Deprescribing tool for use in older Australians with life-limiting illnesses and limited life expectancy: a modified-Delphi study protocol

BackgroundMaking a meaningful decision on deprescribing of potentially inappropriate medications in older adults with life-limiting illnesses (LLIs) and limited life expectancy (LLE) is often challenging. Therefore, we aimed to elicit opinion and gain consensus on a deprescribing tool for use in this population.Methods and analysisA modified-Delphi method will be used to obtain a consensus from a panel of experts in geriatric therapeutics on a deprescribing tool for use in people aged ≥65 years with LLIs and LLE. Through an online survey, in the initial round, the panel will anonymously elicit their opinion on a series of items related to the conceptual model of the deprescribing tool, its practicality and deprescribing of medications, while on the controlled feedback in subsequent rounds till a consensus is reached or the panellists stop revising their answers. In each round, panel members will be using a 5-point Likert scale to rate their agreement with the statement. Consensus will be considered on ≥75% of agreement on the statements.Ethics and disseminationAll the participants will receive an invitation and participant information but they need to consent for the participation. Ethics approval has been granted from the University of Queensland Health and Behavioural Sciences, Low and Negligible Risk Ethics Sub-Committee (reference: 2020001069). The results of this project will be disseminated through conferences and a peer-reviewed clinical journal.

Download Full-text

052Prevalence of Potentially Inappropriate Medications (PIMs) According to STOPPFrail in an Older Frailer Cohort with Limited Life Expectancy

Age and Ageing ◽

10.1093/ageing/afx145.9 ◽

2017 ◽

Vol 46 (Suppl_3) ◽

pp. iii1-iii12 ◽

Cited By ~ 2

Author(s):

Amanda Lavan ◽

Paul Gallagher ◽

Denis O’Mahony

Keyword(s):

Life Expectancy ◽

Potentially Inappropriate Medications ◽

Limited Life Expectancy ◽

Limited Life ◽

Inappropriate Medications

Download Full-text

Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life

Current Epidemiology Reports ◽

10.1007/s40471-021-00264-7 ◽

2021 ◽

Author(s):

Jennifer Tjia ◽

Jennifer L. Lund ◽

Deborah S. Mack ◽

Attah Mbrah ◽

Yiyang Yuan ◽

...

Keyword(s):

Life Expectancy ◽

End Of Life ◽

Epidemiologic Studies ◽

Potentially Inappropriate Medications ◽

Limited Life Expectancy ◽

Patient Goals ◽

Limited Life ◽

Medication Dose ◽

Selection Of

Abstract Purpose of Review To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL). Recent Findings We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators. Summary EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind.

Download Full-text

Deprescribing in Older Adults With Cancer and Limited Life Expectancy: An Integrative Review

American Journal of Hospice and Palliative Medicine® ◽

10.1177/10499091211003078 ◽

2021 ◽

pp. 104990912110030

Author(s):

Edwin J. Brokaar ◽

Frederiek van den Bos ◽

Loes E. Visser ◽

Johanneke E. A. Portielje

Keyword(s):

Quality Of Life ◽

Older Adults ◽

Life Expectancy ◽

Antihypertensive Drugs ◽

Lipid Lowering ◽

Potentially Inappropriate Medications ◽

Limited Life Expectancy ◽

Limited Life ◽

Preventive Medication

Polypharmacy is common in older adults with cancer and deprescribing potentially inappropriate medications becomes very relevant when life expectancy decreases due to metastatic disease. Especially preventive medications may no longer be beneficial, because they may decrease quality of life and reduction in morbidity and mortality may be futile. Although deprescribing of preventive medication is common in the last period of life, it is still unusual during active cancer treatment for advanced disease, although life expectancy is often limited to less than 1 to 2 years in that stage. We performed a systematic search of the literature in Pubmed and Embase on the discontinuation of commonly utilized groups of preventive medication and evaluated the evidence of potential benefits and harms in patients aged 65 years or older with cancer and a limited life expectancy (LLE). From 21 included studies, it can be concluded that deprescribing lipid lowering drugs, antihypertensive drugs, osteoporosis drugs and antihyperglycemic drugs is feasible in a considerable part of patients with a LLE. Discontinuation may be performed safely, without the occurrence of serious adverse events or decrease of survival. The only study that addressed quality of life after deprescribing showed that discontinuation of statins improves quality of life in patients with a LLE. Recurrence of symptoms requiring reintroduction occurred in 0-13% of patients on antihyperglycemic treatment and 8-60% of patients using antihypertensive drugs. In order to reduce pill burden and futile treatment clinicians should discuss deprescribing of preventive medication with older patients with advanced cancer and a LLE.

Download Full-text

Perceptions and Attitudes at End of Life in Georgia: The Similarities Regardless of the Causes of Limited Life Expectancy - Cancer or Advanced Age

10.26226/morressier.5c76c8b7e2ea5a7237612341 ◽

2019 ◽

Author(s):

Dimitri Kordzaia

Keyword(s):

Life Expectancy ◽

End Of Life ◽

Advanced Age ◽

Limited Life Expectancy ◽

Perceptions And Attitudes ◽

Limited Life

Download Full-text

Who Orders Screening Mammograms in Older Women with Limited Life Expectancy?

