Preparing and Caring for Patients with Dementia
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This article appears in the June 2014 issue of HealthLeaders magazine.
An aging population is already expected to strain U.S. healthcare resources, and recent studies suggest that dementia represents both a major health risk and a considerable cost driver. In addition, this long-term decline in cognition takes a significant toll on patients, their families, and the providers who care for them.
Some healthcare systems and hospitals are now coordinating care for these patients so they can stay at home and also avoid unnecessary hospitalizations. Patients with dementia are at risk for falls, pneumonia, medication noncompliance, anxiety, and other comorbid conditions that could lead to long hospital stays. Not addressing the needs of what's been called a silver tsunami now could be a prescription for readmission rates that are difficult to drive down in the future.
A 2013 RAND study of dementia published in the April 2013 New England Journal of Medicine estimated the cost of caring for patients with dementia will more than double by 2040, from $109 billion to at least $259 billion, and that figure does not include the costs shouldered by family members and caregivers who pay out-of-pocket for sitters and other services, or forgo careers in order to stay home to care for a family member.
Success key No. 1: Thoughtful avoidance of medical intervention
Among the special considerations for caring for patients with dementia is defining the goals of care, including possibly paring down the number of medications a patient is prescribed.
"We're talking about supportive care, rational, [and] reasonable care that's going to provide them with increased quality of life because we can't increase their life span with the dementia but we can increase the number of days that they have that are more functional," says Evelyn Granieri, MD, MPH, chief of the division of geriatric medicine and aging at New York-Presbyterian/Columbia University Medical Center, which is part of the six-hospital New York City–based New York-Presbyterian. "And oftentimes, some of the medications that are prescribed by other clinicians actually decrease the quality of their life."
For example, Granieri says diuretics that are often prescribed for blood pressure require frequent trips to the bathroom. For a patient with dementia, not only is medication adherence complicated by memory issues, but mobility also becomes a problem. Other maintenance medications, such as statins, may not be optimal for dementia patients because the drugs are not increasing or maintaining their quality of life.
"When you're looking at a limited life expectancy, you don't need medications that are meant for 40-, 50-, or 60-year-olds that are meant to help them live a little bit longer," she says, calculating the number of medications the average patient comes to her with at 10–12, which she usually reduces to 4–5.
Granieri also advises physicians to be more thoughtful about other medical interventions, such as mammograms and colonoscopies.
"They don't need these to keep them alive any longer," she says. "We try to work with other physicians they may see and say, 'Look, this is not necessary at this point. It's not going to provide them with any benefit. Yes, you would expect to do this for a younger person or someone who doesn't have a cognitive disorder, but they're not going to get a benefit from it.' "
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