scholarly journals How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study

2019 ◽  
Vol 33 (8) ◽  
pp. 1080-1090 ◽  
Author(s):  
Lucas Morin ◽  
Jonas W Wastesson ◽  
Marie-Laure Laroche ◽  
Johan Fastbom ◽  
Kristina Johnell
Keyword(s):  
Older Adults ◽  
Cohort Study ◽  
End Of Life ◽  
Clinical Benefit ◽  
Older Persons ◽  
Death Certificate ◽  
Limited Life Expectancy ◽  
Limited Life ◽  
Antidementia Drugs ◽  
Drug Treatments

Background: The high burden of disease-oriented drugs among older adults with limited life expectancy raises important questions about the potential futility of care. Aim: To describe the use of drugs of questionable clinical benefit during the last 3 months of life of older adults who died from life-limiting conditions. Design: Longitudinal, retrospective cohort study of decedents. Death certificate data were linked to administrative and healthcare registries with national coverage in Sweden. Setting: Older adults (≥75 years) who died from conditions potentially amenable to palliative care between 1 January and 31 December 2015 in Sweden. We identified drugs of questionable clinical benefit from a set of consensus-based criteria. Results: A total of 58,415 decedents were included (mean age, 87.0 years). During their last 3 months of life, they received on average 8.9 different drugs. Overall, 32.0% of older adults continued and 14.0% initiated at least one drug of questionable clinical benefit (e.g. statins, calcium supplements, vitamin D, bisphosphonates, antidementia drugs). These proportions were highest among younger individuals (i.e. aged 75–84 years), among people who died from organ failure and among those with a large number of coexisting chronic conditions. Excluding people who died from acute and potentially unpredictable fatal events had little influence on the results. Conclusion: A substantial share of older persons with life-limiting diseases receive drugs of questionable clinical benefit during their last months of life. Adequate training, guidance and resources are needed to rationalize and deprescribe drug treatments for older adults near the end of life.

scholarly journals End of life care for frail older people; do we have a consensus guideline on deprescribing?

2021 ◽  
Author(s):  
Arjun Poudel ◽  
Shakti Shrestha ◽  
Anna Lukacisinova ◽  
Lisa Nissen
Keyword(s):  
Older Adults ◽  
Life Expectancy ◽  
Older People ◽  
End Of Life ◽  
End Of Life Care ◽  
Life Care ◽  
Frail Older People ◽  
Limited Life Expectancy ◽  
Limited Life ◽  
Medication Appropriateness

Background: Deprescribing interventions have shown to improve medication appropriateness in older people. However, the evidence on the actual benefits and risks of deprescribing in older adults at the end of life are limited. Due to the lack of evidence on the safety and efficacy of medication in these populations, the most appropriate deprescribing approach is unclear. We aimed to conduct a narrative review of research on existing deprescribing guidelines targeted to frail older people at the end of life. Methods: A literature search was conducted in PubMed, Embase, CINAHL and Google Scholar to identify studies from inception to January 2021 on deprescribing guidelines/tools for frail older adults near end-of-life or palliative situation or life-limiting illnesses or limited life expectancy were included. Results: A total of nine studies were included. The deprescribing guidelines used in these studies were helpful to some extent in optimising medications in patients with limited life expectancy and life-limiting illnesses. Some of them have been tested in prospective studies that showed their usefulness in minimising the number of potentially inapproapriate medications. These studies however were not randomised and involved small sample sizes and had little insight into the clinical outcomes of using these tools. Conclusions: The existing tools and guidelines on deprescribing do not represent the end of life care nor address the medication appropriateness among individuals with a specific condition. An explicit and rigorous consensus-based guideline needs to be developed and tested in a well-designed clinical trial to measure clinically significant outcomes

Deprescribing in older people approaching end-of-life: development and validation of STOPPFrail version 2

2020 ◽  
Author(s):  
Denis Curtin ◽  
Paul Gallagher ◽  
Denis O’Mahony
Keyword(s):  
Literature Review ◽  
Older People ◽  
End Of Life ◽  
Older Persons ◽  
Practical Method ◽  
Delphi Consensus ◽  
Limited Life Expectancy ◽  
Limited Life ◽  
Development And Validation ◽  
New Criteria

Abstract Background Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy (STOPPFrail) criteria were developed in 2017 to assist physicians with deprescribing decisions in older people approaching end-of-life. Updating was required to make the tool more practical, patient-centred and complete. Methods a thorough literature review was conducted to, first, devise a practical method for identifying older people who are likely to be approaching end-of-life, and second, reassess and update the existing deprescribing criteria. An eight-member panel with a wide-ranging experience in geriatric pharmacotherapy reviewed a new draft of STOPPFrail and were invited to propose new deprescribing criteria. STOPPFrail version 2 was then validated using Delphi consensus methodology. Results STOPPFrail version 2 emphasises the importance of shared decision-making in the deprescribing process. A new method for identifying older people who are likely to be approaching end-of-life is included along with 25 deprescribing criteria. Guidance relating to the deprescribing of antihypertensive therapies, anti-anginal medications and vitamin D preparations comprises the new criteria. Conclusions STOPPFrail criteria have been updated to assist physicians in efforts to reduce drug-related morbidity and burden for their frailest older patients. Version 2 is based on an up-to-date literature review and consensus validation by a panel of experts.

