An 85-year-old woman with advanced Alzheimer disease, type II diabetes, hyperlipidemia, and osteoporosis presents with her family to her primary care provider's office for decreasing functionality at home. The patient, who lives alone, has difficulty with day-to-day tasks such as taking medications and managing bills and appointments. The patient recently wandered away from home but was found after a short time. How can you best help this patient and her caregivers?
AN AGING POPULATION
The United States is experiencing a demographic transformation. Each day, more than 10,000 Baby Boomers reach age 65 years.1 The number of people age 65 years and older increased by 33% from 37.2 million in 2006 to 49.2 million in 2016 and is projected to almost double to 98 million in 2060.2
The number of people age 85 years and older is projected to more than double from 6.4 million in 2016 to 14.6 million in 2040.2
This growth in the older population has led to the increased use of hospice benefits. In 2016, more than 1.4 million Medicare beneficiaries were enrolled in hospice care for 1 day or longer. Of the Medicare hospice beneficiaries, 95% were age 65 years or older and 64% were age 80 years or older.3
Due to this growth in the older population and hospice use, clinicians have an increasingly essential role in caring for patients near the end of life, including addressing the issues of medication management. Recognizing that a patient is reaching the end of life is as important as addressing medication issues. This article defines polypharmacy and futile medications, reviews guidelines for deprescribing in adults in the last year of life, and discusses how to properly engage patients in end-of-life decisions.
POLYPHARMACY AND FUTILE MEDICATIONS
Patients with a life expectancy of less than 1 year are at an increased risk of polypharmacy, commonly defined as the simultaneous use of five or more medications.4 A study of 2,623 adults in hospice found that each patient took an average of 10.2 daily medications.5 Polypharmacy is associated with multiple negative consequences, including an increased risk for adverse drug reactions, drug-drug interactions, and drug-disease interactions.6
Clinicians should think about the utility of all of a patient's medications. Some patients use symptom-specific medications (for example, to treat pain, dyspnea, or nausea) while at the same time take medications to control their terminal disease or prevent or manage chronic conditions.5,7,8 For this reason, it is better to define medications as either medically necessary or futile in patients approaching the end of life.4,9
Futile medications are medications that no longer provide benefit and may cause harm. Medications once classified as preventive could be categorized as futile in patients toward the end of life. Unfortunately, these medications are commonly prescribed to actively dying patients.8,10,11 Preventive drugs that are not consistent with the overall care plan should be discontinued.9,12
RECOGNIZING THE END OF LIFE
Recognizing that a patient is reaching the end of life can shift the clinician's focus from disease prevention to maximizing the patient's quality of life. A systematic review of observational studies determined that a decline in activities of daily living (ADLs) is the strongest predictor of mortality in adults age 60 years and older.13,14 The Walter Index incorporates this criterion to predict the 1-year life expectancy.15
After a patient has been identified as being near the end of life, consider a medication review to identify futile medications. We recommend using the STOPPFrail criteria to assist in deprescribing futile medications.16 This tool comprises 27 criteria relating to medications that are potentially futile in patients over age 65 years who have limited life expectancy. The first two criteria recommend deprescribing any drug when compliance is poor and deprescribing any drug without an indication. The other 25 criteria review drug classification to assess the purpose in this patient population (for example, statins, bisphosphonates, and muscarinic antagonists).16 STOPPFrail was created based on an expert panel consensus and was designed to be simple to use in a clinical setting.
BENEFITS OF DEPRESCRIBING
Throughout a patient's lifespan, prescribed medications should be regularly monitored and evaluated on their benefits and harms in relation to the patient's treatment goals. Clinicians are taught to prescribe but have limited training on deprescribing, defined as a planned and supervised process of identifying, discontinuing, or reducing the dose of futile medications. Deprescribing considers the patient's care goals, current level of functioning, life expectancy, values, and preferences.17 The process of deprescribing requires shared decision-making with the patient or family (Figure 1).18
A systematic review examined studies assessing the presence of prescribed futile medications by drug class in patients with limited life expectancy. The common classes of futile medications identified were vitamins, statins, antihypertension medications, and diabetes medications.8
A consensus panel of 12 geriatricians concluded that lipid-lowering medications, memantine, and acetylcholinesterase inhibitors are always futile medications in patients with advanced dementia.19 Further, bisphosphonates are rarely appropriate in patients with advanced dementia.19 See Table 1 for a list of reasons for discontinuing futile medications.
