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Hattori Y, Hamada S, Yamanaka T, Kidana K, Iwagami M, Sakata N, Tamiya N, Kojima T, Ogawa S, Akishita M. Drug prescribing changes in the last year of life among homebound older adults: national retrospective cohort study. BMJ Support Palliat Care 2024; 13:e1156-e1165. [PMID: 35831182 DOI: 10.1136/spcare-2022-003639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/21/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study aimed to evaluate the prescription patterns of drugs during the last year of life in homebound older adults who received home medical care. METHODS We used a nationwide claims database in Japan and selected older adults aged ≥75 years who received home medical care services from ≥12 months before their death. We evaluated medications prescribed 12 months before death (month 12), 3 months before death (month 3) and in the last month of life (month 1). We explored the factors associated with the decreased number of cardiovascular preventive drugs from month 12 to both month 3 and month 1. RESULTS A total of 118 661 participants were included, and the majority were aged ≥90 years and women. The prevalence of cardiovascular preventive drugs decreased but remained common in month 1, which included antihypertensives (34.7%), antiplatelets (15.9%), oral anticoagulants (7.6%), antidiabetic drugs (7.3%) and lipid-lowering drugs (6.1%). The relative decrease from month 12 to month 1 was the largest for lipid-lowering drugs (44.8%) and the smallest for oral anticoagulants (13.6%). Among other drugs, laxatives (enema), antiemetics, oral corticosteroids, analgesics, expectorants, bronchodilators and antibiotics showed a large relative increase. Older age, duration of home medical care services for <1 year and diagnoses of cancer, dementia and Parkinson's disease were associated with a greater likelihood of a decreased number of cardiovascular preventive drugs. CONCLUSIONS There is room for deprescribing to avoid inappropriate polypharmacy by balancing preventive and symptom management drugs in those receiving home medical care with a limited life expectancy.
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Affiliation(s)
- Yukari Hattori
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shota Hamada
- Research Department, Institute for Health Economics 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, Tokyo, Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Takashi Yamanaka
- Department of Home Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiwami Kidana
- Department of Home Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masao Iwagami
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Nobuo Sakata
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Nanako Tamiya
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Taro Kojima
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sumito Ogawa
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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2
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Mahzoni H, Naghsh E, Sharifi M, Moghaddas A, Momenzadeh M, Moghaddas A. Potential Drug Interactions in Terminally-Ill Cancer Patients, a Report from the Middle East. J Pain Palliat Care Pharmacother 2023; 37:278-285. [PMID: 37712672 DOI: 10.1080/15360288.2023.2253223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 07/07/2023] [Accepted: 08/20/2023] [Indexed: 09/16/2023]
Abstract
This study aims to evaluate the epidemiology of potential drug interactions in terminally-ill cancer patients receiving exclusively supportive care. In this cross-sectional study, during a 6-month follow-up, we considered the medical record of terminally-ill cancer patients referred to palliative care at the cancer center in Isfahan, Iran. Potential drug-drug interactions (DDIs) were assessed by Lexi-Interact ver.1.1 online software. During the study period, 133 terminally-ill cancer patients were recruited. We detected 1678 DDIs with moderate or major severity levels. Among them, 330, 219, 32, 1075, and 51 interactions were categorized in B, C, D, and X drug interactions categories, respectively. One hundred and twenty-two patients (91.73%) encountered at least one potential drug-drug interaction during the end of life care. Mechanistically, most drug-drug interactions (64.5%) were pharmacodynamics. The most frequent pharmacological class of drugs responsible for DDIs were quetiapine (91 cases), oxycodone (87 cases), and sertraline (55 cases). Interaction between oxycodone and sertraline was found to be in the top 10 detected DDIs (13.7%). Our results showed that potentially moderate or major drug-drug interactions often occur among terminally-ill cancer patients and the clinical significance of DDIs should be considered meticulously in the palliative care cancer setting.
