3033 — Recognizing Hospice Eligibility in Parkinson's Disease
Goy ER (PVAMC REAP) , Ganzini LK
To improve recognition of hospice eligibility for Veterans with Parkinson's Disease (PD) by ascertaining which variables have a higher probability of occurring uniquely at 6-12 months prior to death when compared to 18-24 months before death.
We identified 339 VISN 20 decedent patients diagnosed with PD and treated with dopaminergic prescriptions for at least 3 years between 1/1/98 and 6/15/09, using the VISN 20 Data Management System database. Medical record review by a physician excluded those who died from causes other than PD. Three time periods (30-36 months, 24-18 months, and 12-6 months before death) were compared within subjects for number, length, and cause of hospitalizations; number of falls or choking episodes; occurrence of infections, use of antibiotics, diagnoses of psychosis, depression, delirium, or dementia; weight and body mass index (BMI); medications/dosages; number of dopaminergic medication changes, and place of residence. Change values were computed for 6-12 and 18-24 month periods for: BMI; number of distinct dopaminergic prescriptions; levodopa equivalent daily dose; and number of choking, psychosis, depression, or hallucination diagnoses. Analysis utilized generalized linear models, controlling for repeated measures.
Fewer (p < .0001) dopaminergic medications were prescribed 6-12 months before death. A significantly higher proportion of patients were underweight (BMI < 18.5) 6-12 months before death than in the 18-24 month period (p = .003). Although mean BMI decreased across all periods, normal-weight patients at 30-36 months had accelerated weight loss 6-12 months before death (p = .003). In contrast, patients overweight at 30-36 months did not have accelerated weight loss (p = .88). No other measured variables distinguished the 6-12 month time period before death.
Low weight and/or a decrease in dopaminergic agent prescriptions are seen 6-12 months before death in patients with PD and therefore may signal consideration of hospice referral. The decrease in dopaminergic agents may indicate that adverse effects begin to outweigh benefits.
Physicians' ability to appropriately refer PD patients for hospice at the end of life may improve, and people with PD and their families may benefit from earlier supportive hospice care. Further longitudinal research may determine whether these markers specifically predict the terminal stage of Parkinson's disease.