This document provides information about dementia care at the end of life. It begins by defining common causes of dementia like Alzheimer's disease and vascular dementia. It then discusses the natural progression of dementia and common complications that contribute to death, such as pneumonia, falls, and malnutrition. The document emphasizes that hospice can improve outcomes for dementia patients by providing better care and support at the end of life compared to traditional medical care alone.

1. Dementia Care
at the End of Life
The information in the pages that follow is considered by VITAS®
Healthcare Corporation to be confidential.

2. CE Provider Information
VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through:
VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of
Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental
Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists
through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number:
139000207/RT CE Provider Number: 195000028/Approved By the Illinois Division of Profession Regulation for: Licensed Nursing
Home Administrators and Illinois Respiratory Care Practitioner.
VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB)
Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and
provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing
education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2018 – 06/06/2021.
Social workers completing this course receive 1.0 ethics continuing education credits.
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board
of Registered Nursing, Provider Number 10517, expiring 01/31/2021.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ:
No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive
CE Credit in Illinois

3. Goal
Describe and document the factors
that qualify dementia patients as
hospice-eligible.

4. By the end of this presentation, you should be able to:
• Define the most common etiologies of dementia
• Describe the complications that contribute to the underlying cause of death for
dementia patients
• Describe the differences between Alzheimer’s disease and other forms of dementia
• Identify the value of advance care planning (ACP) and how to bill for it
Objectives

5. Changes in Death Rates for Major Diseases
1Harrison, K. L., Hunt, L. J., Ritchie, C. S., & Yaffe, K. (2019). Dying with Dementia: Underrecognized and Stigmatized. Journal of the American Geriatrics Society, 67(8), 1548-1551.
2Xu J., Murphy S. L.,, Kochanek K.D., Brigham Bastian B. S., Arias E. Deaths: Final Data for 2016. National Vital Statistics Report. 2018;67(5): 1-76. Available from:
https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_05.pdf

6. • 2019 US Alzheimer’s estimate: 5.8 million
– 5.6 million people are aged 65+
– 2/3 are women
• Alzheimer’s cases projected for 2050:
14 million
• Between 2000-2017, Alzheimer’s-related
deaths have increased 145%
• Someone new develops dementia every
65 seconds in the US
Background: Dementia Epidemiology
Alzheimer's Association. (2019). 2019 Alzheimer’s Disease Facts and Figures. Alzheimer's & Dementia, 15(3), 321-387.

7. • One million people with advanced dementia lack meaningful communication
and are functionally dependent
• 1 in 3 seniors dies with Alzheimer’s or another dementia
• Diagnosis of dementia cuts one's life expectancy in half
• Dementia is the fifth-leading cause of death in persons over the age of 65
• 2/3 of dementia patients are admitted to a nursing home (NH) near end of life
– 67% of all dementia deaths occur in a NH
• More than 500,000 dementia deaths a year in the US are attributed to dementia
Background: Dementia Near the End of Life
Hebert, L. E., Scherr, P. A., Bienias, J. L., Bennett, D. A., & Evans, D. A. (2003). Alzheimer Disease in the US Population: Prevalence Estimates Using the 2000
Census. Archives of Neurology, 60(8), 1119-1122.

8. Dementia Trajectory
Function
Death
Low
ADL Dependency Slow decline
High
Functional Dependency and Disease Related Complication
Hospice-Eligible
• Dependence in 3/6 ADLs (bathing, dressing,
feeding, continence, ambulation, transferring)
• Disease-related complication within last 6 months

9. Number of Hospice Decedents by Principal Diagnosis for 2016 & 2017
National Hospice and Palliative Care Organization. (2018). NHPCO Facts and Figures: Hospice Care in America.
Hospice Use by Primary Diagnosis
2016
Cancer
Circulatory/Heart
Dementia
Other
Respiratory
Stroke
Chronic Kidney Disease
327,344
185,483
161,983
142,191
114,356
97,074
25,382
2017
332,718
194,512
172,643
153,963
122,004
103,684
24,953
15.3% 15.6%

10. Alzheimer’s Association. Differentiating Dementias. In Brief for Healthcare Professionals. Issue 7. Retrieved February 27, 2020 from https://www.alz.org/media/Documents/inbrief-differentiating-dementias.pdf
Common Forms of Dementia

