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Peralta T, Castel-Branco MM, Reis-Pina P, Figueiredo IV, Dourado M. Prescription trends at the end of life in a palliative care unit: observational study. BMC Palliat Care 2022; 21:65. [PMID: 35505394 PMCID: PMC9066954 DOI: 10.1186/s12904-022-00954-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 04/22/2022] [Indexed: 11/30/2022] Open
Abstract
Background Symptomatic control is essential in palliative care, particularly in end-of-life, in which the pathophysiological changes that characterize this last phase of life strengthen the need to carry out an early therapeutic review. Hence, we aim to evaluate the prescribing pattern at a palliative care unit at two different time points: on admission and the day of the patient’s death. Methods Quantitative, analytic, longitudinal, retrospective and observational study. Participants were adult patients who were admitted and died in a palliative care unit, in Portugal. Sociodemographic, clinical and pharmacological data were collected, including frequencies and routes of administration of schedule prescribed drugs and rescue drugs, from the day of admission until the day of death. Results 115 patients were included with an average age of 70.0 ± 12.9 years old, 53.9 were male, mostly referred by the Hospital Palliative Care Support Teams. The most common pathology was cancer, mainly in advanced stage. On admission, the median scheduled prescription was seven and “as needed” was three drugs. On the day of death, a decrease of prescriptions was observed. Opioids were always the most prescribed drugs. Near death, there was a higher tendency to prescribe butylscopolamine, midazolam, diazepam and levomepromazine. The most frequent route of drug administration was oral on admission and subcutaneous on the day of death. Conclusions Polypharmacy is a reality in palliative care despite specialist palliative care teams. A reduction of prescribed drugs was verified, essentially due less comorbidity-oriented drugs. Further studies are required to analyse the importance of Hospital Palliative Care Support Teams.
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Affiliation(s)
- Tatiana Peralta
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
| | - Maria Margarida Castel-Branco
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.,Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Paulo Reis-Pina
- Palliative Care Unit "Bento Menni", Casa de Saúde da Idanha, Sintra, Portugal.,Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Isabel Vitória Figueiredo
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.,Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Marília Dourado
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Center for Studies and Development of Continuous and Palliative Care (CEDCCP), Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Centre for Health Studies and Research of the University of Coimbra (CEISUC), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Prescribing practices, patterns, and potential harms in patients receiving palliative care: A systematic scoping review. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2021; 3:100050. [PMID: 35480601 PMCID: PMC9031741 DOI: 10.1016/j.rcsop.2021.100050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/12/2021] [Accepted: 07/20/2021] [Indexed: 01/25/2023] Open
Abstract
Background Patients receiving palliative care often have existing comorbidities necessitating the prescribing of multiple medications. To maximize quality of life in this patient cohort, it is important to tailor prescribing of medication for preventing and treating existing illnesses and those for controlling symptoms, such as pain, according to individual specific needs. Objective(s) To provide an overview of peer-reviewed observational research on prescribing practices, patterns, and potential harms in patients receiving palliative care. Methods A systematic scoping review was conducted using four electronic databases (PubMed, EMBASE, CINAHL, Web of Science). Each database was searched from inception to May 2020. Search terms included ‘palliative care,’ ‘end of life,’ and ‘prescribing.’ Eligible studies had to examine prescribing for adults (≥18 years) receiving palliative care in any setting as a study aim or outcome. Studies focusing on single medication types (e.g., opioids), medication classes (e.g., chemotherapy), or clinical indications (e.g., pain) were excluded. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, and the findings were described using narrative synthesis. Results Following deduplication, 16,565 unique citations were reviewed, and 56 studies met inclusion criteria. The average number of prescribed medications per patient ranged from 3 to 23. Typically, prescribing changes involved decreases in preventative medications and increases in symptom-specific medications closer to the time of death. Twenty-one studies assessed the appropriateness of prescribing using various tools. The prevalence of patients with ≥1 potentially inappropriate prescription ranged from 15 to 92%. Three studies reported on adverse drug events. Conclusions This scoping review provides a broad overview of existing research and shows that many patients receiving palliative care receive multiple medications closer to the time of death. Future research should focus in greater detail on prescribing appropriateness using tools specifically developed to guide prescribing in palliative care and the potential for harm.
