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Elsten EECM, Pot IE, Geijteman ECT, Hedman C, van der Heide A, van der Kuy PHM, Fürst CJ, Eychmüller S, van Zuylen L, van der Rijt CCD. Recommendations for Deprescribing of Medication in the Last Phase of Life: An International Delphi Study. J Pain Symptom Manage 2024:S0885-3924(24)00909-6. [PMID: 39094669 DOI: 10.1016/j.jpainsymman.2024.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 07/23/2024] [Accepted: 07/25/2024] [Indexed: 08/04/2024]
Abstract
CONTEXT Medications may become inappropriate for patients in the last phase of life and may even compromise their quality of life. OBJECTIVE To find consensus on recommendations regarding deprescribing of medications for adult patients with a life expectancy of six months or less. METHODS Experts working in palliative care or other relevant disciplines were asked to participate in this international Delphi study. Existing tools for deprescribing of medication in the last phase of life were integrated in a list of 42 recommendations regarding potential deprescription of various medication types. In two Delphi rounds, experts were asked to rate their agreement with each recommendation on a 5-point Likert-scale (strongly agree-strongly disagree). Recommendations were accepted, if at least 70% of the experts (strongly) agreed, the interquartile range (IQR) was one or less, and less than 10% strongly disagreed. RESULTS About 47 experts from 10 countries participated (response rate 53%). In most cases (76%), consensus was reached on deprescribing recommendations for patients with a life expectancy of six months or less. The highest level of consensus was reached for recommendations on the deprescription of diuretics in case of decreasing fluid intake or increasing fluid loss, lipid modifying agents if prescribed for primary prevention, and vitamin K antagonists and direct oral anticoagulants in case of high bleeding risk. CONCLUSION A high level of consensus was reached on recommendations on potential deprescription of several medications for patients with a life expectancy of six months or less.
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Affiliation(s)
- Eline E C M Elsten
- Department of Medical Oncology (E.E.C.M.E., I.E.P., E.C.T.G., C.C.D.V.D.R.), Erasmus Medical Center, Cancer Institute Rotterdam, Netherlands; Department of Public Health (E.E.C.M.E., A.V.D.H.), Erasmus Medical Center, University Medical Center Rotterdam, Netherlands
| | - Iris E Pot
- Department of Medical Oncology (E.E.C.M.E., I.E.P., E.C.T.G., C.C.D.V.D.R.), Erasmus Medical Center, Cancer Institute Rotterdam, Netherlands.
| | - Eric C T Geijteman
- Department of Medical Oncology (E.E.C.M.E., I.E.P., E.C.T.G., C.C.D.V.D.R.), Erasmus Medical Center, Cancer Institute Rotterdam, Netherlands
| | - Christel Hedman
- R & D Department (C.H.), Stockholms Sjukhem Foundation, Stockholm, Sweden; Department of Molecular Medicine and Surgery (C.H.), Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences (C.H.), Lund University, Lund, Sweden; Institute for Palliative Care (C.H., C.J.F.), Lund University and Region Skåne, Lund, Sweden
| | - Agnes van der Heide
- Department of Public Health (E.E.C.M.E., A.V.D.H.), Erasmus Medical Center, University Medical Center Rotterdam, Netherlands
| | - P Hugo M van der Kuy
- Department of Hospital Pharmacy (H.V.D.K.), Erasmus Medical Center, Rotterdam, Netherlands
| | - Carl-Johan Fürst
- Institute for Palliative Care (C.H., C.J.F.), Lund University and Region Skåne, Lund, Sweden
| | - Steffen Eychmüller
- University Center for Palliative Care (S.E.), University Hospital Inselspital Bern, Bern, Switzerland
| | - Lia van Zuylen
- Department of Medical Oncology (L.V.Z.), Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Carin C D van der Rijt
- Department of Medical Oncology (E.E.C.M.E., I.E.P., E.C.T.G., C.C.D.V.D.R.), Erasmus Medical Center, Cancer Institute Rotterdam, Netherlands