11. • Alzheimer’s Disease
– Amyloid plaques and neurofibrillary tangles
• Mixed: Cerebral atherosclerosis and Alzheimer’s Disease
– Combination of Alzheimer’s disease and cerebral atherosclerosis (vascular)
• Lewy body dementia
– Alpha-synuclein protein
• Cerebral atherosclerosis (vascular dementia)
• Cortical infarcts, subcortical infarcts, and leukoaraiosis
• Frontotemporal Dementia
– Tau protein
Pathophysiologies of Dementia
Alzheimer’s Association. Differentiating Dementias. In Brief for Healthcare Professionals. Issue 7. Retrieved February 27, 2020 from https://www.alz.org/media/Documents/inbrief-differentiating-dementias.pdf

12. Neuriticplaque
Neurofibrillary tangle
Protein Deposition in Alzheimer’s Disease

13. Cerebral Atherosclerosis

14. Dementia Mortality by Diagnosis
Garcia-Ptacek, S., Farahmand, B., Kåreholt, I., Religa, D., Cuadrado, M. L., & Eriksdotter, M. (2014). Mortality Risk After Dementia Diagnosis by Dementia Type and Underlying Factors: a Cohort of 15,209 Patients
Based on the Swedish Dementia Registry. Journal of Alzheimer's Disease, 41(2), 467-477.

15. Complication Cause of Death Mode of Death
Acute infection Malnutrition
Muscle weakness
Immobility
Pneumonia
Urinary tract infection
Swallowing difficulties Malnutrition
Dysphagia
Aspiration pneumonia
Electrolyte imbalance
Injuries
Trauma
Immobility/Atrophy
Osteoporosis
Hip fracture
Other fracture
Vascular disease Inflammation
Amyloid deposition
Seizure
Stroke
Dementia as the Cause of Death

16. Symptoms of Advanced Dementia
Mitchell, S. L., Teno, J. M., Kiely, D. K., Shaffer, M. L., Jones, R. N., Prigerson, H. G., ... & Hamel, M. B.(2009). The Clinical Course of Advanced Dementia. New England Journal of Medicine, 361(160), 1529-1538.
0
5
10
15
20
25
30
35
40
Dyspnea Pain Pressure ulcers Aspiration Agitation
ResidentswithSymptoms(%)
Distressing Symptoms
Months Before Death (no. of residents alive during interval)
>9–12 (N=67) >6–9 (N=96) >3–6 (N=128) 0–3 (N=177)

17. • Hospice enrollees were:
– Significantly more likely to die at home (76% vs. 38%)
– Less likely to die in the hospital (7% vs. 45%)
• Better pain and symptom management
• Fewer end-of-life transitions
• Decrease in caregiver burden
• Increased caregiver satisfaction with care
Hospice and Dementia
Gozalo, P. L., & Miller, S. C. (2007). Hospice Enrollment and evaluation of its Causal Effect on Hospitalization of Dying Nursing Home Patients. Health Services Research, 42(2), 587-610.
Casarett, D., Karlawish, J., Morales, K., Crowley, R., Mirsch, T., & Asch, D. A. (2005). Improving the Use of Hospice Services in Nursing Homes: A Randomized Controlled Trial. JAMA, 294(2), 211-217.
Shega, J. W., Hougham, G. W., Stocking, C. B., Cox-Hayley, D., & Sachs, G. A. (2008). Patients Dying with Dementia: Experience at the End of Life and Impact of Hospice Care. Journal of Pain and
Symptom Management, 35(5), 499-507.
Sternberg, S. A., Sabar, R., Katz, G., Segal, R., Fux-Zach, L., Grupman, V., ... & Bentur, N. (2019). Home Hospice for Older People with Advanced Dementia: a Pilot Project. Israel Journal of Health Policy
Research, 8(1), 42.

18. Hospice Care’s Impact on Caregiver Health
Irwin, S. A., Mausbach, B. T., Koo, D., Fairman, N., Roepke-Buehler, S. K., Chattillion, E. A., ... & Von Känel, R. (2013). Association Between Hospice Care and Psychological Outcomes in Alzheimer’s
Spousal Caregivers. Journal of Palliative Medicine, 16(11), 1450-1454.

