Burden of medications increases near the end of life
There is a sharp increase in polypharmacy throughout the last year of life of older adults, and this is driven not only by symptomatic medications but also by long-term preventive treatments of questionable benefit, according to a recent study.
“To reduce the burden of medications of questionable benefit in older adults with life-limiting illness, robust evidence about the benefit and safety of deprescribing is needed,” researchers said.
The proportion of individuals exposed to ≥10 different medications over the course of the final year before death increased from 30.3 to 47.2 percent (p<0.001 for trend). The largest increase in the number of drugs (mean difference, 3.37; 95 percent CI, 3.35 to 3.40) was among older adults who died from cancer, but an independent association existed between living in an institution and a slower escalation (β=−0.90; −0.92 to −0.87). [Am J Med 2017;130:927–936.e9]
The five most commonly used drug classes during the final month prior to death were analgesics (60.8 percent), antithrombotic agents (53.8 percent), diuretics (53.1 percent), psycholeptics (51.2 percent) and β-blocking agents (41.1 percent). Moreover, 21.4 percent of all individuals used angiotensin-converting enzyme inhibitors and 15.8 percent used statins during their final month of life.
These results match earlier studies. For example, McNeil et al found that patients with a life-limiting disease took on average 10.7 drugs at time of death, with 69 percent of patients using nine or more different medications. In addition, a retrospective cohort study of 100 patients who died from advanced cancer revealed a median of 11 prescribed drugs 9 days prior to death. [J Pain Symptom Manage 2016;51:178–183e2; Support Care Cancer 2016;24:2067–2074]
“Despite a considerable heterogeneity in study designs and populations, other studies investigating drug use near the end of life have reported comparable results,” researchers said. “These findings demonstrate the challenge of managing the accumulation of health problems in older adults with life-limiting illness.” [BMJ Support Palliat Care 2016;doi:10.1136/bmjspcare-2015-000941; Lancet Oncol 2015;16:e333–e341; Br Med J 2004;329:909–912]
Two key questions should be considered when assessing the value and the appropriateness of drug treatments in a context of limited life expectancy: (1) Is the patient’s life expectancy longer than the time needed for the medication to achieve its benefit? (2) Are the objectives of the prescribed medication in keeping with the goals of care that the physician and the patient discussed and agreed upon? [Arch Intern Med 2006;166:605–609]
“This prescribing model relies on the idea that drug treatments should be adapted to mirror the course of the disease as the remaining life expectancy diminishes,” researchers explained. “In other words, physicians should consider discontinuing drugs that may be effective and otherwise appropriate but whose potential harms outweigh the benefits that patients can reasonably expect before death occurs.”
“[B]ecause end-of-life situations are shaped by different disease trajectories, symptoms and personal preferences, the goals of care vary considerably from one person to another. Future clinical practice guidelines should thus foster personalized decision making rather than promote the systematic discontinuation of medications according to a one-size-fits-all set of criteria,” they added.
In this study, a total of 511,843 older adults (>65 years) who died in Sweden between 2007 and 2013 were identified. The investigators then reconstructed the decedents’ drug prescription history for each of the last 12 months of life through the Swedish Prescribed Drug Register. They evaluated the decedents’ characteristics at time of death through record linkage with the National Patient Register, the Social Services Register and the Swedish Education Register.