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Patel K, Irizarry-Caro JA, Khan A, Holder T, Salako D, Goyal P, Kwak MJ. Definition of Polypharmacy in Heart Failure: A Scoping Review of the Literature. Cardiol Res 2024; 15:75-85. [PMID: 38645827 PMCID: PMC11027783 DOI: 10.14740/cr1636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/29/2024] [Indexed: 04/23/2024] Open
Abstract
Patients with heart failure (HF) have a high prevalence of polypharmacy, which can lead to drug interactions, cognitive impairment, and medication non-compliance. However, the definition of polypharmacy in these patients is still inconsistent. The aim of this scoping review was to find the most common definition of polypharmacy in HF patients. We conducted a scoping review searching Medline, Embase, CINAHL, and Cochrane using terms including polypharmacy, HF and deprescribing, which resulted in 7,949 articles. Articles without a definition of polypharmacy in HF patients and articles which included patients < 18 years of age were excluded; only 59 articles were included. Of the 59 articles, 49% (n = 29) were retrospective, 20% (n = 12) were prospective, 10% (n = 6) were cross-sectional, and 27% (n = 16) were review articles. Twenty percent (n = 12) of the articles focused on HF with reduced ejection fraction, 10% (n = 6) focused on HF with preserved ejection fraction and 69% (n = 41) articles either focused on both diagnoses or did not clarify the specific type of HF. The most common cutoff for polypharmacy in HF was five medications (59%, n = 35). There was no consensus regarding the inclusion or exclusion of over-the-counter medications, supplements, or vitamins. Some newer studies used a cutoff of 10 medications (14%, n = 8), and this may be a more practical and meaningful definition for HF patients.
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Affiliation(s)
- Keshav Patel
- Department of Internal Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Jorge A. Irizarry-Caro
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Adil Khan
- Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Travis Holder
- Houston Academy of Medicine, The Texas Medical Center Library, Houston, TX, USA
| | | | - Parag Goyal
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Min Ji Kwak
- Department of Internal Medicine, Division of Geriatric and Palliative Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
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3
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[Translated article] Hip fracture in centenarians, what can we expect? Rev Esp Cir Ortop Traumatol (Engl Ed) 2022. [DOI: 10.1016/j.recot.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Shrestha S, Poudel A, Cardona M, Steadman KJ, Nissen LM. Impact of deprescribing dual-purpose medications on patient-related outcomes for older adults near end-of-life: a systematic review and meta-analysis. Ther Adv Drug Saf 2021; 12:20420986211052343. [PMID: 34707802 PMCID: PMC8543710 DOI: 10.1177/20420986211052343] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/14/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: The decision to deprescribe medications used for both disease prevention and
symptom control (dual-purpose medications or DPMs) is often challenging for
clinicians. We aim to establish the impact of deprescribing DPMs on
patient-related outcomes for older adults near end-of-life (EOL). Methods: This systematic review was conducted according to the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses) guideline.
Literature was searched on PubMed, EMBASE, CINAHL, PsycINFO and Google
Scholar until December 2019 for studies on deprescribing intervention with a
control group (with or without randomisation); targeting ⩾65-year olds, at
EOL, with at least one life-limiting illness and at least one potentially
inappropriate DPM. We were interested in any patient-related outcomes.