19. Reisberg, B. (1988). Functional Assessment Staging (FAST). Psychopharmacology Bulletin, 24(4), 653-659.
FAST Scale (Functional
Assessment Staging)
1. No difficulties
2. Subjective forgetfulness
3. Decreased job functioning and
organizational capacity
4. Difficulty with complex tasks,
instrumental ADLs
5. Requires supervision with ADLs
Alzheimer’s Progression: Function
6. Impaired ADLs, with incontinence
7. A. Speaking ability limited to five words
or less
B. All intelligible vocabulary lost
C. Loss of ambulation
D. Inability to sit
E. Inability to smile
F. Inability to hold head up

20. Specific Comorbidity
• CHF
• COPD
• CAD
• Diabetes
Hospice Eligibility Reference Guidelines: Alzheimer’s Disease
Dementia of sufficient severity to limit activity FAST 7a
Secondary Condition/Activity Limitation
• Pneumonia
• Pyelonephritis/UTI
• Sepsis
• Febrile episode
• Difficulty eating
or dysphagia
• Delirium
Centers for Medicare & Medicaid Services. Local Coverage Determination (LCD): Hospice Alzheimer's Disease & Related Disorders (L34567). Retrieved February 27, 2020 from
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34567
• Poor nutritional status
and/or dehydration
• Feeding tube (decision)
• Pressure sores
• Hip fracture
• Recurrent hospitalizations for
disease-related complications

21. Dementia Types
• Alzheimer’s
• Multi-infarct
• Lewy body
• Frontotemporal dementia
• Parkinson’s-related
• Head trauma/CTE
• Alcohol
Dementia Diagnosis
Most dementia diagnoses stem from a combination of pathological processes
Medical Conditions
• Delirium
• Liver disease
• Renal failure
• Depression
• Sleep apnea
• Polypharmacy/anticholinergic
Alzheimer's Association. (2019). 2019 Alzheimer’s Disease Facts and Figures. Alzheimer's & Dementia, 15(3), 321-387.

22. • Functional Disability–progressive
– 3/6 activities of daily living (ADL)
dependency
• Disease-related Complication(s)
– Pneumonia
– Pyelonephritis/UTI
– Sepsis
– Febrile episode
– Difficulty eating or dysphagia
– Poor nutritional status and/or
dehydration
Centers for Medicare & Medicaid Services. Local Coverage Determination (LCD): Hospice Alzheimer's Disease & Related Disorders (L34567). Retreived February 27, 2020 from
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34567
Considerations for Hospice in Dementia
– Feeding tube (decision)
– Pressure sores
– Hip fracture
– Delirium
– Recurrent hospitalizations for disease-
related complications

23. 87-year-old with progressive dementia secondary to cerebral atherosclerosis and
Alzheimer’s disease. Diagnosed four years ago; now presents to the emergency
department (ED) with a change in mental status and low-grade fevers to 100 degrees.
No infection was identified, but RA was dehydrated.
Past Medical History: HTN, normal EF HF, atrial fibrillation, osteopenia,
hospitalized four months ago for pneumonia.
Medications: diltiazem, lisinopril, aspirin, calcium, vitamin D, acetaminophen
as needed.
Social History: Daughter is RA’s primary caretaker with support from church.
RA is homebound.
Case of RA

24. • Get stronger
• Better nutritional status
• Less confused and more awake
• Avoid burdensome interventions
• Get back home
• Live as long as possible
Goals-of-Care Conversation
Allen, L. A., Stevenson, L. W., Grady, K. L., Goldstein, N. E., Matlock, D. D., Arnold, R. M., ... & Havranek, E. P. (2012). Decision Making in Advanced Heart Failure: a Scientific Statement from the
American Heart Association. Circulation, 125(15), 1928-1952.
Survival
Costs/Burden
Direct Medical Costs
Indirect Costs
Lost Opportunities
Caregiver Burden
Outcomes
Relevant to
and individual
Patient
Quality of Life
Symptoms
Physical Function
Mental
Emotional
Social

25. Nutrition: Weight loss seven pounds over six months (7%), BMI 22; increased
dysphagia on pureed diet
Function: 3/6 ADL-dependent (bathing, continence, and transferring) with
recent decline; assist with dressing and ambulation, eats independently with
set-up; PPS 40; homebound
Cognition: Increased sleepiness with hospitalization, oriented to person and
recognizes family
Healthcare Utilization: Second hospital admission in last four months,
previous for pneumonia
Symptoms: Sleepier (delirium), some pain; spends more time in bed
RA Case Study (cont.)

