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Clinical Pearls

To FAST or Not to FAST?

Lauren Templeton, DO HMDC FAAHPM

Dr. Barry Reisberg developed scales to correspond to his “retrogenesis” theory stipulating a degenerative reversal of normal human development in primary degenerative dementia.1,2 In 1988, he published the Functional Assessment Staging Tool (FAST), a seven-stage, 16-level scale, for predictable linear deterioration in patients with Alzheimer-type dementia (AD) as a continuum from the 1982 Global Deterioration Scale.1,3

The FAST scale is a validated tool for AD. Patients have unique variations and non-AD patients do not follow the same retrogenesis trajectory. Hospice providers use the FAST for documentation and prognostication toward terminally ill status for patients with dementia. Should that same linear regression be applied to other types of dementia?

A role of a hospice and palliative medicine physician is to determine a patient’s prognosis and certify them as terminally ill if that patient’s prognosis is 6 months or less, should the disease run its normal course. Assessment tools such as the FAST score are guidelines, as are Local Coverage Determinations (LCDs).4 To make these determinations, physicians should be applying their education from biology, physiology, pathophysiology, treatment of pathophysiology, and experience with mortality from such pathophysiology.

Utilizing the FAST score as the sole criterion for dementia-related hospice eligibility is inappropriate, AD or not. Around 50% of hospice beneficiaries are on hospice for 18 days or less, so these guidelines may act as a barrier to admitting rapidly declining patients. The FAST score is not designed to prognosticate in all types of dementia, and attaining a FAST score of 7 or beyond is not essential to qualify for hospice admission.

Consider a patient with vascular dementia returning to her long-term care facility after hospitalization for aspiration pneumonia due to dysphagia. Her albumin is 2.1 with severe protein calorie malnutrition. A hospice registered nurse evaluates the patient and documents a FAST 6e score. The hospice physician can use their expertise in interpretation of the LCD guidelines, understanding that different dementias progress at different rates and the combination of comorbidities can be used to certify for hospice eligibility. The poor prognosis for this patient with vascular dementia correlates to her aspiration and ongoing dysphagia. A FAST score reported as 6e could be misleading to the certifying hospice physician in this scenario and does not apply in prognostication of this vascular dementia patient.

Documenting the components contributing to the physician’s decision making in the clinical record, particularly in the written Certification of Terminal Illness, is a vital component in withstanding the scrutiny of payment-related audits. Clinically, this also guides members of the interdisciplinary group in their care and documentation.

HPM providers must understand that the FAST score is only one component of prognostication for dementia. As specialists, we must differentiate clinical trajectories for all types of dementia and consider comorbidities in our determination of a patient’s prognosis.

Further complicating the use of the FAST are inconsistencies in provider interpretation. One clinician’s FAST 7a is another’s FAST 7c. For a non-ambulatory patient to be assigned FAST 7c, they must first be incontinent of bowel and bladder and minimally verbal.

In the linear model associated with AD patients, there is no “skipping” steps. Again, this linear model does not work for other dementias outside of primary degenerative dementias, like Alzheimer's disease.

Functional Assessment Staging (FAST)a

Stage

1

No difficulty either subjectively or objectively.

2

Complains of forgetting location of objects. Subjective work difficulties.

3

Decreased job functioning evident to co-workers. Difficulty in traveling to new locations. Decreased organizational capacity.

4

Decreased ability to perform complex tasks, e.g., planning dinner for guests, handling. personal finances (such as forgetting to pay bills), difficulty marketing, etc.*

5

Requires assistance in choosing proper clothing to wear for the day, season, or occasion, e.g., patient may wear the same clothing repeatedly, unless supervised.*

6a

Improperly putting on clothes without assistance or prompting (e.g., may put street clothes on overnight clothes, or put shoes on wrong feet, or have difficulty buttoning clothing) occasionally or more frequently over the past weeks.*

6b

Unable to bathe (shower) properly (e.g., difficulty adjusting bathwater [shower] temperature) occasionally or more frequently over the past weeks.*

6c

Inability to handle mechanics of toileting (e.g., forgets to flush the toilet, does not wipe properly or properly dispose of toilet tissue) occasionally or more frequently over the past weeks.*

6d

Urinary incontinence (occasionally or more frequently over the past weeks).*

6e

Fecal incontinence (occasionally or more frequently over the past weeks).*

7a

Ability to speak limited to approximately a half-dozen intelligible different words or fewer in the course of an average day or in the course of an intensive interview.