Studies with similar outcome assessment criteria were subjected to
meta-analysis and narrative synthesis otherwise. The risk of bias was
assessed using Cochrane Risk of Bias and ROBINS-I tools for randomised
controlled trials (RCTs) and quasi-experimental non-randomised controlled
studies, respectively. Results: Five studies covering 689 participants with mean age 81.6–85.7 years, the
majority (74.6–100%) with dementia were included. The risk of bias was
moderate to low. The deprescribing of DPMs lowered the risk of mortality
(risk ratio (RR) = 0.59, 95% confidence interval (CI) = 0.44–0.79) and
referral to acute care facilities (RR = 0.40, 95% CI = 0.22–0.73), but did
not have a significant impact on the risk of falls, non-vertebral fracture,
emergency presentation, unplanned hospital admission, or general
practitioner visits. No significant difference was observed in the quality
of life, physical and cognitive functions between the intervention and
control groups. Conclusion: There is some evidence that deprescribing of DPMs for older adults near the
EOL can lower the risk of mortality and referral to acute care facilities,
but there are insufficient good-quality studies powered to confirm a benefit
in terms of quality of life, physical or cognitive function, health service
utilisation and adverse events. Plain Language Summary What is the health impact of withdrawal or dose reduction of
medication used for disease prevention and symptom control in older
adults near end-of-life? Introduction: Older adults (aged ⩾ 65 years) with advanced
diseases such as cancer, dementia, and organ failure tend to have a limited
life expectancy. With the progression of these diseases towards the
end-of-life, the intensity for day-to-day supportive care becomes
increasingly necessary. The use of medications for symptom management is a
critical part of such care, but the use of medications for long-term disease
prevention can become irrelevant due to the already shortened life
expectancy and may become harmful due to alterations in physiology and
pharmacology associated with age and frailty. This necessitates the
withdrawal or dose reduction of inappropriate medications, the process
called deprescribing. The decision to deprescribe medications used for both
disease prevention and symptom control (DPMs) in this population is often
challenging for clinicians. In this context, whether deprescribing of DPMs
can improve patient-related health outcomes is unknown. Methods: Evidence from the literature was reviewed and analysed,
and the quality of studies was assessed. Five studies were identified, which
had 689 participants with an average age above 80 years and mostly suffering
from dementia. Results: The analysis of these studies showed deprescribing of
DPMs lowered the risk of death and referral to acute care facilities at 12
months but had no significant impact on falls, non-vertebral fractures,
emergency presentations, unplanned hospital admission, general practitioner
visits, quality of life, physical and mental functions. Conclusion: In conclusion, there were insufficient numbers of
high-quality studies powered to confirm whether deprescribing of DPMs
reduces adverse events, health service use, or improves the quality of life
or functioning in older adults near the end of life.
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Affiliation(s)
- Shakti Shrestha
- School of Pharmacy, The University of Queensland, Pharmacy Australia Centre of Excellence, Level 4, 20 Cornwall Street, Woolloongabba, Brisbane, QLD 4102, Australia
| | - Arjun Poudel
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Magnolia Cardona
- EBP Professorial Unit, Gold Coast University Hospital, Institute for Evidence-Based Healthcare, Bond University, Gold Coast, QLD, Australia
| | - Kathryn J Steadman
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Lisa M Nissen
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
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Sarasa-Roca M, Torres-Campos A, Redondo-Trasobares B, Angulo-Castaño MC, Gómez-Vallejo J, Albareda-Albareda J. Hip fracture in centenarians, what can we expect? Rev Esp Cir Ortop Traumatol (Engl Ed) 2021; 66:267-273. [PMID: 34344619 DOI: 10.1016/j.recot.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/29/2021] [Accepted: 04/12/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Hip fractures in centenarians are rising due to the increase in life expectancy. The objective of this study is to compare the characteristics of centenarians' hip fracture with a younger control group, and to analyze whether there are differences in terms of in-hospital mortality, complications, and short-medium-term survival between them. MATERIAL AND METHODS Retrospective case-control study, with a series of 24 centenarians and 48 octogenarians with a hip fracture. Comorbidities and Charlson index, surgical delay, complications and mortality during admission, and hospital stay were analyzed. At discharge, early mortality, survival after one year, and return to previous functionality were assessed. RESULTS No significant differences were found in baseline parameters or comorbidities (P>.05), and the type of was a woman with an extracapsular fracture. Hospital stay was longer in the control group (P=.038), and the most frequent complication was anemia requiring transfusion (23/24 in centenarians, P<.0001). In-hospital mortality and accumulated at one year in the centenarians was 33 and 67%, respectively, compared to 10 and 25% in the octogenarians (P=.017, OR=4.3 [1,224-15,101] and P=.110). Only 2 centenarian patients were able to walk again after the intervention, while in the control group 53.84% returned to the previous functional situation (P=.003). CONCLUSIONS Compared to a control group of younger patients, in-hospital mortality and in the first year after a hip fracture is significantly higher in centenarians, and very few recover activity prior to the fracture.
