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

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.

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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.

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Symptom burden, health-related quality of life, and treatment preference over time as reported by patients with metastatic colorectal cancer (mCRC).

Journal of Clinical Oncology ◽

10.1200/jco.2015.33.29_suppl.82 ◽

2015 ◽

Vol 33 (29_suppl) ◽

pp. 82-82

Author(s):

Amy Little Jones ◽

Nrupen Anjan Bhavsar ◽

Amy Pickar Abernethy ◽

Yousuf Zafar

Keyword(s):

Quality Of Life ◽

Pilot Study ◽

Life Expectancy ◽

Symptom Burden ◽

Treatment Preference ◽

Change Over Time ◽

Limited Life Expectancy ◽

Limited Life ◽

Over Time

82 Background: Clinicians have difficulty predicting longitudinal changes in patient symptom burden and quality of life, and then how those changes might affect treatment preference. The primary aim of this pilot study was to investigate how self-reported symptom burden, quality of life, and treatment preference change over time in mCRC patients with limited life expectancy. Methods: Eligible mCRC patients had incurable disease, received chemotherapy at Duke or Duke Raleigh, were > = 18 years old, and spoke English. Patients were surveyed at each clinic visit and followed for up to 3.8 years on study. Measures included FACT-C (Functional Assessment of Cancer Therapy-Colorectal), PCM (Patient Care Monitor; a validated, 87-item review of systems survey; items measured on a 0-10 scale), and QQQ (Quality-Quantity Questionnaire; a validated, 8-item measure of cancer patient preference for quantity vs. quality of life; items measured on a 1-5 Likert scale). Demographic, disease, and treatment data were abstracted from the medical record. Results: The 56 patients were primarily male (68%) and Caucasian (79%) with a mean age of 55 at diagnosis of metastatic disease. Patients answered surveys a mean of 6.8 times each, with a median 364 days between first and last surveys. Over time, patients reported most symptoms improved or stayed the same (72%, n = 63 symptoms). Mean symptom scores that improved the most from first to last survey were fatigue (3.92 to 3.03) and nausea (2.1 to 1.4), while pain (1.9 to 2.5) and cough (0.4 to 0.7) worsened the most. Decision making about treatment preference also did not change over time, with mean QQQ scores from first survey (22, n = 28) to last survey (22, n = 16) remaining stable. Mean QQQ length and quality scores likewise were unchanged (12.9 to 12.8; 12.4 to 12.2 respectively). Conclusions: In this pilot study of mCRC patients with limited life expectancy, reported symptom burden scores remained stable or modestly improved over time, while preferences for quality vs. quantity of life remained stable. These findings suggest that patients with advanced cancer might perceive symptom burden differently over the course of their treatment.

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Physicians' Opinions on Anticoagulant Therapy in Patients with a Limited Life Expectancy

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0041-1725115 ◽

2021 ◽

Author(s):

Bregje A.A. Huisman ◽

Eric C.T. Geijteman ◽

Nathalie Kolf ◽

Marianne K. Dees ◽

Lia van Zuylen ◽

...

Keyword(s):

Quality Of Life ◽

Decision Making ◽

Life Expectancy ◽

End Of Life ◽

Bleeding Complications ◽

Mixed Method Research ◽

Limited Life Expectancy ◽

Limited Life ◽

Increased Risk

AbstractPatients with a limited life expectancy have an increased risk of thromboembolic and bleeding complications. Anticoagulants are often continued until death, independent of their original indication. We aimed to identify the opinions of physicians about the use of anticoagulants at the end of life. A mixed-method research design was used. A secondary analysis was performed on data from a vignette study and an interview study. Participants included general practitioners and clinical specialists. Physicians varied in their opinions: some would continue and others would stop anticoagulants at the end of life because of the risk of thromboembolic or bleeding complications. The improvement or preservation of patients' quality of life was a reason for both stopping and continuing anticoagulants. Other factors considered in the decision-making were the types of anticoagulant, the indication for which the anticoagulant was prescribed, underlying diseases, and the condition and life expectancy of the patient. Factors that made decision-making difficult were the lack of evidence on either strategy, uncertainty about patients' life expectancy, and the fear of harming patients. Which decision was eventually made seems largely dependent on the choice of the patient. In conclusion, there is a substantial variation in physicians' opinions regarding the use of anticoagulants in patients with a limited life expectancy. Physicians agree that the primary goal of medical care at end of life is the improvement or preservation of patients' quality of life. An important barrier to decision-making is the lack of evidence about the risks and benefits of stopping anticoagulants.

