Drug therapy optimization at the end of life

Recommendations to prescribe in complex older adults: results of the CRIteria to assess appropriate Medication use among Elderly complex patients (CRIME) project

The occurrence of several geriatric conditions may influence the efficacy and limit the use of drugs prescribed to treat chronic conditions. Functional and cognitive impairment, geriatric syndromes (i.e. falls or malnutrition) and limited life expectancy are common features of old age, which may limit the efficacy of pharmacological treatments and question the appropriateness of treatment. However, the assessment of these geriatric conditions is rarely incorporated into clinical trials and treatment guidelines. The CRIME (CRIteria to assess appropriate Medication use among Elderly complex patients) project is aimed at producing recommendations to guide pharmacologic prescription in older complex patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes, and providing physicians with a tool to improve the quality of prescribing, independent of setting and nationality. To achieve these aims, we performed the following: (i) Existing disease-specific guidelines on pharmacological prescription for the treatment of diabetes, hypertension, congestive heart failure, atrial fibrillation and coronary heart disease were reviewed to assess whether they include specific indications for complex patients; (ii) a literature search was performed to identify relevant articles assessing the pharmacological treatment of complex patients; (iii) A total of 19 new recommendations were developed based on the results of the literature search and expert consensus. In conclusion, the new recommendations evaluate the appropriateness of pharmacological prescription in older complex patients, translating the recommendations of clinical guidelines to patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes. These recommendations cannot represent substitutes for careful clinical consideration and deliberation by physicians; the recommendations are not meant to replace existing clinical guidelines, but they may be used to help physicians in the prescribing process.

[Tools for optimizing pharmacotherapy for geriatric patients with multimorbidity at the end of life: helpful oder just raising awareness?]

Pharmacotherapy for end-of-life patients with multimorbidity is a major challenge. Estimating prognosis can be much more difficult when compared to patients suffering from cancer alone.Nevertheless, it is crucial in order to prescribe in the context of the following determining factors: disease, co-morbidities, functional status, life expectancy and therapy goals.Since such patients are prone to adverse drug reactions, inappropriate prescriptions should be avoided, since evidence concerning the benefits or risks for various drugs used is as yet inadequate.Several tools can be of help to improve pharmacotherapy for this vulnerable group of patients.

Prevalence and factors associated with polypharmacy in older people with cancer

PURPOSE

Polypharmacy has been associated with drug-drug interactions, adverse drug events, hospitalisation and increased mortality. The purpose of this study was to investigate the prevalence and factors associated with polypharmacy in older people with cancer.

PATIENTS AND METHODS

Patients aged≥70 years (n=385) presenting to the medical oncology outpatient clinic at Royal Adelaide Hospital between January 2009 and July 2010 completed a structured data collection instrument. The instrument included domains related to medications, diagnoses, instrumental activities of daily living (IADLs), Karnofsky Performance Scale (KPS), physical function (SF-36), pain (ten-point visual analogue scale, VAS), weight loss (patient self-reported over previous 6 months), exhaustion (CES-D) and distress (ten-point VAS). Frailty was computed using Fried's frailty phenotype. Logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the association between polypharmacy (defined as five or more self-reported daily medications) and clinical parameters.

RESULTS

Polypharmacy was present in 57% (n=221) of patients. When adjusting for age, gender and Charlson Comorbidity Index (CCI), polypharmacy was associated with being pre-frail (OR=2.35, 95%CI=1.43-3.86) and frail (OR=4.48, 95%CI=1.90-10.54) compared to being robust. When adjusting for age, gender, exhaustion, KPS, IADLs, pain and distress, polypharmacy was associated with higher CCI scores (OR=1.58, 95%CI=1.29-1.94) and poorer physical function (OR=1.13, 95%CI=1.06-1.20).

CONCLUSIONS

Polypharmacy is highly prevalent in older people with cancer and associated with impaired physical function and being pre-frail and frail compared to being robust. Research is needed to identify strategies to minimize patients' medication regimens.

Assessment of factors that influence physician decision making regarding medication use in patients with dementia at the end of life

OBJECTIVE

This study aimed to evaluate the extent to which patient-related factors and physicians' country of practice (Northern Ireland [NI] and the Republic of Ireland [RoI]) influenced decision making regarding medication use in patients with end-stage dementia.

