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Frisk G, Szilcz M, Hedman C, Björkhem-Bergman L. Treatment with Antithrombotics in the Last Year of Life-Incidence of Bleeding and Side Effects After Deprescribing. J Palliat Med 2024. [PMID: 38973710 DOI: 10.1089/jpm.2024.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
Background: Patients in palliative care are often treated with antithrombotics, even in the late stages of disease. Clear guidelines regarding deprescribing are lacking. Objective: The aims of this study were to investigate bleeding as a side effect of antithrombotic treatments the last year in life and map the timing of deprescribing. Methods: A retrospective cohort study was performed. All medical records were screened for deceased patients admitted to a palliative care unit in Stockholm, Sweden, over a 3-year period. Patients with antithrombotics were identified; data on bleeding, and on side effects due to deprescribing, were extracted from the medical records. Log-binomial models were used to explore factors associated with bleeding. Results: Of 1501 patients, 897 were treated with antithrombotics during the last year of life (mean age 75 years, 41% women). Of these, 56% continued treatment up until the last 3 days of life. Of the 897 patients, 144 (16%) had at least one bleeding during the treatment. The risk for bleeding was significantly higher for men with prostate cancer compared to other cancer forms, adjusted relative risk 1.9 (95% CI 1.1-3.2). No difference in risk for bleeding was found between sex, age groups, type of antithrombotics, or indication. Two patients (0.2%) developed strokes after antithrombotics were deprescribed. Conclusions: Treatment with antithrombotics during the last year of life is associated with a high risk of bleeding. In this cohort, men with prostate cancer seemed to have more side effects of bleeding than other groups. Few experienced side effects from deprescribing.
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Affiliation(s)
- Gabriella Frisk
- ASIH Stockholm Södra, Specialized home care and Specialized palliative ward, Älvsjö, Sweden
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Huddinge, Sweden
| | - Máté Szilcz
- Department of Medical Epidemiology and Biostatistics, C8 Medicinsk epidemiologi och biostatistik, MEB Jonell, Karolinska Institutet, Stockholm, Sweden
| | - Christel Hedman
- Stockholms Sjukhems R&D Department, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Clinician Sciences Lund, Lund University, Lund, Sweden
| | - Linda Björkhem-Bergman
- ASIH Stockholm Södra, Specialized home care and Specialized palliative ward, Älvsjö, Sweden
- Stockholms Sjukhems R&D Department, Stockholm, Sweden
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2
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Mughrabi AE, Salmany SS, Aljarrat B, Dabbous A, Ayyalawwad H. Appropriate use of medication among home care adult cancer patients at end of life: a retrospective observational study. BMC Palliat Care 2024; 23:108. [PMID: 38671427 PMCID: PMC11046754 DOI: 10.1186/s12904-024-01432-4] [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: 01/04/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Medications are commonly used for symptom control in cancer patients at the end of life. This study aimed to evaluate medication utilization among home care palliative patients with cancer at the end of life and assess the appropriateness of these medications. METHOD This retrospective observational study included adult cancer patients who received home care in 2020. Medications taken during the last month of the patient's life were reviewed and classified into three major categories: potentially avoidable, defined as medications that usually have no place at the end of life because the time to benefit is shorter than life expectancy; medications of uncertain appropriateness, defined as medications that need case-by-case evaluation because they could have a role at the end of life; and potentially appropriate, defined as medications that provide symptomatic relief. RESULTS In our study, we enrolled 353 patients, and 2707 medications were analyzed for appropriateness. Among those, 1712 (63.2%) were classified as potentially appropriate, 755 (27.9%) as potentially avoidable, and 240 (8.9%) as medications with uncertain appropriateness. The most common potentially avoidable medications were medications for peptic ulcers and gastroesophageal reflux disease (30.5%), vitamins (14.6%), beta-blockers (9.8%), anticoagulants (7.9%), oral antidiabetics (5.4%) and insulin products (5.3%). Among the potentially appropriate medications, opioid analgesics were the most frequently utilized medications (19.5%), followed by laxatives (19%), nonopioid analgesics (14.4%), gamma-aminobutyric acid analog analgesics (7.7%) and systemic corticosteroids (6%). CONCLUSION In home care cancer patients, approximately one-third of prescribed medications were considered potentially avoidable. Future measures to optimize medication use in this patient population are essential.
