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.

The ‘Geriatrician’s Salute’: emerging evidence on deprescribing

Professor Sarah Hilmer works as a geriatrician and clinical pharmacologist at Royal North Shore Hospital in Sydney, and conjoint professor of geriatric pharmacology at Sydney University, Australia.  Dr Danijela Gnjidic is a pharmacologist who is a NHMRC Dementia Leadership Fellow and Senior Lecturer in Pharmacy Practice at Sydney University, Australia. 

One of the most reversible causes of a geriatric syndrome in our older patients is an adverse drug event.  Approximately 1 in 5 hospital admissions amongst older people are due to adverse drug reactions and during their time in hospital 1 in 6 older people experience an adverse drug reaction.  Consequently, comprehensive medication review is an integral part of the practice of geriatric medicine.

The process of a health professional withdrawing medicines for which the current risk may outweigh the benefit in their patient has been given a variety of names including the ‘geriatrician’s salute’ and increasingly ‘deprescribing’. 

Catching some zzz’s with Z-drugs? You might want to reconsider

Dr Ilan Matok heads the pharmacoepidemiology research unit in the Hebrew University of Jerusalem’s School of Pharmacy, and directs research evaluating the safety of medication. Their research was recently published in Age and Ageing.

Insomnia is a very common medical complaint, and increases with age. Patients with insomnia often report increased daytime fatigue, confusion, anxiety, and depression. While insomnia can have a significant negative impact on quality of life, a recent study highlights the need for careful consideration in the use of sleeping medication to manage this condition, especially among older adults.

It is widely recognized that the use of traditional “benzodiazepine” type sleeping medication (e.g. nitrazepam), increase the risk of fractures and falls in older adults. However, less is known about the safety of “non-benzodiazepine” sleeping medication, otherwise known as “Z-drugs” (e.g zopiclone). In fact, these drugs have been marketed as safer than benzodiazepine medication, and are often perceived as such by clinicians and patients alike.

Antidementia medication may improve survival in Alzheimer’s disease

Dr Christoph Mueller is an Academic Clinical Lecturer at the Department of Old Age Psychiatry at King’s College London. He and his co-authors published a paper on the influence of antidementia medication on survival in Alzheimer’s disease in Age and Ageing. He tweets at @DrChrisMueller

At present Acetylcholinesterase inhibitors, as Donepezil or Rivastigmine, are the only medications available for treatment of the early stages of Alzheimer’s disease. They can slow down the progression of the illness and alleviate distressing symptoms. However, their benefits are modest and they can have side effects, such as a slow heartbeat, indigestion, weight loss or an increased risk of falls. Moreover, dementia and Alzheimer’s disease is the leading cause of death for men and women 80 years or older in England and Wales. We investigated whether being prescribed antidementia medication was associated with survival in patients with Alzheimer’s disease.

Always on my mind: Understanding the role of music in dementia

Sally Bowell is a Research Fellow at the International Longevity Centre – UK (ILC-UK). In this blog post she discusses a new Commission on Dementia and Music, set up and run by ILC-UK.

Music is an undeniably significant part of being human. It spans different genres, cultures and eras, and it promotes bonding, communication and wellbeing.

From listening to music in the car, to playing in an orchestra, discussing the charts, to joking about each other’s ‘bad’ music tastes: music is a crucial part of daily life.

Research also suggests that our connection to music stays with us throughout our lives, even whilst living with dementia. This powerful notion underpins the creation of a new Commission on Dementia and Music, being coordinated by the International Longevity Centre – UK (ILC-UK) and funded by the Utley Foundation.

Frailty among older persons living with HIV: a new burden for their clinical care

Alfonso Zamudio-Rodriguez holds a master’s degree in Public Health and is interested in frailty of older persons living with HIV. He develops his work in the department of Dr. Ávila-Funes @geriatriainnsz at the National Institute of Medical Science and Nutrition Salvador Zubiran, Mexico City.

Population ageing remains a continuous challenge for health care providers due to the escalating number of patients with chronic conditions. This represents a considerable economic burden for health systems across the globe. Ever since its debut in the 80’s, prevention, early diagnosis, and treatment of human immunodeficiency virus (HIV) infection has captured the attention of the scientific community. Highly active antiretroviral therapy (HAART) radically modified the paradigm of living with HIV by prolonging survival and improving the prognosis of a previously terminal disease. Today, thanks to HAART, HIV is a chronic condition with a life expectancy similar to that of the general population and a significantly improved quality of life. However, the changes in survival for HIV infected individuals have unearthed the appearance at an earlier age of health problems that used to be observed exclusively in older adults.

July 2017 issue of Age and Ageing journal is out now

The July 2017 issue of Age and Ageing, the journal of the British Geriatrics Society is out now.  A full table of contents is available here, with editorials, research papers, reviews, short reports, case reports book reviews and more.

Hot topics in this issue include:

Care home leadership

Physical restraint

Diet and muscle function

Prescribing for frail older
adults

Treatment of overactive
bladder

The Editor’s View article gives an overview of the issue with a summary of highlights. This article is free to read and can be viewed here.

