Potentially inappropriate prescribing in older adults with cancer receiving specialist palliative care: a retrospective observational study

Implementation of a Standardized Palliative Care Pharmacist Deprescribing Assessment

Background: Palliative care (PC) patients are at high risk of polypharmacy, thereby imposing a substantial burden on patients, including increased pill burden, adverse drug events, and falls. PC pharmacists play a critical role in deprescribing and aligning medications with goals of care for this population, but few studies demonstrate deprescribing opportunities. Objectives: The purpose of this study was to (1) summarize deprescribing opportunities among a sample of hospitalized PC patients, (2) identify patient variables associated with deprescribing opportunities, and (3) summarize deprescribing recommendations, implementation, and short-term clinical harm outcomes. Design: We conducted a retrospective review of the electronic health record. Setting/Subjects: All adult patients across six hospitals in Washington, DC, and Maryland referred to inpatient PC consultation service during the study period were included in this study. Results: Among 125 patients referred to the PC service, 84.5% were evaluated by a PC pharmacist for deprescribing opportunities, and 39.2% were appropriate for deprescribing. There was an average of 3.4 deprescribing recommendations made per patient. White patients and patients with higher severity of illness were significantly more likely to be deprescribing appropriately. The most commonly deprescribed medication classes were bowel regimens and electrolyte repletion, vitamins, and fluids. Deprescribing recommendations were widely accepted by inpatient primary care teams and patients and their caregivers. No short-term clinical harm was observed for patients with deprescribing recommendations implemented. Conclusion: Approximately two in five PC patients in this study were appropriate for deprescribing. PC pharmacists are effective at assessing and implementing deprescribing opportunities.

Pharmacist-led deprescribing interventions for cancer patients in a specialist palliative care setting

PURPOSE

This study aimed to determine the prevalence of potentially inappropriate medications (PIMs) among adult cancer patients in palliative care, the rate at which physicians implemented pharmacists' deprescribing recommendations, and some cost implications of deprescribing.

METHODS

Medication reconciliation was performed for each eligible patient, with both the OncPal deprescribing guideline and clinical judgement applied to identify PIMs. PIM prevalence was evaluated for each medication class. The physician recommendation implementation rate and medication cost savings were calculated.

RESULTS

In the 48 included patients, 25.2% of medications were PIMs (mean 2.4/patient) - with 86.7% OncPal-defined PIMs, most commonly vitamins, medications for gastro-oesophageal reflux disease (GORD), and lipid-modifying agents. Pharmacist deprescribing recommendations were implemented 71.7% of the time, equivalent to 1.7 fewer medications per patient. The 28-day cost was €948.27 for deprescribed PIMs. Implementation rates varied based on patient admission type, with a significantly higher (p<0.05) rate in those admitted for end-of-life care (83.3%) versus symptom control (65.1%) and respite (30%) admissions. Recommendations to deprescribe GORD medications had a significantly lower rate of implementation (26.7%) compared to all other medications (p<0.0001).

CONCLUSION

This study underscores the benefits of pharmacist-led deprescribing in inpatient palliative care, resulting in cost savings and reduced medication burden. There is a notable need for proactive deprescribing before reaching inpatient care. Different deprescribing rates across medication types highlight the significance of reviewing medications which may have a role in symptom management. The omission of some medications from OncPal emphasises the importance in refining future deprescribing guidelines in palliative care.

Effect of polypharmacy and potentially inappropriate medications on physical functional decline among older adults with advanced cancer receiving systemic treatment

BACKGROUND

Polypharmacy and potentially inappropriate medications (PIM) are common among older adults with advanced cancer, but their association with physical functional outcomes is understudied. This study aimed to estimate the risk of physical functional decline associated with medication measures in older adults with advanced cancer starting a new line of systemic treatment.

METHODS

This secondary analysis of GAP 70+ Trial (PI: Mohile) enrolled patients aged 70+ with advanced cancer, had ≥ 1 geriatric assessment domain impairment and planned to start a new antineoplastic regimen with a high risk of toxicity. Polypharmacy (concurrent use of ≥ 8 medications (meds)) was assessed before initiation of treatment. PIM were categorized using Screening Tool of Older Person's Prescriptions (STOPP) criteria and 2019 Beers criteria. Physical functional outcomes were assessed within 3 months of treatment initiation: (1) Activity of Daily Living (ADL) decline: 1-point decrease in ADL score between baseline and 3 months; (2) Instrumental ADL (IADL) decline: 1-point decrease in IADL score between baseline and 3 months; (3) Short physical performance battery (SPPB) decline, defined as 1-point decrease on SPPB; (4) ≥ 1 falls within 3 months of treatment. Separate multivariable, cluster-weighted Generalized Estimating Equations models adjusted for relevant covariates (e.g., age, baseline function/comorbidities).

