Common Hospice Sedatives Linked To 41% Higher Death Risk In Dementia Patients

ANN ARBOR, Mich. — Nearly half of nursing home residents with dementia receive benzodiazepines during hospice care, and a new national study reveals these commonly prescribed sedatives are associated with a 41% increased risk of death within six months. Antipsychotics, given to about one in eight patients, showed a 16% increase in mortality risk.

The findings challenge current end-of-life prescribing practices for the 25% of hospice patients who have Alzheimer’s disease and related dementias. Unlike cancer patients, who typically have more predictable disease trajectories, people with dementia often live for months or even years after enrolling in hospice. One in five will outlive the six-month prognosis required for hospice eligibility.

“While these medications may provide symptom relief in appropriate clinical scenarios, their use is associated with substantial risks,” the researchers wrote in JAMA Network Open. The study examined 139,103 Medicare beneficiaries with dementia who enrolled in hospice between 2014 and 2018. Researchers then created carefully matched comparison groups totaling 53,859 participants to isolate the effects of these medications. The authors note the study was not designed to estimate national prevalence.

The Link Between Hospice Sedatives and Risk Of Death

Hospice providers routinely prescribe benzodiazepines like lorazepam and antipsychotics such as haloperidol to manage agitation, anxiety, and terminal delirium. For dementia patients, these behaviors often distress not just the patient but also family members and nursing staff.

Both medication classes carry documented risks in older adults. Antipsychotics have an FDA boxed warning specifically for increased mortality in dementia patients. Benzodiazepines are linked to respiratory suppression, sedation, falls, and aspiration.

The research team, led by Dr. Lauren Gerlach, a geriatric psychiatrist from the University of Michigan Medical School, used Medicare claims data to track patients who started these medications after hospice enrollment. They compared outcomes to similar patients who didn’t receive the drugs. Most patients began taking benzodiazepines or antipsychotics within three days of entering hospice.

Among those who started benzodiazepines, 73.6% had died by 180 days. Only 58.3% of matched patients who didn’t receive the drugs died in the same timeframe. For antipsychotics, 70.7% of users died compared to 63.3% of nonusers.

The study controlled for age, cognitive function, overall health, functional status, disruptive behaviors, and baseline use of other medications affecting the central nervous system. The link between medication initiation and increased mortality held across multiple statistical approaches.

Prescribing Rates Vary Wildly Between Hospice Facilities

The lack of consistency in prescribing is striking. Previous research has shown benzodiazepine prescribing rates in hospice range from 12% to 80% across different agencies. Antipsychotic rates vary from 6% to 62%. Whether a dementia patient receives these medications appears to depend more on which hospice agency they use than on their actual symptoms or clinical needs.

Hospice clinicians themselves disagree about these medications. In one national survey, 40% of hospice physicians believed benzodiazepines were overused in their facilities. Only 8% of hospice nurses shared that view.

Gerlach and her colleagues argue for national guidelines for hospice prescribing in dementia. Standardized protocols could reduce unwarranted variation and promote safer practices.

Why Dementia Patients Face Unique Challenges in Hospice

Hospice was originally designed around a cancer care model. Cancer patients typically have weeks or a few months to live. Dementia follows a fundamentally different path. The condition involves gradual functional and cognitive decline over an extended, unpredictable timeline. Doctors struggle to determine when someone is truly at the end of life.

People with dementia have the longest hospice stays of all diagnosis groups. In this study, average hospice length of stay exceeded 130 days. For patients who aren’t actively dying, families may prioritize preserving alertness and communication during remaining months. Sedating medications could work against these priorities.

The researchers noted that patients earlier in the hospice trajectory, who may have months to live, face particular risks. Sedating effects may compromise quality of life, impair communication, and interfere with functional independence.

The study found that more frequent prescriptions compounded the mortality risk. The analysis of medication patterns during the first 30 days of hospice showed that each additional benzodiazepine prescription was associated with a 15% higher risk of death by 180 days. Each additional antipsychotic prescription was associated with a 6% higher risk. Patients typically received their last prescription about two weeks before death for benzodiazepines and three weeks before death for antipsychotics.

Medicare No Longer Tracks Hospice Medications

From 2014 to 2018, Medicare briefly required hospice agencies to report medications billed to the hospice benefit. That program has expired. Hospice medication use now goes entirely unmonitored.

The researchers called this a blind spot in oversight of end-of-life care. They urged renewed efforts to track and evaluate medication use in hospice to guide evidence-based practice and protect patient safety.

The study focused on nursing home residents with Medicare fee-for-service coverage. Findings may not apply to all hospice patients. The researchers couldn’t measure actual medication consumption, only prescriptions filled. They also lacked information about symptom severity that might have prompted prescribing decisions.

Roughly 30% of all hospice patients have a dementia diagnosis, even when enrolled for other primary conditions like heart disease or stroke. The researchers included all dementia patients regardless of their primary hospice-qualifying diagnosis. This approach reflects the reality that dementia often coexists with other terminal conditions.

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