A new national study has raised some questions about the safety of a pair of common sedatives prescribed to people with dementia in hospice care.
A group of University of Michigan researchers report that initiating benzodiazepines or antipsychotics in hospice patients with Alzheimer’s disease and related dementias (ADRD) is linked to significantly higher mortality within six months—a finding that may prompt new scrutiny of how comfort medications are prescribed at the end of life.
A Vulnerable Population, a Difficult Balance
Dementia now accounts for roughly one-quarter of all hospice admissions – up from less than 1% 20 years ago. And yet its slow and unpredictable progression makes decisions about medication and timing all the more challenging.
“Dementia is now the most common qualifying condition among hospice enrollees, yet many of these patients are not imminently dying,” Lauren B. Gerlach, DO, MS, lead author and geriatric psychiatrist at UM’s academic medical center, explained. “Because prognosis in dementia is so difficult to determine, nearly 1 in 5 patients will outlive the six-month eligibility window for hospice. This makes it critical that medications used during this period enhance, rather than diminish, quality of life.”
Caregivers rely on benzodiazepines and antipsychotics to help ease agitation, anxiety, or delirium in their patients. But both drug classes carry risks: falls, confusion, aspiration, and in the case of antipsychotics, an FDA “black box” warning for increased mortality in dementia.
Methodology
The JAMA Network Open study analyzed data from 139,103 U.S. nursing home residents with dementia who enrolled in hospice between 2014 and 2018. Relying on Medicare claims and Minimum Data Set assessments, the researchers identified those who began taking either benzodiazepines or antipsychotics after entering hospice, after having avoided those drugs for at least six months before.
The researchers paired each new user with a similar nonuser based on age, sex, cognitive function, comorbidities, and enrollment timing. They then tracked the participants for 180 days to assess all-cause mortality.
Striking Results
Some clear trends emerged.
- Starting benzodiazepines increased the risk of death within six months by 41%.
- Starting antipsychotics carried a smaller but still significant 16% mortality jump.
Nearly half of all dementia patients in the study initiated benzodiazepines during hospice, while 13% started taking antipsychotics. Median time to first prescription was just three days after hospice enrollment.
The link persisted even after adjusting for potential confounders and running multiple sensitivity analyses, including models that accounted for the number of prescription fills. Each additional fill raised mortality risk further – by as much as 15% for benzodiazepines and 6% for antipsychotics.
The findings highlight a difficult tension in hospice medicine. How do you relieve suffering without hastening decline?
The authors stress that benzodiazepines and antipsychotics can be appropriate in the final days of life, when agitation and terminal delirium are increasingly common and the quality of wakefulness starts to become less relevant.
But for patients months from death, the sedating effects could rob them of valuable time.
Worse still, prescription patterns vary widely based on geography. Previous research from the same group found that benzodiazepine use in hospice can range from 12% to 80% depending on the agency. These are variations that might reflect institutional norms more than patient need.
A Call for Better Guidelines
The researchers argue that dementia-specific hospice guidelines are urgently needed. There is no national framework for safe psychotropic prescribing in this setting, and Medicare no longer requires hospices to report the drugs they dispense. It’s a data gap that, the authors warn, “leaves hospice medication use entirely unmonitored.”
They call for renewed oversight, better clinician training, and greater investment in nonpharmacologic interventions to manage behavioral symptoms in dementia.
For dementia patients in hospice care, medications intended to make patients more comfortable might be risking their lives. As the dementia population continues to swell and hospice use expands, the study’s authors urge clinicians and policymakers alike to confront at least one uncomfortable question: When does easing suffering risk crossing into accelerating death?
Their answer, at least for now, is clear: Proceed with caution when it comes to benzodiazepines and antipsychotics.
Further Reading
How the ‘Big 5’ Personality Traits Influence Dementia Risk
US Dementia Cases Will Double By 2060
Your Chances of a Dementia Diagnosis Depend on Where You Live