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Affiliation(s)
| | - Sewar S Salmany
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
| | | | - Ala'a Dabbous
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
| | - Haya Ayyalawwad
- Department of Nursing, King Hussein Cancer Center, Amman, Jordan
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Carollo M, Boccardi V, Crisafulli S, Conti V, Gnerre P, Miozzo S, Omodeo Salè E, Pieraccini F, Zamboni M, Marengoni A, Onder G, Trifirò G. Medication review and deprescribing in different healthcare settings: a position statement from an Italian scientific consortium. Aging Clin Exp Res 2024; 36:63. [PMID: 38459218 PMCID: PMC10923734 DOI: 10.1007/s40520-023-02679-2] [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: 11/22/2023] [Accepted: 12/17/2023] [Indexed: 03/10/2024]
Abstract
Recent medical advancements have increased life expectancy, leading to a surge in patients affected by multiple chronic diseases and consequent polypharmacy, especially among older adults. This scenario increases the risk of drug interactions and adverse drug reactions, highlighting the need for medication review and deprescribing to reduce inappropriate medications and optimize therapeutic regimens, with the ultimate goal to improving patients' health and quality of life. This position statement from the Italian Scientific Consortium on medication review and deprescribing aims to describe key elements, strategies, tools, timing, and healthcare professionals to be involved, for the implementation of medication review and deprescribing in different healthcare settings (i.e., primary care, hospital, long-term care facilities, and palliative care). Challenges and potential solutions for the implementation of medication review and deprescribing are also discussed.
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Affiliation(s)
- Massimo Carollo
- Department of Diagnostics and Public Health, University of Verona, P.Le L.A. Scuro 10, 37124, Verona, Italy
| | - Virginia Boccardi
- Institute of Gerontology and Geriatrics, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Salvatore Crisafulli
- Department of Diagnostics and Public Health, University of Verona, P.Le L.A. Scuro 10, 37124, Verona, Italy
| | - Valeria Conti
- Clinical Pharmacology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | | | - Simonetta Miozzo
- Italian Society of General Medicine and Primary Care, Florence, Italy
| | - Emanuela Omodeo Salè
- Division of Pharmacy, IEO European Institute of Oncology IRCCS, Milan, Italy
- IRCCS Centro Cardiologico Monzino, Milan, Italy
| | | | - Mauro Zamboni
- Department of Medicine-Geriatric Division, University of Verona, Verona, Italy
| | - Alessandra Marengoni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Graziano Onder
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - Gianluca Trifirò
- Department of Diagnostics and Public Health, University of Verona, P.Le L.A. Scuro 10, 37124, Verona, Italy.
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Alwidyan T, McCorry NK, Black C, Coulter R, Forbes J, Parsons C. Prescribing and deprescribing in older people with life-limiting illnesses receiving hospice care at the end of life: A longitudinal, retrospective cohort study. Palliat Med 2024; 38:121-130. [PMID: 38032069 PMCID: PMC10798021 DOI: 10.1177/02692163231209024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Although prescribing and deprescribing practices in older people have been the subject of much research generally, there are limited data in older people at the end of life. This highlights the need for research to determine prescribing and deprescribing patterns, as a first step to facilitate guideline development for medicines optimisation in this vulnerable population. AIMS To examine prescribing and deprescribing patterns in older people at the end of life and to determine the prevalence of potentially inappropriate medication use. DESIGN A longitudinal, retrospective cohort study where medical records of eligible participants were reviewed, and data extracted. Medication appropriateness was assessed using two sets of consensus-based criteria; the STOPPFrail criteria and criteria developed by Morin et al. SETTING/PARTICIPANTS Decedents aged 65 years and older admitted continuously for at least 14 days before death to three inpatient hospice units across Northern Ireland, who died between 1st January and 31st December 2018, and who had a known diagnosis, known cause of death and prescription data. Unexpected/sudden deaths were excluded. RESULTS Polypharmacy was reported to be continued until death in 96.2% of 106 decedents (mean age of 75.6 years). Most patients received at least one potentially inappropriate medication at the end of life according to the STOPPFrail and the criteria developed by Morin et al. (57.5 and 69.8% respectively). Limited prevalence of proactive deprescribing interventions was observed. CONCLUSIONS In the absence of systematic rationalisation of drug treatments, a substantial proportion of older patients continued to receive potentially inappropriate medication until death.