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Affiliation(s)
- Hamed Mahzoni
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Erfan Naghsh
- Research Associate, Department of Electrical, Computer and Biomedical Engineering, Toronto Metropolitan University, Toronto, Canada
| | - Mehran Sharifi
- Associate Professor of Internal Medicine, Department of Internal Medicine, Oncology and Hematology Section, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ayda Moghaddas
- Internal Medicine Physician, Department of Internal Medicine, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Momenzadeh
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azadeh Moghaddas
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Isfahan University of Medical Sciences, Isfahan, Iran
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3
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Soo JEJ, Chan MY, Bte Adb Rashid NAB, Bte Mohamad Yusri LI, Wynn YY, Noda M, Tewani K. Medication chart review at end of life of paediatric palliative patients. J Paediatr Child Health 2022; 58:392-396. [PMID: 34553811 DOI: 10.1111/jpc.15719] [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: 09/12/2020] [Revised: 02/18/2021] [Accepted: 08/10/2021] [Indexed: 11/28/2022]
Abstract
AIM This study aimed to review the use of medications in a paediatric palliative care (PPC) population during the last two weeks of life. METHODS This is a retrospective observational cohort study that included 50 consecutive patients who were referred to KK Hospital PPC service from 2011 to 2015. Those who died after two weeks from discharge date were excluded. Medication charts were reviewed and relevant data were extracted. RESULTS The study population included 42 patients and consists predominantly oncological and neurological diagnoses. The median number of medications used was 11.5. Ninety-five percent (40 out of 42) of study population required analgesia where 81% (34 out of 42) were opioid. There was prevalent use of antibiotics (86% of study population, 36 out of 42). Less frequently used medications included steroids, sedatives, laxatives and antiemetics (48%, 52%, 48% and 38% of study population respectively). CONCLUSION Significant number of medications was used in PPC during the last two weeks of life. Apart from significant use of analgesia, there is also notable use of antibiotics. Future directions in education such as prescription of laxatives with opioid are proposed.
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Affiliation(s)
| | - Mei Yoke Chan
- KK Women's and Children's Hospital, Singapore, Singapore
| | | | | | - Yi Yi Wynn
- KK Women's and Children's Hospital, Singapore, Singapore
| | - Misa Noda
- KK Women's and Children's Hospital, Singapore, Singapore
| | - Komal Tewani
- KK Women's and Children's Hospital, Singapore, Singapore
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4
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Kochovska S, Agar MR, Phillips JL, Tieman J, Sheehan C, Clark K, Currow DC. Applying evidence-based symptomatic treatments from other clinical disciplines to palliative care. Palliat Med 2021; 35:458-460. [PMID: 33641525 DOI: 10.1177/0269216321996984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Meera R Agar
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Jane L Phillips
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Jennifer Tieman
- Palliative and Supportive Services, Flinders University, Bedford Park, SA, Australia
| | | | - Katherine Clark
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia.,Northern Sydney Local Health District Cancer and Palliative Care Network, Sydney, NSW, Australia.,Royal North Shore Hospital, St Leonards, NSW, Australia.,The University of Sydney, Sydney, NSW, Australia
| | - David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia.,Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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5
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Chan YC, Yang MLC, Ho HF. Characteristics and Outcomes of Patients Referred to an Emergency Department-Based End-of-Life Care Service in Hong Kong: A Retrospective Cohort Study. Am J Hosp Palliat Care 2020; 38:25-31. [PMID: 32425050 DOI: 10.1177/1049909120926148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This study describes the characteristics and outcomes of patients referred to an emergency department (ED)-based end-of-life (EOL) service in a tertiary acute hospital in Hong Kong. We examine how emergency physicians (EPs) perform in recognizing and managing dying patients. METHODS From September 2010 to April 2018, patients referred to this EOL service in this hospital were included. A group of 5 EPs assessed whether the referred patient would die within a few days. Dying patients (EOL group) were admitted to ED-based EOL service whereas those not likely dying within few days (non-EOL group) would continue management in respective specialty wards. Baseline characteristics of these 2 groups were compared. The time-to-death and use of opioids and anticholinergics were compared. RESULTS In total, 783 of 830 patients assessed were recognized as being in dying phase, with 688 admitted under ED-based EOL care. Their demographics and characteristics were described. Mean time from assessment to death (time-to-death) was significantly less in EOL group (38.93 hours) than in non-EOL group (250.36 hours; P = .004). Mean time-to-death was not significantly different between those under EP-based EOL service or not. The ED-based EOL care had significantly more patients receiving symptomatic treatment. INTERPRETATION The characteristics of patients under an ED-based EOL service are described. Emergency physicians are capable of recognizing dying patients. Emergency department-based EOL service does not alter the dying process and offers adequate palliation of symptoms. Emergency physician should assume a more active role in providing adequate EOL care to suitable patients.
