Dementia Due To Alzheimers (Hospice Eligibility)

1 MUST BE MET AND AT LEASE ONE OF THE CONDITIONS IN 2

1. ADL (all in this section should be met)
a. Is Karnofsky Performance Status (KPS) < 70?
b. Is Palliative Performance Status (PPS) < 70?
c. Stage 7A or beyond according to Functional Assessment Staging Scale (FAST > 7A)?
d. Unable to ambulate without assistance / dependent to get to and from specific locations? (Ambulation = 3)
e. Unable to dress without assistance? (Dressing = 3)
f. Unable to bathe without assistance? (Bathing = 3)
g. Urinary and fecal incontinence is intermittent or constant/dependent on catheter or ostomy care? (Incontinence > or = 1)
h. Is unable to consistently have meaningful verbal communication; utters stereotypical phrases only; or ability to speak six or fewer intelligible words?

AND

2. Documented history/progression of at least any one of the following:
a. Aspiration pneumonia in past 12 months?
b. Pyelonephritis in past 12 months?
c. Septicemia in past 12 months?
d. Decubitus ulcer – stage 3 or 4 in past 12 months?
e. Recurrent fever after antibiotics in past 12 months?
f. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin < 2.5 gm/dl?