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Affiliation(s)
- Tahani Alwidyan
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, The Hashemite University, Zarqa, Jordan
| | - Noleen K McCorry
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, Northern Ireland, UK
| | | | | | - June Forbes
- Northern Ireland Hospice, Belfast, Northern Ireland, UK
| | - Carole Parsons
- School of Pharmacy, Queen’s University Belfast, Belfast, UK
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Porcu L, Recchia A, Bosetti C, Chiaruttini MV, Uggeri S, Lonati G, Ubezio P, Rizzi B, Corli O. Development and external validation of a predictive multivariable model for last-weeks survival of advanced cancer patients in the palliative home care setting (PACS). Support Care Cancer 2023; 31:536. [PMID: 37624424 DOI: 10.1007/s00520-023-07990-2] [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: 04/27/2023] [Accepted: 08/09/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE Various prognostic indexes have been proposed to improve physicians' ability to predict survival time in advanced cancer patients, admitted to palliative care (PC) with a survival probably to a few weeks of life, but no optimal score has been identified. The study aims therefore to develop and externally validate a new multivariable predictive model in this setting. METHODS We developed a model to predict short-term overall survival in cancer patients on the basis of clinical factors collected at PC admission. The model was developed on 1020 cancer patients prospectively enrolled to home palliative care at VIDAS Milan, Italy, between May 2018 and February 2020 and followed-up to June 2020, and validated in two separate samples of 544 home care and 247 hospice patients. RESULTS Among 68 clinical factors considered, five predictors were included in the predictive model, i.e., rattle, heart rate, anorexia, liver failure, and the Karnofsky performance status. Patient's survival probability at 5, 15, 30 and 45 days was estimated. The predictive model showed a good calibration and moderate discrimination (area under the receiver operating characteristic curve between 0.72 and 0.79) in the home care validation set, but model calibration was suboptimal in hospice patients. CONCLUSIONS The new multivariable predictive model for palliative cancer patients' survival (PACS model) includes clinical parameters routinely at patient's admission to PC and can be easily used to facilitate immediate and appropriate short-term clinical decisions for PC cancer patients in the home setting.
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Affiliation(s)
- Luca Porcu
- Methodological Research Unit, Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Angela Recchia
- Fondazione VIDAS, Via U. Ojetti, 66, 20151, Milan, Italy.
| | - Cristina Bosetti
- Unit of Cancer Epidemiology, Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Maria Vittoria Chiaruttini
- Unit of Cancer Epidemiology, Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Sara Uggeri
- Unit of Pain and Palliative Care Research, Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | - Paolo Ubezio
- Unit of Biophysics, Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Barbara Rizzi
- Fondazione VIDAS, Via U. Ojetti, 66, 20151, Milan, Italy
| | - Oscar Corli
- Unit of Pain and Palliative Care Research, Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
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Højen AA, Nielsen PB, Overvad TF, Albertsen IE, Klok FA, Rolving N, Søgaard M, Ording AG. Long-Term Management of Pulmonary Embolism: A Review of Consequences, Treatment, and Rehabilitation. J Clin Med 2022; 11:jcm11195970. [PMID: 36233833 PMCID: PMC9571065 DOI: 10.3390/jcm11195970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/29/2022] [Accepted: 10/01/2022] [Indexed: 12/02/2022] Open
Abstract
The concept of pulmonary embolism is evolving. Recent and emerging evidence on the treatment of specific patient populations, its secondary prevention, long-term complications, and the unmet need for rehabilitation has the potential to change clinical practice for the benefit of the patients. This review discusses the recent evidence from clinical trials, observational studies, and guidelines focusing on anticoagulation treatment, rehabilitation, emotional stress, quality of life, and the associated outcomes for patients with pulmonary embolism. Guidelines suggest that the type and duration of treatment with anticoagulation should be based on prevalent risk factors. Recent studies demonstrate that an anticoagulant treatment that is longer than two years may be effective and safe for some patients. The evidence for extended treatment in cancer patients is limited. Careful consideration is particularly necessary for pulmonary embolisms in pregnancy, cancer, and at the end of life. The rehabilitation and prevention of unnecessary deconditioning, emotional distress, and a reduced quality of life is an important, but currently they are unmet priorities for many patients with a pulmonary embolism. Future research could demonstrate optimal anticoagulant therapy durations, follow-ups, and rehabilitation, and effective patient-centered decision making at the end of life. A patient preferences and shared decision making should be incorporated in their routine care when weighing the benefits and risks with primary treatment and secondary prevention.
