Drug burden in older people approaching end of life

Dr. Denis Curtin is a specialist registrar in Geriatric Medicine in Cork University Hospital, Ireland. His paper Drug consumption and futile medication prescribing in the last year of life: an observational study was recently published the Age and Ageing journal.

The vast majority of older adults are admitted to hospital in their last year of life. For many of these people, hospitalizations are frequent and prolonged.

We reviewed the medical records of 410 older adults who were admitted to our hospital in the year prior to death. The median number of days spent in hospital was 32. While in hospital, patients consumed an average of 24 different medications. One-in-six patients consumed 35 or more individual medications. When discharged home from hospital, patients were prescribed an average of 2 unnecessary or inappropriate medications.

What sense can we make of this?

The results highlight that symptom burden is high in the last year of life and trials of different medications may be necessary to achieve good symptom control. Importantly, the results also show that high levels of medication consumption are due to the continued prescribing of unnecessary medications.

Physicians are often uncomfortable with the idea of stopping or deprescribing long-term medications. Fear of negative consequences – “What if I stop his statin and he has a stroke next week?” – seems to be the main barrier to deprescribing. STOPPFrail, a recently validated deprescribing tool for frail older people with limited life expectancy, may help allay such fears. The tool, developed by a panel with expertise in geriatric medicine, palliative care and general practice, highlights circumstances where commonly used medications can be safely stopped.  In our study, one-in-four long-term medications could have been stopped using this tool.

A hospital admission is often a major life event for an older person and physicians should consider it an opportunity to review and discuss goals of care. We know from previous studies that the number of drugs that a patient takes is the most important predictor of side effects. Older people with declining health are likely to be particularly vulnerable to these complications. If the goal of care is to enhance quality of life and alleviate troublesome symptoms, then surely we can help our patients by cutting out unnecessary medications?

Read the Age and Ageing Paper: Drug consumption and futile medication prescribing in the last year of life: an observational study

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