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Physician decision-making regarding
medication use in patients with dementia
at the end of life
Dr Carole Parsons
School of Pharmacy
Queen’s University Belfast
Introduction
• Studies in populations with a reduced life expectancy
have highlighted the prevalence of suboptimal and
inappropriate medication use
• Little discussion regarding medication use in patients
with advanced dementia nearing the end of life
• No attempt to define decision-making processes for
physicians in determining which of the dying
dementia patient’s medications should be withheld or
discontinued
Introduction
Method
Results
Discussion
Acknowledgements
Introduction
• Study funded by CARDI
• Cross-border and inter-disciplinary collaboration with
University College Cork, practitioners in nursing,
medicine and pharmacy, representatives from the
voluntary sector
• Aim: To evaluate, using a factorial design with
vignette-based survey methodology, the extent to
which patient-related factors and physician country of
practice influence decision-making among Northern
Ireland (NI) and Republic of Ireland (RoI) physicians
with respect to medication use in patients with endstage dementia
Introduction
Method
Results
Discussion
Acknowledgements
Method
• 3x2x3 factorial survey design
• Four different patient clinical scenarios (vignettes)
• Each vignette prefaced with statement indicating doctor is caring for
a patient with advanced dementia nearing the end of life
• Drug regimen for patient outlined
Table 1: Summary of vignettes and issues considered
Vignette
Medical Issues
Vignette 1: patient with pneumonia
and fever
How to manage? Start or withhold antibiotic?
Change any of patient’s other medications?
Vignette 2: patient taking
acetylcholinesterase inhibitor and
memantine
Continue or discontinue acetylcholinesterase inhibitor
and/or memantine?
Change any of patient’s other medications?
Vignette 3: patient taking statin
Continue or discontinue statin?
Change any of patient’s other medications?
Vignette 4: patient taking atypical
antipsychotic
Continue or discontinue antipsychotic?
Change any of patient’s other medications?
Introduction
Method
Results
Discussion
Acknowledgements
Method
Suppose that you are seeing Mrs. Mary Jones today. Mrs Jones is an 82 year-old retired
seamstress who is <RANDOM ASSIGNMENT: “resident in a nursing home” OR “cared for in
her own home.” She has developed pneumonia with severe respiratory failure and has a
fever of 38.9°C. She was diagnosed with Alzheimer’s Disease seven years ago. RANDOM
ASSIGNMENT: “She has a signed advance directive expressing a preference for supportive
care, rather than for more aggressive treatment measures, at the end-of-life”. OR “There is
no advance directive concerning treatment.” Recently her mental condition has declined.
Although she is alert, she is no longer orientated in terms of time, place and situation. She
displays little spontaneous speech and when she does speak, her speech is unintelligible
with the exception of single random words. She is totally dependent on her caregiver for all
activities of daily living. She can no longer walk since suffering a series of falls three months
ago and refuses food and fluids often, slapping at the hand of the person attempting to feed
her. She has lost 7% of her body weight in the last two months. RANDOM ASSIGNMENT:
“Mrs. Jones’ family desires active treatment measures be taken to save her life in the event
of a life-threatening condition.” OR “Mrs. Jones’ family desires supportive treatment
measures be taken to provide symptomatic relief only and make her comfortable.” OR
“There is no family involvement.”
