Physician decision-making regarding medication use in patients with dementia at the end of life

1

• Physician decision-making regarding medication
  use in patients with dementia at the end of life
• Dr Carole Parsons
• School of Pharmacy
• Queens University Belfast

2
Introduction

• Studies in populations with a reduced life
  expectancy have highlighted the prevalence of
  suboptimal and inappropriate medication use
• Little discussion regarding medication use in
  patients with advanced dementia nearing the end
  of life
• No attempt to define decision-making processes
  for physicians in determining which of the dying
  dementia patients medications should be withheld
  or discontinued

Introduction Method Results
Discussion Acknowledgements
3
Introduction

• Study funded by CARDI
• Cross-border and inter-disciplinary collaboration
  with University College Cork, practitioners in
  nursing, medicine and pharmacy, representatives
  from the voluntary sector
• Aim To evaluate, using a factorial design with
  vignette-based survey methodology, the extent to
  which patient-related factors and physician
  country of practice influence decision-making
  among Northern Ireland (NI) and Republic of
  Ireland (RoI) physicians with respect to
  medication use in patients with end-stage
  dementia

Introduction Method Results
Discussion Acknowledgements
4
Method

• 3x2x3 factorial survey design
• Four different patient clinical scenarios
  (vignettes)
• Each vignette prefaced with statement indicating
  doctor is caring for a patient with advanced
  dementia nearing the end of life
• Drug regimen for patient outlined

Table 1 Summary of vignettes and issues
considered
Vignette Medical Issues
Vignette 1 patient with pneumonia and fever How to manage? Start or withhold antibiotic? Change any of patients other medications?
Vignette 2 patient taking acetylcholinesterase inhibitor and memantine Continue or discontinue acetylcholinesterase inhibitor and/or memantine? Change any of patients other medications?
Vignette 3 patient taking statin Continue or discontinue statin? Change any of patients other medications?
Vignette 4 patient taking atypical antipsychotic Continue or discontinue antipsychotic? Change any of patients other medications?
Introduction Method Results
Discussion Acknowledgements
5
Method

• Suppose that you are seeing Mrs. Mary Jones
  today. Mrs Jones is an 82 year-old retired
  seamstress who is ltRANDOM ASSIGNMENT resident
  in a nursing home OR cared for in her own
  home. She has developed pneumonia with severe
  respiratory failure and has a fever of 38.9C.
  She was diagnosed with Alzheimers Disease seven
  years ago. RANDOM ASSIGNMENT She has a signed
  advance directive expressing a preference for
  supportive care, rather than for more aggressive
  treatment measures, at the end-of-life. OR
  There is no advance directive concerning
  treatment. Recently her mental condition has
  declined. Although she is alert, she is no
  longer orientated in terms of time, place and
  situation. She displays little spontaneous
  speech and when she does speak, her speech is
  unintelligible with the exception of single
  random words. She is totally dependent on her
  caregiver for all activities of daily living.
  She can no longer walk since suffering a series
  of falls three months ago and refuses food and
  fluids often, slapping at the hand of the person
  attempting to feed her. She has lost 7 of her
  body weight in the last two months. RANDOM
  ASSIGNMENT Mrs. Jones family desires active
  treatment measures be taken to save her life in
  the event of a life-threatening condition. OR
  Mrs. Jones family desires supportive treatment
  measures be taken to provide symptomatic relief
  only and make her comfortable. OR There is no
  family involvement.

Introduction Method Results
Discussion Acknowledgements
6
Method

• Physician asked to indicate whether he/she would
  make any changes to patients prescribed
  medication in the scenario
• Patient-related factors were systematically
  manipulated in the vignettes
• Place of residence of patient (community-dwelling,
  resident in nursing home, hospital inpatient)
• Signed advance directive (present or absent)
• Level of family involvement (desire for active
  treatment measures, desire for supportive
  treatment measures or no family involvement)
• Dependent variables assessed were whether the
  physician chose to
• 1. initiate an antibiotic
• 2. continue or discontinue donepezil
  hydrochloride
• 3. continue or discontinue memantine
  hydrochloride
• 4. continue or discontinue simvastatin
• 5. continue or discontinue quetiapine

