Tag - medications

Statin Discontinuation in Hospice Patients
Medication Discontinuation in Dementia Patients

Statin Discontinuation in Hospice Patients

Hospice prescribers and pharmacists have long approached statins as appropriate for discontinuation in their patients who have no active cardiovascular disease since preventative or prophylaxis medications, as well as medications with long-term therapeutic outcomes, are not considered part of palliative care.  With the benefits of statin discontinuation ranging from decreasing pill burden to preventing myopathy, from cost-savings to fewer drug-drug interactions, it has become a common practice.  However, many hospice prescribers still overlook the potential benefits of statin discontinuation such that they do not always consider it in a timely manner after admission to hospice.

When the hospice team admits a patient with no known cardiovascular disease who is on a statin, it is helpful to remind new hospice prescribers of research demonstrating that the discontinuation of statins in this population does not alter mortality rates within 60 days of discontinuation or alter the median time to death.  Similarly, discontinuation does not appear to affect rates of cardiovascular events but may actually provide improvements in quality of life.  Research findings also imply that it is possible that statin deprescribing may lead to a reduction in the number of non-statin prescriptions required, perhaps due to fewer adverse effects requiring treatment for patient comfort.  It is prudent to consider the risks of continuation of any medication that no longer provides benefit, especially when dysphagia is present.

Of course, discussions about discontinuing any therapy should occur in the context of shared decision making, especially in the case of statins as research indicates that neither continuation nor discontinuation is clearly superior.  Furthermore, the data surrounding the topic of stopping statins in late-stage terminal patients serves as a reminder of the importance of utilizing patient-centered ongoing medication therapy reviews as an opportunity to continually assess the risk versus benefit of all components of a hospice patient’s medication regimen.



Kutner, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA. 2015 May;175(5):691-700  https://www.ncbi.nlm.nih.gov/pubmed/25798575

Holmes H. & Todd A. Evidence-based deprescribing of statins in patients with advanced illness. JAMA. 2015 May;175(5):701-702  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4420700/

Voelker R. Statin use may stop when illness is terminal, study says. JAMA. 2014 Jul 16;312(3):221

Medication Discontinuation in Dementia Patients

Understanding the progressive nature of dementia can help in the decision to continue or discontinue dementia medications in patients on hospice care for end-stage dementia.  Goals change as patients progress from mild to severe dementia.  In mild to moderate dementia, the primary goal is to slow the progression of the disease.  As dementia nears its end stages, the goal of care generally shifts to the control of dementia symptoms, especially when patients qualify for hospice care.

Neither the cholinesterase inhibitors nor the NMDA receptor antagonists have been proven beneficial in end-stage dementia.  Both classes of medications have the potential to cause significant adverse effects in declining patients whose bodies are less able to efficiently metabolize these medications.  Diarrhea, loss of appetite, nausea, symptomatic slow heart rate, and fainting are all potential side effects of cholinesterase inhibitors; memantine puts patients at greater risk for dizziness, headache, confusion and constipation.  When such medications are added to others commonly prescribed for patients admitted to hospice for dementia, the rates of these and other adverse effects often increase.  Though some patients gain a small benefit from the continuation of dementia medications, the potential dangers of continuing dementia medications must be considered.

The decision to continue or discontinue dementia medications can at first appear difficult, but a simple discontinuation plan can guide therapy options and ease caregiver concerns.  A prudent plan often includes a gradual discontinuation of dementia medications, monitoring patients for any new or worsening symptoms.  Some symptoms are better managed with other medications commonly used to manage dementia symptoms at end of life.  More often than not, patients do well with the discontinuation, have less risk of adverse effects from their remaining medications, and are well managed with conventional symptom management.


Buckley JS, Salpeter SR. A risk-benefit assessment of dementia medications: systematic review of the evidence. Drugs Aging. 2015; 32(6):453-467.

Yang Z, Zhou X, Shand Q. Effectiveness and safety of memantine treatment for Alzheimer’s disease. J Alzheimers Dis. 2013; 36(3):445-458.

Minett TS, Thomas A, Wilkinson LM, Daniel SL, Sanders J. Richardson J, Littlewood E, Myint P, Newby J, McKeith IG. What happens when donepezil is suddenly withdrawn? An open label trial in dementia with Lewy bodies and Parkinson’s disease with dementia. Int J Geriatr Psychiatry. 2003; 18(11):988-93.

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