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Affiliation(s)
- Anette Arbjerg Højen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Thure Filskov Overvad
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Clinical Pharmacology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Ida Ehlers Albertsen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, 2333 Leiden, The Netherlands
| | - Nanna Rolving
- Department of Physical and Occupational Therapy, Aarhus University Hospital, 8200 Aarhus, Denmark
- Department of Public Health, Aarhus University, 8200 Aarhus, Denmark
| | - Mette Søgaard
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Anne Gulbech Ording
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
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Polypharmacy in Hospice and Palliative Care. Clin Geriatr Med 2022; 38:693-704. [DOI: 10.1016/j.cger.2022.05.009] [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]
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Recchia A, Rizzi B, Favero A, Nobili A, Pasina L. Prevalence of Delirium in End-of-Life Palliative Care Patients: An Observational Study. Med Princ Pract 2022; 31:118-124. [PMID: 35038708 PMCID: PMC9209975 DOI: 10.1159/000521994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 12/28/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the prevalence of delirium, using the Assessment Test for Delirium and Cognitive Impairment (4AT) in end-of-life palliative care patients. SUBJECTS AND METHODS This retrospective cross-sectional study was conducted on end-of-life patients in a hospice or at home. All patients were evaluated with the 4AT for the presence of delirium. RESULTS Of the 461 patients analyzed, 76 (16.5%) were inpatients and 83.5% (385) outpatients. The median age was 79.5 (72-86) years, and 51.0% were female. According to the 4AT score, 126 patients (27.3%) had delirium (A4T ≥4) at admission, 28 (36.8%) were inpatients, and 98 (25.5%) outpatients. Around 33.8% of the cancer inpatients had delirium, while 20.6% of the cancer outpatients had delirium. The prevalence of delirium varied according to the setting, clinical condition, and life expectancy. In addition, 55.0% (11) actively dying inpatients, within 3 days, had delirium, and 56.7% (17) outpatients had delirium; while among those with life expectancy longer than 4 days, 30.4% (17) inpatients and 22.8% (81) outpatients were with delirium. CONCLUSIONS Our study confirms that delirium is common in cancer and noncancer palliative care patients. Further research on delirium in end-of-life palliative care patients should consider the complexity of palliative care of this population as well as of the characteristics of the settings.
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Affiliation(s)
| | | | | | - Alessandro Nobili
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Luca Pasina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
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Tjia J, Lund JL, Mack DS, Mbrah A, Yuan Y, Chen Q, Osundolire S, McDermott CL. Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life. CURR EPIDEMIOL REP 2021; 8:116-129. [PMID: 34722115 PMCID: PMC8553236 DOI: 10.1007/s40471-021-00264-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Purpose of Review To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL). Recent Findings We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators. Summary EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind.