scholarly journals Choosing Wisely? Measuring the Burden of Medications in Older Adults near the End of Life: Nationwide, Longitudinal Cohort Study

2017 ◽  
Vol 130 (8) ◽  
pp. 927-936.e9 ◽  
Author(s):  
Lucas Morin ◽  
Davide L. Vetrano ◽  
Debora Rizzuto ◽  
Amaia Calderón-Larrañaga ◽  
Johan Fastbom ◽  
...  
Keyword(s):  
Older Adults ◽  
Cohort Study ◽  
End Of Life ◽  
Choosing Wisely ◽  
Longitudinal Cohort Study ◽  
Longitudinal Cohort

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

2019 ◽  
Vol 28 (6) ◽  
pp. 501-508 ◽  
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.

Immunotherapy in Older Adults: A Checkpoint to Palliation?

2019 ◽  
pp. e110-e120 ◽  
Author(s):  
Rawad Elias ◽  
Oreofe Odejide
Keyword(s):  
Older Adults ◽  
Older Adult ◽  
Advanced Disease ◽  
Checkpoint Inhibitor ◽  
Checkpoint Inhibitors ◽  
Treatment Options ◽  
Limited Life Expectancy ◽  
Goals Of Care ◽  
Limited Life ◽  
Checkpoint Inhibitor Therapy

The excitement about immunotherapy is justified. Patients with advanced disease and limited life expectancy before immune checkpoint inhibitors are now having prolonged and sometimes complete responses to treatment; however, most patients do not respond to checkpoint inhibitors. The hope for a meaningful response with only a limited risk of high-grade toxicity generated a prognostic dilemma for patients with advanced cancers and their treating oncologists. Older adults with advanced cancers are at the intersection of multiple biologic and clinical factors that can influence the efficacy of immunotherapy. Treating physicians should take all of these elements into account when considering treatment options for an older adult with advanced disease. Oncologists should have an honest conversation with their patients regarding the uncertainty around the clinical profile of checkpoint inhibitors. Early high-quality goals of care discussions can help manage expectations of older adults with advanced cancer treated with immunotherapy. We review in this paper select clinical characteristics that are important to consider when evaluating an older adult for checkpoint inhibitor therapy. In addition, we discuss strategies to optimize goals of care discussion given the increasing complexity of prognostication in the immunotherapy era.

scholarly journals 065STOPPFRAIL (SCREENING TOOL OF OLDER PERSONS PRESCRIPTIONS IN FRAIL ADULTS WITH LIMITED LIFE EXPECTANCY): CONSENSUS VALIDATION

2016 ◽  
Vol 45 (suppl 2) ◽  
pp. ii1.10-ii12 ◽  
Author(s):  
Amanda Lavan ◽  
Paul Gallagher ◽  
Carole Parsons ◽  
Denis O'Mahony
Keyword(s):  
Life Expectancy ◽  
Older Persons ◽  
Screening Tool ◽  
Limited Life Expectancy ◽  
Limited Life

scholarly journals The ‘Surprise question’ in heart failure: a prospective cohort study

2021 ◽  
pp. bmjspcare-2021-003143
Author(s):  
Valentina Gonzalez-Jaramillo ◽  
Luisa Fernanda Arenas Ochoa ◽  
Clara Saldarriaga ◽  
Alicia Krikorian ◽  
John Jairo Vargas ◽  
...  
Keyword(s):  
Heart Failure ◽  
Cohort Study ◽  
Life Expectancy ◽  
Ejection Fraction ◽  
Prospective Cohort Study ◽  
Prospective Cohort ◽  
Left Ventricular Ejection ◽  
Limited Life Expectancy ◽  
Limited Life ◽  
Surprise Question

ObjectiveThe Surprise Question (SQ) is a prognostic screening tool used to identify patients with limited life expectancy. We assessed the SQ’s performance predicting 1-year mortality among patients in ambulatory heart failure (HF) clinics. We determined that the SQ’s performance changes according to sex and other demographic (age) and clinical characteristics, mainly left ventricular ejection fraction (LVEF) and the New York Heart Association (NYHA) functional classifications.MethodsWe conducted a prospective cohort study in two HF clinics. To assess the performance of the SQ in predicting 1-year mortality, we calculated the sensitivity, specificity, positive and negative likelihood ratios, and the positive and negative predictive values. To illustrate if the results of the SQ changes the probability that a patient dies within 1 year, we created Fagan’s nomograms. We report the results from the overall sample and for subgroups according to sex, age, LVEF and NYHA functional class.ResultsWe observed that the SQ showed a sensitivity of 85% identifying ambulatory patients with HF who are in the last year of life. We determined that the SQ’s performance predicting 1-year mortality was similar among women and men. The SQ performed better for patients aged under 70 years, for patients with reduced or mildly reduced ejection fraction, and for patients NYHA class III/IV.ConclusionsWe consider the tool an easy and fast first step to identify patients with HF who might benefit from an advance care planning discussion or a referral to palliative care due to limited life expectancy.

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