How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study

Abstract

Background: The high burden of disease-oriented drugs among older adults with limited life expectancy raises important questions about the potential futility of care. Aim: To describe the use of drugs of questionable clinical benefit during the last 3 months of life of older adults who died from life-limiting conditions. Design: Longitudinal, retrospective cohort study of decedents. Death certificate data were linked to administrative and healthcare registries with national coverage in Sweden. Setting: Older adults (≥75 years) who died from conditions potentially amenable to palliative care between 1 January and 31 December 2015 in Sweden. We identified drugs of questionable clinical benefit from a set of consensus-based criteria. Results: A total of 58,415 decedents were included (mean age, 87.0 years). During their last 3 months of life, they received on average 8.9 different drugs. Overall, 32.0% of older adults continued and 14.0% initiated at least one drug of questionable clinical benefit (e.g. statins, calcium supplements, vitamin D, bisphosphonates, antidementia drugs). These proportions were highest among younger individuals (i.e. aged 75–84 years), among people who died from organ failure and among those with a large number of coexisting chronic conditions. Excluding people who died from acute and potentially unpredictable fatal events had little influence on the results. Conclusion: A substantial share of older persons with life-limiting diseases receive drugs of questionable clinical benefit during their last months of life. Adequate training, guidance and resources are needed to rationalize and deprescribe drug treatments for older adults near the end of life.

Sex-Differences in Discontinuation of Statin Treatment in Cancer Patients the Year before Death

“…The observation that statins were deprescribed on average 1.5 to 3 months before death in men and women respectively, are in line with a larger, population-based Swedish study, in which 52% of cancer patients were on statin treatment 90 days before death [ 2 ]. However, in that study no analysis of gender differences was made.…”

“…Preventive medications to lower cholesterol and blood pressure can often be discontinued in patients with advanced cancer since they are considered to do more harm than good. However, studies show that such medications are generally discontinued very late in the disease trajectory [ 1 , 2 , 3 , 4 ]. This may be due to patient perception of deprescribing, to the physician’s opinion on the effects of statins in the elderly or to physician fear of causing harm to the patient [ 5 , 6 , 7 ].…”

Use of preventive drugs during the last year of life in older adults with cancer or chronic progressive diseases

“…The prescriptive behavior of preventive drugs did not differ considerably in patients with cancer and those with other chronic non neoplastic diseases, although in the latter group of patients there was a more marked tendency towards a reduction in prescription over the The results of our study are consistent with those of previous investigations on end-of-life-patients -conducted largely on (cancer) patients treated in hospice or palliative carewhich reported a frequent use of avoidable medications up to the last months of life. 5,[8][9][10][11][12][13]25,26 In particular, our results on oncologic patients are very consistent with those of a similar study conducted in the Swedish population. 12 All these data suggest that drug prescription at the endof-life needs to be improved.…”

Healthcare professionals must communicate with patients and relatives. They must enable informed, realistic and appropriate decisions in end-of-life pharmacotherapy

“…This study4 presents a retrospective analysis of Swedish Health Registry data on prescribing in 58 415 decedents aged over 75 years who were assigned to ‘palliative care’ (defined as ‘cancer’, ‘organ failure’ or ‘prolonged dwindling’) during the last 3 months of life.…”