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Polypharmacy increases significantly during end of life
Older patients are often prescribed potentially futile drugs during their last 12 months of life, thus clinical guidelines are needed to aid physicians in deciding to continue or discontinue medications near the end of life, according to findings published in The American Journal of Medicine.
“Under the combined effect of increased longevity, chronic multimorbidity, and single-disease clinical guidelines, the concomitant use of multiple medications has become commonplace among older adults,” Lucas Morin, MS, from the Aging Research Center at Karolinska Institutet in Sweden, and colleagues wrote. “Polypharmacy increases inappropriate drug use and drug-drug interactions and exposes older adults to serious adverse effects.”
Morin and colleagues measured the burden of medications in older adults during their last months of life. They used the Swedish Prescribed Drug Register to identify 511,843 patients aged older than 65 years who died in Sweden between 2007 and 2013. For each of the patients’ last 12 months of life, the researchers reconstructed their drug prescription history. They also evaluated participants’ characteristics at time of death via record linkage with the National Patient Register, the Social Services Register and the Swedish Education Register. Over-the-counter drugs were not included in the study, the researchers noted.
They found that over the course of a patient’s final year of life, the rate of exposure to or more different drugs increased from 30.3% to 47.2%. The largest increase in the number of drugs prescribed was seen in older adults who died from cancer (mean difference, 3.37; 95% CI, 3.35-3.4). Compared with patients living in a community, those living in an institution received a greater number of medications; however, the number of drugs rose slower for these patients.
The five most commonly used drug classes during the final month before death included analgesics (60.8%), antithrombotic agents (53.8%), diuretics (53.1%), psycholeptics (51.2%) and beta-blocking agents (41.1%). A total of 21.3% and 15.8% of all patients used angiotensin-converting enzyme inhibitors and statins, respectively, during their final month of life.
These findings indicate that polypharmacy near the end of life is driven by preventive treatment and disease targeting in addition to symptom management, according to the researchers.
“The clinical benefit of treatment drugs aiming at preventing cardiovascular diseases during the final month of life is at the very least questionable,” Morin and colleagues concluded.
“To reduce the burden of medications of questionable benefit in older adults with life-limiting illness, robust evidence about the benefit and safety of deprescribing is needed ... Future clinical trials should be conducted to evaluate the effects of withdrawing preventive medications in people with advanced illness,” they added. “These findings should then be embedded into clinical guidelines ... However, because end-of-life situations are shaped by different disease trajectories, symptoms, and personal preferences, the goals of care vary considerably from one person to another. Future clinical practice guidelines should thus foster personalized decision making rather than promote the systematic discontinuation of medications according to a one-size-fits-all set of criteria.” – by Alaina Tedesco
Disclosure: The researchers report receiving support from the Swedish Research Council for Health, Working Life and Welfare.
Perspective
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The article by Morin et al serves as a reminder to primary care physicians of the importance of recognizing the limitations of therapeutic interventions for older patients who are approaching the end of life. The prevalence of advanced chronic diseases that are incurable in older adults, such as dementia, metastatic cancer, congestive heart failure, COPD and end-stage renal disease, is growing and “curative” therapies are often burdensome to these patients while adding to the stress of caregiving by family members. Preventative therapies, such as statins, bisphosphonates or antihypertensive agents, prescribed to asymptomatic patients with advanced illnesses offer little comfort but add burden to their lives. “Less is more” when medications with limited benefits but potential harms are no longer prescribed. “Deprescribing” of medications becomes the norm to prevent overtreatment of chronic conditions and to reduce the number and the risk of medications in the vulnerable older patient. As the disease progresses and bothersome symptoms become harder to control with usual treatments, the conversation with the patient shifts from cure to palliation, from polypharmacy to comfort measures only. Shared decision-making between patient and physician is the driver of that conversation. For the patients with advanced illnesses, a review of their medication lists each visit can identify those medications to be discontinued without harm. In limiting burdensome treatments, both patients and their families will be grateful.