Recently, an article in JAMA Internal Medicine suggested that more than 50% of nursing home patients with advanced dementia are on “medications of questionable benefit.” The study went on to define those drugs as memantine, cholinesterase inhibitors, and statins.
Shocker, huh?
“Questionable benefit” is in the eyes of the beholder. Two of the above drugs have FDA indications for advanced dementia (statins for dyslipidemia), so you could argue there’s nothing “questionable” about it. The FDA says we can do it, so we will.
Right, but we all use drugs off label in this business without hesitation. So why should we think twice about using them on label?
It’s a valid point. Why do we prescribe these drugs to advanced dementia patients? How many of you have actually seen meaningful clinical benefit with them in this group, not just graphed points on a detail piece?
I use them, too, but I try to lower expectations with patients and their families. If all they see are direct-to-consumer ads, they’ll think this is a cure. Nope.
The fact is that the best we can do today is to slow progression ... somewhat. So if they’re already in end-stage disease, why bother? At some point, trying to keep these patients alive becomes more of an emotional torture for their families. All of us have seen these patients. How many of us want to live like that? I’m going to say none.
So, if their use in this population is “questionable,” I have to question why we do it at all.
This is where medicine gets hazy. On one side are those who claim that anyone with end-stage dementia should be treated with comfort care only. On the other are those who argue we need to do everything possible to keep them alive (usually politicians, not doctors). But most people are in a gray middle.
There’s also a big difference between what we can do and what we should do. This point, unfortunately, is often lost in the complex web of patient care. Advanced dementia patient = memantine + cholinesterase inhibitor. Medicine becomes a flowchart rather than a thinking specialty.
Then there’s the families. None of us wants to destroy hope. So we go with “Well, let’s try this medicine and see what happens.” It is, admittedly, easier than saying “I have nothing that will make a meaningful difference.” People see these advertised and want to believe these magical drugs will fix what ails grandma.
There’s also nursing staff, leaving Post-It notes on the chart that say “Patient has Alzheimer’s disease. Do you want to start Aricept?” I see that here and there, too. I think most of us okay it, because it’s easier than saying “What’s the point?”
Hiding in the background is, lastly, the specter of a malpractice suit. Even if the patient is beyond you making them worse, there’s always another neurologist out there willing to testify (for a fee) that by not prescribing these drugs, you fell beneath the standard of care.
The practice of using these drugs in end-stage dementia is indeed questionable. But the possible answers, and the dilemmas they put us in, often lead to doing what’s possible instead of simply necessary.
And when that happens, the only ones who benefit are the legal profession and drug companies.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.