26. • Median survival was 478 days,
24.7% within 6 months
• 54.8% died, 93.8% in NH
6-month mortality 38.6%
6-month mortality 44.5%
6-month mortality 46.7%
Mitchell SL, Teno JM, Kiely DK, et al. The Clinical Course of Advanced Dementia. New England Journal of Medicine. 2009 61(16):1529-1538.
Natural History of Dementia

27. Cabre, M., Serra-Prat, M., Palomera, E., Almirall, J., Pallares, R., & Clavé, P. (2010). Prevalence and Prognostic Implications of Dysphagia in Elderly Patients with Pneumonia. Age and Aging, 39(1), 39-45.
Dysphagia and Survival
Mortality with Dysphagia
30-day: 22.9%
1-year: 55.4%

28. Olajide, O., Hanson, L., Usher, B. M., Qaqish, B. F., Schwartz, R., & Bernard, S. (2007). Validation of the Palliative Performance Scale in the Acute Tertiary Care Hospital Setting.
Journal of Palliative Medicine, 10(1), 111-117.
Survival by Palliative Performance Score (PPS) at
Acute-Care Hospital

29. Boyd, C. M., Landefeld, C. S., Counsell, S. R., Palmer, R. M., Fortinsky, R. H., Kresevic, D., ... & Covinsky, K. E. (2008). Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute
Medical Illness. Journal of the American Geriatrics Society, 56(12), 2171-2179.
Hospitalization, ADL Change and Death
83.3
33.5
80
37.4
73.3
36.5
67.0
30.1
13.5
53
12.9
40.2
14.9
32.4
15.2
28.6
2.7
13.5
7.1
22.4
11.4
31.2
17.8
41.3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Discharged at
baseline
function
Discharged with
a new or
additonal
disability in ADL
Discharged at
baseline
function
Discharged with
a new or
additonal
disability in ADL
Discharged at
baseline
function
Discharged with
a new or
additonal
disability in ADL
Discharged at
baseline
function
Discharged with
a new or
additonal
disability in ADL
Baseline Decline Death
3-Month Outcome 6-Month Outcome 12-Month Outcome1-Month Outcome
41% of patients who had functional decline during hospitalization died within the next year

30. Gill, T. M., Gahbauer, E. A., Leo-Summers, L., Murphy, T. E., & Han, L. (2019). Days Spent at Home in the Last Six Months of Life Among Community-Living Older Persons.
The American Journal of Medicine, 132(2), 234-239.
Taking to Bed Supports Hospice Eligibility
Bed rest increases as death approaches:
24 months before death: 12.4%
5 months before death: 19.0%
1 month before death: 51.6%
The number of days of bed rest increases
as death approaches:
24 months before death: 3 days of bed rest
4 months before death: 7 days of bed rest
• Almost 90% of patients
take to the bed prior
to death, with a similar
increase in the number
of days in bed
• Increases in the last
3-5 months of life
suggest that the
burden of bed rest may
be an indicator that
death is approaching
Occurrence of Bed Rest

31. Pneumonia
Six-month mortality
• 53% Impaired
• 13% Intact
Survival After Acute Illness: Severe Dementia
vs. Cognitively Intact
Morrison, R. S., & Siu, A. L. (2000). Survival in End-Stage Dementia Following Acute Illness. JAMA, 284(1), 47-52.
Hip Fracture
Six-month mortality
• 55% Impaired
• 12% Intact

32. Teno, J. M., Gozalo, P., Mitchell, S. L., Tyler, D., & Mor, V. (2013). Survival After Multiple Hospitalizations for Infections and Dehydration in Nursing Home Residents with Advanced Cognitive
Impairment. JAMA, 310(3), 319-320.
Two or More Hospitalizations Among NH Residents
With Dementia in One Year

33. Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying Confusion: the Confusion Assessment Method: a New Method for Detection of Delirium.
Annals of Internal Medicine, 113(12), 941-948.
Delirium: Under-Detected
Acute Onset and Fluctuating
Course + Inattention
plus either
Altered LOC
Disorganized
Thinking
DELIRIUM

34. 12-month mortality
• Delirium: 41.6%
• Non-delirium: 14.4%
McCusker, J., Cole, M., Abrahamowicz, M., Primeau, F., & Belzile, E. (2002). Delirium Predicts 12-month mortality. Archives of Internal Medicine, 162(4), 457-463.
Hospital Delirium and Subsequent Mortality

35. • IV fluids initiated and oral intake improved over two days
• Physical therapy consult for deconditioning
– RA is now dependent with dressing, maximal assist with ambulation
• Speech therapy consult for dysphagia
– Continue pureed diet
• Cognition improves somewhat as RA is more awake but sleeping
more than usual and exhibiting poor attention
RA Case Study: Hospital Course

36. • Skilled Nursing Facility
– 24-hour care provided, PT/OT and speech
• Home Health
– Nursing support at home, usually twice a week; PT/OT and speech
• Hospice
– Nurse, social worker, chaplain, aide, volunteer, palliative therapy services
• No services at all
RA Case Study: Transition of Care Options