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Bosetti C, Santucci C, Pasina L, Fortino I, Merlino L, Corli O, Nobili A. Use of preventive drugs during the last year of life in older adults with cancer or chronic progressive diseases. Pharmacoepidemiol Drug Saf 2021; 30:1057-1065. [PMID: 33675260 DOI: 10.1002/pds.5223] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/01/2021] [Indexed: 01/17/2023]
Abstract
PURPOSE To evaluate the prescription of preventive medications with questionable usefulness in community dwelling elderly adults with cancer or chronic progressive diseases during the last year of life. METHODS Through the utilization of the healthcare databases of the Lombardy region, Italy, we identified two retrospective cohorts of patients aged 65 years or more, who died in 2018 and had a diagnosis of either a solid cancer (N = 19 367) or a chronic progressive disease (N = 27 819). We estimated prescription of eight major classes of preventive drugs 1 year and 1 month before death; continuation or initiation of preventive drug use during the last month of life was also investigated. RESULTS Over the last year of life, in both oncologic and non-oncologic patients, we observed a modest decrease in the prescription of blood glucose-lowering drugs, anti-hypertensives, lipid-modifying agents, and bisphosphonates, and a slight increase in the prescription of vitamins, minerals, antianemic drugs, and antithrombotic agents (among oncologic patients only). One month before death, the prescription of preventive drugs was still common, particularly for anti-hypertensives, antithrombotics, and antianemics, with more than 60% of patients continuing to be prescribed most preventive drugs and an over 10% starting a therapy with an antithrombotic, an antianemic, or a vitamin or mineral supplement. CONCLUSION These findings support the need for an appropriate drug review and improvement in the quality of drug prescription for vulnerable populations at the end-of-life.
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Affiliation(s)
- Cristina Bosetti
- Department of Oncology, Unit of Cancer Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Claudia Santucci
- Department of Oncology, Unit of Cancer Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Luca Pasina
- Department of Neuroscience, Unit of Pharmacotherapy and Prescription Appropriateness, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Ida Fortino
- Regional Ministry of Health, Lombardy Region, Milan, Italy
| | - Luca Merlino
- Regional Ministry of Health, Lombardy Region, Milan, Italy
| | - Oscar Corli
- Department of Oncology, Unit of Pain and Palliative Care Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Alessandro Nobili
- Department of Neuroscience, Laboratory for Quality Assessment of Geriatric Therapies and Services, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
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Disalvo D, Luckett T, Bennett A, Davidson PM, Agar M. Multidisciplinary perspectives on medication-related decision-making for people with advanced dementia living in long-term care: a critical incident analysis. Eur J Clin Pharmacol 2020; 76:567-578. [PMID: 31932874 DOI: 10.1007/s00228-019-02820-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/22/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aimed to explore medication-related decision-making by health professionals from different disciplines and specialties caring for people with advanced dementia living in long-term care facilities, focusing on dilemmas associated with starting, continuing or deprescribing medications commonly regarded as potentially inappropriate. METHODS Four focus groups were undertaken, each on a different medication type (antibiotics, lipid-lowering agents, opioids and acetylcholinesterase inhibitors). Transcripts underwent qualitative analysis using line by line inductive coding and then a person-centred framework to highlight themes across medication types. RESULTS Sixteen participants participated in focus groups. Regardless of medication type or dilemma, results suggested decision-making for residents with advanced dementia should begin with discussing goals of care and engaging with families, and be viewed as an iterative process involving regular monitoring and adjustment. Decision-making was seen as requiring a dialectical approach involving multiple perspectives, with an emphasis on establishing communication between health professionals, family and the person with dementia to better understand goals/preferences for care. CONCLUSION Inter-professional collaboration enables sharing of clinical experience/expertise, differing disciplinary perspectives and knowledge about the resident. Continuing a medication should be considered an active decision that carries as much responsibility as starting or deprescribing.