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Affiliation(s)
- M Sarasa-Roca
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España.
| | - A Torres-Campos
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - B Redondo-Trasobares
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - M C Angulo-Castaño
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J Gómez-Vallejo
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J Albareda-Albareda
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
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Hattori Y, Abe T, Kojima T, Hamada S, Ogawa S, Ura N, Akishita M. Potential prescribing omissions may have no influence on cause of death in care‐dependent older adults with percutaneous endoscopic gastrostomy tube. Geriatr Gerontol Int 2020; 20:961-966. [DOI: 10.1111/ggi.14009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/02/2020] [Accepted: 07/20/2020] [Indexed: 01/21/2023]
Affiliation(s)
- Yukari Hattori
- Department of Geriatric Medicine, Graduate School of Medicine The University of Tokyo Bunkyo‐ku Japan
| | | | - Taro Kojima
- Department of Geriatric Medicine, Graduate School of Medicine The University of Tokyo Bunkyo‐ku Japan
| | - Shota Hamada
- Research Department, Institute for Health and Policy Association for Health Economics Research and Social Insurance and Welfare Tokyo Japan
- Department of Home Care Medicine, Graduate School of Medicine The University of Tokyo Bunkyo‐ku Japan
| | - Sumito Ogawa
- Department of Geriatric Medicine, Graduate School of Medicine The University of Tokyo Bunkyo‐ku Japan
| | | | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine The University of Tokyo Bunkyo‐ku Japan
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Shrestha S, Poudel A, Steadman K, Nissen L. Outcomes of deprescribing interventions in older patients with life-limiting illness and limited life expectancy: A systematic review. Br J Clin Pharmacol 2019; 86:1931-1945. [PMID: 31483057 DOI: 10.1111/bcp.14113] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/07/2019] [Accepted: 08/24/2019] [Indexed: 01/01/2023] Open
Abstract
AIMS Older patients with life-limiting illness (LLI) and limited life expectancy (LLE) continue to receive potentially inappropriate medicines, consequently deprescribing is often necessary. However, deprescribing in this population can be complex and challenging. Therefore, we aimed to investigate the evidence for outcomes of deprescribing interventions in older patients with LLI and LLE. METHODS Studies on deprescribing intervention and their outcomes in age ≥65 years with LLI and LLE were searched using PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Google Scholar. Medication appropriateness was primary outcome, while clinical and cost-related outcomes were secondary. Eligibility, data extraction and quality assessment were followed by a narrative synthesis of data. RESULTS Of 9 studies (1375 participants), 3 reported on primary outcome. One study showed a significant reduction in medication inappropriateness by 34.9% (P < .001) from admission to close-out, the second achieved 29.4% (P < .001) and 15.1% (P = .003) reduction at 12 and 24 months, respectively. The third reported that their intervention stopped (17.2%) and altered the dose (2.6%) of high-risk medications. Commonly reported clinical outcomes were mortality (n = 3), quality of life (n = 2) and falls (n = 2). Outcomes in terms of cost were reported as overall cost (n = 2), medication cost (n = 1) and health care expenditure (n = 1). CONCLUSION Our findings suggest that deprescribing in older patients with LLI and LLE can improve medication appropriateness, and has potential for enhancement of several clinical outcomes and cost savings, but the evidence needs to be better established.
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Affiliation(s)
- Shakti Shrestha
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia
| | - Arjun Poudel
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kathryn Steadman
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia
| | - Lisa Nissen
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
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Roux B, Morin L, Papon A, Laroche ML. Prescription and deprescription of medications for older adults receiving palliative care during the last 3 months of life: a single-center retrospective cohort study. Eur Geriatr Med 2019; 10:463-471. [PMID: 34652792 DOI: 10.1007/s41999-019-00175-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/18/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Near the end of life, drugs to ensure comfort and improve quality of life should be prioritized, and unnecessary drugs should be avoided. The aim was to assess the evolution and quality of drug therapy throughout the last 3 months of life of older adults in need of palliative care. METHODS A single-center retrospective cohort study included older adults (≥ 65 years) who died in a teaching hospital between 1 January 2014 and 30 June 2014 and had been identified as patients in need of palliative care in their last 3 months of life. Drugs were collected from electronic medical records and defined as 'unnecessary' or 'essential' based on a review of the literature. RESULTS A total of 149 patients were included [age: 82.1 (SD 8.6) years, women: 46.3%]. The mean number of medications varied from 6.7 (SD 3.3) drugs 90 days before death, to 7.5 (SD 4.1) 7 days before death, to 5.6 (SD 3.6) on the day of death. During the final week of life, one additional prescription of essential drugs was observed for 75.2% of patients and 79.3% of patients had at least one unnecessary drug deprescribed. The most prescribed and deprescribed drug classes were, respectively, analgesics (56.4%) and antithrombotic agents (38.2%) during the last week of life. CONCLUSIONS Near the end of life, medication therapy is adapted to the goals of palliative care. However, this only occurs during the last week of life. Earlier transition to palliative care is necessary to avoid exposure to unnecessary drugs.