7b

Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview (the person may repeat the word over and over).

7c

Ambulatory ability is lost (cannot walk without personal assistance).

7d

Cannot sit up without assistance (e.g., the individual will fall over if there are no lateral rests [arms] on the chair)

7e

Loss of ability to smile.

7f

Loss of ability to hold head up independently.

*Scored primarily on the basis of information obtained from knowledgeable informant and or/caregiver.

Scoring instructions: The FAST Stage is the highest consecutive level of disability. For clinical purposes, in addition to staging the level of disabilitiy, additional, non-ordinal (nonconsecutive) deficits should be noted, since these additional deficites are of clear clinical relevance.

a Used with permission from Reisberg, B. Functional Assessment Staging (FAST). Psychopharmacology Bulletin, 1988; 24:653-659. View the scale at https://medworksmedia.com/product/functional-assessment-staging-fast.

Rather than document FAST 6e for the above patient's prognosis from end-stage vascular dementia, the level of disability is better expressed in words, such as, “This patient is incontinent of bowel and bladder, unable to verbally express needs, non-ambulatory, and unable to sit up without support due to lack of core strength. These indicators demonstrate end-stage debility of the patient’s neurologic disease."

It has been my experience that hospices are paying the price of misapplication of the FAST score. This comes from struggling with prognostication for certification and recertification, which results in both barriers to admission and discharging patients who remain terminally ill. This price paid also comes from the auditing world where I have seen it applied to deny providers financial reimbursement for excellent hospice care based on misinterpreted audits. These payment-related denials typically surround inconsistent documentation by clinicans and lack of "progression on the FAST score," even in non–Alzheimer's type dementia patients.

Ultimately, through prognostication and documentation, hospice physicians support the business and care of hospice. Utilizing our expertise to go beyond the guidelines established for the generalist and justifying such rationales will allow more patients to benefit from hospice and reduce worry that audits will decimate the agency or employer.

Lauren Templeton, DO HMDC FAAHPM, is a practicing hospice medical director in Texas and works as a physician consultant with Weatherbee Resources. In this role, she serves as a national expert in the hospice industry, helping hospices with education surrounding payment-related scrutiny including assisting with audit responses and expert witness testimony. She serves as a member of the regulatory committee for the National Hospice and Palliative Care Organization and is very passionate about advocating for the role of the engaged hospice physician. Dr. Templeton lives on a ranch in Texas with her husband and two young boys.

References

  1. Reisberg B, Ferris SH, de Leon MJ, Crook T. The Global Deterioration Scale for assessment of primary degenerative dementia. Am J Psychiatry. 1982;139(9):1136-1139. doi:10.1176/ajp.139.9.1136.
  2. Reisberg B, Franssen EH, Hasan SM, et al. Retrogenesis: clinical, physiologic, and pathologic mechanisms in brain aging, Alzheimer's and other dementing processes. Eur Arch Psychiatry Clin Neurosci. 1999;249 Suppl 3:28-36. doi: 10.1007/pl00014170. PMID: 10654097.
  3. Reisberg B. Functional assessment staging (FAST). Psychopharmacol Bull. 1988;24(4):653-659.
  4. Centers for Medicare & Medicaid Services. Local Coverage Determination (LCD)—Hospice Alzheimer’s Disease & Related Disorders. (n.d.). Accessed June 23, 2023. https://www.cms.gov/medicare-coverage-database/view/lcd.

Bibliography

National Hospice and Palliative Care Organization. NHPCO facts and figures. Published December 2022. Accessed May 5, 2023. https://www.nhpco.org/wp-content/uploads/NHPCO-Facts-Figures-2022.pdf

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