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Cholinesterase Inhibitor and NMDA Receptor Antagonist Use in End-Stage Dementia: A Survey of Hospice Medical Directors (749)
558
Schedule with Abstracts
Cholinesterase Inhibitor and NMDA Receptor Antagonist Use in End-Stage Dementia: A Survey of Hospice Medical Directors (749) Lynn Ellner, MD, Midwest Palliative Care Center, Chicago, IL; Joseph W. Shega, MD, Northwestern University Medical School, Chicago, IL; Terri L. Maxwell, PhD APRN BC-PCM, ExcelleRX Inc., Philadelphia, PA Objectives 1. Assess the potential benefits of cholinesterase inhibitor and NMDA receptor antagonist use in end-stage dementia patients. 2. Review the risks and benefits of a therapeutic trial of cholinesterase inhibitor or NMDA receptor antagonist discontinuation. I. Background. Cholinesterase inhibitors and NMDA receptor antagonists are FDA approved for the treatment of moderate to severe Alzheimer’s disease. As the dementia progresses and patients become hospice-eligible, whether to continue these therapies is frequently discussed as part of the hospice plan of care. A paucity of research exists on physician experiences and practices regarding these therapies in this population. II. Research Objectives. (1) Estimate the number of patients who were prescribed these therapies at the time of hospice enrollment; (2) Assess the potential benefits of these therapies in persons with end-stage disease; (3) Describe the recommendations respondents make to families regarding the ongoing use of these therapies; and (4) Assess the observed impact of medication discontinuation on patients and caregivers. III. Methods. Mail survey of hospice medical directors obtained from a random sample from the NHPCO. IV. Results. Of the 432 eligible participants, 152 completed surveys were returned, yielding a response rate of 37%. 75% and 33% of respondents reported at least 20% of patients on a cholinesterase inhibitor or memantine, respectively, at the time of hospice admission. A subset of respondents believe that these therapies improved patient outcomes including stabilization of cognition (22%), decrease in challenging behaviors (28%), and maintenance of patient function (22%) as well as caregiver outcomes namely reduced caregiver burden (20%) and improved quality of life (20%). While 80% of respondents recommended discontinuing these therapies to families at the time of hospice enrollment, 75% of respondents reported that families experienced difficulty stopping these
Vol. 37 No.3 March 2009
therapies. Respondents were significantly less likely to recommend medication discontinuation if they reported clinical benefit from these therapies (P < .05). A subset of respondents observes accelerated cognitive (30%) and functional decline (26%) or emergence of challenging behaviors (32%) with medication discontinuation. V. Conclusions. A subset of physicians report clinical benefit with ongoing use of cholinesterase inhibitors and NMDA receptor antagonists and decline has been observed with discontinuation. Respondents report families have a difficult time stopping these therapies. VI. Implications for research, policy, or practice. Research is needed to better delineate the clinical impact of discontinuing these therapies in hospice-eligible patients to facilitate evidencebased clinical decision making.