Introduction Method Results Discussion
Acknowledgements
7
Method
Family desires active measures
Advance Directive
Family desires supportive measures
No family involved
Vignettes for hospital physicians
Family desires active measures
No Advance Directive
Family desires supportive measures
No family involved
Figure 1 Variants of vignettes for hospital
physicians
Introduction Method Results
Discussion Acknowledgements
8
Method
Figure 2 Variants of vignettes for GPs
Introduction Method Results
Discussion Acknowledgements
9
Method

• Physicians randomly assigned one variant of each
  vignette appropriate to their practice
• Questionnaire also gathered demographic
  information and included a series of open
  questions
• Piloted with 4 hospital physicians and 5 GPs
• Ethical approval granted by the Office for
  Research Ethics Committees Northern Ireland
  (ORECNI) and the Irish College of General
  Practitioners Research Ethics Committee
• Questionnaires mailed to all hospital physicians
  in geriatric medicine (NI n 73 RoI n 86) and
  all GPs (NI n 1161 RoI n 1900) with a reminder
  three weeks later

Introduction Method Results
Discussion Acknowledgements
10
Method - Analysis

• All responses coded and entered into SPSS
  Version 18.0
• Logistic regression analysis examined impact of
  patient-related factors and physician country of
  practice on decision-making about key medications
• P 0.05
• Qualitative analysis of free text responses

Introduction Method Results
Discussion Acknowledgements
11
Results

• Response rates
• Hospital physicians NI n 38 (52.1) RoI n
  31 (36.2)
• GPs NI n 245 (21.1) RoI n 348 (18.3)

Table 2. Frequency and percentage of GPs and
hospital physicians who recommended
initiating/discontinuing the five key medications
of interest
Medication of interest NI hospital physicians RoI hospital physicians All hospital physicians NI GPs RoI GPs All GPs
Antibiotic (prescribed) 15/36 (41.7) 12/30 (40.0) 27/66 (40.9) 126/237 (53.2) 189/329 (57.4) 315/566 (55.7)
Donepezil hydrochloride 10 mg nocte (discontinued) 15/38 (39.5) 22/31 (71.0) 37/69 (53.6) 131/230 (57.0) 185/339 (54.6) 316/569 (55.5)
Memantine hydrochloride 10 mg bd (discontinued) 7/38 (18.4) 14/31 (45.2) 21/69 (30.4) 101/225 (44.9) 139/336 (41.4 240/561 (42.8)
Simvastatin 20mg nocte (discontinued) 32/37 (86.5) 30/31 (96.8) 62/68 (91.2) 176/236 (74.6) 232/337 (68.8) 408/573 (71.2)
Quetiapine 100mg bd (discontinued) 12/36 (33.3) 7/29 (24.1) 19/65 (29.2) 61/232 (26.3) 54/336 (16.1) 115/568 (20.2)
Introduction Method Results
Discussion Acknowledgements
12
Results
Table 3 Logistic regression model statistics for
the five key medications of interest
Outcome variable ?2 (df) p (Cox Snell) R2 decisions regarding drug initiation/continuation correctly classified decisions regarding drug initiation/continuation correctly classified
Outcome variable ?2 (df) p (Cox Snell) R2 Before IVs entered After IVs entered
Antibiotic initiated 48.340 (8) lt.001 .073 54.1 61.2
Donepezil continued 19.190 (10) .038 .030 57.7 55.3
Memantine continued 14.789 (8) .063 .023 58.9 58.6
Simvastatin continued 36.222 (10) lt.001 .055 73.3 73.3
Quetiapine continued 26.011 (6) lt.001 .040 78.8 78.8
IV independent variable
Introduction Method Results
Discussion Acknowledgements
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Results