Introduction
Method
Results
Discussion
Acknowledgements
Method
•
•
•
Physician asked to indicate whether he/she would make any changes to patient’s
prescribed medication in the scenario
Patient-related factors were systematically manipulated in the vignettes
– Place of residence of patient (community-dwelling, resident in nursing home,
hospital inpatient)
– Signed advance directive (present or absent)
– Level of family involvement (desire for active treatment measures, desire for
supportive treatment measures or no family involvement)
Dependent variables assessed were whether the physician chose to
1. initiate an antibiotic
2. continue or discontinue donepezil hydrochloride
3. continue or discontinue memantine hydrochloride
4. continue or discontinue simvastatin
5. continue or discontinue quetiapine
Introduction
Method
Results
Discussion
Acknowledgements
Method
Family desires active measures
Advance
Directive
Family desires supportive measures
No family involved
Vignettes for
hospital
physicians
Family desires active measures
No Advance
Directive
Family desires supportive measures
No family involved
Figure 1: Variants of vignettes for hospital physicians
Introduction
Method
Results
Discussion
Acknowledgements
Method
Family desires active measures
Advance
Directive
Family desires supportive measures
No family involved
Patient resident
in own home
Family desires active measures
No Advance
Directive
Family desires supportive measures
No family involved
Vignette
for GPs
Family desires active measures
Advance
Directive
Family desires supportive measures
No family involved
Patient resident
in nursing home
Family desires active measures
No Advance
Directive
Family desires supportive measures
No family involved
Figure 2: Variants of vignettes for GPs
Introduction
Method
Results
Discussion
Acknowledgements
Method
• Physicians randomly assigned one variant of each
vignette appropriate to their practice
• Questionnaire also gathered demographic information and
included a series of open questions
• Piloted with 4 hospital physicians and 5 GPs
• Ethical approval granted by the Office for Research Ethics
Committees Northern Ireland (ORECNI) and the Irish
College of General Practitioners Research Ethics
Committee
• Questionnaires mailed to all hospital physicians in geriatric
medicine (NI n= 73; RoI n= 86) and all GPs (NI n= 1161;
RoI n= 1900) with a reminder three weeks later
Introduction
Method
Results
Discussion
Acknowledgements
Method - Analysis
• All responses coded and entered into SPSS® Version 18.0
• Logistic regression analysis examined impact of patientrelated factors and physician country of practice on
decision-making about key medications
• P ≤ 0.05
• Qualitative analysis of free text responses
Introduction
Method
Results
Discussion
Acknowledgements
Results
• Response rates
– Hospital physicians: NI: n = 38 (52.1%); RoI: n = 31 (36.2%)
– GPs: NI: n = 245 (21.1%); RoI: n = 348 (18.3%)
Table 2. Frequency and percentage of GPs and hospital physicians who
recommended initiating/discontinuing the five key medications of interest
Medication of interest
NI hospital
RoI
All hospital
NI GPs
RoI GPs
All GPs
physicians
hospital
physicians
Antibiotic (prescribed)
15/36
(41.7%)
physicians
12/30
(40.0%)
27/66
(40.9%)
126/237
(53.2%)
189/329
(57.4%)
315/566
(55.7%)
Donepezil hydrochloride 10 mg
15/38
(39.5%)
22/31
(71.0%)
37/69
(53.6%)
131/230
(57.0%)
185/339
(54.6%)
316/569
(55.5%)
7/38
(18.4%)
14/31
(45.2%)
21/69
(30.4%)
101/225
(44.9%)
139/336
(41.4%
240/561
(42.8%)
32/37
(86.5%)
30/31
(96.8%)
62/68
(91.2%)
176/236
(74.6%)
232/337
(68.8%)
408/573
(71.2%)
12/36
(33.3%)
7/29
(24.1%)
19/65
(29.2%)
61/232
(26.3%)
54/336
(16.1%)
115/568
(20.2%)
nocte (discontinued)
Memantine hydrochloride 10 mg
bd (discontinued)
Simvastatin 20mg nocte
(discontinued)
Quetiapine 100mg bd
(discontinued)
Introduction
Method
Results
Discussion
Acknowledgements
Results
Table 3: Logistic regression model statistics for the five key medications of interest
Outcome variable
Χ2 (df)
p
(Cox &
Snell) R2
Antibiotic initiated
48.340 (8)
<.001
.073
54.1
61.2
Donepezil
19.190 (10)
.038
.030
57.7
55.3
14.789 (8)
.063
.023
58.9
58.6
36.222 (10)
<.001
.055
73.3
73.3
26.011 (6)
<.001
.040
78.8
78.8
% decisions regarding drug
initiation/continuation
correctly classified
Before IVs
After IVs
entered
entered
continued
Memantine
continued
Simvastatin
continued
Quetiapine
continued
IV – independent variable
Introduction
Method
Results
Discussion
Acknowledgements
Results
•
•
•
•
•
•
Regression models only explained a small percentage of the variance in
physicians’ prescribing decisions
Across the five medications of interest, patient place of residence and
physician’s country of practice appeared to have the strongest and most
consistent effects on decision-making (of those factors examined in the study),
albeit yielding small effect sizes.
