Transcript 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 their
primary 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
STAGE 1: No difficulty, either subjectively or objectively
STAGE 2: Complains of forgetting location of objects; subjective
work difficulties
STAGE 3: Decreased job functioning evident to coworkers;
difficulty in traveling to new locations
STAGE 4: Decreased ability to perform complex tasks
(e.g. handling finances)
STAGE 5: Requires assistance in choosing proper clothing
STAGE 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
 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.