Excellent article that addresses what I frequently encounter as an RN Patient Advocate. Key points are to talk to patients about their medication goals, assess medication appropriateness on a regular basis, engage pharmacists to do comprehensive medication reviews, and consider the appropriateness of “deprescibing”, with the communication skills needed to address all of these issues.

Too Many Drugs Too Close to the End?

Older adults often receive drugs that can be of questionable benefit during their last months of life, according to a large study that looked at the end-of-life medications prescribed across an entire nation.

Clinical guidelines that support health care providers when they face the decision to continue or discontinue medications near the end of life are sorely needed, the researchers said (Am J Med 2017 Apr 25. [Epub ahead of print]).

Among older adults, polypharmacy has become commonplace. In high-income countries, an estimated 25% to 40% of those aged 65 years or older are prescribed at least five medications (Lancet 2012;380[9836]:37-43). This polypharmacy can lead to drug–drug interactions and serious adverse effects, according to lead author Lucas Morin, MS, of the Aging Research Center at Karolinska Institutet, in Stockholm.

The researchers identified more than 500,000 adults older than 65 years of age who died in Sweden between 2007 and 2013, and reconstructed their drug prescription history for each of the last 12 months of life through the Swedish Prescribed Drug Register. The characteristics of study participants at time of death were assessed through record linkage with the National Patient Register, the Social Services Register and the Swedish Education Register. This investigation did not consider over-the-counter medications.

They found that patients received more medications as death approached. The proportion of older adults exposed to at least 10 different prescription drugs rose from 30% to 47% over the course of the last year before death. Older adults who died from cancer and individuals living in institutions received a greater number of medications than those suffering from another condition or living in the community. The number of drugs increased more slowly for those living in an institution than in the community, however.

Sean M. Jeffery, PharmD, BCGP, FASCP, AGSF, a geriatric specialist, who was not part of the study, said he was not surprised by the results, which are applicable to the United States. “[The results] are generally consistent with the trends we see in prescribing here: Community-dwelling elderly use fewer meds than institutionalized elderly,” said Dr. Jeffery, who is the director of clinical pharmacy services of Integrated Care Partners, Hartford Healthcare, in Wethersfield, Conn. “The general categories of medications used are also fairly consistent with what you would see in the United States.”

However, just because it is more medication doesn’t mean that it is inappropriate medication, he reminded. “People use more medications in the last year of life, as they may be experiencing significantly worsening of symptoms that leads them to seek relief,” said Dr. Jeffery, who is also a clinical professor at the University of Connecticut School of Pharmacy, in Storrs.

However, the frequent continuation of long-term, preventive treatments probably is not needed in many cases. For instance, the researchers found that during their last month of life, a large proportion of older adults used platelet antiaggregants (45%), beta blockers (41%), angiotensin-converting enzyme inhibitors (21%), vasodilators (17%), statins (16%), calcium channel blockers (15%) or potassium-sparing agents (12%). Those who died of cancer saw the greatest increase in the number of prescription drugs, even when analgesics were excluded from the total count.

Dr. Jeffery said the prescribing shows that many clinicians have a difficult time predicting death, and therefore, might be reluctant to discontinue maintenance medications. The study also couldn’t capture the influence of family members on decisions regarding whether to withdraw medications. He added that singling out patients who were in hospice or receiving palliative care would have been helpful to see whether the same trends occurred in that population.

This is a role made for pharmacists, who can help clinicians decide when to discontinue unnecessary medications, as well as adjust needed medications based on the pharmacokinetics of the patient, he noted. “There is a growing push for deprescribing whereby clinicians would start the process of removing medications that are unwarranted, no longer aligned with the patients goals of care or are potentially harmful,” Dr. Jeffery explained.

However, the researchers noted that “the process of de-prescribing requires timely dialogue between the patient, family, and physician, and close monitoring of symptoms. It is also essential that patients and their relatives receive clear information about their options in terms of palliative care in order to counter the feeling of abandonment that they may experience when treatments are withdrawn.”

The researchers said polypharmacy during end-of-life care raises ethical questions about the potential futility of treatments close to death, citing issues such as increased adverse events.

“By continuing active treatments when death is likely, it creates a disconnect between the likelihood of death and the patients and families awareness that death is near,” said Dr. Jeffery, which could result in patients receiving treatments “that have no way of extending life but do incur potential harm, may hasten death and are still costly.”

The researchers suggested that clinical guidelines be developed to support practitioners in their effort to reduce potentially futile drug treatments near the end of life.

Until then, Dr. Jeffery suggested that pharmacists:

  • empower patients to talk about their medication goals of care;
  • perform an annual assessment of medication appropriateness;
  • engage Part D patients in comprehensive medication reviews; and
  • develop motivational interviewing skills to help patients with deprescribing.

A weakness of the study was that it did not include OTC medications, he added. “Don’t forget the OTC medications,” he said. “The number of medications people use and cycle through may be greater than expected.”