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EVALUATION OF QUALITY OF LIFE IN PATIENTS TREATED FOR METASTATIC DISEASE OF THE PROXIMAL FEMUR

Acta Ortopédica Brasileira ◽

10.1590/1413-785220182604191223 ◽

2018 ◽

Vol 26 (4) ◽

pp. 248-251

Author(s):

Marcos Hajime Tanaka ◽

Marcello Martins de Souza ◽

Daniel Luiz Ceroni Gibson ◽

Monica Paschoal Nogueira

Keyword(s):

Quality Of Life ◽

Life Expectancy ◽

Proximal Femur ◽

Lower Limbs ◽

Bone Lesions ◽

Limited Life Expectancy ◽

Limited Life ◽

Toronto Extremity Salvage Score ◽

Significant Difference

ABSTRACT Objective: Patients with metastatic bone lesions have a limited life expectancy. These metastatic lesions compromise the proximal femur, and fractures are quite common. The survival of these patients depends on the behavior of the primary tumor. The aim of this study was to evaluate the quality of life of patients with extensive metastatic lesion of the proximal femur with pathological or imminent fracture, treated with non-conventional endoprosthesis. Methods: From May 2008 to August 2012, twenty-five (25) patients with bone metastases of the proximal femur, with pathological or imminent fracture were recruited into this study. These patients had survived for at least six weeks after surgery and the TESS questionnaire (Toronto Extremity Salvage Score) was administered. Results: The final score of the TESS was an average of 57 points (SD 23.78 points). There was no significant difference in TESS values considering: sex, presence of fracture, or site of the bone lesion. Conclusion: The TESS questionnaire provides information about the function and quality of life of patients with malignant tumors of the lower limbs, from the patient's perspective. The results can be considered positive, when compared to the limited life expectancy and complexity of this group of patients. Level of evidence III, Therapeutic studies, retrospective comparative study.

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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.

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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

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Eating Patterns and Physical Activity in Older Adults Carpio Córdoba, Spain and Guadalajara Jalisco, Mexico

Current Research in Nutrition and Food Science Journal ◽

10.12944/crnfsj.2.3.12 ◽

2014 ◽

Vol 2 (3) ◽

pp. 182-195

Author(s):

Padilla Leticia ◽

Ruvalcaba Carlos

Keyword(s):

Quality Of Life ◽

Physical Activity ◽

Older Adults ◽

Life Expectancy ◽

Eating Patterns ◽

Cross Sectional ◽

Feeding Programs ◽

Life Expectancy At Birth ◽

Process Component

Aging is a complex phenomenon and obvious, old age in Mexico is compared to disability, vulnerability, complexity and discrimination in our country's life expectancy is not very long compared to other countries. "Diet is the most important to delay or accelerate the aging process component." Aim. Determine differences in eating patterns and physical activity in older adults in El Carpio Córdoba, Spain and Guadalajara Jalisco, Mexico. Methods. A descriptive, cross-sectional comparative study in 156 elderly residents of El Carpio Córdoba Spain and Guadalajara Jalisco Mexico 156 was performed. Results. The results suggest that differences in life expectancy at birth, feeding, toxic habits and sporting aspects. The differences in patterns of diet and physical activity detected in this study in adults over. Conclusion. The Carpio Córdoba, Spain and Guadalajara Jalisco, Mexico could have transcendent meaning in the movement of life expectancy at birth, it represents in Mexico a possibility for feeding programs and physical activity for older people in order to support them in style and quality of life when young people built a legacy of experience and deserve to live longer and with better quality of life. In Spain Carpio live longer, have a higher consumption of toxic habits and do more sports activities in Guadalajara Mexico.

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The role of VES-13 to identify limited life expectancy in older adults in primary healthcare settings

Revista da Escola de Enfermagem da USP ◽

10.1590/s1980-220x2020003603743 ◽

2021 ◽

Vol 55 ◽

Author(s):

Danilo Lopes Assis ◽

Virgínia Oliveira Chagas ◽

Helton Saulo ◽

Claudia Kimie Suemoto ◽

Alfredo Nicodemos Cruz Santana

Keyword(s):

Older Adults ◽

Life Expectancy ◽

Primary Healthcare ◽

Multiple Logistic Regression Analysis ◽

Cross Sectional ◽

Limited Life Expectancy ◽

Healthcare Settings ◽

Limited Life ◽

The Mean

ABSTRACT Objective To investigate the potential role of the Vulnerable Elders Survey to identify older adults with limited life expectancy in primary healthcare settings. Method This cross-sectional study was performed in all (nine) healthcare units in Jatai, Goiás (Brazil) from July to December 2018. A sample size of 407 older adults was obtained considering an older population (≥ 60 years old). Participants answered a questionnaire about sociodemographic and clinical characteristics, including the Vulnerable Elders Survey and the Suemoto index. We tested the association between limited life expectancy and the Vulnerable Elders Survey using multiple logistic regression analysis. Results The mean age was 68.9 ± 6.6 yo, and 58.0% were women. The mean score of the Vulnerable Elders Survey was 2.0 ± 2.2, the mean score of Suemoto index was 31.5 ± 21.1%, and 17.2% had limited life expectancy. The Vulnerable Elders Survey was associated with limited life expectancy (OR = 1.57; p = < 0.0001). Conclusion The Vulnerable Elders Survey was able to identify older adults with limited life expectancy in primary healthcare settings and can play a role in detecting older adults who would not benefit from screening and strict control of chronic diseases.

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