Physician’s Corner

Dementia Provider Corner

Dementia is a group of conditions that affect brain function leading to impairment of cognition and function and is considered a major cause of dependency and disability. Additionally, dementia can have a serious physical and psychological impact on patients as well as their families and caregivers. Typically, dementia is a progressive and chronic condition that impacts intellectual processes, judgement and behavior. When dementia advances to the terminal stages usually the patient can no longer walk, struggles with speech and is only able to say a few words, is dependent on caregivers for activities of daily living, has dysphagia and problems with incontinence. If this is the case it may be time to consider hospice care. The presence of other medical problems can increase the likelihood a patient is eligible for hospice, these include heart failure or other cardiovascular disease, chronic obstructive pulmonary disease, cancer, recent weight loss, dehydration, pressure ulcers, infections and increased sleep during the day. Evidence shows that malnutrition, feeding issues, and dysphagia were strongly correlated with a prognosis of less than 6 months in patients with advanced dementia. A recent hospitalization is also associated with a poor prognosis, for example mortality after being in the hospital for pneumonia was 53% and 55% for a hip fracture. The National Hospice and Palliative Care Organization (NHPCO) recommends the Functional Assessment Staging (FAST), a 7-step staging system, to determine hospice eligibility. The FAST identifies progressive steps and sub-steps of functional decline. Usually, Medicare requires a patient to have a FAST score of at least 7 on the scale to be eligible for hospice, which means they are unable to dress, use the bathroom, bathe or walk without help and have trouble speaking and expressing thoughts. The presence of comorbid conditions can affect what FAST score is needed and having accurate medical records and a complete patient history is very helpful when determining hospice eligibility. Unfortunately, although many prognostic risk factors have been identified there is no gold standard to help clinicians determine a less than 6 months prognosis with any degree of certainty. The criteria adopted by NHPCO for hospice eligibility is based on very limited research and lacks important studies to determine FAST scale reliability and validity. Providers can best help their patients by working with families to help them establish goals of care and levels of medical intervention that are most consistent with current medical research and the family and patient preferences. The goal of hospice care is to provide services for those in the end stages of dementia with a focus on relieving pain, controlling symptoms, improving quality of life and reducing anxiety and stress for patients and their families. The holistic approach of hospice care addresses the physical aspects of the disease as well as the spiritual and emotional elements of care and preparing for end of life. In addition to helping patients, hospice supports the entire family of those suffering from dementia and provides bereavement services for those coping with the loss of a loved one.