RESULTS

Among 616 participants, mean number of meds was 6 (range 0-24); 28% received ≥ 8 meds. Polypharmacy was associated with increased risk of ADL decline (adjusted risk ratio [aRR], 1.31; 95% CI, 1.00-1.71). Taking ≥ 1 PIM per STOPP was associated with increased risk of IADL decline (aRR, 1.21; 95% CI, 1.04-1.40) and falls (aRR, 1.93; 95% CI, 1.49-2.51).

CONCLUSIONS

In a large cohort of vulnerable older adults with advanced cancer receiving systemic treatment, polypharmacy and PIM were independently associated with an increased risk of physical functional decline. This emphasizes the need to develop interventions to optimize medication use, intending to improve outcomes in these patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02054741. Registered 01-31-2014.

Polypharmacy and Potentially Inappropriate Medications in Patients With Advanced Cancer: Prevalence and Associated Factors at the End of Life

Background: Polypharmacy and potentially inappropriate medications (PIMs) impose a burden on patients with advanced cancer near the end of their lives. However, only a few studies have addressed factors associated with PIMs in such patients. Objective: To examine polypharmacy and factors associated with PIMs in end-of-life patients with advanced cancer. Design: Retrospective chart review. Setting/Subjects: We analyzed 265 patients with advanced cancer who died in a palliative care unit (PCU) or at home in a home medical care (HMC) from April 2018 to December 2022 in Japan. Measurements: Sociodemographic, clinical, and prescription data at the time of PCU admission or HMC initiation were collected from electronic medical records. PIMs were assessed using OncPal Deprescribing Guidelines. Results: Patients with advanced cancer with an average age of 76.3 years and median survival days of 20 were included in the analyses. The average number of medications was 6.4 (standard deviation = 3.4), and PIMs were prescribed to 50.2%. Frequent PIMs included antihypertensive medications, peptic ulcer prophylaxis, and dyslipidemia medications. A multivariate logistic regression analysis revealed that age ≥75 years (adjusted odds ratio [aOR] = 2.30, 95% confidence interval [CI] = 1.30-4.05), referral from an outpatient setting compared with inpatient setting (aOR = 2.06, 95% CI = 1.12-3.80), more than two comorbidities (aOR = 1.88, 95% CI = 1.08-3.29), and more than five medications (aOR = 1.84, 95% CI = 1.03-3.28) were associated with PIMs. Conclusions: Medication reconciliation is recommended at the time of transition to a PCU or HMC, especially for older patients with advanced cancer who were referred from an outpatient setting and present more comorbidities and prescriptions.

Deprescribing in older patients with advanced cancer referred to palliative care

OBJECTIVES

This study aimed to explore the prevalence of potentially inappropriate medications (PIMs) in a cohort of older adults with advanced cancer referred to palliative care. Secondary objectives were to describe the categories of identified PIMs and assess risk factors associated with their presence in this population.

METHODS

This retrospective, observational study evaluated patients with advanced cancer admitted to a tertiary university hospital in Madrid, Spain and referred to palliative care between 1 January 2020 and 30 June 2020. Demographic, clinical, and pharmacotherapeutic data were obtained from the electronic medical records and regional databases. PIMs were assessed using the Screening Tool of Older Persons Prescriptions in Frail adults (STOPPFrail) criteria, V1.

RESULTS

Among 123 patients (median age 80 years (IQR 73.5-87), 64.2% male), 74% presented at least one PIM according to the STOPPFrail criteria. The most common categories of inappropriate medications were lipid-lowering therapies, proton pump inhibitors, calcium supplements, and oral antidiabetics. The number of chronic comedications was significantly associated with PIM presence.

CONCLUSIONS

Our study found a high prevalence of PIM among a cohort of older adults with advanced cancer and short life expectancy. This underlines the need for a comprehensive medication review to optimise pharmacotherapy in this population.

Delivering Palliative and Supportive Care for Older Adults with Cancer: Interactions between Palliative Medicine and Geriatrics

The world's population is aging rapidly, with projections indicating that by 2050 one in six people will be aged ≥65 years. As a result, the number of cancer cases in older people is expected to increase significantly. Palliative care is an essential component of cancer care with a direct impact on quality of life. However, older adults with cancer often suffer from multiple comorbidities, cognitive impairment, and frailty, posing unique challenges in the delivery of palliative care. The complex healthcare needs of older patients with cancer therefore require a comprehensive assessment, including a geriatric evaluation. Collaboration between geriatrics and palliative care can offer a solution to the challenges faced by older people with cancer, since this is a population with overlapping concerns for both disciplines. This review highlights the importance of palliative care for older adults with cancer and the benefits of a multidisciplinary approach. It also addresses the coordination of palliative care and geriatrics for specific symptom management and decision making.