A STARK warning has emerged as antipsychotic medication use in hospice patients with dementia is associated with increased mortality, raising urgent questions about prescribing practices in end-of-life care.
Rising Concerns Over Antipsychotic Medication in Hospice Care
Use of antipsychotic medication in patients with Alzheimer disease and related dementias (ADRD) is widespread, particularly to manage agitation, anxiety and distress. However, evidence guiding its safety in hospice settings remains limited. Individuals with ADRD in hospice are reportedly three times more likely to receive these drugs than those not in hospice, intensifying concerns over potential harm. As sedation, falls and worsening cognition are well-recognised side effects, clinicians face a difficult balance between symptom relief and safety.
Study Findings
A national retrospective case-control study examined 139 103 long-term nursing home residents with ADRD enrolled in hospice using Medicare claims and Minimum Data Set assessments between 2014 and 2018. Residents with no benzodiazepine or antipsychotic use in the six months prior were included, and incident users were matched 1:1 to non-users. Among matched cohorts, 26 872 pairs formed the benzodiazepine group and 10 240 the antipsychotic group, with a mean age of 89.0 years and 83.8% female. Initiation of benzodiazepine use was linked to a 41% increased 180-day mortality risk (HR, 1.41; 95% CI, 1.38-1.44), while antipsychotic medication initiation was associated with a 16% increase (HR, 1.16; 95% CI, 1.12-1.20). These patterns persisted across propensity score–weighted models and cumulative exposure analyses, strengthening the indication of harm.
Clinical Implications and Future Prescribing Guidelines
The association between antipsychotic medication use and higher mortality underscores the need for caution and informed decision-making in hospice dementia care. While these drugs may offer symptom relief, clinicians must carefully weigh potential benefits against serious risks. The findings highlight the urgent need for dementia-specific prescribing guidelines, expansion of non-pharmacological interventions and policy reform to improve monitoring. Ensuring safety, dignity and quality of life in the final stages of dementia requires a more tailored and evidence-based approach.
Reference
Gerlach LB et al. Benzodiazepine or antipsychotic use and mortality risk among patients with dementia in hospice care. JAMA Netw Open. 2025;8(10):e2537551.
