Medications frequently prescribed to hospice patients with Alzheimer’s disease and dementia might be accelerating their deaths, according to new research.
Benzodiazepines and antipsychotics given to dementia patients in hospice care appear to increase their risk of earlier death compared to similar patients who weren’t prescribed these drugs, researchers reported on October 14 in JAMA Network Open.
The study found that dementia patients who started taking benzodiazepines faced a 41% higher likelihood of dying within six months, while those on antipsychotics had a 16% increased death risk.
Lead researcher Dr. Lauren Gerlach, a geriatric psychiatrist at the University of Michigan, explained in a news release: “Dementia is now the most common qualifying condition among hospice enrollees, yet many of these patients are not imminently dying.”
She added: “Because prognosis in dementia is so difficult to determine, nearly 1 in 5 patients will outlive the six-month eligibility window for hospice. This makes it critical that medications used during this period enhance, rather than diminish, quality of life.”
The Changing Face of Hospice Care
Hospice care was initially designed to support people dying from cancer but has expanded to serve individuals with other terminal conditions, including dementia.
The proportion of hospice patients with Alzheimer’s disease or dementia has surged from less than 1% in 1995 to 25% in 2023, researchers noted in their background materials.
However, Alzheimer’s and dementia follow more extended and unpredictable courses than cancer, creating uncertainty about whether a hospice patient will actually die soon.
In reality, 20% of these patients outlive the six-month prognosis required for hospice eligibility and end up being discharged from the program, researchers found.
Gerlach stated: “The Medicare hospice benefit was designed when most patients enrolling had cancer and short, predictable trajectories. For people with dementia, whose disease course can span years, we need care models and prescribing guidance that better reflect their experience.”
Medications and Their Risks
Benzodiazepines and antipsychotics are routinely prescribed to hospice patients to address agitation, anxiety, and delirium, according to researchers.
Yet these medications also elevate risks of falls, confusion, and sedation, potentially compromising patients’ quality of life.
Study Methodology and Results
Researchers examined national Medicare data from July 2015 through September 2018, a period when hospice facilities were mandated to report prescription information.
None of the 139,000 Alzheimer’s or dementia patients studied had received benzodiazepines or antipsychotics during the six months before entering hospice care.
Despite this clean medication history, nearly half (48%) received new benzodiazepine prescriptions and 13% got antipsychotics after hospice enrollment—most within just days of admission, results showed.
The average hospice stay among these patients exceeded 130 days, suggesting that many were not in their final days or weeks of life.
Patients prescribed these drugs faced higher mortality risks while in hospice compared to those who didn’t receive them.
Gerlach observed: “These early prescribing patterns suggest that these medications may sometimes be used as part of standard hospice care practices rather than fully tailored to each individual.”
She continued: “For many patients, these medications can provide meaningful relief from distressing symptoms, but they also carry risks. Our findings highlight an opportunity for hospice teams to regularly reassess medication use, especially early in care, when maintaining communication and alertness may be prioritized by patients and families.”
A Lack of Oversight
Researchers expressed concern about minimal oversight of medication practices in hospice settings.
Since 2018, hospice agencies have no longer been required to report prescribing data to the federal government.
Gerlach noted: “Right now, hospice prescribing is a black box. Medications covered under the hospice benefit are not reported to Medicare, so we have almost no visibility into what patients are receiving. That makes it impossible to monitor prescribing safety or quality on a national level.”
Interestingly, benzodiazepine and antipsychotic prescriptions are monitored as part of nursing home quality reporting, yet the same medications aren’t tracked for hospice patients, researchers pointed out.
Gerlach concluded: “We need better transparency in prescribing data and support for hospice clinicians to make more evidence informed, individualized decisions about how to best care for patients with dementia at end of life.”
The findings raise important questions about medication practices in hospice care and the need for more personalized, evidence-based approaches to end-of-life treatment for dementia patients.