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Affiliation(s)
- Barbara Roux
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France. .,INSERM UMR 1248, University of Limoges, Limoges, France.
| | - Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Arnaud Papon
- Department of Geriatric Medicine, University Hospital of Limoges, Limoges, France
| | - Marie-Laure Laroche
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France.,INSERM UMR 1248, University of Limoges, Limoges, France
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Paque K, De Schreye R, Elseviers M, Vander Stichele R, Pardon K, Dilles T, Christiaens T, Deliens L, Cohen J. Discontinuation of medications at the end of life: A population study in Belgium, based on linked administrative databases. Br J Clin Pharmacol 2019; 85:827-837. [PMID: 30667540 DOI: 10.1111/bcp.13874] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 12/17/2022] Open
Abstract
AIMS The aim of this study was to examine the use of potentially inappropriate medication (PIM) in relation to time before death, to explore whether PIMs are discontinued at the end of life, and the factors associated with this discontinuation. METHODS We conducted a retrospective register-based mortality cohort study of all deceased in 2012 in Belgium, aged at least 75 years at time of death (n = 74 368), using linked administrative databases. We used STOPPFrail to identify PIMs received during the period from 12 to 6 months before death (P1) and the last 4 months (P2) of life. RESULTS Median age was 86 (IQR 81-90) at time of death, 57% were female, 38% were living in a nursing home, and 16% were admitted to hospital between 2 years and 4 months before death. Overall, PIM use was high, and increased towards death for all PIMs. At least one PIM was discontinued during P2 for one in five (20%) of the population, and 49% had no discontinuation. Being hospitalized in the period before the last 4 months of life, living in a nursing home, female gender and a higher number of medications used during P1 were associated with discontinuation of PIMs (respective aOR [95% CI]: 2.89 [2.73-3.06], 1.29 [1.23-1.36], 1.26 [1.20-1.32], 1.17 [1.16-1.17]). CONCLUSION Initial PIM use was high and increased towards death. Discontinuation was observed in only one in five PIM users. More guidance for discontinuation of PIMs is needed: practical, evidence-based deprescribing guidelines and implementation plans, training for prescribers and a better consensus on what inappropriate medication is.
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Affiliation(s)
- Kristel Paque
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium.,Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Robrecht De Schreye
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Monique Elseviers
- Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium.,Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (NuPhaC), University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Robert Vander Stichele
- Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Koen Pardon
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Tinne Dilles
- Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (NuPhaC), University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Thierry Christiaens
- Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
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Paque K, Vander Stichele R, Elseviers M, Pardon K, Dilles T, Deliens L, Christiaens T. Barriers and enablers to deprescribing in people with a life-limiting disease: A systematic review. Palliat Med 2019; 33:37-48. [PMID: 30229704 DOI: 10.1177/0269216318801124] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND: Knowing the barriers/enablers to deprescribing in people with a life-limiting disease is crucial for the development of successful deprescribing interventions. These barriers/enablers have been studied, but the available evidence has not been summarized in a systematic review. AIM: To identify the barriers/enablers to deprescribing of medications in people with a life-limiting disease. DESIGN: Systematic review, registered in PROSPERO (CRD42017073693). DATA SOURCES: A systematic search of MEDLINE, Embase, Web of Science and CENTRAL was conducted and extended with a hand search. Peer-reviewed, primary studies reporting on barriers/enablers to deprescribing in the context of explicit life-limiting disease were included in this review. RESULTS: A total of 1026 references were checked. Five studies met the criteria and were included in this review. Three types of barriers/enablers were found: organizational, professional and patient (family)-related barriers/enablers. The most prominent enablers were organizational support (e.g. for standardized medication review), involvement of multidisciplinary teams in medication review and the perception of the importance of coming to a joint decision regarding deprescribing, which highlighted the need for interdisciplinary collaboration and involving the patient and his family in the decision-making process. The most important barriers were shortages in staff and the perceived difficulty or resistance of the nursing home resident's family - or the resident himself. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: The scarcity of findings in the literature highlights the importance of filling this gap. Further research should focus on deepening the knowledge on these barriers/enablers in order to develop sustainable multifaceted deprescribing interventions in palliative care.