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Affiliation(s)
- Domenica Disalvo
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, 235 Jones St, Ultimo, Sydney, NSW, Australia.
| | - Tim Luckett
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, 235 Jones St, Ultimo, Sydney, NSW, Australia
| | | | | | - Meera Agar
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, 235 Jones St, Ultimo, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
- Ingham Institute of Applied Medical Research, Sydney, NSW, Australia
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Morin L, Wastesson JW, Laroche ML, Fastbom J, Johnell K. How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study. Palliat Med 2019; 33:1080-1090. [PMID: 31172885 PMCID: PMC6691599 DOI: 10.1177/0269216319854013] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The high burden of disease-oriented drugs among older adults with limited life expectancy raises important questions about the potential futility of care. AIM To describe the use of drugs of questionable clinical benefit during the last 3 months of life of older adults who died from life-limiting conditions. DESIGN Longitudinal, retrospective cohort study of decedents. Death certificate data were linked to administrative and healthcare registries with national coverage in Sweden. SETTING Older adults (≥75 years) who died from conditions potentially amenable to palliative care between 1 January and 31 December 2015 in Sweden. We identified drugs of questionable clinical benefit from a set of consensus-based criteria. RESULTS A total of 58,415 decedents were included (mean age, 87.0 years). During their last 3 months of life, they received on average 8.9 different drugs. Overall, 32.0% of older adults continued and 14.0% initiated at least one drug of questionable clinical benefit (e.g. statins, calcium supplements, vitamin D, bisphosphonates, antidementia drugs). These proportions were highest among younger individuals (i.e. aged 75-84 years), among people who died from organ failure and among those with a large number of coexisting chronic conditions. Excluding people who died from acute and potentially unpredictable fatal events had little influence on the results. CONCLUSION A substantial share of older persons with life-limiting diseases receive drugs of questionable clinical benefit during their last months of life. Adequate training, guidance and resources are needed to rationalize and deprescribe drug treatments for older adults near the end of life.
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Affiliation(s)
- Lucas Morin
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden.,2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas W Wastesson
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden.,2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marie-Laure Laroche
- 3 Centre de pharmacovigilance et de pharmaco-épidémiologie, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, CHU Limoges, Limoges, France.,4 INSERM 1248, University of Limoges, CHU Limoges, Limoges, France
| | - Johan Fastbom
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Johnell
- 2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Bertolotti M, Lancellotti G, Mussi C. Management of high cholesterol levels in older people. Geriatr Gerontol Int 2019; 19:375-383. [PMID: 30900369 DOI: 10.1111/ggi.13647] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 01/23/2019] [Accepted: 01/31/2019] [Indexed: 12/22/2022]
Abstract
The management of hypercholesterolemia in older adults still represents a challenge in clinical medicine. The pathophysiological alterations of cholesterol metabolism associated with aging are still incompletely understood, even if epidemiological evidence suggests that serum cholesterol levels increase with ongoing age, possibly with a plateau after the age of 80 years. Age is also one of the main determinants of cardiovascular disease, according to all cardiovascular risk estimate tools. Cholesterol-lowering treatment, therefore, would be expected to bring significant protection, even in these patients. Unfortunately, direct experimental evidence is extremely limited, particularly in the very old age strata of the population; a clinical benefit still seems to be present, but the risk for drug-related adverse events is clearly higher. At any rate, at the present time, definite guidelines for the correct management of hypercholesterolemia in older patients are not available. Therefore, the decision whether or not a pharmacological treatment should be set up, and the choice of the drug, need to be tailored to the individual patient, and requires accurate clinical judgment. The specific aspects of frailty and disability, along with the actual age of the patients, have to be considered together, with a comprehensive assessment approach. The present review summarizes the evidence regarding the modifications of cholesterol metabolism in older patients, the impact of lipid-lowering drugs on cardiovascular outcomes and focuses on the considerations that can help to define the most appropriate treatment strategy, in view of the individual functional profile. Geriatr Gerontol Int 2019; 19: 375-383.
