Alzheimer's Disease (AD) and related disorders may support a prognosis of 6
months or less under many clinical scenarios. The identification of specific
structural/functional impairments, together with any relevant activity
limitations, should serve as the basis for palliative interventions and care
planning. The structural and functional impairments associated with a primary
diagnosis of AD are often complicated by comorbid and/or secondary conditions.
Comorbid conditions affecting beneficiaries with AD are by definition distinct
from the AD  itself. Examples include coronary heart disease (CHD) and chronic
obstructive pulmonary disease (COPD). Secondary conditions, on the other hand,
are directly related to a primary condition. In the case of AD examples
include delirium and pressure ulcers. The important roles of comorbid and
secondary conditions are described below in order to facilitate their
recognition and assist providers in documenting their impact.  
  
The Reisberg Functional Assessment Staging (FAST) scale has been used for many
years to describe Medicare beneficiaries with AD and a prognosis of 6 months
or less. The FAST scale is a 16-item scale designed to parallel the
progressive activity limitations associated with AD. Stage 7 identifies the
threshold of activity limitation that would support a 6 month prognosis. The
FAST scale does not address the impact of comorbid and secondary conditions.
These 2 variables are thus considered separately by this policy.  
  
 **FAST Scale Items:**  
  
Stage #1: No difficulty, either subjectively or objectively  
  
Stage #2: Complains of forgetting location of objects; subjective work
difficulties  
  
Stage #3: Decreased job functioning evident to coworkers; difficulty in
traveling to new locations  
  
Stage #4: Decreased ability to perform complex tasks (e.g., planning dinner
for guests; handling finances)  
  
Stage #5: Requires assistance in choosing proper clothing  
  
Stage #6: Decreased ability to dress, bathe, and toilet independently:  
* Sub-stage 6a: Difficulty putting clothing on properly  
* Sub-stage 6b: Unable to bathe properly; may develop fear of bathing  
* Sub-stage 6c: Inability to handle mechanics of toileting (i.e., forgets to flush, does not wipe properly)  
* Sub-stage 6d: Urinary incontinence  
* Sub-stage 6e: Fecal incontinence  
  
Stage #7: Loss of speech, locomotion, and consciousness:  
* Sub-stage 7a: Ability to speak limited (1 to 5 words a day)  
* Sub-stage 7b: All intelligible vocabulary lost  
* Sub-stage 7c: Non-ambulatory  
* Sub-stage 7d: Unable to sit up independently  
* Sub-stage 7e: Unable to smile  
* Sub-stage 7f: Unable to hold head up.  
  
 **Comorbid Conditions:**  
  
The significance of a given comorbid condition is best described by defining
the structural/functional impairments, together with any limitation in
activity, related to the comorbid condition. For example a beneficiary with AD
and clinically significant CHD or COPD would have specific impairments of
cardiorespiratory function (e.g., dyspnea, orthopnea, wheezing, chest pain),
which may or may not respond or be amenable to treatment. The identified
impairments in cardiorespiratory function would be associated with both
specific structural impairments of the coronary arteries or bronchial tree,
and may be associated with activity limitations (e.g., mobility, self-care).
Ultimately, the combined effects of the AD (FAST stage 7 or beyond) and any
comorbid condition should be such that most beneficiaries with AD (FAST stage
7 or beyond) and similar impairments would have a prognosis of 6 months or
less.  
  
 **Secondary Conditions:**  
  
AD may be complicated by secondary conditions. The significance of a given
secondary condition is best described by defining the structural/functional
impairments, together with any limitation in activity, related to the
secondary condition. The occurrence of secondary conditions in beneficiaries
with AD is facilitated by the presence of impairments in such body functions
as mental functioning and movement functions. Such functional impairments
contribute to the increased incidence of secondary conditions, such as
delirium and pressure ulcers, observed in Medicare beneficiaries with
Alzheimer's Disease. Secondary conditions themselves may be associated with a
new set of structural/functional impairments that may or may not respond or be
amenable to treatment. Ultimately, the combined effects of the AD (FAST stage
7 and beyond) and any secondary condition should be such that most
beneficiaries with AD and similar impairments would have a prognosis of
months or less.  
  
The documentation of structural/functional impairments and activity
limitations facilitate the selection of intervention strategies (palliative
vs. curative) and provide objective criteria for determining the effects of
such interventions. The documentation of these variables is thus essential in
the determination of reasonable and necessary Medicare Hospice Services.  
  
**Summary:**  
  
For beneficiaries with AD to be eligible for hospice the individual should
have a FAST level of greater than or equal to 7 and specific comorbid or
secondary conditions meeting the above criteria.