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.

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.

Getting to grips with multimorbidity and polypharmacy for older people

Dr Kevin Mc Namara is a Senior Research Fellow at Deakin University’s School of Medicine and Centre for Population Health Research. He has a particularly interest in the implementation of models for chronic disease prevention and management, including the management of multimorbidity. His paper, Health professional perspectives on the management of multimorbidity and polypharmacy for older patients in Australia, has been published in Age and Ageing.

Researchers from Australia offer some valuable insights about effective multidisciplinary care for older people who often have multiple health conditions (multimorbidity) and take multiple medications (polypharmacy). In ageing populations across the developed world, multimorbidity and polypharmacy pose unique and growing challenges for health professionals and systems. Treatments and goals for different health conditions are often not compatible, guideline recommendations may not be feasible, the evidence often lacking for older adults, and health systems are not designed to coordinate the activities of multiple health professionals often involved with care.

Getting to grips with multimorbidity and polypharmacy for older people

Dr Kevin Mc Namara is a Senior Research Fellow at Deakin University’s School of Medicine and Centre for Population Health Research. He has a particularly interest in the implementation of models for chronic disease prevention and management, including the management of multimorbidity. His paper, Health professional perspectives on the management of multimorbidity and polypharmacy for older patients in Australia, has been published in Age and Ageing journal.

Researchers from Australia offer some valuable insights about effective multidisciplinary care for older people who often have multiple health conditions (multimorbidity) and take multiple medications (polypharmacy). In ageing populations across the developed world, multimorbidity and polypharmacy pose unique and growing challenges for health professionals and systems. Treatments and goals for different health conditions are often not compatible, guideline recommendations may not be feasible, the evidence often lacking for older adults, and health systems are not designed to coordinate the activities of multiple health professionals often involved with care.

Can doing nothing sometimes be the best approach?

Dr Amit Arora is a Consultant Physician and Geriatrician at University Hospital of North Staffordshire, Stoke on Trent and an Honorary Clinical Lecturer at Keele University.

You may have seen recent stories in the national media about a new campaign launched by the Academy of Medical Royal Colleges called Choosing Wisely. It says that patients should be encouraged to ask if tests are really needed, that doctors should discuss potential harms of treatment with patients, and calls for experts to develop lists of common practices that should be stopped.

Inappropriate drug use among older persons: is it time for action?

Andreas Schoenenberger works with the Division of Geriatrics, Department of General Internal Medicine at Bern University Hospital, and with the University of Bern, Switzerland. Here he describes his recent editorial in Age and Ageing journal, written with Andreas Stuck.

Despite recent efforts to improve drug management for older people, we have not yet arrived at an optimal strategy for reducing inappropriate drug use. Drugs are considered inappropriate, if the risk outweighs the potential benefit of the drug. Along with pathophysiological changes during the ageing process, and the increasing number of co-morbidities/-medications, the potential risks of drugs increase with age and adverse drug reactions (ADRs) are encountered more frequently in older persons.

Medicines management of polypharmacy – Making it Safe and Sound

Stephen Jackson is Professor of Clinical Gerontology at King’s Health Partners

This is a recent King’s Fund Report which takes another look at polypharmacy. It is unclear why as there has been a rather better report published by NHS Scotland. One would assume the King’s fund would check who is doing what before commissioning such a report. Interestingly there is no mention of the G (geriatrician) word anywhere in the report although the terms “older care clinician”, “clinicians who specialise in care of older people” and orthogeriatrician do appear. I thought there was insufficient recognition of the fact that multiple pathology and hence polypharmacy is essentially a problem associated with ageing.  The authors rightly differentiate between appropriate polypharmacy and what they call problematic polypharmacy known to many as inappropriate polypharmacy. Polypharmacy merely means “many medicines” as opposed to “too many medicines”.  The report could be criticised for giving the impression that appropriate prescribing is only necessary when polypharmacy is present.

Which drugs to stop in which older patients?

Tischa van der Cammen is a Consultant Geriatrician and Carolyn Sterkeis a public health researcher. Both are based at the Erasmus University Medical Center in Rotterdam, Netherlands and have recently published a paper in Age and Ageing journal.

Drug treatment has brought many benefits for older patients. For example, the treatment of hypertension in patients aged over 80 led to a major reduction in stroke and mortality, as was shown in the HYVET study.

As people age, diseases may accumulate, and hence older patients usually are prescribed several drugs at the same time. It is ‘rule rather than exception’ that patients above age 75 use 4 or more drugs, this is called polypharmacy. There are a variety of definitions for polypharmacy – in the UK it is generally 4 or more prescribed medicines – as specified by Department of health and Rollason.

Inappropriate poly-pharmacy in older patients may lead to negative health impacts

Hypertension in people with dementia – what should we do?

Tomas Welsh is a Clinical Lecturer in the Medicine of Older People at the University of Nottingham and a recent recipient of a BGS grant to support research in geriatric medicine. 

Antihypertensive therapy is effective even in the oldest old. However, the large trials of antihypertensive medications, even in older people, frequently excluded people with dementia. This causes difficulties in applying these findings to many of our typical patient group.

People with dementia are more likely to be physically frail, are at higher risk of adverse events due to polypharmacy and are more likely to experience orthostatic hypotension than their cognitively intact peers.  There is reason to suspect, therefore, that the risk-benefit ratio of treating hypertension may be different in this group and many clinicians intuitively feel this to be the case.