Dementia and Hospice Eligibility

Hospice Eligibility for Dementia Patients: Part One — Disease-Specific Criteria

Dementia is common, debilitating, and heartbreaking. The many forms of this disease, including Alzheimer's dementia (or “disease”), Lewy Body dementia, and vascular dementia, all cause cognitive impairment, memory loss, impaired functioning, and varying degrees of physical (or motor) impairment. While medication may delay the progression of dementia (depending on type) – and only modestly at best -- the disease is invariably progressive, and ultimately robs its victims of the ability to recognize loved ones, talk, get out of bed, feed or take care of themselves, and eventually causes death. The course of this terminal illness is about 7 to 10 years. Dementia is increasing in prevalence as America ages; it is estimated that more than 9 million Americans aged 65 and older could be living with dementia by 2030, and nearly 12 million by 2040.

For a more detailed description of the different types of dementia, see, Understanding Dementia Progression, Hospice Eligibility, and the Importance of the FAST Score.

How to Qualify for Hospice with Dementia Under Medicare

The Connecticut Hospice can provide much needed information and help for the care of people with dementia. However, to be enrolled in hospice, a loved one with dementia must meet Medicare’s requirements for eligibility. Unsurprisingly, these are far from straightforward. Hopefully, this post will help you better understand them such that you can effectively advocate for your loved one and obtain hospice services.

Per Medicare, a physician must certify a prognosis of six months or less “if the terminal illness runs its normal course” for a patient to qualify for hospice. For people with dementia, such a prognosis can be established by two methods.

Medicare’s Disease-Specific Guidelines for Alzheimer’s and Related Dementias

One is by using Medicare’s “Disease Specific” guidelines, which establish very particular criteria as to both the type of dementia a patient must suffer and its severity.

Dementia Diagnoses That Meet Medicare Hospice Criteria

The type(s) of dementia required by Medicare are called “Alzheimer’s Disease and Related Disorders.”

Again, Medicare is very specific. Your loved one must be diagnosed with Alzheimer’s disease or have one of the several other possible causes of cognitive impairment (see below*). Most of these additional diagnoses are relatively rare. Fortunately, however, one, “senile degeneration of the brain, not elsewhere classified” – broadly defined as progressive decline in cognitive function, including memory and reasoning, associated with old age and not specifically due to Alzheimer's disease or other explicitly defined conditions -- provides a work around for hospice enrollment. That is, your loved one must either have Alzheimer’s dementia, one of the other less common causes of cognitive impairment, or “senile degeneration of the brain” to qualify for hospice.

FAST Score Requirements for Hospice Eligibility with Dementia

Next is the severity of illness. This is where the FAST score comes in. FAST, or Functional Assessment Staging Tool, is a scale used to evaluate functional decline in individuals with Alzheimer’s disease and other dementias. A FAST score of 7 or greater, ranging from “a” to “f,” is required by Medicare for hospice enrollment.

A FAST score of 7 means that dementia is advanced, and the afflicted individual is unable to walk, dress, bathe, or toilet without assistance, is occasionally (or always) incontinent of bowel and bladder, and has speech limited to six or fewer words in a single utterance. A patient with FAST 7a or b may still be able to walk with assistance and eat independently, though some hospices require a score of 7c, meaning they are no longer able to walk at all.

For those with FAST 7a, Medicare also says they “should have had” one of several medical complications in the year prior to enrollment. These complications include pneumonia, kidney infections, sepsis (bacteria in the blood), severe bedsores, recurrent fever, and reduced oral intake with a 10% weight loss in the prior six months or a serum albumin (a blood test measuring body protein) of 2.5 or less.

Other conditions that contribute to eligibility include “functional status,” including level of consciousness and ability for self-care, and “co-morbid” diseases such as hypertension, diabetes, stroke, thyroid disease, and other chronic illnesses.

Summary of Medicare Hospice Criteria for Dementia Patients

To summarize, you may seek hospice care for a loved one with dementia if he or she has an established diagnosis of Alzheimer’s disease or a “related condition,” is dependent on others for walking, dressing, bathing, and toileting, is occasionally (or always) incontinent, can only meaningfully use 6 or fewer words in a single utterance, and has suffered a complication like pneumonia in the last year, or has lost 10% or more of their body weight in the last 6 months. Eligibility is supported by increased caregiver needs, fluctuating level of consciousness, and the presence of other chronic illnesses. Some hospices may insist on a FAST score of 7c or greater (up to 7f), meaning they can no longer walk at all, in addition to the above complications.

Coming Next: Non-Disease-Specific Hospice Guidelines for Dementia

The next Connecticut Hospice blog post will explore Medicare’s “Non-Disease Specific” guidelines for enrollment in hospice, which may offer your loved one with dementia an opportunity to receive hospice care even if the disease is not quite as advanced as described in this post.