Case Report: Extended Survival of an Elderly Hospice Patient with Advanced Chronic Kidney Disease (750) Douglas Smucker, MD, University of Cincinnati, Cincinnati, OH Objectives 1. Describe an elderly patient with advanced chronic kidney disease (CKD) who survived longer than anticipated under hospice care. 2. Review published literature describing elderly patients with advanced CKD who refuse dialysis. I. Background. Advanced CKD is the strongest predictor of short stay among all hospice patients. A MEDLINE search resulted in only two small cohort studies focused on survival of CKD patients who refuse dialysis, but with few details to inform prognosis for specific patients. II. Case Description. Ms. E was an 85-year-old Caucasian female referred to home hospice care in early 2007. She had refused the initiation of renal dialysis for Stage 5 CKD (initial serum creatinine 9.3 mg/dL, estimated glomerular filtration rate [eGFR] <5 mL/min). She politely refused to take any of the oral medications prescribed by her nephrologist to control high potassium, phosphorus, and acid-base balance. Her nephrologist estimated prognosis at 1 to 2 months. The patient functioned independently in her apartment with daily visits by her son. Mild foot edema, daytime fatigue, and dyspnea from chronic obstructive pulmonary disease (COPD) were her only symptoms. Repeat serum creatinine level was
Schedule with Abstracts
Cholinesterase Inhibitor and NMDA Receptor Antagonist Use in End-Stage Dementia: A Survey of Hospice Medical Directors (749) Lynn Ellner, MD, Midwest Palliative Care Center, Chicago, IL; Joseph W. Shega, MD, Northwestern University Medical School, Chicago, IL; Terri L. Maxwell, PhD APRN BC-PCM, ExcelleRX Inc., Philadelphia, PA Objectives 1. Assess the potential benefits of cholinesterase inhibitor and NMDA receptor antagonist use in end-stage dementia patients. 2. Review the risks and benefits of a therapeutic trial of cholinesterase inhibitor or NMDA receptor antagonist discontinuation. I. Background. Cholinesterase inhibitors and NMDA receptor antagonists are FDA approved for the treatment of moderate to severe Alzheimer’s disease. As the dementia progresses and patients become hospice-eligible, whether to continue these therapies is frequently discussed as part of the hospice plan of care. A paucity of research exists on physician experiences and practices regarding these therapies in this population. II. Research Objectives. (1) Estimate the number of patients who were prescribed these therapies at the time of hospice enrollment; (2) Assess the potential benefits of these therapies in persons with end-stage disease; (3) Describe the recommendations respondents make to families regarding the ongoing use of these therapies; and (4) Assess the observed impact of medication discontinuation on patients and caregivers. III. Methods. Mail survey of hospice medical directors obtained from a random sample from the NHPCO. IV. Results. Of the 432 eligible participants, 152 completed surveys were returned, yielding a response rate of 37%. 75% and 33% of respondents reported at least 20% of patients on a cholinesterase inhibitor or memantine, respectively, at the time of hospice admission. A subset of respondents believe that these therapies improved patient outcomes including stabilization of cognition (22%), decrease in challenging behaviors (28%), and maintenance of patient function (22%) as well as caregiver outcomes namely reduced caregiver burden (20%) and improved quality of life (20%). While 80% of respondents recommended discontinuing these therapies to families at the time of hospice enrollment, 75% of respondents reported that families experienced difficulty stopping these
Vol. 37 No.3 March 2009
therapies. Respondents were significantly less likely to recommend medication discontinuation if they reported clinical benefit from these therapies (P < .05). A subset of respondents observes accelerated cognitive (30%) and functional decline (26%) or emergence of challenging behaviors (32%) with medication discontinuation. V. Conclusions. A subset of physicians report clinical benefit with ongoing use of cholinesterase inhibitors and NMDA receptor antagonists and decline has been observed with discontinuation. Respondents report families have a difficult time stopping these therapies. VI. Implications for research, policy, or practice. Research is needed to better delineate the clinical impact of discontinuing these therapies in hospice-eligible patients to facilitate evidencebased clinical decision making.
Case Report: Extended Survival of an Elderly Hospice Patient with Advanced Chronic Kidney Disease (750) Douglas Smucker, MD, University of Cincinnati, Cincinnati, OH Objectives 1. Describe an elderly patient with advanced chronic kidney disease (CKD) who survived longer than anticipated under hospice care. 2. Review published literature describing elderly patients with advanced CKD who refuse dialysis. I. Background. Advanced CKD is the strongest predictor of short stay among all hospice patients. A MEDLINE search resulted in only two small cohort studies focused on survival of CKD patients who refuse dialysis, but with few details to inform prognosis for specific patients. II. Case Description. Ms. E was an 85-year-old Caucasian female referred to home hospice care in early 2007. She had refused the initiation of renal dialysis for Stage 5 CKD (initial serum creatinine 9.3 mg/dL, estimated glomerular filtration rate [eGFR] <5 mL/min). She politely refused to take any of the oral medications prescribed by her nephrologist to control high potassium, phosphorus, and acid-base balance. Her nephrologist estimated prognosis at 1 to 2 months. The patient functioned independently in her apartment with daily visits by her son. Mild foot edema, daytime fatigue, and dyspnea from chronic obstructive pulmonary disease (COPD) were her only symptoms. Repeat serum creatinine level was