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Affiliation(s)
- Yat Chun Chan
- Department of Accident and Emergency, Queen Elizabeth Hospital, 434412Hospital Authority, Hong Kong
| | - Marc L C Yang
- Department of Accident and Emergency, Queen Elizabeth Hospital, 434412Hospital Authority, Hong Kong
| | - Hiu Fai Ho
- Department of Accident and Emergency, Queen Elizabeth Hospital, 434412Hospital Authority, Hong Kong
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6
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Inappropriate medications among end-of-life patients living at home: an Italian observational study. Eur Geriatr Med 2020; 11:505-510. [DOI: 10.1007/s41999-020-00315-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/23/2020] [Indexed: 01/12/2023]
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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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8
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Cytochrome P450 in Palliative Care and Hospice Kits. J Hosp Palliat Nurs 2019; 21:280-285. [DOI: 10.1097/njh.0000000000000524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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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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Pasina L, Brignolo Ottolini B, Cortesi L, Tettamanti M, Franchi C, Marengoni A, Mannucci PM, Nobili A. Need for Deprescribing in Hospital Elderly Patients Discharged with a Limited Life Expectancy: The REPOSI Study. Med Princ Pract 2019; 28:501-508. [PMID: 30889568 PMCID: PMC6944931 DOI: 10.1159/000499692] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 03/19/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Older people approaching the end of life are at a high risk for adverse drug reactions. Approaching the end of life should change the therapeutic aims, triggering a reduction in the number of drugs.The main aim of this study is to describe the preventive and symptomatic drug treatments prescribed to patients discharged with a limited life expectancy from internal medicine and geriatric wards. The secondary aim was to describe the potentially severe drug-drug interactions (DDI). MATERIALS AND METHODS We analyzed Registry of Polytherapies Societa Italiana di Medicina Interna (REPOSI), a network of internal medicine and geriatric wards, to describe the drug therapy of patients discharged with a limited life expectancy. RESULTS The study sample comprised 55 patients discharged with a limited life expectancy. Patients with at least 1 preventive medication that could be considered for deprescription at the end of life were significantly fewer from admission to discharge (n = 30; 54.5% vs. n = 21; 38.2%; p = 0.02). Angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, lipid-lowering drugs, and clonidine were the most frequent potentially avoidable medications prescribed at discharge, followed by xanthine oxidase inhibitors and drugs to prevent fractures. Thirty-seven (67.3%) patients were also exposed to at least 1 potentially severe DDI at discharge. CONCLUSION Hospital discharge is associated with a small reduction in the use of commonly prescribed preventive medications in patients discharged with a limited life expectancy. Cardiovascular drugs are the most frequent potentially avoidable preventive medications. A consensus framework or shared criteria for potentially inappropriate medication in elderly patients with limited life expectancy could be useful to further improve drug prescription.
