Dementia Med Goals

Mom has some dementia and you’ve written that the fewer pills a senior takes the better.  But, her doctor says she needs to continue all her pills, including her cholesterol ones.  What should we do?


Dementias are devastating for patients and families:  there is no cure, they are progressive and fatal, and can make caregivers unwell because of the stress trying to look after their loved one.
While practice guidelines tell doctors patients must be on a “statin” [cholesterol-lowering drug to prevent heart attacks (such as atorvastatin / Lipitor)], some newer guidelines [such as from the Choosing Wisely Campaign] recommend that seniors with any life-limiting disease (like Alzheimer’s) not take statins, because the risks and side-effects outweigh any benefit. 
What side-effects?  In seniors, statins have a higher risk of muscle aches, numbness/tingling in arms/legs, and confusion.  So for someone with dementia, it doesn’t make sense to take a drug which may worsen their confusion. 
So what is a family, caught between the conflicting advice from different doctors, to do? 
Focus on what’s ultimately best for the whole patient, not just one part.  For example, the additional months or years of life gained through efforts to keep an Alzheimer’s patient’s heart pumping longer, may only end up allowing more time for their brain to degenerate to the point where everyone—patient and family—is really miserable!    
Therefore, we must ask, if someone has dementia, what’s the goal?  Is it to be kept alive regardless of any suffering; or, to live as comfortable as possible and do nothing which might prolong suffering.   More patients and families are now choosing this “Comfort Care Only” (CCO) option.
CCO usually means “avoid any treatment which doesn’t improve comfort”.   That could include no “statins”, no insulin, no blood pressure pills; even “no antibiotics” for pneumonia—a disease once known as “the old person’s best friend” in the days before antibiotics (it’s still the most common cause of death in dementia).
Why avoid these treatments, and “no antibiotics” in particular?  The rationale seems to be, “if I can’t get better and have no quality of life, why take something which may only prolong my suffering and my being a burden to my family?”  Antibiotics don’t help for comfort at this point; they artificially interfere in a natural end of life.  So we have the option to step aside and allow this person to end their journey in a more peaceful and dignified manner.
Each of us has the right to make informed decisions based on reasonable goals and doctors are ethically obligated to support those decisions.  Hospice can help do that.