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Geriatric patients with cancer at risk for potentially inappropriate medication use
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The prevalence of polypharmacy, excessive polypharmacy and potentially inappropriate medicine use was high among senior patients with cancers, according to results of a pharmacist-led comprehensive medication assessment.
“Older adults with cancer are particularly prone to medication errors attributed to medication changes, complex regimens and incomplete information handoff between providers,” Ginah Nightingale, PharmD, BCOP, assistant professor in the department of pharmacy practice of the Jefferson School of Pharmacy at Thomas Jefferson University, and colleagues wrote. “Polypharmacy and potentially inappropriate medication use warrant substantial interest and concern on behalf of medical oncologists and oncology health providers because of the perils associated with their use in this vulnerable population.”
Existing studies on polypharmacy and potentially inappropriate medication use in geriatric populations were limited by patient self-reporting and medical record extraction, according to study background.
Nightingale and colleagues evaluated data from 234 geriatric patients with cancer (any stage or type). The mean age of the population was 80 years, 64% were women and 74% were white.
Eighty-seven percent of the participants had solid tumors — most of which were advanced stage or metastatic disease — and 13% of participants had hematologic malignancies.
The researchers collected data through a geriatric oncology assessment conducted between January 2011 and June 2013. Patients were instructed to bring all medications (including prescription, nonprescription, herbals and supplements) to pharmacist-led sessions. Pharmacists assessed each medication along with the patient or caregiver to ascertain possession and/or self-administration, indication and adverse events. Additionally, pharmacists assessed the patients’ abilities to read medication label directions and to manage medication in an efficient manner.
Polypharmacy was defined as the concurrent use of five to 10 medications, and excessive polypharmacy was defined as the concurrent use of 10 or more medications. Researchers used the 2012 Beers criteria, the Screening Tool of Older Person’s Prescription (STOPP) criteria and the Healthcare Effectiveness Data and Information Set (HEDIS) criteria to determine potentially inappropriate medication usage.
Overall, the patients used 2,163 medications, 1,430 of which were prescriptions. Patients each used a mean of 9.23 (standard deviation [SD], 4.79; range, 1-30) medications.
The most commonly reported prescription medicines were drugs that act on the cardiovascular system (77%), dyslipidemics (53%), gastrointestinal medications (41%), diuretics (40%) and endocrine-related medications (37%).
Polypharmacy occurred in 41% of patients and excessive polypharmacy occurred in 43%.
The prevalence of potentially inappropriate medication use was roughly equal using Beers (40%; n = 94) and STOPP (38%; n = 88) criteria but slightly lower (21%; n = 49) using the HEDIS criteria. The mean number of inappropriate medications used was 0.74 (SD = 0.89; range, 0-4). The most frequently misused medications were benzodiazepines (16%), gastrointestinal medications (9.4%), NSAIDs (8.5%), antiplatelet medications (8%) and first-generation antihistamines (6%).
Potentially inappropriate medication use was more likely among patients whose medication use fit the criteria for polypharmacy (P < .001) and patients with an increased number of comorbidities (P = .005). Comorbidities significantly associated with potentially inappropriate medication use were cardiovascular (P = .014), gastrointestinal (P = .013), neurologic (P = .02) and psychiatric (P < .001) conditions.
The researchers said follow-up to these findings will be important because medication frequently changes among geriatric populations, and patient outcomes associated with excessive and inappropriate medication use were not determined.
“Because of the minimal overlap between 2012 Beers and STOPP criteria, a modified potential inappropriate medication use tool that integrates 2012 Beers and STOPP criteria and considers cancer diagnosis, prognosis and cancer-related therapy is needed to identify and minimize potentially inappropriate medication use,” Nightingale and colleagues concluded. “Additional follow-up studies are needed to longitudinally evaluate medication use to identify associations with increased risk of adverse events that compromise cancer management plans and worsen patient outcomes in this complex and vulnerable population.”
The growing geriatric population has made understanding effective drug management one of the most important elements for front-line oncologists, Stuart M. Lichtman, MD, FACP, of Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, wrote in an accompanying editorial.
“All adult oncologists are now geriatric oncologists,” Lichtman wrote. “This is no longer a niche field with only a few dedicated researchers. The demographic shift brought on by the baby boomer generation has already happened and is creating a rapid increase in the population of adults older than 65 years of age. … This demographic change and aging as an established risk factor for the development of cancer will result in a marked increase in the number of older patients with cancer.”
Overall, these results indicate an analysis of current medication is an important component of the geriatric assessment in patients with cancer, Lichtman wrote.
“Evaluating polypharmacy by using one of the accepted guidelines is one way clinicians can begin to feel comfortable with geriatric evaluation and make a tangible impact on patient care,” Lichtman wrote. “By reducing unnecessary medications, an evaluation can help optimize drug therapy, reduce costs, increase compliance and reduce adverse drug events and toxicity. … Clinicians should not fear the words ‘geriatric assessment.’ The dramatic increase in the number of older patients with cancer makes the incorporation of a geriatric-specific evaluation a requirement for providing high-quality, safe and cost-effective cancer care.” – by Cameron Kelsall
Disclosures: Nightingale reports no relevant financial disclosure. One researcher reports honoraria and travel expenses from Kaplan Medical and Prime Therapeutics. Lichtman reports consultant/advisory and speakers bureau roles with and honoraria from Magellan Health and PleXus Communications.
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