METHODS

The study utilised a factorial survey design comprising four vignettes to evaluate initiating/withholding or continuing/discontinuing specific medications in patients with dementia nearing death. Questionnaires and vignettes were mailed to all hospital physicians in geriatric medicine and to all general practitioners (GPs) in NI (November 2010) and RoI (December 2010), with a second copy provided 3 weeks after the first mailing. Logistic regression models were constructed to examine the impact of patient-related factors and physicians' country of practice on decision making. Significance was set a priori at p ≤ 0.05. Free text responses to open questions were analysed qualitatively using content analysis.

RESULTS

The response rate was 20.6% (N = 662) [21.1% (N = 245) for GPs and 52.1% (N = 38) for hospital physicians in NI, 18.3% (N = 348) for GPs and 36.0% (N = 31) for hospital physicians in RoI]. There was considerable variability in decision making about initiating/withholding antibiotics and continuing/discontinuing the acetylcholinesterase inhibitor and memantine hydrochloride, and less variability in decision making regarding statins and antipsychotics. Patient place of residence and physician's country of practice had the strongest and most consistent effects on decision making although effect sizes were small.

CONCLUSIONS

Further research is required into other factors that may impact upon physicians' prescribing decisions for these vulnerable patients and to clarify how the factors examined in this study influence prescribing decisions.

Drug cessation in complex older adults: time for action

BACKGROUND

general opinion is growing that drug cessation in complex older patients is warranted in certain situations. From a clinical viewpoint, drug cessation seems most warranted in four situations, i.e., falls, delirium, cognitive impairment and end-of-life situations. To date, little information about the effects of drug cessation in these four situations is available.

OBJECTIVES

to identify the effects and effectiveness of drug cessation on falls, delirium and cognitive impairment. For end-of-life situations, we reviewed cessation of inappropriate drug use.

METHODS

electronic databases were searched using MeSH terms and relevant keywords. Studies published in English were included if they evaluated the effects of drug cessation in older persons, aged ≥65 years, with falls, delirium or cognitive impairment; or cessation of inappropriate drug use in end-of-life situations.

RESULTS

we selected seven articles for falls, none for delirium, two for cognition and two for end-of-life situations. Withdrawal of psychotropics reduced fall rate; a prescribing modification programme for primary care physicians reduced fall risk. Withdrawal of psychotropics and a systematic reduction of polypharmacy resulted in an improvement of cognition. Very little rigorous research has been conducted on reducing inappropriate medications in patients approaching end of life.

CONCLUSION

little research has focussed on drug cessation. Available studies showed a beneficial impact of cessation of psychotropic drugs on falls and cognitive status. More research in this field is needed. The issue of systematic drug withdrawal in end-of-life cases is controversial, but is increasingly relevant in the face of rising numbers of older people of this clinical status.

Studies to reduce unnecessary medication use in frail older adults: a systematic review

BACKGROUND

Overuse of unnecessary medications in frail older adults with limited life expectancy remains an understudied challenge.

OBJECTIVE

To identify intervention studies that reduced use of unnecessary medications in frail older adults. A secondary goal was to identify and review studies focusing on patients approaching end of life. We examined criteria for identifying unnecessary medications, intervention processes for medication reduction, and intervention effectiveness.

METHODS

A systematic review of English articles using MEDLINE, EMBASE, and International Pharmaceutical Abstracts from January 1966 to September 2012. Additional studies were identified by searching bibliographies. Search terms included prescription drugs, drug utilization, hospice or palliative care, and appropriate or inappropriate. A manual review of 971 identified abstracts for the inclusion criteria (study included an intervention to reduce chronic medication use; at least 5 participants; population included patients aged at least 65 years, hospice enrollment, or indication of frailty or risk of functional decline-including assisted living or nursing home residence, inpatient hospitalization) yielded 60 articles for full review by 3 investigators. After exclusion of review articles, interventions targeting acute medications, or studies exclusively in the intensive care unit, 36 articles were retained (including 13 identified by bibliography review). Articles were extracted for study design, study setting, intervention description, criteria for identifying unnecessary medication use, and intervention outcomes.

