Scale may help ‘quickly identify’ high-risk medications for older adults with blood cancer
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Key takeaways:
- Multiple high-risk medications may increase the likelihood of falls among older adults with blood cancers.
- The GO-PIMs scale identifies medications of concern in older adults with blood cancers.
- Researchers emphasized the need to consider deprescribing high-risk medications in this patient population.
Gerontology researchers and hematologic oncology investigators from Brigham and Women’s Hospital and Dana-Farber Cancer Institute have devised a scale for assessing high-risk medications in older patients with blood cancers.
The investigators also evaluated the association between polypharmacy in older adults with blood cancers and frailty.
“We know that reviewing and adjusting medications can be challenging for busy clinicians and they may also feel they lack expertise to do this effectively,” co-lead author Tammy T. Hshieh, MD, MPH, associate physician at Dana-Farber Cancer Institute and Brigham Cancer Center, as well as instructor in medicine at Harvard Medical School, told Healio. “We hope our geriatric oncology-potentially inappropriate medications [GO-PIMs] scale will help clinicians collaborate with their patients to quickly identify and deprescribe medications that are most potentially inappropriate based on the NCCN Clinical Practice Guidelines for Older Adult Oncology.”
Hshieh and co-lead author Clark DuMontier, MD, MPH, instructor in medicine at Harvard Medical School and Brigham and Women's Hospital, spoke with Healio about the findings of their study, published in JNCCN — Journal of the National Comprehensive Cancer Network, and their NCCN guidelines-based scale for assessing PIMs and predicting frailty in older patients with blood cancer.
Healio: How might polypharmacy and PIMs make adhering to blood cancer treatment more difficult for older adults?
DuMontier: Many older patients with blood cancers take too many medications and/or PIMs in addition to their prescribed cancer treatments. Evaluating the association of polypharmacy and PIMs with frailty is important because these medications may be contributing to frailty. Multiple high-risk medications may by themselves or together with cancer treatments put a frail older patient at high risk for falls, toxicity or other adverse events. Any of these events will make adhering to blood cancer treatments more difficult. The need to find efficient and effective ways for hematologic oncologists to identify these medications motivated this research.
Healio: How did you conduct this study?
DuMontier: There are many ways to define polypharmacy and PIMs, and we set out to test some of these definitions and determine their association with frailty and cognitive impairment in older patients with blood cancers. We follow one of the largest groups of older patients with leukemia, lymphoma and multiple myeloma, in whom we have rigorously measured both frailty and cognition. We extracted from their medical charts all chronic medications documented in the initial consult with their oncologist at our cancer center. We then applied different ways of measuring whether these lists of chronic medications were associated with the likelihood of being frail or cognitively impaired. We used existing cutoffs to define polypharmacy, the most common being five or more medications, and an existing PIM scale called the Anticholinergic Risk Scale. We also developed a new scale from the NCCN guidelines list of medications of concern in older adults with cancer, naming it the GO-PIMs scale.
Healio: What did you find?
DuMontier: Polypharmacy and PIMs are prevalent in older adults with blood cancers and strongly associated with frailty, independently of patient comorbidity. Steroids, benzodiazepines and antidepressants (selective serotonin reuptake inhibitors, or SSRIs) were the most prevalent PIMs. We found that the GO-PIMs scale carried the strongest association with frailty, whereas the commonly used polypharmacy cutoff of five or greater total medications carried no association. These findings suggest that evaluating the specific types of medications an older patient is taking is more important than measuring the sheer number of medications. The GO-PIMs scale can help hematologists identify these high-risk medications, and the NCCN Guidelines for Older Adult Oncology provide expert and evidenced-based recommendations on finding alternative options or deprescribing them.
Healio: How might clinicians go about deciding which medications could safely be discontinued?
Hshieh: We highlight the importance of reviewing the medication lists for all older adults with blood cancers, given that these medications can increase frailty risk. Also, deprescribing high-risk medications in this population may be a high yield in improving patient health.
Healio: Is personalized medication monitoring and reconciliation needed for older patients?
Hshieh: Perhaps for certain older patients who are already frail and/or have complex medical history, it would be helpful to have a clinician on the oncology treatment team monitoring their medications, reconciling any drug interactions and being on the lookout for PIMs.
Healio: What do you have planned next in terms of research into this topic?
Hshieh: We hope that future work will be an intervention, maybe using our GO-PIMs scale to deprescribe medications and improve overall health and care for these older adults with blood cancers. We feel that older patients are increasingly proactive about their care, so future research might examine ways patients can partner with their clinicians in managing their medications in a positive way.
We were surprised that polypharmacy and PIMs were not associated with cognitive impairment. We think this means that cognitive dysfunction among older patients with cancer is complex and multifactorial. Thus, future research is needed to better understand the pathophysiology of cognitive dysfunction, and we need to use multidisciplinary approaches to tackle this problem.
For more information :
Clark DuMontier, MD, MPH, can be reached at cdumontier@bwh.harvard.edu.
Tammy T, Hshieh, MD, MPH, can be reached at tshieh@partners.org.
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