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Affiliation(s)
- Kristel Paque
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Robert Vander Stichele
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Monique Elseviers
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,3 Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Antwerp, Belgium
| | - Koen Pardon
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Tinne Dilles
- 3 Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Antwerp, Belgium.,4 Department of Nursing and Midwifery, Thomas More University College, Lier, Belgium
| | - Luc Deliens
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,5 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Thierry Christiaens
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
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11
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Hip fractures in the oldest old. Comparative study of centenarians and nonagenarians and mortality risk factors. Injury 2018; 49:2198-2202. [PMID: 30274759 DOI: 10.1016/j.injury.2018.09.043] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 09/24/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Centenarians and nonagenarians constitute a rapidly growing age group in Western countries and they are expected to be admitted to hospital with hip fractures. The aim of this study was to compare outcomes of centenarian and nonagenarian patients following a hip fracture and to identify risk factors related to in-hospital and post-discharge mortality in both groups. PATIENTS AND METHODS A prospective evaluation of centenarian patients and nonagenarian controls admitted to a tertiary university hospital in Barcelona with hip fractures over a period of 5 years and 9 months. Baseline characteristics and outcomes in both patient groups were compared. Variables associated with in-hospital, 30-day, 3-month and 1-year mortality were also analyzed. RESULTS Thirty-three centenarians and 82 nonagenarians were included. The most relevant statistically significant differences found were: Barthel index at admission (61.90 vs. 75.22), number of drugs before admission (4.21vs 5.55), in-hospital complication rates (97 vs. 78%), readmissions at 3 months and 1 year (0 vs 11.7% and 3.4 vs. 19.5% respectively) and mortality at 3 months and 1 year (41.4 vs. 20.8% and 62.1 vs. 29.9%, respectively). Mean number of complications, rapid atrial fibrillation, mean age, and urinary tract infection were risk factors associated with mortality. CONCLUSIONS Centenarian patients had similar in-hospital outcomes to nonagenarians, but experienced more complications and twice the 3-month and 1-year mortality rate. The mean number of complications was the risk factor most consistently related to in-hospital and post-discharge mortality. These findings emphasize the need to improve care in very old patients to prevent complications.
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12
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Beaumier A, Rush JE, Yang VK, Freeman LM. Clinical findings and survival time in dogs with advanced heart failure. J Vet Intern Med 2018; 32:944-950. [PMID: 29635788 PMCID: PMC5980388 DOI: 10.1111/jvim.15126] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 02/21/2018] [Accepted: 03/05/2018] [Indexed: 12/02/2022] Open
Abstract
Background Dogs with advanced heart failure are a clinical challenge for veterinarians but there are no studies reporting clinical features and outcome of this population. Hypothesis/Objectives To describe clinical findings and outcome of dogs with advanced heart failure caused by degenerative mitral valve disease (DMVD). Animals Fifty‐four dogs with advanced heart failure because of DMVD. Methods For study purposes, advanced heart failure was defined as recurrence of congestive heart failure signs despite receiving the initially prescribed dose of pimobendan, angiotensin‐converting‐enzyme inhibitor (ACEI), and furosemide >4 mg/kg/day. Data were collected for the time of diagnosis of Stage C heart failure and time of diagnosis of advanced heart failure. Date of death was recorded. Results At the diagnosis of advanced heart failure, doses of pimobendan (n = 30), furosemide (n = 28), ACEI (n = 13), and spironolactone (n = 4) were increased, with ≥1 new medications added in most dogs. After initial diagnosis of advanced heart failure, 38 (70%) dogs had additional medications adjustments (median = 2 [range, 0‐27]), with the final total medication number ranging from 2‐10 (median = 5). Median survival time after diagnosis of advanced heart failure was 281 days (range, 3‐885 days). Dogs receiving a furosemide dose >6.70 mg/kg/day had significantly longer median survival times (402 days [range, 3‐885 days] versus 129 days [range 9‐853 days]; P = .017). Conclusions and Clinical Importance Dogs with advanced heart failure can have relatively long survival times. Higher furosemide dose and non‐hospitalization were associated with longer survival.