37. Restoration Potential and Goals of Care (GOC)
Poor
Restorative
Potential =
Need for GOC
Discussion
Pressure ulcers
Consider age, motivation,
ability to learn/participate
Tolerate <20 minutes
of therapy a day,
6-7 days/week
Advanced age,
multiple comorbidities,
progressive dementia
Ongoing decline
anticipated and
unavoidable
Ultimate discharge
plan to LTC or
24-hour care
Significant functional
debility, low likelihood of
return to independence
Custodial needs >
skilled needs

38. • Participates in OT/PT and speech
– Not much progress as still dependent in dressing, and ambulation
requires assistance
– Ongoing mild dysphagia and on pureed diet
• Delirium continues to improve but attention still not back to baseline
• Discharge planning initiated and daughter elects home health over
hospice for the inclusion of therapy services
RA Case Study: Skilled Facility Course

39. Aragon, K., Covinsky, K., Miao, Y., Boscardin, W. J., Flint, L., & Smith, A. K. (2012). Use of the Medicare Posthospitalization Skilled Nursing Benefit in the Last 6 Months of Life. Archives of Internal Medicine,
172(20), 1573-1579.
SNF Use in Older Adults During the Last Six Months of Life
Only 1.5% enrolled in
hospice at day of
discharge from SNF

40. • Transitions to home with home health services
• Week 1
– Not much improvement with OT/PT speech as still dependent in dressing and
assistance with ambulation
– Ongoing dysphagia but tolerating pureed diet, consuming 50-75%
– RA’s attention still not “back to normal” with periods of increased sleepiness
• Week 2
– Episode of coughing with eating
– Spikes fever with lethargy and some shortness of breath
– Transferred to the ED, admitted to ICU and placed on ventilator for airway
protection and respiratory distress
RA Case Study: Home Health Course

41. Teno, J. M., Gozalo, P., Khandelwal, N., Curtis, J. R., Meltzer, D., Engelberg, R., & Mor, V. (2016). Association of Increasing Use of Mechanical Ventilation Among Nursing Home Residents with Advanced
Dementia and Intensive Care Unit Beds. JAMA Internal Medicine, 176(12), 1809-1816.
Mechanical Ventilation Use in Advanced Dementia
and One-Year Mortality

42. • Remained on ventilator for six days while being treated for pneumonia and was
able to be weaned off
• Hypoactive delirium recurred and persisted
• NG feedings initiated but RA developed Stage III pressure sore on coccyx
• Now dependent in 6/6 ADLs
• Daughter wants to focus on comfort but does not want RA to die at home
• Decision to transfer to LTC on hospice for comfort care
– Continuous care for management of delirium, pain and shortness of breath
– Comfort feedings, no artificial nutrition or hydration
– DNR
RA Case Study: ICU Course

43. • Admitted to LTC on continuous care for management of symptoms
• RA actively dying and responds to risperidone for intermittent agitation
and opioids for pain and shortness of breath
• Palliative wound care
• RA dies comfortably at LTC four days later
RA Case Study: Long-Term Care Course

44. • RA had clear clinical indicators of a poor prognosis four to five months prior to death
• Pattern recognition is important as RA endured multiple burdensome transitions
• No clear ACP conversation that detailed key factors and preferences
– Natural history of dementia, including clinical complications
– Understood relationship between clinical complications and poor prognosis
• Ability of hospice to support the daughter’s goal for therapy services
• Caregiver experienced substantial distress after RA’s death due to the late referral
to hospice
– Distress could have been prevented with an earlier, timelier referral to hospice
RA Case: Study Reflection

45. • Functional Disability–progressive
– 3/6 ADL dependency
• Disease-related Complications
– Pneumonia
– Pyelonephritis/UTI
– Sepsis
– Febrile episode
– Difficulty eating or dysphagia
– Poor nutritional status
– Feeding tube (decision)
– Pressure sores
– Hip fracture
– Delirium at time of hospital
discharge
– Recurrent hospitalizations for
disease- related complications
Local Coverage Determinations (LCDs) for Palmetto GBA. Retrieved March 6, 2020 from https://www.cms.gov/medicare-coverage-database/indexes/lcd-
list.aspx?Cntrctr=373&ContrVer=1&CntrctrSelected=373*1&bc=AAACAAAAAAAA&DocType=2#aFinal
Considerations for Hospice in Dementia

46. Wang, S. Y., Aldridge, M. D., Gross, C. P., Canavan, M., Cherlin, E., & Bradley, E. (2017). End-of-life Care Transition Patterns of Medicare Beneficiaries.
Journal of the American Geriatrics Society, 65(7), 1406-1413.
Transitions: Last Six Months of Life
46