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Affiliation(s)
- Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA 01605, USA
| | - Jennifer L Lund
- Department of Epidemiology, UNC Gillings School of Global Public Health, UNC Chapel Hill, Chapel Hill, NC, USA
| | - Deborah S Mack
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA 01605, USA
| | - Attah Mbrah
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA 01605, USA
| | - Yiyang Yuan
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA 01605, USA
| | - Qiaoxi Chen
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA 01605, USA
| | - Seun Osundolire
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA 01605, USA
| | - Cara L McDermott
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
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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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11
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Huisman BAA, Geijteman ECT, Arevalo JJ, Dees MK, van Zuylen L, Szadek KM, van der Heide A, Steegers MAH. Use of antithrombotics at the end of life: an in-depth chart review study. BMC Palliat Care 2021; 20:110. [PMID: 34271885 PMCID: PMC8285840 DOI: 10.1186/s12904-021-00786-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/20/2021] [Indexed: 12/20/2022] Open
Abstract
Background Antithrombotics are frequently prescribed for patients with a limited life expectancy. In the last phase of life, when treatment is primarily focused on optimizing patients’ quality of life, the use of antithrombotics should be reconsidered. Methods We performed a secondary analysis of a retrospective review of 180 medical records of patients who had died of a malignant or non-malignant disease, at home, in a hospice or in a hospital, in the Netherlands. All medication prescriptions and clinical notes of patients using antithrombotics in the last three months of life were reviewed manually. We subsequently developed case vignettes based on a purposive sample, with variation in setting, age, gender, type of medication, and underlying disease. Results In total 60% (n=108) of patients had used antithrombotics in the last three months of life. Of all patients using antithrombotics 33.3 % died at home, 21.3 % in a hospice and 45.4 % in a hospital. In total, 157 antithrombotic prescriptions were registered; 30 prescriptions of vitamin K antagonists, 60 of heparins, and 66 of platelet aggregation inhibitors. Of 51 patients using heparins, 32 only received a prophylactic dose. In 75.9 % of patients antithrombotics were continued until the last week before death. Case vignettes suggest that inability to swallow, bleeding complications or the dying phase were important factors in making decisions about the use of antithrombotics. Conclusions Antithrombotics in patients with a life limiting disease are often continued until shortly before death. Clinical guidance may support physicians to reconsider (dis)continuation of antithrombotics and discuss this with the patient. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00786-3.
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Affiliation(s)
- Bregje A A Huisman
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands. .,Hospice Kuria, 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
| | - Jimmy J Arevalo
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Marianne K Dees
- Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Karolina M Szadek
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Monique A H Steegers
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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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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Anticholinergic load and delirium in end-of-life patients. Eur J Clin Pharmacol 2021; 77:1419-1424. [PMID: 33733683 DOI: 10.1007/s00228-021-03125-w] [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] [Received: 12/04/2020] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Delirium is a neuropsychiatric syndrome associated with negative outcomes, including worsening of cognitive and functional status and an increased burden on patients and caregivers. Medications with anticholinergic effect have been associated with delirium symptoms, but the relationship is still debated. OBJECTIVE To assess the relation between delirium and anticholinergic load according to the hypothesis that the cumulative anticholinergic burden increases the risk of delirium. METHODS This retrospective cross-sectional study was conducted in a sample of end-of-life patients in a hospice or living at home between February and August 2019. Delirium was diagnosed on admission using the 4 'A's Test (4AT) and each patient's anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale. RESULTS Of the 461 eligible for analysis, 124 (26.9%) had delirium. Anticholinergic medications were associated with an increased risk of delirium in univariate (OR (95% CI) 1.26 (1.16-1.38), p < 0.0001) and multivariate models adjusted for age, sex, dementia, tumors, Karnofsky Performance Status (KPS) score, days of palliative assistance, and setting (OR (95% CI) 1.16 (1.05-1.28), p < 0.0001). Patients with delirium had a greater anticholinergic burden than those without, with a dose-effect relationship between total ACB score and delirium. Patients who scored 4 or more had 2 or 3 times the risk of delirium than those not taking anticholinergic drugs. The dose-response relationship was maintained in the multivariate model. CONCLUSIONS Anticholinergic drugs may influence the development of delirium due to the cumulative effect of multiple medications with modest antimuscarinic activity.
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14
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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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15
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Abstract
The use of multiple medications is common in palliative care, putting patients at risk of adverse events and a high tablet burden. Deprescribing is the process of reviewing and stopping potentially inappropriate medications in order to improve quality of life. Barriers to deprescribing exist meaning many patients will take multiple medications despite being in the final months of life. The OncPal deprescribing guideline is a useful tool to support the process for patients with a limited life expectancy. There is evidence for the safety of stopping certain medications, particularly those aimed at primary prevention. A systematic process of reviewing individual medications and their appropriateness is recommended.
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Affiliation(s)
- Jo Thompson
- Royal Surrey County Hospital / St Luke's Cancer Centre, Guildford, UK
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