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Affiliation(s)
- Amelie Beaumier
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts
| | - John E Rush
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts
| | - Vicky K Yang
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts
| | - Lisa M Freeman
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts
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13
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Arevalo JJ, Geijteman EC, Huisman BA, Dees MK, Zuurmond WW, van Zuylen L, van der Heide A, Perez RS. Medication Use in the Last Days of Life in Hospital, Hospice, and Home Settings in the Netherlands. J Palliat Med 2018; 21:149-155. [DOI: 10.1089/jpm.2017.0179] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Jimmy J. Arevalo
- Department of Anesthesiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Eric C.T. Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bregje A.A. Huisman
- Department of Anesthesiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Marianne K. Dees
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Wouter W.A. Zuurmond
- Department of Anesthesiology, VU University Medical Center, Amsterdam, the Netherlands
- Hospice Kuria, Amsterdam, the Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto S.G.M. Perez
- Department of Anesthesiology, VU University Medical Center, Amsterdam, the Netherlands
- Hospice Kuria, Amsterdam, the Netherlands
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14
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Poudel A, Yates P, Rowett D, Nissen LM. Use of Preventive Medication in Patients With Limited Life Expectancy: A Systematic Review. J Pain Symptom Manage 2017; 53:1097-1110.e1. [PMID: 28192226 DOI: 10.1016/j.jpainsymman.2016.12.350] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 12/05/2016] [Accepted: 12/29/2016] [Indexed: 01/20/2023]
Abstract
CONTEXT Optimal prescribing in patients with limited life expectancy (LLE) remains unclear. OBJECTIVES This study systematically reviews the published literature regarding the use of preventive medication in patients with reduced life expectancy. METHODS A systematic literature search was conducted using three databases (MEDLINE, EMBASE, and CINAHL). Articles published in English from January 1995 to December 2015 were retrieved for analysis to identify peer-reviewed, observational studies assessing use of preventive medications in patients with LLE. Inclusion criteria were: patients with a LLE (less than or equal to two years); prescribed/used preventive medications. RESULTS Of the 15 studies meeting our eligibility criteria, six were from inpatient hospital settings, five in palliative care, three in nursing homes, and one in community settings. The most common life-limiting illnesses described in the studies were cancer (n = 6), cardiovascular diseases (n = 4), dementia and cognitive impairment (n = 2), and other life-limiting illnesses (n = 3). Lipid-lowering medications, especially the statins were frequently prescribed preventive medication followed by antiplatelets, angiotensin converting enzyme inhibitors and angiotensin receptor blockers, anti-osteoporosis medications, and calcium channel blockers. Only four studies reported the instances of medication withdrawal. CONCLUSION Patients continue to receive medications that are not prescribed as symptomatic treatment despite having a LLE. Very few rigorous studies have been conducted on minimizing preventive medications in patients with LLE, and expert opinion varies on medication optimization at the end of life. A consensus guideline that addresses this gap is of paramount importance.
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Affiliation(s)
- Arjun Poudel
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia.