47. 1
Harrison, K. L., Hunt, L. J., Ritchie, C. S., & Yaffe, K. (2019). Dying with Dementia: Underrecognized and Stigmatized. Journal of the American Geriatrics Society, 67(8), 1548-1551.
2Miller, S. C., Lima, J. C., Intrator, O., Martin, E., Bull, J., & Hanson, L. C. (2017). Specialty Palliative Care Consultations for Nursing Home Residents with Dementia. Journal of Pain and Symptom Management,
54(1), 9-16.https://www.sciencedirect.com/science/article/abs/pii/S0885392417301562
Integrating a Palliative Approach to Dementia Across
the Decline Trajectory
• This approach to dementia care can help
guide clinicians on when and how to:
– Conduct advance care planning conversations
– Determine how to meet current needs and
anticipate future ones
– Decide on the necessity for consultations or
referrals (eg, referral to hospice)
• Cognitive and functional impairments resulting
from dementia alter end-of-life care needs, even
when dementia is not formally the cause of death
• Palliative care intervention for older adults with
dementia in nursing homes, are effective at
reducing burdensome transitions and improving
quality of symptom management2

48. • Basis for high-quality, person-centered care
• Opportunity to discuss wishes/preferences and care choices before crises arise
• Serves as an open and continuous dialogue to match preferences with care
– Code status/power of attorney for healthcare
– Role of hospice vs. emergency department/hospital
• In a retrospective outcomes analysis of 1,818 deceased patients with POLSTs,
treatment-limiting POLSTs were associated with significantly lower rates of ICU
admission, compared with full-treatment POLSTs
– However, 38% of patients with treatment-limiting POLSTs received intensive care
that was potentially discordant with their POLST
• Hospice acts as a safeguard to honor advance directives/ACP and ensure goal-
concordant care
Value of Advance Care Planning
Lee, R. Y., Brumback, L. C., Sathitratanacheewin, S., Lober, W. B., Modes, M. E., Lynch, Y. T., ... & Engelberg, R. A. (2020). Association of Physician Orders for Life-Sustaining Treatment with ICU Admission
Among Patients Hospitalized Near the End of Life. JAMA.
48

49. • Eligible providers
– Physician
– Nurse practitioner and physician assistant
• Medicare Part A and Part B benefit
Code Overview
Advance Care Planning Codes
CPT Code Description
99497
Advance care planning including the explanation and discussion of advance directives such as standard forms (with
completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes,
face-to-face with the patient, family member(s), and/or surrogate.
99498
Advance care planning including the explanation and discussion of advance directives such as standard forms (with
completion of such forms, when performed), by the physicians or other qualified health care professional; each additional
30 minutes (List separately in addition to code for primary procedure).
49

50. Mitchell, S. L., Teno, J. M., Kiely, D. K., Shaffer, M. L., Jones, R. N., Prigerson, H. G., ... & Hamel, M. B. (2009). The Clinical Course of Advanced Dementia. New England Journal of Medicine, 361(16), 1529-1538.
Proxy Appreciation of Disease Trajectory Impacts Care
Proxy’s Understanding of Prognosis
and Expected Complications
Residents Who Died during
18-Mo Study Period (N = 177)
Residents Who Underwent Any
Burdensome Intervention during
Last 3 Mo of Life
Odds Ratio for Burdensome Intervention
during Last 3 Months of Life (95% CI)
no. (%) no./total no. (%) Unadjusted Adjusted
Believed resident had <6 months to live
Yes 46 (26.0) 14/46 (30.4) 0.45 (0.19–1.04) 0.34 (0.14–0.81)
No 131 (74.0) 58/131 (44.3) Reference category Reference category
Understood expected clinical complications
Yes 146 (82.5) 52/146 (35.6) 0.30 (0.15–0.62) 0.33 (0.17–0.63)
No 31 (17.5) 20/31 (64.5) Reference category Reference category
Believed resident had <6 months to live and
understood expected clinical complications
37 (20.9) 10/37 (27.0) 0.13 (0.04–0.44) 0.12 (0.04–0.37)
Either believed resident had <6 months to live
or understood expected clinical complications,
but not both
118 (66.7) 46/118 (39.0) 0.23 (0.10–0.57) 0.25 (0.13–0.49)
Neither believed resident had <6 months to live
nor understood expected clinical complications
22 (12.4) 16/22 (72.7) Reference category Reference category

