Improving Hospice Dementia Care: Reducing Antipsychotic Use Through Implementation of a Dementia Care Program

Key Message : A comprehensive quality improvement program implemented in this trial shows promise for reducing antipsychotic use among hospice patients living with dementia when fully implemented. Although no overall effect was observed, exploratory findings highlight the importance of implementation in realizing benefits and support further study of non-pharmacological approaches in hospice care.

Abstract: Background / Purpose
Hospice is increasingly utilized by persons living with dementia (PLWD) and their care partners. To equip hospice interdisciplinary teams with essential skills to provide high-quality care to this rapidly growing population, our team developed a comprehensive Dementia Care Program (CDCP). This agency-wide, multi-component, team-based quality improvement program includes discipline-specific training, evidence-based tools (assessments, care plans, educational articles, a mobile app), clinical workflow changes, and mentorship to promote best practices for dementia care and care partner support. The primary objective was to evaluate the effectiveness of CDCP in reducing hospice antipsychotic use among PLWD.
Approach
We conducted the HAS-QOL embedded pragmatic, stepped-wedge, cluster randomized controlled trial. The dataset included 14,156 PLWD admitted across 15 hospices between July 1, 2020, and August 31, 2022. Baseline characteristics were summarized descriptively. The study sample was diverse in race/ethnicity; only approximately 55% were White. We used a generalized linear model with Poisson distribution and a spline term for month to model antipsychotic use not in the last 7 days of life. In the primary analysis comparing pre- and post-intervention periods, we found no significant overall effect of CDCP on antipsychotic use. In exploratory analyses, we examined interactions between intervention period (pre, transition, post) and implementation status (full, partial or none). This improved model fit and showed a significant negative interaction effect (–0.117 ± 0.032, p < .001), suggesting that full implementation of CDCP was associated with an approximately 11% reduction in the rate of antipsychotic use compared to no or partial implementation.
Implications / Lessons Learned
Despite overlap with the COVID-19 pandemic, which limited full implementation at some hospices, exploratory findings suggest that full implementation of CDCP may reduce antipsychotic use among PLWD. These results highlight the potential value of comprehensive, evidence-based, interdisciplinary approaches to support dementia care in real-world hospice settings.

References: 1. Lin, S., Schneider, C.E., Bristol, A.A., et al (2022). Pilot Testing Aliviado Dementia Care-Hospice Edition in Preparation for an Embedded Pragmatic Clinical Trial. The Gerontologist. 62, 304-314. DOI: 10.1093/geront/gnaa220 PMCID: PMC8827334
2. Murali, K. Gogineni, S., Bullock, et al (In Press). Interventions and Predictors of Transition to Hospice for People Living with Dementia: An Integrative Review. The Gerontologist. DOI: 10.1093/geront/gnaf046
3. Lin, S., Lassell, R.K. Jones, T., et al (2022). Supporting Dementia Family Caregivers During COVID-19: Perspectives from Hospice Staff. Geriatric Nursing. 47, 262-272. DOI: 10.1016/j.gerinurse.2022.08.003 PMCID: PMC9359485
4. David, D., Lin, S, Groom, L.L., Ford, A., Brody, A.A. on behalf of the HAS-QOL Investigators. (2022). Aliviado Mobile Application for Hospice Providers: A Usability Study. Journal of Pain and Symptom Management. 63, e37-45. DOI: 10.1016/j.jpainsymman.2021.07.019
5. Jones, T.M. & Brody, A.A. (2021). Adaption of a dementia symptom management program, Aliviado Dementia Care, for Hospice Social Workers. American Journal of Hospice and Palliative Medicine. 38, 452-458. DOI: 10.1177/1049909120962459