Journal of General Internal Medicine ◽

10.1007/s11606-019-05044-0 ◽

2019 ◽

Vol 34 (12) ◽

pp. 2720-2722 ◽

Cited By ~ 1

Author(s):

Nancy L. Schoenborn ◽

Jin Huang ◽

Cynthia M. Boyd ◽

Sarah Nowak ◽

Craig E. Pollack

Keyword(s):

Life Expectancy ◽

Older Women ◽

Limited Life Expectancy ◽

Limited Life ◽

Screening Mammograms

Download Full-text

Drugs and prescribing in the older patient

Oxford Textbook of Medicine ◽

10.1093/med/9780198746690.003.0058 ◽

2020 ◽

pp. 571-578

Author(s):

Miles Witham ◽

Jacob George ◽

Denis O’Mahony

Keyword(s):

Side Effects ◽

Life Expectancy ◽

Drug Metabolism ◽

Older People ◽

Drug Interactions ◽

Central Component ◽

Pharmacological Agents ◽

Limited Life Expectancy ◽

Limited Life ◽

Great Harm

The use of pharmacological agents is often a central component of medical therapy for older people. Medications can relieve symptoms, improve function, and prevent illness, but they also have the capacity to inflict great harm. Older people are at particular risk of such harms as a result of impaired homeostatic reserve, of altered drug metabolism, the presence of multimorbidity and consequent polypharmacy, which increases both exposure to potentially harmful agents and the chance of drug–drug interactions. The therapeutic priorities for older, frail people may differ when compared to younger, robust patients; limited life expectancy means that attempts to prolong life may become relatively less important than the relief of symptoms and avoidance of side effects and medication burden.

Download Full-text

Need for Deprescribing in Hospital Elderly Patients Discharged with a Limited Life Expectancy: The REPOSI Study

Medical Principles and Practice ◽

10.1159/000499692 ◽

2019 ◽

Vol 28 (6) ◽

pp. 501-508 ◽

Cited By ~ 2

Author(s):

Luca Pasina ◽

Barbara Brignolo Ottolini ◽

Laura Cortesi ◽

Mauro Tettamanti ◽

Carlotta Franchi ◽

...

Keyword(s):

Internal Medicine ◽

Life Expectancy ◽

Elderly Patients ◽

End Of Life ◽

Drug Prescription ◽

Inappropriate Medication ◽

Lipid Lowering ◽

Limited Life Expectancy ◽

Limited Life ◽

Preventive Medication

Objective: Older people approaching the end of life are at a high risk for adverse drug reactions. Approaching the end of life should change the therapeutic aims, triggering a reduction in the number of drugs.The main aim of this study is to describe the preventive and symptomatic drug treatments prescribed to patients discharged with a limited life expectancy from internal medicine and geriatric wards. The secondary aim was to describe the potentially severe drug-drug interactions (DDI). Materials and Methods: We analyzed Registry of Polytherapies Societa Italiana di Medicina Interna (REPOSI), a network of internal medicine and geriatric wards, to describe the drug therapy of patients discharged with a limited life expectancy. Results: The study sample comprised 55 patients discharged with a limited life expectancy. Patients with at least 1 preventive medication that could be considered for deprescription at the end of life were significantly fewer from admission to discharge (n = 30; 54.5% vs. n = 21; 38.2%; p = 0.02). Angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, lipid-lowering drugs, and clonidine were the most frequent potentially avoidable medications prescribed at discharge, followed by xanthine oxidase inhibitors and drugs to prevent fractures. Thirty-seven (67.3%) patients were also exposed to at least 1 potentially severe DDI at discharge. Conclusion: Hospital discharge is associated with a small reduction in the use of commonly prescribed preventive medications in patients discharged with a limited life expectancy. Cardiovascular drugs are the most frequent potentially avoidable preventive medications. A consensus framework or shared criteria for potentially inappropriate medication in elderly patients with limited life expectancy could be useful to further improve drug prescription.

Download Full-text

Identifying and prioritising systematic review topics with public health stakeholders: A protocol for a modified Delphi study in Switzerland to inform future research agendas

BMJ Open ◽

10.1136/bmjopen-2016-015500 ◽

2017 ◽

Vol 7 (8) ◽

pp. e015500 ◽

Cited By ~ 2

Author(s):

Dyon Hoekstra ◽

Margot Mütsch ◽

Christina Kien ◽

Ansgar Gerhardus ◽

Stefan K Lhachimi

Keyword(s):

Public Health ◽

Systematic Review ◽

Priority Setting ◽

Delphi Study ◽

Future Research ◽

Review Author ◽

Modified Delphi ◽

Delphi Round ◽

A Priority ◽

The University

IntroductionThe Cochrane Collaboration aims to produce relevant and top priority evidence that responds to existing evidence gaps. Hence, research priority setting (RPS) is important to identify which potential research gaps are deemed most important. Moreover, RPS supports future health research to conform both health and health evidence needs. However, studies that are prioritising systematic review topics in public health are surprisingly rare. Therefore, to inform the research agenda of Cochrane Public Health Europe (CPHE), we introduce the protocol of a priority setting study on systematic review topics in several European countries, which is conceptualised as pilot.Methods and analysisWe will conduct a two-round modified Delphi study in Switzerland, incorporating an anonymous web-based questionnaire, to assess which topics should be prioritised for systematic reviews in public health. In the first Delphi round public health stakeholders will suggest relevant assessment criteria and potential priority topics. In the second Delphi round the participants indicate their (dis)agreement to the aggregated results of the first round and rate the potential review topics with the predetermined criteria on a four-point Likert scale. As we invite a wide variety of stakeholders we will compare the results between the different stakeholder groups.Ethics and disseminationWe have received ethical approval from the ethical board of the University of Bremen, Germany (principal investigation is conducted at the University of Bremen) and a certificate of non-objection from the Canton of Zurich, Switzerland (fieldwork will be conducted in Switzerland). The results of this study will be further disseminated through peer reviewed publication and will support systematic review author groups (i.a. CPHE) to improve the relevance of the groups´ future review work. Finally, the proposed priority setting study can be used as a framework by other systematic review groups when conducting a priority setting study in a different context.

Download Full-text