Hospice & Dementia

A functional assessment staging tool, or FAST Scale, is used to identify functional abilities of those with Alzheimer’s or types of dementia.

Items are scored based on clinical analysis or information obtained from a knowledgeable informant and include:

• Subjective work difficulties
• Decreased ability to perform complex tasks (dinner planning, paying bills, etc)
• Improperly putting on clothing without assistance or prompting
• Unable to bathe frequently or properly without assistance
• Urinary and/or fecal incontinence
• Unable to speak more than a half-dozen intelligible words or fewer in the course of one day
• Limited ambulatory ability (cannot walk without personal assistance)
• Cannot sit up without assistance
• Loss of ability to hold up head without assistance or prop

Aside from this score, other dementia-related eligibility criteria, like the presence of co-morbid disease or secondary conditions, are considered in whether hospice is warranted.   

While some patients with end-stage dementia steadily decline and receive benefits indefinitely, others who do not meet criteria at the prescribed 30, 60, or 90 day intervals are often discharged from hospice. This is due in part to a policy implemented in 2014 by the Center for Medicare and Medicaid Services that decreased Medicare reimbursement for patients who are in hospice for greater than 60 days. Unfortunately, the patient population that accounts for the most lengthy hospice stays is those with some form of dementia, so these patients are more likely to be discharged while alive. According to research published in the Journal of American Geriatrics Society, nearly 40% of dementia patients in hospice in 2019 were discharged while alive. This is possibly due to improvement in the patients’ functional abilities, but may also reflect the reluctance of hospice providers to continue caring for patients once reimbursement declines. 

Sources

“Functional Assessment Staging Tool (FAST Scale) for Dementia”. Compassus. https://www.compassus.com/healthcare-professionals/determining-eligibility/functional-assessment-staging-tool-fast-scale-for-dementia/ 

“Survival in hospice patients with dementia: the effect of home hospice and nurse visits”. Journal of American Geriatrics Society. https://pmc.ncbi.nlm.nih.gov/articles/PMC8192457/

As long as recertification requirements continue to be met, there is no set time limit for how long someone can receive hospice benefits. This means, for example, that if patients with late-stage dementia outlive their 6-month life expectancy confirmed upon admission, hospice will still provide ongoing care if clinical decline is continually confirmed. Patients with other terminal diagnoses can remain on hospice for a period of more than 6 months as long as the hospice medical director or another hospice physician certifies that they are terminally ill. After the initial six-month admission, the doctor must recertify the patient’s status every 60 days. 

Dementia is one of the top four primary diagnoses for hospice patients (others include cancer, heart disease, and lung disease). However, Alzheimer’s disease and other forms of dementia have become the largest group of principal diagnoses for hospice patients since 2002 according to the National Hospice and Palliative Care Organization. More than half of all hospice recipients have some form of dementia.

Unlike patients with cancer or other end-stage diseases, gauging life expectancy for those with dementia can be quite difficult. NHPCO reports the average hospice enrollee received benefits for an average of 92.6 days in 2019. Patients with cancer were in hospice only an average of 45 days while those with dementia averaged 126 days.

Sources
“Certification and Recertification”. National Alliance for Care at Home. https://allianceforcareathome.org/regulatory-compliance/certification-and-recertification/ 

“10 Signs Death Is Near When a Person Has Dementia”. VeryWell Health. https://www.verywellhealth.com/what-is-it-like-to-die-of-dementia-1132331 

“Hospice care”. Medicare. https://www.medicare.gov/coverage/hospice-care 

“Hospice Regulations May Be Adversely Affecting Dementia Patients”. Hospice News. https://hospicenews.com/2022/05/27/hospice-regulations-may-be-adversely-affecting-dementia-patients/