for example by email) is useful for general knowledge but isn’t useful to answer specific questions. Most of the push email services require enrollment to get the emails and many clinicians probably don’t even know this exists. Maintenance of certification could be a useful tool to improve knowledge if it was designed properly but can’t cover everything for all clinicians.

So we have a dilemma. Studies like this show areas for improvements in knowledge and practice but there are no great practical ways to improve either in a nursing home setting. Clinical reminders still have to be acted upon. Payers could refuse to pay for certain services but docs will likely continue to order them with the patient picking up the bill. Protocols could be put in place but they have to be followed and agreed upon by clinicians. They all will have anecdotal evidence of grandpa getting worse when his cholinesterase inhibitor was stopped. And they will say “What’s the harm in continuing it?”.

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