When the patient was resident in hospital (compared to resident at home or in a
nursing home) it was less likely that an antibiotic would be prescribed, and more
likely that simvastatin and quetiapine would be discontinued.
If the physician practised in RoI (compared to NI), it was less likely that
quetiapine would be discontinued.
If the physician practised in hospital in the RoI (compared to NI), it was more
likely that donepezil hydrochloride and memantine hydrochloride would be
discontinued.
An antibiotic was more likely to be prescribed when the patient did not have an
advance directive, or when the patient’s family desired active treatment
measures
Introduction
Method
Results
Discussion
Acknowledgements
Results - free text responses
•
Discontinuation of donepezil hydrochloride and memantine hydrochloride: little clinical
benefit
“Patient is not going to get long term benefit of Alzheimer's drugs (not much use anyway),
and if used, should only be in early stages of disease. Pointless now.” (RoI physician 302,
GP)
• Discontinuation of simvastatin: primary/secondary prevention inappropriate, little clinical
benefit
“I would discontinue any medication used for longer term secondary prevention because of
advanced stage of dementia” (RoI physician 352, hospital physician)
• Discontinuation of quetiapine: lack of indication, possibility of side-effects
“Hold quetiapine as may be making her confusion worse” (RoI physician 126, GP)
“No clinical benefit ….. risk of adverse effects” (NI physician 112, GP)
• Other reasons for discontinuing medications: focus on patient comfort or symptom
management, reduce polypharmacy, recognition of distress caused by medication
“Stop all preventative treatment as not necessary for providing comfort or support and may
increase distress” (NI physician 169, GP)
“No compelling reason to continue, relative meds benefit now minimal. Reduce
polypharmacy and risk of mistakes” (NI physician 231, GP)
Introduction
Method
Results
Discussion
Acknowledgements
Discussion
• Considerable variability exists in NI and RoI physician
decision-making regarding medication use in patients with
advanced dementia who are nearing the end of life
• Uncertainty exists with regard to prescribing antibiotics,
discontinuing donepezil hydrochloride and memantine
hydrochloride
• Less variability exists in decision-making regarding
simvastatin and quetiapine
• Patient place of residence and physician country of practice
had the strongest and most consistent effects on decisionmaking
Introduction
Method
Results
Discussion
Acknowledgements
Discussion
• Study limitations
– Low response rates, using vignette approach
• Future research to
– clarify how patient place of residence and physician
country of practice impact on prescribing decisions
– identify other factors which may account for unexplained
variance in decision-making
• Development and clarification of the evidence base regarding
prescribing for patients with end-stage dementia required
Introduction
Method
Results
Discussion
Acknowledgements
Acknowledgements
• Dr Noleen McCorry
• Dr Stephen Byrne
• Prof Carmel Hughes
• Dr Denis O’Mahony
• Prof Peter Passmore
• Mr David O’Sullivan
• Dr Susan Patterson
• Mr Kevin Murphy
• Mr Gordon Kennedy
• Ms Mary Hickey
• Mrs Valerie Megraw
• Ms Ursula Collins
• Mrs Anne Olver
All hospital physicians and GPs who responded to the
questionnaires
Centre for Ageing Research and Development in Ireland
Introduction
Method
Results
Discussion
Acknowledgements
Thank-you
[email protected]
Discussion
• Considerable variability exists in NI and RoI physician decisionmaking regarding medication use in patients with advanced dementia
who are nearing the end of life
• Uncertainty exists with regard to prescribing antibiotics, discontinuing
donepezil hydrochloride and memantine hydrochloride
• Less variability exists in decision-making regarding simvastatin and
quetiapine
• Patient place of residence and physician country of practice had the
strongest and most consistent effects on decision-making
• Future research to
– clarify how patient place of residence and physician country of
practice impact on prescribing decisions
– identify other factors which may account for unexplained variance
in decision-making
• Development and clarification of the evidence base regarding
prescribing for patients with end-stage dementia required