Older HIV-Infected Adults are Geriatricians’ Business

Fátima Brañas is a consultant geriatrician and the clinical lead for orthogeriatrics at the Infanta Leonor University Hospital in Madrid (Spain). She holds a PhD, specializing in HIV infection in older adults, and is working hard in this field—from both a clinical and a research point of view—to provide all the benefits of a geriatric assessment for older HIV-infected adults. She recently co-authored ‘Frailty and physical function in older HIV-infected adults‘ @FatimaBranas

The HIV-infected population is aging due to the success of combination antiretroviral therapy, which prolongs survival, and also because of the growing number of newly diagnosed cases in older adults. Nowadays, over half of people infected with HIV are older than fifty years, which is the age cutoff accepted by the scientific community to consider someone an HIV-infected older adult. Fifty is only their chronological age, but biologically they are older, as accelerated aging in this population has been demonstrated. So, it seems that in the coming years, HIV care is going to be focused on a growing group of older adults and their specific problems. This means more than only survival, infection control, or avoiding the adverse events caused by antiretroviral drugs; it also includes consideration of comorbidities, polypharmacy, functional decline, and geriatric syndromes.

Thyroxine treatment is a serious business

Timo Strandberg is a Professor of Geriatrics who works at the Universities of Helsinki and Oulu.

Amid important clinical issues such as the dangers of dental amalgam fillings, the evils of chronic candida yeast syndrome, the big benefits of low-carb diets and the like, thyroxine has been on the headlines during recent years. We’ve heard especially about the lack of thyroxine, and even some distinguished colleagues seem to have thought that if you’re a bit depressed, tired, cognitively impaired, gaining weight etc. thyroxine is the drug for you. Accordingly, treatments with this hormone have clearly increased, for example in the UK 3-fold between 1998 and 2010, and treatment for marginally elevated thyroid-stimulating hormone (TSH) levels have become more common. And lo and behold: patients often get better – at least temporarily (ever heard of the placebo effect?).

Dropping the drugs: Who? What? Why?

Danielle Ní Chróinín is a geriatrician at St. Vincent’s Hospital, Sydney, who has a keen interest in research, education, and anything related to geriatric medicine. Her paper on deprescribing is published in the latest edition of Age and Ageing and can be accessed online now.

Mr. T. is an 85 year-old man who has been attending your Geriatric Clinic for the last couple of years. He has a background of hypertension, ischaemic heart disease, osteoarthitis of his knees, and constipation. He now has moderate dementia, with a progressively worsening Mini-Mental State Examination score, 17/30 today. His wife, with whom he lives, has taken over the shopping and financial duties.

Blood pressure is up, once again, at clinic today. His current medications include aspirin, a statin, a calcium channel blocker, an ACE inhibitor, laxatives, donepezil, paracetamol and tramadol. If you shook him, he just might rattle…

Polypharmacy is ridiculously prevalent- 42% of over-50s in Australia are taking five or more medications; terms such as ‘hyperpolypharmacy’ (≥10 drugs), have been coined, in an attempt to stratify polydrug recipients in the context of a multiple-medications epidemic.

So, would you stop any of Mr. T.’s drugs? Which ones? Why?

Immediately, or when he becomes frailer, more demented, more dependent, or when his life-expectancy has dropped to months? The evidence base for making these types of decisions is limited. And individual doctor (de)prescribing practices vary widely. In a survey of Antipodean physicians specialising in the care of older patients, we sought to explore the factors which influence our decisions to ‘stop the drugs’.

A hundred-and-thirty-four busy physicians kindly lay down their prescribing pens to answer our survey. Given a list of factors which might influence their deprescribing practices, these doctors most commonly rated limited life expectancy (96.2%) and cognitive impairment (84.1%) as very/extremely important to deprescribing practices. Interestingly, the age and gender of the doctor appeared to influence  the answers supplied. Older respondents less commonly rated functional dependency and limited life expectancy important when deprescribing. On the other hand, female participants, and trainees, more often rated adherence to evidence-based guidelines important.

Confronted with a series of five case vignettes, physicians were more likely to stop many of the listed medications as the case described a patient with increasing dependency and cognitive impairment.

So we asked: “Why are you stopping these medications?” The answers commonly centred on two central themes- dementia severity and pill burden. So it’s comforting to think that if I ever develop bad Alzheimer’s disease, one of these doctors might take a look at my medication list, and strike off a couple of tablets, so that I can enjoy an ice-cream unencumbered by hidden pills. Or that if I ever end up the victim of half-a-dozen different evidence-based guidelines, a sympathetic medic might kindly prioritise the top six or seven pharmaceuticals I really need.

But the fact is that the ‘right time’, the ‘right medications’ and the ‘right deprescriptions’ for frailer older persons aren’t always so clear. Such patients are most often notable for their absence from randomised trials. But a dramatic red pen-slash, crossing off the whole shebang, may not be appropriate outside of an end-of-life scenario. Our geriatric cohort can be the victims of missed treatment opportunities, and not just over-medication. Studies continue to evolve, assessing the benefit and harms of prescribing- and deprescribing- in such patients. In the interim, I admit I mostly rely on the good habit that my first bosses drummed into me: review the meds list regularly, and look at the whole person and not just the diagnosis list. It’s likely Mr. T. will thank you for it.