51. Comprehensive Services
Services Overview:
Service VITAS Home Health
Palliative Care
Physician Support
Yes No
Nurse Frequency
of Visits
Unlimited based
on patient need
Diagnosis
driven
RT/PT/OT/Speech Yes Yes
Equipment Included Yes No
After Hours Staff
Availability
Yes No
Levels of Care 4 Levels Home
Care Plan Review Weekly Variable
Targeted Disease-
Specific Program
Yes Variable
Bereavement Support Yes No
Service VITAS Home Health
Eligibility • Physician-certified prognosis
<6 months, if disease runs
normal course
• Hospice prognosis must be
re-certified periodically
• Patient agrees to palliative, not curative,
plan of care
• Plan of care determined by initial and
ongoing doctor/team assessment,
combined with patient/family wishes
• Not required to be homebound
• Must require skilled level of care and a
specific plan of care confirming need,
frequency and duration of visits
• Skilled nursing care need must be
re-certified periodically
• As skilled needs change, approved
services change
• Must be homebound, except for
short durations
Length of Care Unlimited number of visits based on
patient need, if prognosis remains 6
months or less
• Limited number of visits
• Must document progress within the
length of service allowed
Medications
Included
VITAS provides Rx and OTC medications
related to hospice diagnosis at no charge
to the patient
Medications are not covered under the
Medicare Home Health Benefit

52. Questions

53. Download the VITAS app now.
Explore interactive assessment tools on the VITAS app
PPS and BMI resources provide eligibility guidance
at your fingertips.
• Disease-specific Palliative Performance Scale (PPS):
– Assess activities of daily living on a sliding scale
– Offers immediate insight into hospice eligibility
• Updated Body-Mass Index (BMI) tool
• View and share disease-specific hospice
eligibility guidelines
Take the Guesswork out of
Hospice Eligibility

54. Allen, L. A., Stevenson, L. W., Grady, K. L., Goldstein, N. E., Matlock, D. D., Arnold, R. M., ... & Havranek, E. P. (2012). Decision Making in
Advanced Heart Failure: a Scientific Statement from the American Heart Association. Circulation, 125(15), 1928-1952.
Alzheimer's Association. (2019). 2019 Alzheimer’s Disease Facts and Figures. Alzheimer's & Dementia, 15(3), 321-387.
Alzheimer’s Association. Differentiating Dementias. In Brief for Healthcare Professionals. Issue 7. Accessed February 27, 2020:
https://www.alz.org/media/Documents/inbrief-differentiating-dementias.pdf
Aragon, K. N., Covinsky, K., Miao, Y., Boscardin, W. J., & Smith, A. (2011, May). Medicare Post-Hospitalization Skilled Nursing Benefit
in the Last Six Months of Life. Journal of General Internal Medicine (26), 181-182.
Boyd, C. M., Landefeld, C. S., Counsell, S. R., Palmer, R. M., Fortinsky, R. H., Kresevic, D., ... & Covinsky, K. E. (2008). Recovery of Activities
of Daily Living in Older Adults After Hospitalization for Acute Medical Illness. Journal of the American Geriatrics Society, 56(12), 2171-2179.
Cabre, M., Serra-Prat, M., Palomera, E., Almirall, J., Pallares, R., & Clavé, P. (2010). Prevalence and Prognostic Implications of Dysphagia
in Elderly Patients with Pneumonia. Age and Ageing, 39(1), 39-45.
Casarett, D., Karlawish, J., Morales, K., Crowley, R., Mirsch, T., & Asch, D. A. (2005). Improving the Use of Hospice Services in
Nursing Homes: A Randomized Controlled Trial. JAMA, 294(2), 211-217.
Centers for Medicare & Medicaid Services. Local Coverage Determination (LCD): Hospice Alzheimer's Disease & Related Disorders (L34567).
Accessed February 27, 2020: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34567
Garcia-Ptacek, S., Farahmand, B., Kåreholt, I., Religa, D., Cuadrado, M. L., & Eriksdotter, M. (2014). Mortality Risk After Dementia Diagnosis by
Dementia Type and Underlying Factors: a Cohort of 15,209 Patients Based on the Swedish Dementia Registry.
Journal of Alzheimer's Disease, 41(2), 467-477.
References

