An asymptomatic 85-year-old woman is brought to the physician for a routine followup visit. She has a history of progressively worsening Alzheimer's dementia for 8 years. In the past 6 months, she has become nonverbal and can no longer walk. Her son reports that she is eating less, and he is concerned that she is not ingesting enough calories. She is not resistant to care and has had no behavioral disturbances. The patient lives with her son, who assists her with all activities of daily living. Her other medical problems include hypertension, hypercholesterolemia, and a hospitalization for aspiration pneumonia in the past year. Her medications include donepezil 10 mg once daily, lisinopril, and simvastatin. She has no known drug allergies.
The patient's vital signs are within normal limits. She weighs 50 kg (110.2 lb). Her weight 6 months earlier was 55 kg (121 lb). She is awake but not oriented to person, place, or time. There is a small stage II decubitus ulcer on her sacrum. The remainder of the examination shows no other abnormalities.
Which of the following is the most appropriate course of action?

Question

An asymptomatic 85-year-old woman is brought to the physician for a routine followup visit.  She has a history of progressively worsening Alzheimer's dementia for 8 years.  In the past 6 months, she has become nonverbal and can no longer walk.  Her son reports that she is eating less, and he is concerned that she is not ingesting enough calories.  She is not resistant to care and has had no behavioral disturbances.  The patient lives with her son, who assists her with all activities of daily living.  Her other medical problems include hypertension, hypercholesterolemia, and a hospitalization for aspiration pneumonia in the past year.  Her medications include donepezil 10 mg once daily, lisinopril, and simvastatin.  She has no known drug allergies.
The patient's vital signs are within normal limits.  She weighs 50 kg (110.2 lb).  Her weight 6 months earlier was 55 kg (121 lb).  She is awake but not oriented to person, place, or time.  There is a small stage II decubitus ulcer on her sacrum.  The remainder of the examination shows no other abnormalities.
Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

11ec193a_9947_3190_853d_19505e49810d_MD0002_00 This patient meets the criteria for advanced dementia, characterized by profound memory deficits, total functional dependence, no knowledge of recent or past events, little to no verbal communication, and limited ability to ambulate. Prognosticating a 6-month life expectancy can be difficult in these patients. However, her dependence on her son for activities of daily living, lack of ability to ambulate and communicate verbally, eating problems, and episode of aspiration pneumonia in the past year would make her eligible for hospice services (Figure). Hospice care has been shown to improve end-of-life experiences for patients with dementia, lower rates of hospitalization, increase the likelihood of appropriate pain management, and provide bereavement services for caregivers. Therefore, a recommendation to enroll this patient into hospice services is most appropriate at this time. (Choice A) Eating problems are a common feature of end-stage dementia. There is no evidence that appetite stimulant medications such as megestrol lead to weight gain or improved nutritional status, and therefore they are not recommended for routine use in advanced dementia. (Choices B and C) Recent studies have provided additional data on the medical management of Alzheimer's that continues to progress despite initial therapy. Continuing donepezil results in better outcomes than discontinuing the drug, and is somewhat better than replacing donepezil with memantine. Increasing the dosage of donepezil is unlikely to have a significant impact on this patient and may cause adverse effects such as nausea, diarrhea, and bradycardia. Therefore, a palliative approach focused on enhancing quality of life and minimizing the symptom burden would be more appropriate. (Choice D) Use of artificial feeding in severe dementia has not been shown to reduce malnutrition, prevent recurrent aspiration pneumonia, or promote wound healing in cohort studies of patients with advanced dementia. Educational objective: Hospice services should be offered to surrogate decision makers for patients with advanced dementia. Criteria for enrollment include dependence on others for all activities of daily living, lack of verbal communication, and inability to ambulate, in addition to a medical condition such as aspiration pneumonia or eating problems in the past year. __________ References: Donepezil and memantine for moderate-to-severe Alzheimer's disease. (http://www.ncbi.nlm.nih.gov/pubmed/22397651) A 93-year-old man with advanced dementia and eating problems. (http://www.ncbi.nlm.nih.gov/pubmed/17986683) Criteria for enrolling dementia patients in hospice. (http://www.ncbi.nlm.nih.gov/pubmed/9288011)

An Asymptomatic 85-Year-Old Woman Is Brought to the Physician for a Routine