When to consult hospice in end-stage Alzheimer’s disease

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Lori E. Rousche, MD, a family physician in Souderton, Pennsylvania. She is also the hospice medical director for Grand View Health in Sellersville, Pennsylvania. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

Hospice consults for end-stage Alzheimer’s Disease will improve the patient’s quality of death, decrease end-of-life care burdens for families and nursing home staff, and save Medicare and Medicaid money. What’s not to like? Physicians and their extenders should consider involving hospice when the dementia has advanced to its last stages.

More from Dr. Rousche: Hospice consultation should be a quality metric

Alzheimer’s Dementia is a progressive neurologic disease that affects an estimated 5.5 million patients in the United States. It is an unbearably difficult disease for patients and families alike. We all have patients who are caregivers to a parent or spouse with this ugly disease, and know how challenging it can be. The caregivers can frequently become overwhelmed and depressed. As a patient with Alzheimer’s reaches the end-stage of the disease, they often don’t know their family members’ names, need to be fed and are incontinent of bowel and bladder. They will no longer even be able to hold their head up while in a seated position. These patients require total assistance, and it is not an easy road for the committed spouse, son or daughter.

The emotional costs are devastating, but so are the monetary costs. According to the Alzheimer’s Association, in 2017, the estimated cost of caring for those with Alzheimer’s (and other dementias) in the United States will total approximately $259 billion. More telling is a recent study which found that in the last five years of life, the costs of a person with dementia totals more than $287,000 (Compare that to the estimated cost of raising a child from birth to eighteen years old of $233,610). Most of these costs are covered by Medicare and Medicaid. In 2017, Medicare and Medicaid will spend approximately $175 billion caring for those with Alzheimer’s and other dementias, which is a big portion of their total budgets.

Further reading: Top facts physicians need to know about hospice care

Hospice is a covered Medicare service that allows patients to die with dignity. It also provides added family/caregiver support, volunteer services and bereavement help. A hospice consult is a gift to every end-stage Alzheimer’s patient. So, when should you, as the primary provider, ask for a hospice consult? The following is a breakdown of what makes a patient eligible for hospice care in end-stage Alzheimer’s disease.  

Next: Make sure to follow this criteria

Patient must have a severity of dementia of a Reisberg’s Functional Assessment Staging (FAST) scale of 7C or higher. The FAST score is a way to estimate how advanced the Alzheimer’s is. To have a FAST score of 7C, the patient should meet the following criteria:

*Can’t walk without assistance

*Can’t dress without assistance

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*Can’t bathe without assistance

*Bowel and bladder incontinence

*Can’t speak more than 6 intelligible words/day or no meaningful verbal communication

Also, the patient should have had one of the following comorbid conditions in the last 6 months:

*Aspiration Pneumonia

*Pyelonephritis

*Sepsis

*Multiple progressive stage 3-4 decubiti

*Fever after antibiotics

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*Unable to maintain fluids/caloric intake to sustain life:  weight loss of 10% of body weight in 6 months and /or albumin less than 2.5gm/dl.

Next: "Please consider giving the gift of hospice"

The following general changes that indicate a worsening will support the end-stage diagnosis:

*Falls

* Infection (UTI, URI, cellulitis)

*Uncontrolled pain or other symptoms

*Psychosocial issues

*Hypotension with systemic BP less than 90 or postural hypotension, edema, ascites, pleural/pericardial effusion and weakness

The provider should assess the patient and if the criteria above are met, consult hospice. Hospice has aides that will come in to help with bathing, nurses that help with medications and comfort, volunteers that may bring a pet or a musical instrument, chaplains to provide spiritual support and bereavement specialists to help the family with the death.

Practical advice: How to keep your patients from switching physicians

The hospice team can also be integral in helping the families decide to make the patient a “do-not-hospitalize” or “do-not-resuscitate” patient, and this is crucial in end-stage Alzheimer’s. The goal should be comfort, not treating to prolong a life whose quality is incredibly bereft. Repeated hospital stays to treat dehydration, aspiration pneumonia and urinary tract infections are very expensive for the insurance company, but more importantly, are devastating for the end-stage Alzheimer’s patient who may become delirious and would probably be much more at peace in his or her friendly bed at home. The hospice gift is a blessing to the patient and the family. And it is a gift to Medicare and Medicaid as well, because the patient will not continually be sent back and forth to the hospital for infections, increasing costs and utilization. Please consider giving the gift of hospice.