Consider the balance between adverse reactions and benefits when deciding to discontinue any medication. Account for the possibility of an adverse withdrawal reaction, defined as a clinically significant set of symptoms or signs caused by the removal of a drug.20 Adverse withdrawal reactions may be prevented by tapering the dose, rather than abruptly stopping it.21 Monitor patients for withdrawal symptoms as the medication is tapered. Discontinue medications sequentially so that any withdrawal reactions can be easily attributed to the medication ceased.
Medications that may not require tapering include aspirin, statins, bisphosphonates, multivitamins, and iron supplements.22 Beta-blockers, cholinesterase inhibitors, proton-pump inhibitors, and benzodiazepines should be tapered to prevent a withdrawal reaction. For more information, see https://deprescribing.org/resources/deprescribing-guidelines-algorithms.
The deprescribing conversation starts by gaining insight into the patient's daily life. First, learn where the patient lives, and with whom. Assess the patient's physical function; ask what his or her daily needs are and who is available to assist with those needs. Next, discover how the patient spends his or her time—for example, in hobbies, priorities, or obligations. Developing this understanding lets clinicians find a direction for the goals-of-care conversation. Often the primary goal in the last year of life is simply to remain comfortable, and patients who are active will seek to offset a physical decline for as long as possible. During the terminal stages of life, prevention of future disease is no longer a major priority.
After assessing goals of care, take an inventory of the patient's medications, including how they are organized, what adverse reactions the patient experiences, and whether the patient can afford the medications.17 Understand why the patient has been prescribed these medications and take the time to research potential adverse reactions and drug interactions. The STOPPFrail criteria provide an efficient way to guide clinicians through the medication evaluation. A list of questions to help guide this conversation is provided in Table 2.
Using interprofessional teamwork helps with the safety and efficacy of the deprescribing process. For example, home healthcare or hospice may provide an extra set of eyes to monitor for withdrawal symptoms. Clinical pharmacists can be consulted when determining when to deprescribe each medication and at what rate. Incorporating caregivers in the discussion also is invaluable because they likely are involved in organizing and administering medications. Each participant in the patient's care provides another perspective when navigating the challenges in the final stage of life.
Most patients approaching the end of life will be open to taking fewer medications, and many will be grateful for the suggestion. Medications and their adverse reactions become an incredible burden to terminally ill patients. However, in a small percentage of patients, suggesting a change in the medication regimen may produce resistance. Patients may fear worsening illness or contradicting the original prescriber.23 Ensuring the prevention of withdrawal symptoms may help assuage the patient's concerns. Deprescribing will be a topic of conversation throughout multiple encounters. For each medication to be discontinued, discuss the risks and benefits with the patient and caregivers.
To conclude the conversation, let the patient know this is not a binding contract. Explain that if symptoms reemerge, or if the patient develops adverse withdrawal reactions, the medication can easily be restarted. Deprescribing is a patient-centered process, and its course should be guided by the patient's preferences and quality of life. Patients must understand that deprescribing is not the cessation of care; instead, it is adjusting care to the patient's current needs.
The case patient, an 85-year-old woman with advanced Alzheimer disease, had a poor prognosis. But like many patients at the end of life, she was taking some potentially futile medications. Deprescribing these medications shifted the focus of her care to managing medications for symptom control and comfort care. An individualized approach is required to assess prognosis, recognize the end of life, and meet the patient's goals. The STOPPFrail criteria can assist clinicians in deprescribing medications in a structured fashion.
Involving patients and addressing their concerns about deprescribing is paramount. Many medications can be safely deprescribed with frequent follow-up and assessment for withdrawal adverse reactions.
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