By Ileana Leyva, MD
When clinicians and family caregivers recognize ongoing signs of decline in a patient or loved one with Alzheimer’s disease/dementia, they often arrive at a difficult decision point: Should we place Mom or Dad in a nursing home or memory care facility, and how will we know it’s time?
To those of us who specialize in hospice and palliative care, the questions should be expanded to:
• When are patients with Alzheimer’s/dementia eligible for hospice care?
• What kind of care will cause the least amount of disruption to a patient who struggles to make sense of what’s happening in their world?
• What kind of care honors the wishes of an Alzheimer’s patient who prefers to be cared for and die at home?
Hospice supports aging in place
“Aging in place” is a well-accepted concept in the long-term and residential-care industry. Hospice accommodates aging in place through supportive care teams who deliver expert end-of-life care, equipment, medications, and supplies to patients and their families.
Patients with Alzheimer’s/dementia can receive hospice care from specially trained teams in the places they already call home: their own homes, nursing homes, assisted living communities, and more.
Aging-in-place hospice care includes a physician, nurse, and aide who oversee an individualized care plan focused on managing symptoms and pain. The medical team also provides caregiver education so that families feel confident caring for a loved one at home. A hospice social worker, chaplain, and bereavement specialist provide emotional and spiritual support to families and caregivers.
The Medicare hospice benefit covers up to 100% of the costs of care related to a patient’s Alzheimer’s/dementia diagnosis. It also delivers comfort-focused medications and supplies, including hospital beds, bedside commodes, and over-bed tables, to the patient and family.
With nearly 70% of Americans saying they would prefer to die at home (2017 Kaiser Family Foundation survey), hospice care for Alzheimer’s/dementia honors patients’ wishes and provides the resources their families and caregivers need to honor those wishes.
Hospice can have a profound impact
Studies show that hospice for Alzheimer’s/dementia patients leads to:
• 50% reduction in hospitalizations; fewer care transitions near the end of life
• Increased satisfaction with care
• Improved pain and symptom management
• Less depression/anxiety and improved overall health for patients’ families and caregivers (Mitchell, S., et al. (2009); Shega, J., et al. (2008))
Studies also show that hospice care can prevent costly, unnecessary, or unwanted care transitions in a patient’s final months: fewer admissions to the emergency department, intensive care unit, or a skilled-care facility. A 2017 study (Wang, S., et al.) found that 80% of Medicare beneficiaries 66 and older experienced at least one healthcare transition in the last six months of life; 33% had four or more disruptive transitions.
Look for signs and symptoms of hospice eligibility
Hospice should be considered if a patient spends more than 50% of their time in bed, or if family members are considering ordering a hospital bed at home. Clinically, patients with Alzheimer’s or dementia are eligible for hospice if these two factors are present:
• Functional disability in three of six activities of daily living
• Any one of these complications: pneumonia, pyelonephritis/urinary tract infection, sepsis, febrile episode, difficulty eating or swallowing, poor nutritional status, feeding tube decision, pressure sores, hip fracture, delirium at time of hospital discharge, or recurrent hospitalization for disease-related complications.
Clinicians can play an important role in decision-making by initiating advance care planning conversations with patients and their families with a few simple questions early in the disease:
• What do you understand about your loved one’s prognosis?
• What does a good day look like?
• What are your/your loved one’s preferences for care as the end of life approaches?
• Are you interested in healthcare that meets those goals?
At VITAS Healthcare, our hospice professionals are available 24/7 to facilitate patient-family discussions and to support consultations, admissions, and seamless transitions to hospice care in a patient’s preferred setting. To refer a patient or for information, call (800) 93-VITAS (available 24/7/365) or download the VITAS mobile referral app for interactive hospice eligibility guidelines.
Dr. Ileana Leyva is regional medical director for VITAS® Healthcare, the nation’s leading provider of end-of-life care.
