title: Cholinesterase inhibitor and N-methyl-D-aspartic acid receptor antagonist use in older adults with end-stage dementia: a survey of hospice medical directors.
abstract: BACKGROUND
  Cholinesterase inhibitors and N-methyl-D-aspartic acid (NMDA) receptor antagonists are Food and Drug Administration (FDA) approved for the treatment of moderate to severe Alzheimer's disease. As dementia progresses to the end stage and patients become hospice-eligible, clinicians consider whether or not to continue these therapies without the benefit of scientific evidence. We sought to describe hospice medical directors practice patterns and experiences in the use and discontinuation of cholinesterase inhibitors and NMDA receptor antagonists in hospice patients that meet the Medicare hospice criteria for dementia.
  
  
  METHODS
  Mail survey of hospice medical directors from a random sample from the National Hospice and Palliative Care Organization.
  
  
  RESULTS
  Of the 413 eligible participants, 152 completed surveys were returned, yielding a response rate of 37%. Of the respondents, 75% and 33% reported that at least 20% of their patients were taking a cholinesterase inhibitor or memantine, respectively, at the time of hospice admission. The majority of respondents do not consider these therapies effective in persons with end-stage dementia, however, a subset believe that these medications 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 caregiver quality of life (20%). While 80% of respondents recommended discontinuing these therapies to families at the time of hospice enrollment, 72% of respondents reported that families experienced difficulty stopping these therapies. A subset of respondents observed accelerated cognitive (30%) and functional decline (26%) or emergence of challenging behaviors (32%) with medication discontinuation.
  
  
  CONCLUSIONS
  The findings from this survey indicate that cholinesterase inhibitors and/or NMDA receptor antagonists are prescribed for a subset of patients with advanced dementia and that a proportion of hospice medical directors report clinical benefit from the ongoing use of these agents. In addition, physician preferences for discontinuing these therapies are frequently at odds with the wishes of family members. Prospective studies are needed to evaluate the clinical impact of the discontinuation of these therapies on patient and caregiver outcomes.
authors.affiliation: Section of Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois 60637, USA. j-shega@gmail.com
authors.forename: Joseph W
authors.initials: JW
authors.lastname: Shega
authors.forename: Lynn
authors.initials: L
authors.lastname: Ellner
authors.forename: Denys T
authors.initials: DT
authors.lastname: Lau
authors.forename: Terri L
authors.initials: TL
authors.lastname: Maxwell
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000978:Antiparkinson Agents / Q000627:therapeutic use; D002800:Cholinesterase Inhibitors / Q000627:therapeutic use*; D003704:Dementia / Q000188:drug therapy*; D000077265:Donepezil; D005260:Female; D019538:Health Care Surveys; D006305:Health Status Indicators; D017051:Hospice Care; D006801:Humans; D007189:Indans / Q000627:therapeutic use*; D008297:Male; D008559:Memantine / Q000627:therapeutic use*; D010166:Palliative Care; D008486:Physician Executives; D010880:Piperidines / Q000627:therapeutic use*; D016194:Receptors, N-Methyl-D-Aspartate / Q000037:antagonists & inhibitors*
chemical_list: D000978:Antiparkinson Agents; D002800:Cholinesterase Inhibitors; D007189:Indans; D010880:Piperidines; D016194:Receptors, N-Methyl-D-Aspartate; D000077265:Donepezil; D008559:Memantine