Hospice Clinical Appropriateness: End-Stage Alzheimer's and Other Forms of Dementia
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Alzheimer's disease and other progressive dementias are life-altering and eventually fatal conditions for which curative therapy is not available. Thinking of dementia as a terminal illness from which people are dying over years instead of months allows one to focus explicitly and aggressively on a palliative care plan.1 The patient should show all of the following characteristics:
- Unable to ambulate without assistance
- Unable to dress without assistance
- Unable to bathe properly
- Incontinence of bowel and bladder
- Unable to speak or communicate meaningfully (ability to speak is limited to approximately a half dozen or fewer intelligible and different words)
Intercurrent illnesses associated with advanced dementia:
- Aspiration pneumonia
- Pyelonephritis or upper urinary tract infection
- Decubitus ulcers, multiple, stage 3-4
- Fever recurrent after antibiotics
Impaired nutritional status:
- Difficulty swallowing or refusal to eat
- If receiving artificial nutritional support (NG or G-tube, TPN), patient must be exhibiting continued weight loss despite the feedings
- Protein calorie malnutrition:
- Weight loss over 11% or
- BMI<18 or
- Albumin <3.1
Co-morbid conditions that significantly impair the dementia patient's health and functionality:
- Congestive heart disease or cardiovascular disease
- COPD or restrictive lung disease
- Cerebrovascular disease, including stroke
- Diabetes mellitus
- Renal insufficiency
VITAS provides these guidelines as a convenient tool. They do not take the place of a physician's professional judgment.
1Diagnosis, Management and Treatment of Dementia. American Medical Association, 1999.
2Reisberg B: Dementia: A Systematic Approach to Identifying Reversible Causes. Geriatrics, 41:30, 1986.
Adapted from Stuart B, Herbst L, Kinzbrunner BM, et al: Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases. 2nd edition. Virginia: National Hospice Organization, 1996.