Medication review at the End of Life

Dr Helen WilsonConsultant Geriatric Medicine

January 2014

Stop the Medicalisation of Old Age

Medical ageism…

now includes over-investigation and subjecting frail elders to unpleasant, unnecessary, and unproved procedures and therapies.

Medication review

• Half of patients >75 years are taking more than four drugs

• Associated with • Falls• Hip fractures• Hospitalisation• Death

• Financial cost• Practicalities

Efficacy and Safety in Elderly

• Paucity of studies in elderly• Time to benefit• Amount of benefit• Compliance• Adverse drug reactions• Reduced ability to metabolise

or excrete drugs

What do patients want / expect from medication?

• Effective • Relief of symptoms• Prevention of disease / disability

• Safe – low incidence of adverse effects• Easy to take

• And at the end of life the priority is usually symptom control

Treating the doctor or the patient?

I used to be normal, 80 and normal: I woke up every morning alive. I fed my dog Bruno, I’d read the papers, drink my coffee and walk the dog. Lower is good my doctor said – lower cholesterol, lower blood pressure, lower blood sugar. I feel good, but my numbers should be lower my doctor said.

I think clearly, but I have a case of MIND, my doctor said: Memory Impairment No Dementia (yet). New prescriptions now: cholesterol pills, sugar pills, pressure pills, memory pills. Now my numbers are normal, my doctor says.

My doctor is happy. But I feel bad. I think slow, my muscles ache. Here comes Mr Frail. I am OK now, my doctor says. (Ode to Mr Frail, M Raji)

Potentially Inappropriate Prescription (PIP)

• A medication for which the potential harm outweighs the benefit and for which a suitable alternative is available

PIP in fallers attending A&E

• 1016 patients• Half required admission• 63% took more than four drugs• 42% had one or more PIP• 30% had received hypnosedatives in the

preceding year• 17% were taking anxiolytics• 15% were prescribed antipsychotics

Age and Aging 2014;43:44-50

Inappropriate Prescription

• Wrong indication• No indication• Inappropriate dose• High risk of adverse event • Of unlikely benefit• Unnecessarily expensive• Too short or too long a time period• Under-prescribing

Evidence for Drug cessation at the end of life

• Discontinuation of drugs aimed at prolonging or preventing clinical events with no symptomatic benefit

• Very little published • Recent review article Tischa JM Age and Aging 2014;43:20-25

• Need to develop a consensus criteria for inappropriate prescriptions at the end of life

De-prescribing towards the end of life

• In conjunction with patient / carer• Establishing priorities• Relaxing targets for therapy such as BP and

blood sugars• Avoid sense of hopelessness

Beers Criteria

• Mark Beers, American Geriatrician 1991• Catalogue of potentially inappropriate

medications for the elderly due to pharmacological properties and physiological changes in aging

• Updated and evidence based 2012• Based on US prescribing

STOPP / START tool – O’Mahony and Gallagher

• STOPP• Screening Tool of Older Peoples potentially

inappropriate Prescriptions

• START• Screening Tool to Alert doctors to Right

Treatments

Gallagher et al, Age and Aging 2009, 38(5), 603

• 18 expert opinions• Delphi technique (2 rounds)• STOPP criteria (65)• START criteria (22)

Use of STOPP / START

• Secondary Care • Potentially inappropriate prescribing (STOPP) 34%• Potential Omissions (START) 57%

Gallagher et al, Age and Aging, 2008

• Nursing Homes • Potentially inappropriate prescribing (STOPP) 55%

Ryan et al, Ir J Med Sci, 2009O’Sullivan et al, Eur Ger Med,

2010• Primary Care• Potentially inappropriate prescribing (STOPP) 21%• Potential Omissions (START) 22%

Ryan et al,Br J Clin Pharm, 2009

Financial Implications of STOPP

• Economic Implications of potentially inappropriate prescribing

• Irish Population based study• 36% inappropriate prescribing• 45 million Euro

Cahir et al, Br J Clin Pharmacology 2010, 69, 543

Evidence for De-prescribing

• Israeli paper• Discontinued 332 drugs in 119 patients• Followed evidence based consensus where

adverse effects outweighed any benefits• De-prescribing failed in 18% patients• Mortality fell (21% compared with 45% in control

group)• Fewer patients required hospital admission

De-prescribing

• Is associated with • reduction in mortality• Reduction in hospital admissions• Reduced falls

British Geriatric Society Support

• Autumn meeting • Commissioning for care

homes• Session on dying in care

homes not hospital• Anticipatory care

documentation – less than 8% have anything written down

The Kings Fund

Questions to ask

• Is the drug still needed?• Has the condition changed?• Can the patient continue to benefit?• Has the evidence changed? • Have the guidelines changed?• Is the drug being used to treat an iatrogenic problem?• What are the ethical issues about withholding care? • Would discontinuation cause problems?

Some therapies should not be stopped abruptly following long-term use.

Stopping Medicines, WeMeReC 2010

Boyd and Murray, 2010

• Would I be surprised if this person were to die in the next 12 months?

• Review goals of care• Revision of treatments – particularly those

for secondary prevention• Limit investigations

Case Study

• Frail 84 year old lady • Previously at home with qds care package• Being discharged to NH following admission

with hip fracture and profound anaemia• Rotunda transfers to recliner chair• Needs assistance with all ADLs• Doubly incontinent

Medical Problem List

• Vascular Dementia (MMSE 14)• Ischaemic heart disease – no recent angina• Atrial Fibrillation with no history of stroke• Admission with Congestive cardiac failure 2 yrs ago• Diabetes – was overweight but lost 4 st over last yr • History of bullous pemphigoid 5 yrs ago• Anaemia investigated 5 yrs ago and attributed to

diverticulosis • CKD stage 4

Exercise in De-prescribing at End of Life

• Digoxin 125mcg• Warfarin 3mg• Bisoprolol 2.5mg• Ramipril 2.5mg• Bumetanide 1mg od• Simvastatin 40mg• Metformin 500mg bd• Gliclazide 40mg od

• Certirazine 10mg• Lansoprazole 15mg• Prednisolone 5mg• Paracetamol 1g qds• Ferrous sulphate

200mg bd• Adcal D3 bd• Nitrazepam 5mg

Exercise in De-prescribing at End of Life

• Digoxin 125mcg• Warfarin 3mg• Bisoprolol 2.5mg• Ramipril 2.5mg• Bumetanide 1mg od• Simvastatin 40mg• Metformin 500mg bd• Gliclazide 40mg od

• Certirazine 10mg• Lansoprazole 15mg• Prednisolone 5mg• Paracetamol 1g qds• Ferrous sulphate

200mg bd• Adcal D3 bd• Nitrazepam 5mg