END STAGE ALZHEIMER’S DISEASE

AND HOSPICE

Alzheimer’s Disease has edged out Diabetes as the sixth leading cause of death in Americans aged 65 or older.

In 2004, Medicare beneficiaries were 3.1 times more likely to have a hospital stay than those without dementia.

In that year, Medicare’s average per person payments were $33,000 (more than 3 times those without dementia)

In 2009, 11.2% of Hospice patients had Dementia as theirprimary diagnosis

Hospice care is increasingly viewed as an option for end-stage Alzheimer’s patients.

However, since the disease progresses slowly, the “late stage” is not easy to define.

What are the signs of end-stage Alzheimer’s disease:

loss of control of movement – progressing to the inability to walk or sit

loss of ability to communicate coherently

usually requires total care with ADL’s

lose awareness of their surroundings

most likely will not be able to remember familiar faces

incontinent of bladder and bowel

Poor appetite, needing cueing at meals or needing to be fed

Increasingly vulnerable to infections, especially pneumonia

To become eligible for hospice a patient must have Medicare Part A, Both the patient’s physician and a hospice medical director must certify that he or she is terminally ill (life expectancy is 6 months or less if the disease runs its normal course, and The patient chooses to waive the right for Medicare to pay for any other services to treat the terminal illness. Instead, Medicare pays for hospice and any related physician expenses.

GENERAL Hospice Eligibility Guidelines:

Disease progression that is not considered reversible

Multiple ER visits within the last 6 months

Progressive functional decline (unable to ambulate, dress or bathe without assistance)

Patient (or their designee) elects to forego any curative treatments

Progressive impaired nutritional status (difficulty swallowing, refusal to eat, weight loss)

SPECIFIC Hospice guidelines for Alzheimer’s disease and related dementias:

FAST scale Stage 7 or greater

Severe cognitive impairment (progressive confusion, anger, frustration or withdrawal)

Co-morbidities, such as:

CAD/COPD/CHF Pyleonephritis Sepsis/Septicemia Pressure Ulcer(s) Stage 3-4 Progressive Weight Loss (greater than 10% in past 6 months) Serum Albumin (less than 2.5) Fever Recurrent after Antibiotics Delirium Recurrent Aspiration Pneumonia

FAST SCALE

STAGE 1: No difficulty, either subjectively or objectivelySTAGE 2: Complains of forgetting location of objects; subjective work difficultiesSTAGE 3: Decreased job functioning evident to coworkers; difficulty in traveling to new locationsSTAGE 4: Decreased ability to perform complex tasks (e.g. handling finances)STAGE 5: Requires assistance in choosing proper clothingSTAGE 6: Decreased ability to dress, bathe and toilet independently (including fecal and urinary incontinence)STAGE 7: Loss of speech, locomotion and consciousness (including inability to sit up independently or smile)

BEHAVIORAL DISORDERS in Dementia:

Illness related factors -

Constipation Urinary retention Fatigue Impaired Vision and healing Inability to interpret words or actions Infections Pain Medication side effects Visual hallucinations

AND

BEHAVIORAL DISORDERS in Dementia:

Environmental factors -

Feeling vulnerable and insecure Inability to recognize noises and people Excessive noise levels Sensory overload, including too many people Startling noises Sudden movements Forced to engage in personal hygiene behavior (i.e. take a bath or shower)

Comfort care is the mainstay of Hospice

Medication lists need to be reviewed thoroughly to eliminate any non-essential medications

Aggressive treatments, especially emergency interventions have to be scrutinized

To make intelligent decisions, families need to understand that dementia is a terminal illness and that patients with advanced dementia are at the end of life – education is paramount

REFERENCES

Alzheimer’s Association. 2009 Alzheimer’s Disease facts and figures. Alzheimers Dement. 2009, 5(3):234-270.

Amedisys.com. On-line Hospice Care/Referral, Baton Rouge, LA, 2012.

Arizona Center on Aging. Elder Care, A Resource for Interprofessional Providers. March 2013.

Healthcare Financing Administration, Department of Health and Human Services. 6/23/2008.

Modi, Seema, Cassandra Moore. “Which late-stage Alzheimer’s patients should be referred for Hospice care”. Journal of Family Practice 54:11(2005):984-86.

Victor J. Sobolewski, III, D.O. Visiting Physicians West Allis, WI 262-949-1893