RESULTS

The studies included 15 randomized controlled trials, 4 non-randomized trials, 6 pre-post studies, and 11 case series. Control groups were used in over half of the studies (n = 20). Study populations varied and included residents of nursing homes and assisted living facilities (n = 16), hospitalized patients (n = 14), hospice/palliative care patients (n = 3), home care patients (n = 2), and frail or disabled community-dwelling patients (n = 1). The majority of studies (n = 21) used implicit criteria to identify unnecessary medications (including drugs without indication, unnecessary duplication, and lack of effectiveness); only one study incorporated patient preference into prescribing criteria. Most (25) interventions were led by or involved pharmacists, 4 used academic detailing, 2 used audit and feedback reports targeting prescribers, and 5 involved physician-led medication reviews. Overall intervention effect sizes could not be determined due to heterogeneity of study designs, samples, and measures.

CONCLUSIONS

Very little rigorous research has been conducted on reducing unnecessary medications in frail older adults or patients approaching end of life.

Antiretroviral therapy at the end of life: the experience of an academic HIV clinic

INTRODUCTION

There are no guidelines regarding the discontinuation of antiretroviral therapy at the end of life.

METHODS

We retrospectively reviewed our databases and identified patients with HIV/AIDS who died over the last 12 months in our HIV clinic.

RESULTS

A total of 41 patients from our HIV clinic died in a period of 12 months. Seventy-three percent of the patients were on antiretroviral therapy during the last clinic visit. During the last 3 months of life, 32% (13 of 41) were off antiretroviral therapy, with 77% (10 of 13) of them having intermittent therapy due to noncompliance. The remaining 23% (3 of 13) decided to stop antiretroviral therapy after discussion among families, patients, and providers.

CONCLUSION

Discussions among providers, patients, and families are encouraged to establish goals of care and role of antiretrovirals during the last months of life.

Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact

WHAT IS KNOWN AND OBJECTIVE

Potentially inappropriate prescribing (PIP) has significant clinical, humanistic and economic impacts. Identifying PIP in older adults may reduce their burden of adverse drug events. Tools with explicit criteria are being developed to screen for PIP in this population. These tools vary in their ability to identify PIP in specific care settings and jurisdictions due to such factors as local prescribing practices and formularies. One promising set of screening tools are the STOPP (Screening Tool of Older Person's potentially inappropriate Prescriptions) and START (Screening Tool of Alert doctors to the Right Treatment) criteria. We conducted a systematic review of research studies that describe the application of the STOPP/START criteria and examined the evidence of the impact of STOPP/START on clinical, humanistic and economic outcomes in older adults.

METHODS

We performed a systematic review of studies from relevant biomedical databases and grey literature sources published from January 2007 to January 2012. We searched citation and reference lists and contacted content experts to identify additional studies. Two authors independently selected studies using a predefined protocol. We did not restrict selection to particular study designs; however, non-English studies were excluded during the selection process. Independent extraction of articles by two authors used predefined data fields. For randomized controlled trials and observational studies comparing STOPP/START to other explicit criteria, we assessed risk of bias using an adapted tool.

RESULTS AND DISCUSSION

We included 13 studies: a single randomized controlled trial and 12 observational studies. We performed a descriptive analysis as heterogeneity of study populations, interventions and study design precluded meta-analysis. All observational studies reported the prevalence of PIP; however, the application of the criteria was not consistent across all studies. Seven of the observational studies compared STOPP/START with other explicit criteria. The STOPP/START criteria were reported to be more sensitive than the more-frequently-cited Beers criteria in six studies, but less sensitive than a set of criteria developed in Australia. The STOPP criteria identified more medications associated with adverse drug events than the 2002 version of the Beers criteria. Patients with PIP, as identified by STOPP, had an 85% increased risk of adverse drug events in one study (OR = 1·85, 95% CI: 1·51-2·26; P < 0·001). There was limited evidence that the application of STOPP/START criteria optimized prescribing. Research involving the application of STOPP/START on the impact on the quality of life was not found. The direct costs of PIP were documented in three studies from Ireland, but more extensive analyses on the economic impact or studies from other jurisdictions were not found.

WHAT IS NEW AND CONCLUSION

The STOPP/START criteria have been used to review the medication profiles of community-dwelling, acute care and long-term care older patients in Europe, Asia and North America. Observational studies have reported the prevalence and predictors of PIP. The STOPP/START criteria appear to be more sensitive than the 2002 version of the Beers criteria. Limited evidence was found related to the clinical and economic impact of the STOPP/START criteria.