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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
  • Septicemia
  • 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
  • Malignancy

VITAS provides these guidelines as a convenient tool. They do not take the place of a physician's professional judgment.

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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.

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