55. Gill, T. M., Gahbauer, E. A., Leo-Summers, L., Murphy, T. E., & Han, L. (2019). Days Spent at Home in the Last Six Months of Life
Among Community-Living Older Persons. The American Journal of Medicine, 132(2), 234-239.
Gozalo, P. L., & Miller, S. C. (2007). Hospice Enrollment and Evaluation of its Causal Effect on Hospitalization of Dying Nursing
Home Patients. Health Services Research, 42(2), 587-610.
Harrison, K. L., Hunt, L. J., Ritchie, C. S., & Yaffe, K. (2019). Dying with dementia: Underrecognized and Stigmatized.
Journal of the American Geriatrics Society, 67(8), 1548-1551.
Hebert, L. E., Scherr, P. A., Bienias, J. L., Bennett, D. A., & Evans, D. A. (2003). Alzheimer Disease in the US Population:
Prevalence Estimates Using the 2000 Census. Archives of Neurology, 60(8), 1119-1122.
Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying Confusion: the Confusion
Assessment Method: a New Method for Detection of Delirium. Annals of Internal Medicine, 113(12), 941-948.
Irwin, S. A., Mausbach, B. T., Koo, D., Fairman, N., Roepke-Buehler, S. K., Chattillion, E. A., ... & Von Känel, R. (2013). Association
Between Hospice Care and Psychological Outcomes in Alzheimer’s Spousal Caregivers. Journal of Palliative Medicine, 16(11), 1450-1454.
Lee, R. Y. et al. (2020). Association of Physician Orders for Life-Sustaining Treatment with ICU Admission Among Patients Hospitalized
Near the End of Life. JAMA.
McCusker, J., Cole, M., Abrahamowicz, M., Primeau, F., & Belzile, E. (2002). Delirium Predicts 12-month mortality. Archives of Internal
Medicine, 162(4), 457-463.
Mitchell, S. L., Teno, J. M., Kiely, D. K., Shaffer, M. L., Jones, R. N., Prigerson, H. G., ... & Hamel, M. B. (2009). The Clinical Course of
Advanced Dementia. New England Journal of Medicine, 361(16), 1529-1538.
References

56. Morrison, R. S., & Siu, A. L. (2000). Survival in End-Stage Dementia Following Acute Illness. JAMA, 284(1), 47-52.
National Hospice & Palliative Care Organization. Facts & Figures. Revised 2019. Accessed March 2, 2020: Accessed March 2, 2020:
https://www.nhpco.org/wpcontent/uploads/2019/07/2018_NHPCO_Facts_Figures.pdf
Olajide, O., Hanson, L., Usher, B. M., Qaqish, B. F., Schwartz, R., & Bernard, S. (2007). Validation of the Palliative Performance Scale in the
Acute Tertiary Care Hospital Setting. Journal of Palliative Medicine, 10(1), 111-117.
Reisberg, B. (1988). Functional Assessment Staging (FAST). Psychopharmacology Bulletin, 24(4), 653-659.
Shega, J. W., Hougham, G. W., Stocking, C. B., Cox-Hayley, D., & Sachs, G. A. (2008). Patients Dying with Dementia: Experience at the End of
Life and Impact of Hospice Care. Journal of Pain and Symptom Management, 35(5), 499-507.
Sternberg, S. A., Sabar, R., Katz, G., Segal, R., Fux-Zach, L., Grupman, V., ... & Bentur, N. (2019). Home Hospice for Older People with
Advanced Dementia: a Pilot Project. Israel Journal of Health Policy Research, 8(1), 42.
Teno, J. M., Gozalo, P., Khandelwal, N., Curtis, J. R., Meltzer, D., Engelberg, R., & Mor, V. (2016). Association of Increasing
Use of Mechanical Ventilation Among Nursing Home Residents with Advanced Dementia and Intensive Care Unit Beds.
JAMA Internal Medicine, 176(12), 1809-1816.
Wang, S. Y., Aldridge, M. D., Gross, C. P., Canavan, M., Cherlin, E., & Bradley, E. (2017). End-of-life Care Transition Patterns of Medicare
Beneficiaries. Journal of the American Geriatrics Society, 65(7), 1406-1413.
Xu J., Murphy, S. L., Kochanek, K. D., Brigham Bastian, B. S., Arias, E. Deaths: final data for 2016. National Vital Statistics
Report, 2018;67(5): 1-76. Available from: https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_05.pdf
References

57. This document contains confidential and proprietary business information
and may not be further distributed in any way, including but not limited to
email. This presentation is designed for clinicians. While it cannot replace
professional clinical judgment, it is intended to guide clinicians and
healthcare professionals in establishing hospice eligibility for patients
with advanced Alzheimer's and dementia. It is provided for general
educational and informational purposes only, without a guarantee of the
correctness or completeness of the material presented.