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Affiliation(s)
- Luca Pasina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy,
| | | | - Laura Cortesi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Mauro Tettamanti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Carlotta Franchi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Alessandra Marengoni
- Geriatric Unit, Spedali Civili, Department of Medical and Surgery Sciences, University of Brescia, Brescia, Italy
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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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12
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Kuruvilla L, Weeks G, Eastman P, George J. Medication management for community palliative care patients and the role of a specialist palliative care pharmacist: A qualitative exploration of consumer and health care professional perspectives. Palliat Med 2018; 32:1369-1377. [PMID: 29793391 DOI: 10.1177/0269216318777390] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pharmacists have a key role to play in optimisation of medication regimens and promotion of medication safety. The role of specialist pharmacists as part of the multidisciplinary palliative care team, especially in the primary care setting, is not widely recognised. AIM To explore the perspectives of stakeholders about the gaps in the current model of community palliative care services in relation to medication management and to assess their opinions pertaining to the role of a specialist palliative care pharmacist in addressing some of those gaps. DESIGN Qualitative study utilising three focus groups involving 20 stakeholders. Thematic analysis was carried out using a framework approach and interpreted in the context of the Chronic Care Model for improving primary care for patients with chronic illness. SETTING/PARTICIPANTS Setting was a large regional Australian palliative care service. Participants included palliative care consumers and clinicians specifically patients, caregivers, physicians, nurses and pharmacists. RESULTS Five major themes emerged from the focus groups: access to resources, medicines and information; shared care; challenges of polypharmacy; informal caregiver needs and potential roles of a palliative care pharmacist. Gaps in access to medicines/resources, training for generalist practitioners, communication between treating teams and lack of support for patients and carers were cited as factors adversely impacting medication management in community-based palliative care. CONCLUSION While community-based palliative care is an essential aspect of meeting the health care demands of an ageing society, the current model has several gaps and limitations. An appropriately qualified and skilled pharmacist within the palliative care team may help to address some of the gaps in relation to medication access and appropriateness.
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Affiliation(s)
- Lisha Kuruvilla
- 1 Pharmacy Department, Barwon Health, Geelong, VIC, Australia.,2 Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Greg Weeks
- 1 Pharmacy Department, Barwon Health, Geelong, VIC, Australia.,2 Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Peter Eastman
- 3 Department of Palliative Care, Barwon Health, Geelong, VIC, Australia
| | - Johnson George
- 2 Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia.,4 School of Public Health and Preventative Medicine, Faculty of Medcine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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13
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Pasina L, Recchia A, Agosti P, Nobili A, Rizzi B. Prevalence of Preventive and Symptomatic Drug Treatments in Hospice Care: An Italian Observational Study. Am J Hosp Palliat Care 2018; 36:216-221. [PMID: 30114944 DOI: 10.1177/1049909118794926] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aim of pharmacotherapy in people at the end of life should be symptom control, more than prolonging life. Drugs for disease prevention should therefore be discouraged, but this is not the usual practice. The prevalence of unnecessary preventive drugs at the end of life is not well described, although some studies suggest it is common. METHODS This retrospective longitudinal study describes the prevalence of patients receiving preventive and symptomatic drug treatments at admission (T1) and before death (T2) in an Italian hospice. All adults admitted to the VIDAS hospice between March 2015 and February 2017 were included in the analysis. RESULTS The study sample comprised 589 end-of-life patients with a mean age of 75.3 (12.1) years. The mean number of drugs decreased from admission to the hospice to the time of death (mean [standard deviation]: 9.7 [3.4] and 8.7 [3.0]). All patients were appropriately treated with symptomatic drugs at T1 and T2, while there were significantly fewer patients from T1 to T2 with at least 1 preventive medication that could be considered for deprescription at the end of life (511, 86.8% and 286, 48.6%; P < .0001). CONCLUSIONS Hospice admission can be associated with a definite reduction in the use of commonly prescribed preventive medications. However, about half of end-of-life patients can be prescribed avoidable medications. Drugs for peptic ulcer and gastroesophageal reflux disease and antithrombotics were the potentially avoidable preventive medications most frequently prescribed at admission to the hospice and before death.
