Abstract
BACKGROUND: Documentation of patient goals and preferences within medical records has the potential to align medication use with goals of care (GoC) and individualize medication appropriateness criteria. We characterized patient and surrogate-expressed GoC for older Veterans living with dementia and explored concordance with medication use during VA Community Living Center (CLC) (i.e., nursing home) stays.
METHODS: We conducted a cross-sectional analysis using the VA Residential History File, Minimum Data Set, Corporate Data Warehouse, and Medicare claims for Veterans with dementia admitted to VA CLCs from 4/2021 to 12/2021 for > 7 days. We extracted free text responses for "Veteran goals in own words" from a standardized GoC note. Two coders classified GoC topics using iterative coding. We examined bar code medication administration data for aspirin, benzodiazepines, opioids and antidementia medications within the 7 days following admission. We determined a schema for potential goal-concordant medication use (e.g., opioids for GoC focused on comfort) and assessed concordance of medication use with GoC topics.
RESULTS: Among 1000 VA CLC residents with dementia and GoC documented, 46.4% of responses were reported by the Veteran versus a surrogate. Common topics included comfort (44.6%), life-sustaining treatments (31.8%), function (13.7%), care setting/transitions (12.9%), and life prolongation (11.2%). Medications were seldom discussed. Opioid and benzodiazepine use was classified as goal-concordant for 56.7% and 72.2% of patients who used them. Aspirin and antidementia medication use was more commonly classified as goal-discordant (54.7% and 38.7%, respectively).
CONCLUSIONS: Goals elicited via an open-ended question provided only indirect information relevant to medication use, but in many cases could be used to refine judgments of appropriateness. Integration of patient goals into formal criteria evaluating medication appropriateness is a logical next step for medication optimization research. Future research should explore the utility of questions specific to medications in GoC conversations for individuals with dementia.