• Regression models only explained a small
  percentage of the variance in physicians
  prescribing decisions
• Across the five medications of interest, patient
  place of residence and physicians country of
  practice appeared to have the strongest and most
  consistent effects on decision-making (of those
  factors examined in the study), albeit yielding
  small effect sizes.
• When the patient was resident in hospital
  (compared to resident at home or in a nursing
  home) it was less likely that an antibiotic would
  be prescribed, and more likely that simvastatin
  and quetiapine would be discontinued.
• If the physician practised in RoI (compared to
  NI), it was less likely that quetiapine would be
  discontinued.
• If the physician practised in hospital in the RoI
  (compared to NI), it was more likely that
  donepezil hydrochloride and memantine
  hydrochloride would be discontinued.
• An antibiotic was more likely to be prescribed
  when the patient did not have an advance
  directive, or when the patients family desired
  active treatment measures

Introduction Method Results
Discussion Acknowledgements
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Results - free text responses

• Discontinuation of donepezil hydrochloride and
  memantine hydrochloride little clinical benefit
• Patient is not going to get long term benefit of
  Alzheimer's drugs (not much use anyway), and if
  used, should only be in early stages of disease.
  Pointless now. (RoI physician 302, GP)
• Discontinuation of simvastatin primary/secondary
  prevention inappropriate, little clinical benefit
• I would discontinue any medication used for
  longer term secondary prevention because of
  advanced stage of dementia (RoI physician 352,
  hospital physician)
• Discontinuation of quetiapine lack of
  indication, possibility of side-effects
• Hold quetiapine as may be making her confusion
  worse (RoI physician 126, GP)
• No clinical benefit .. risk of adverse effects
  (NI physician 112, GP)
• Other reasons for discontinuing medications
  focus on patient comfort or symptom management,
  reduce polypharmacy, recognition of distress
  caused by medication
• Stop all preventative treatment as not necessary
  for providing comfort or support and may increase
  distress (NI physician 169, GP)
• No compelling reason to continue, relative meds
  benefit now minimal. Reduce polypharmacy and risk
  of mistakes (NI physician 231, GP)

Introduction Method Results
Discussion Acknowledgements
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Discussion

• Considerable variability exists in NI and RoI
  physician decision-making regarding medication
  use in patients with advanced dementia who are
  nearing the end of life
• Uncertainty exists with regard to prescribing
  antibiotics, discontinuing donepezil
  hydrochloride and memantine hydrochloride
• Less variability exists in decision-making
  regarding simvastatin and quetiapine
• Patient place of residence and physician country
  of practice had the strongest and most consistent
  effects on decision-making

Introduction Method Results
Discussion Acknowledgements
16
Discussion

• Study limitations
• Low response rates, using vignette approach
• Future research to
• clarify how patient place of residence and
  physician country of practice impact on
  prescribing decisions
• identify other factors which may account for
  unexplained variance in decision-making
• Development and clarification of the evidence
  base regarding prescribing for patients with
  end-stage dementia required

Introduction Method Results
Discussion Acknowledgements
17
Acknowledgements

• Dr Noleen McCorry
• Prof Carmel Hughes
• Prof Peter Passmore
• Dr Susan Patterson
• Mr Gordon Kennedy
• Mrs Valerie Megraw
• Mrs Anne Olver

• Dr Stephen Byrne
• Dr Denis OMahony
• Mr David OSullivan
• Mr Kevin Murphy
• Ms Mary Hickey
• Ms Ursula Collins

All hospital physicians and GPs who responded to
the questionnaires Centre for Ageing Research
and Development in Ireland
Introduction Method Results
Discussion Acknowledgements
18
Thank-you

• c.parsons_at_qub.ac.uk

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Discussion

• Considerable variability exists in NI and RoI
  physician decision-making regarding medication
  use in patients with advanced dementia who are
  nearing the end of life
• Uncertainty exists with regard to prescribing
  antibiotics, discontinuing donepezil
  hydrochloride and memantine hydrochloride
• Less variability exists in decision-making
  regarding simvastatin and quetiapine
• Patient place of residence and physician country
  of practice had the strongest and most consistent
  effects on decision-making
• Future research to
• clarify how patient place of residence and
  physician country of practice impact on
  prescribing decisions
• identify other factors which may account for
  unexplained variance in decision-making
• Development and clarification of the evidence
  base regarding prescribing for patients with
  end-stage dementia required