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Affiliation(s)
- Marco Bertolotti
- Department of Biomedical, Metabolic and Neural Sciences, Center for Gerontological Evaluation and Research, University of Modena and Reggio Emilia, Modena, Italy.,Division of Geriatric Medicine, City Hospital Sant'Agostino-Estense of Modena, Modena, Italy
| | - Giulia Lancellotti
- Department of Biomedical, Metabolic and Neural Sciences, Center for Gerontological Evaluation and Research, University of Modena and Reggio Emilia, Modena, Italy.,Division of Geriatric Medicine, City Hospital Sant'Agostino-Estense of Modena, Modena, Italy
| | - Chiara Mussi
- Department of Biomedical, Metabolic and Neural Sciences, Center for Gerontological Evaluation and Research, University of Modena and Reggio Emilia, Modena, Italy.,Division of Geriatric Medicine, City Hospital Sant'Agostino-Estense of Modena, Modena, Italy
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STOPPFrail (Screening Tool of Older Persons’ Prescriptions in Frail adults with a limited life expectancy) criteria: application to a representative population awaiting long-term nursing care. Eur J Clin Pharmacol 2019; 75:723-731. [DOI: 10.1007/s00228-019-02630-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/10/2019] [Indexed: 11/28/2022]
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8
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Tana C, Lauretani F, Ticinesi A, Prati B, Nouvenne A, Meschi T. Molecular and Clinical Issues about the Risk of Venous Thromboembolism in Older Patients: A Focus on Parkinson's Disease and Parkinsonism. Int J Mol Sci 2018; 19:ijms19051299. [PMID: 29701703 PMCID: PMC5983741 DOI: 10.3390/ijms19051299] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 04/18/2018] [Accepted: 04/24/2018] [Indexed: 01/06/2023] Open
Abstract
Venous thromboembolism (VTE) is a common and potentially life-threatening condition which includes both deep-vein thrombosis (DVT) and pulmonary embolism (PE). VTE has a significant clinical and epidemiological impact in the elderly, and its incidence increases to more than 1% per year in older patients, suggesting the presence of specific age-related risk factors in this population. Immobilization seems to predominate as the main cause in patients admitted for medical acute illness in medicine wards, and there is evidence of a high risk in older patients with immobilization resulting from advanced forms of Parkinson’s disease (PD), regardless of the presence of an acute medical condition. In this review, we would to discuss the recent evidence on clinical, molecular and epidemiological features of VTE in older frail subjects focusing on patients with PD and parkinsonism. We also discuss some therapeutic issues about the risk prevention and we suggest a thorough comprehensive geriatric assessment that can represent an optimal strategy to identify and prevent the VTE risk in these patients.
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Affiliation(s)
- Claudio Tana
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
| | - Fulvio Lauretani
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
- Department of Medicine and Surgery, University-Hospital of Parma, 43126 Parma, Italy.
- Cognitive and Motor Center, Medicine and Geriatric-Rehabilitation Department of Parma, University-Hospital of Parma, 43126 Parma, Italy.
| | - Andrea Ticinesi
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
- Department of Medicine and Surgery, University-Hospital of Parma, 43126 Parma, Italy.
| | - Beatrice Prati
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
| | - Antonio Nouvenne
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
| | - Tiziana Meschi
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
- Department of Medicine and Surgery, University-Hospital of Parma, 43126 Parma, Italy.
- Cognitive and Motor Center, Medicine and Geriatric-Rehabilitation Department of Parma, University-Hospital of Parma, 43126 Parma, Italy.
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