| | - Patsy Yates
- School of Nursing, Queensland University of Technology, Brisbane, Australia
| | - Debra Rowett
- Repatriation General Hospital, Adelaide, Australia
| | - Lisa M Nissen
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
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15
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Todd A, Husband A, Andrew I, Pearson SA, Lindsey L, Holmes H. Inappropriate prescribing of preventative medication in patients with life-limiting illness: a systematic review. BMJ Support Palliat Care 2016; 7:113-121. [DOI: 10.1136/bmjspcare-2015-000941] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 10/09/2015] [Accepted: 11/25/2015] [Indexed: 12/20/2022]
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16
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Suárez Fernández C, Fernández S, Formiga F, Camafort M, Cepeda Rodrigo M, Rodrigo JC, Díez-Manglano J, Pose Reino A, Reino P, Tiberio G, Mostaza JM. Antithrombotic treatment in elderly patients with atrial fibrillation: a practical approach. BMC Cardiovasc Disord 2015; 15:143. [PMID: 26530138 PMCID: PMC4632329 DOI: 10.1186/s12872-015-0137-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 10/26/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) in the elderly is a complex condition. It has a direct impact on the underuse of antithrombotic therapy reported in this population. DISCUSSION All patients aged ≥75 years with AF have an individual yearly risk of stroke >4 %. However, the risk of hemorrhage is also increased. Moreover, in this population it is common the presence of other comorbidities, cognitive disorders, risk of falls and polymedication. This may lead to an underuse of anticoagulant therapy. Direct oral anticoagulants (DOACs) are at least as effective as conventional therapy, but with lesser risk of intracranial hemorrhage. The simplification of treatment with these drugs may be an advantage in patients with cognitive impairment. The great majority of elderly patients with AF should receive anticoagulant therapy, unless an unequivocal contraindication. DOACs may be the drugs of choice in many elderly patients with AF. In this manuscript, the available evidence about the management of anticoagulation in elderly patients with AF is reviewed. In addition, specific practical recommendations about different controversial issues (i.e. patients with anemia, thrombocytopenia, risk of gastrointestinal bleeding, renal dysfunction, cognitive impairment, risk of falls, polymedication, frailty, etc.) are provided.
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Affiliation(s)
| | - Suárez Fernández
- Hospital Universitario de La Princesa, Grupo de Riesgo Vascular de la SEMI, Madrid, España.
- Servicio de Medicina Interna, Hospital Universitario de La Princesa, C/Diego de León 62, 28006, Madrid, Spain.
| | - Francesc Formiga
- Hospital Universitari de Bellvitge, Grupo de Riesgo Vascular de la SEMI, Hospitalet de Llobregat, Barcelona, España
| | - Miguel Camafort
- Atrial Fibrillation Unit (UFA), Internal Medicine Department, Hospital Clinic. University of Barcelona. Research Group in Cardiovascular Risk, Nutrition and Aging. Area. 'August Pi i Sunyer' Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Jose Cepeda Rodrigo
- Hospital Vega Baja de Orihuela, Grupo de Riesgo Vascular de la SEMI, Orihuela, Alicante, España
| | - Jesús Díez-Manglano
- Hospital Royo Villanova, Grupo de Riesgo Vascular de la SEMI, Zaragoza, España
| | | | - Pose Reino
- Complexo Hospitalario Universitario de Santiago, Grupo de Riesgo Vascular de la SEMI, Santiago de Compostela, España
| | - Gregorio Tiberio
- Hospital Virgen del Camino, Grupo de Riesgo Vascular de la SEMI, Pamplona, España
| | - Jose María Mostaza
- Hospital Carlos III, Grupo de Riesgo Vascular de la SEMI, Madrid, España
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Xavier SDO, Ferretti-Rebustini REDL, Santana-Santos E, Lucchesi PADO, Hohl KG. [Heart failure as a predictor of functional dependence in hospitalized elderly]. Rev Esc Enferm USP 2015; 49:790-6. [PMID: 26516749 DOI: 10.1590/s0080-623420150000500012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/10/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Identify whether Heart Failure (HF) is a predictor of functional dependence for Basic Activities of Daily Living (BADL) in hospitalized elderly. METHODS We investigated medical records and assessed dependence to BADL (by the Katz Index) of 100 elderly admitted to a geriatric ward of a university hospital. In order to verify if HF is a predictor of functional dependence, linear regression analyzes were performed. RESULTS The prevalence of HF was 21%; 95% of them were dependent for BADLs. Bathing was the most committed ADL. HF is a predictor of dependence in hospitalized elderlies, increasing the chance of functional decline by 5 times (95% CI, 0.94-94.48), the chance of functional deterioration by 3.5 times (95% CI, 1.28-11.66; p <0.02) and reducing 0.79 points in the Katz Index score (p <0.05). CONCLUSION HF is a dependency predictor of ADL in hospitalized elderly, who tend to be more dependent, especially for bathing.
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Affiliation(s)
| | | | - Eduesley Santana-Santos
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Karine Generoso Hohl
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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