The Institute of Medicine has recommended that clinicians minimize interventions in patients with life-limiting disease and instead focus on maximizing quality of life but 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 of questionable benefit, including medications to treat dementia and lower cholesterol, at substantial financial cost.

In an Obamacare world, health care costs have gone up rather than down as promised, so policy makers are scrambling to cut corners where possible. Elderly medical care, once a reliable campaign promise, has now come under scrutiny.   

Few studies have examined the use of chronic disease medications in patients with advanced dementia. Data also is lacking on the associated costs of such prescribing patterns, so Jennifer Tjia, M.D., M.S.C.E., of the University of Massachusetts Medical School, Worcester, and colleagues used a long-term care pharmacy database to study medications used by nursing home residents with advanced dementia.

They analyzed use of medications deemed of questionable benefit for patients with advanced dementia based on published criteria and the average 90-day expenditures attributable to those medications.

Of the 5,406 nursing home residents with advanced dementia, 53.9 percent of the residents (n=2,911) received at least one medication of questionable benefit and the use these medications varied by region, ranging from 44.7 percent in the Mid-Atlantic census region to 65 percent in the West South Central census region.

The most commonly prescribed medications were the dementia therapies cholinesterase inhibitors (36.4 percent) and memantine hydrochloride (25.2 percent), as well as cholesterol-lowering medications (22.4 percent). The likelihood of receiving medications of questionable benefit was lower for patients with eating problems, a feeding tube, a do-not-resuscitate order or who had enrolled in hospice. However, living in a nursing home with a high prevalence of feeding tube use (greater than 10 percent) was associated with a greater likelihood of being prescribed questionably beneficial medications compared with those residents who lived in nursing homes where the use of feeding tubes was less (5 percent or less).

The average 90-day cost for a medication of questionable benefit was $816 and that accounted for 35.2 percent of the total average 90-day medication expenditures for patients with advanced dementia.

"Our findings have important implications because the use of prescription medications in patients with advanced illness presents a burden to the health care system and to patients," the authors write.

Citation: JAMA Intern Med. doi:10.1001/jamainternmed.2014.4103

Commentary: Improving Prescribing Practices Late in Life

In a related commentary, Greg A. Sachs, M.D., of Indiana University School of Medicine and Eskenazi Health, Indianapolis, writes: "I hope that the article by Tjia and colleagues in this issue of JAMA Internal Medicine is read not just by clinicians who care for patients with advanced dementia and nursing home residents. The article contributes to the literature and practice in two important ways."

"First, the study's strengths advance our understanding of medication prescribing practices for nursing home residents with advanced dementia. Second, the work by Tjia et al is part of the 'Less is More' series in this journal and addresses the American Board of Internal Medicine Foundation's Choosing Wisely campaign and other initiatives aimed at curtailing the use of nonbeneficial and potentially harmful medications, tests and treatments. This article should cause all clinicians to reconsider their prescribing practices and other decision making for a broad population of patients late in life," he concludes.

Citation: JAMA Intern Med. doi:10.1001/jamainternmed.2014.3277.