CARING FOR VETERANS WITH DEMENTIA AT THE END OF THEIR LIFE: WHAT DO WE KNOW?

Abstract

Introduction: Many persons with dementia require end-of-life care in an inpatient care setting. Symptoms of pain, air hunger, restlessness, myoclonic jerking, terminal delirium and excessive secretions are commonly encountered during end-of-life care for persons with dementia. Use of opiates, benzodiazepines and anti-psychotics is commonly seen and recommended for treatment of these symptoms. Choosing appropriate route for medication administration in end-of-life care is important as ability to swallow is lost and intravenous access becomes increasingly difficult. Most of the medications used to manage symptoms at end of life can be administered using subcutaneous route effectively and safely. Background: The impact of terminal diagnosis on medication dosage in end-of-life symptom management has received little research attention. However in clinical practice we see variations in medication requirements for symptom management in end-of-life care based on terminal diagnoses. Objective: We want to review medication use, doses, symptoms and diagnoses to establish whether terminal diagnosis of dementia would impact the amount of medications required for symptom management in end-of-life care. Methods: We conducted a retrospective chart review of persons who died in Topeka VA Medical Center inpatient setting from January 1, 2018 to May 31, 2018. Various clinical events were reviewed during the last 48 hours of life for these deceased persons. Results: There were 20 persons who died during the review period; 19 (95%) of them were men and average age of these persons was 74 years. Out of the total, 5 (25%), 5 (25%) and 4 (20%) persons had terminal diagnosis of dementia, cancer and thought-disorder respectively. Thirteen (65%) died in acute care setting and the rest in long-term care setting; none of them had change in care setting in last 48 hours of life. All of them experienced pain, anxiety, terminal delirium as per clinical assessment and received parenteral opiates, benzodiazepine and antipsychotics. During the last 48 hours of life, persons with terminal diagnosis of dementia required 146.8 mg of parenteral morphine equivalent (PME), 40.9 mg of lorazepam and 65.8 mg of haloperidol in comparison to 42 mg, 11.7 mg and 14.9 mg of respective medications for persons without diagnosis of dementia. Conclusion: Persons with terminal diagnosis of dementia required higher doses of medications for symptom management at end of life. Limitations: short retrospective study of a small sample in a single setting Future Implication: Further research is needed to study the impact of dementia on medication requirements at end of life.