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Integrating Palliative Medicine into the Care of Persons with Advanced Dementia: Identifying Appropriate Medication Use

Authors

  • Holly M. Holmes MD,

    1. From the *Section of Geriatrics, Department of Medicine, University of Chicago, Chicago, IllinoisDepartment of General Internal Medicine, Ambulatory Treatment and Emergency Care, Division of Internal Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, TexasDivision of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana§Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, IllinoisJohn A. Hartford Foundation; and #MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois.
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  • Greg A. Sachs MD,

    1. From the *Section of Geriatrics, Department of Medicine, University of Chicago, Chicago, IllinoisDepartment of General Internal Medicine, Ambulatory Treatment and Emergency Care, Division of Internal Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, TexasDivision of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana§Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, IllinoisJohn A. Hartford Foundation; and #MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois.
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  • Joseph W. Shega MD,

    1. From the *Section of Geriatrics, Department of Medicine, University of Chicago, Chicago, IllinoisDepartment of General Internal Medicine, Ambulatory Treatment and Emergency Care, Division of Internal Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, TexasDivision of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana§Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, IllinoisJohn A. Hartford Foundation; and #MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois.
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  • Gavin W. Hougham PhD,

    1. From the *Section of Geriatrics, Department of Medicine, University of Chicago, Chicago, IllinoisDepartment of General Internal Medicine, Ambulatory Treatment and Emergency Care, Division of Internal Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, TexasDivision of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana§Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, IllinoisJohn A. Hartford Foundation; and #MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois.
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  • Deon Cox Hayley DO,

    1. From the *Section of Geriatrics, Department of Medicine, University of Chicago, Chicago, IllinoisDepartment of General Internal Medicine, Ambulatory Treatment and Emergency Care, Division of Internal Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, TexasDivision of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana§Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, IllinoisJohn A. Hartford Foundation; and #MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois.
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  • William Dale MD, PhD

    1. From the *Section of Geriatrics, Department of Medicine, University of Chicago, Chicago, IllinoisDepartment of General Internal Medicine, Ambulatory Treatment and Emergency Care, Division of Internal Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, TexasDivision of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana§Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, IllinoisJohn A. Hartford Foundation; and #MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois.
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  • Related Presentations: Holmes HM, Cox Hayley D, Hougham GW, Shega JW, Dale W, and Sachs GA. Overuse of medications in palliative care patients. Poster at the Annual Meeting of the American Geriatrics Society 2005, Orlando, Florida. End-of-Life Care for Persons with Dementia. Symposium at the Annual Meeting of the American Academy of Hospice and Palliative Medicine 2006, Nashville, Tennessee.

Address correspondence to Holly M. Holmes, MD, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 437, Houston, Texas 77030. E-mail: hholmes@mdanderson.org

Abstract

OBJECTIVES: To evaluate the feasibility of developing consensus recommendations for appropriate prescribing for patients with advanced dementia using a new conceptual framework and to determine the frequency of inappropriate medication use based on these recommendations in a small sample of patients with advanced dementia.

DESIGN: Medication data were obtained using chart review. Recommendations for appropriate prescribing were achieved using a modified Delphi consensus panel.

SETTING: Three long-term care facilities.

PARTICIPANTS: Thirty-four patients with advanced dementia enrolled in the Palliative Excellence in Alzheimer Care Efforts Program were selected to evaluate medication use. Twelve geriatricians at the University of Chicago participated in the modified Delphi consensus panel.

MEASUREMENTS: Prescription and over-the-counter medications were recorded for the 34 patients. Following the modified Delphi process, medications were characterized into one of four categories for use in palliative care patients with advanced dementia: never appropriate, rarely appropriate, sometimes appropriate, or always appropriate.

RESULTS: Patients were taking an average of 6.5 medications at enrollment. Six patients were taking 10 or more medications daily. Consensus was reached ranking the appropriateness of 69 of 81 medication classes for patients with advanced dementia. Overall, 5% of the 221 medications prescribed at enrollment were considered to be never appropriate, and 10 of 34 patients (29%) had been taking a medication considered to be never appropriate.

CONCLUSION: Based on these preliminary findings, consensus criteria for prescribing in advanced dementia are needed to decrease polypharmacy and reduce the use of medications that are of minimal benefit or high risk.

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