How to determine eligibility in Alzheimer’s

When patients can’t walk, consider hospice

Defining a terminal prognosis of six months or less to live, as required for a hospice admission, is one of the biggest barriers to enlarging the role of hospice in Alzheimer’s care. These patients have been declining gradually for many years, and there many not be an obvious transition point or dramatic changes in their condition that would signal the need to consider hospice care. (For additional information on the role of hospice in end-stage Alzheimer’s care, see story at left.)

However, Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases, Second Edition, developed by the National Hospice Organization (NHO) in Arlington, VA, provide a good starting point in qualifying Alzheimer’s patients for the Medicare hospice benefit. NHO’s medical guidelines for determining a terminal prognosis in chronic Alzheimer’s or multi-infarct (stroke) dementias — as opposed to acute, potentially reversible dementias — start with functional status and the use of tools such as the Reisberg Functional Assessment Staging. Other such scales include the Karnofsky Performance Status Scale and the Global Deterioration Scale. According to NHO guidelines, an appropriate Alzheimer’s patient for hospice would show all of the following characteristics:

• inability to ambulate without assistance;

• inability to dress without assistance;

• inability to bathe properly;

• urinary and fecal incontinence;

• inability to speak or communicate meaningfully (with more than six intelligible words).

The first of these is the most critical factor, according to the research, although a recent study suggests that loss of meaningful communication, is also a key indicator of end-stage status. Other critical factors include difficulty in swallowing food or refusal to eat, and the presence of comorbid medical complications such as aspiration pneumonia, upper urinary tract infection, septicemia, or decubitus ulcers. Taken as a whole, the criteria suggest that appropriate hospice candidates with Alzheimer’s disease will have lost the ability to walk and talk, while co-morbid conditions are starting to appear.

Use of the NHO criteria need not be terribly difficult, says Patricia J. Whitney, MA, MBA, director of St. Margaret’s Hospice in Spring Valley, IL. "But if these criteria are in place, why aren’t people putting their loved one into hospice? They’ve been taking care of their loved one for years, struggling on their own. By the time they get to the end, unless someone comes in and says, Hey, here’s something that could really help,’ they don’t know."