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Affiliation(s)
- Luca Pasina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, MI, Italy
| | | | - Pasquale Agosti
- Interdisciplinary Department of Medicine, University of Bari, BA, Italy
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Choosing Wisely? Measuring the Burden of Medications in Older Adults near the End of Life: Nationwide, Longitudinal Cohort Study. Am J Med 2017; 130:927-936.e9. [PMID: 28454668 DOI: 10.1016/j.amjmed.2017.02.028] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 02/01/2017] [Accepted: 02/01/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND The burden of medications near the end of life has recently come under scrutiny, because several studies suggested that people with life-limiting illness receive potentially futile treatments. METHODS We identified 511,843 older adults (>65 years) 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. Decedents' characteristics at time of death were assessed through record linkage with the National Patient Register, the Social Services Register, and the Swedish Education Register. RESULTS Over the course of the final year before death, the proportion of individuals exposed to ≥10 different drugs rose from 30.3% to 47.2% (P <.001 for trend). Although older adults who died from cancer had the largest increase in the number of drugs (mean difference, 3.37; 95% confidence interval, 3.35 to 3.40), living in an institution was independently associated with a slower escalation (β = -0.90, 95% confidence interval, -0.92 to -0.87). During the final month before death, analgesics (60.8%), anti-throm-botic agents (53.8%), diuretics (53.1%), psycholeptics (51.2%), and β-blocking agents (41.1%) were the 5 most commonly used drug classes. Angiotensin-converting enzyme inhibitors and statins were used by, respectively, 21.4% and 15.8% of all individuals during their final month of life. CONCLUSION Polypharmacy increases throughout the last year of life of older adults, fueled not only by symptomatic medications but also by long-term preventive treatments of questionable benefit. Clinical guidelines are needed to support physicians in their decision to continue or discontinue medications near the end of life.
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Hamada S, Gulliford MC. Drug prescribing during the last year of life in very old people with diabetes. Age Ageing 2017; 46:147-151. [PMID: 28181655 PMCID: PMC5388282 DOI: 10.1093/ageing/afw174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 10/05/2016] [Indexed: 12/24/2022] Open
Abstract
Objective to evaluate primary care drug utilisation during the last year of life, focusing on antidiabetic and cardiovascular drugs, in patients of advanced age with diabetes. Design population-based cohort study. Setting primary care database in the UK. Subjects patients with type 2 diabetes who died at over 80 years of age between 2011 and 13. Methods main outcome measures included proportions of patients prescribed different classes of drugs, comparing the first (Q1) and the fourth quarters (Q4) of the last year of life. Results the study included 5,324 patients, with the median age 86 years and 50% female. Three-fourths of the patients received five or more drugs, and the total number of drugs prescribed was almost stable at 6.2 ± 3.1 (mean ± SD) during the last year of life. Substantial proportions of patients were treated with antidiabetic drugs (78%), antihypertensive drugs (76%), statins (62%) and low-dose aspirin (46%) in Q1. Prescribing of these drugs slightly decreased by 3–8% in Q4. There were increases in prescribing of anti-infectives (35% in Q1 to 50% in Q4), drugs for nervous system (63% to 73%), drugs for respiratory system (24% to 33%) and systemic hormonal drugs (22% to 27%). Conclusion patients of advanced age with type 2 diabetes were often treated with antidiabetic and cardiovascular drugs even when approaching death. More research is needed to generate evidence to guide optimal drug utilisation for older people with a limited life expectancy.
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Affiliation(s)
- Shota Hamada
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
- Address correspondence to: S. Hamada, Department of Primary Care and Public Health Sciences, King's College London, 3rd floor, Addison House, London SE1 1UL, UK. Tel: +44 (0)20 7848 6426; Fax: +44 (0)20 7848 6620.
| | - Martin C. Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
- National Institute for Health Research (NIHR) Biomedical Research Centre at Guy's and St Thomas’ NHS Foundation Trust, London, UK
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