S6.5 Less is more? Discontinuing drug therapy to improve health outcomes among frail older adults
Chair: Kristina Johnell
Polypharmacy is frequent among older people. About 40–50% of older adults use ?5 medications on a daily basis. The use of multiple drug treatments can be clinically appropriate if they improve health and quality of life. However, the excessive use of drugs poses important challenges to clinicians because older adults can be exposed to polypharmacy beyond the point where drug therapy is beneficial. Internationally, the process of deprescribing has gained increasing attention in the field of geriatric medicine. Deprescribing could prove to be a powerful instrument to reduce polypharmacy and improve health outcomes in multimorbid and frail older adults. Yet, there is to date only little evidence available to provide guidance on how to deprescribe. In this symposium, we will explore the challenges surrounding the process of deprescribing in older adults, using evidence from four different countries (Denmark, Sweden, Australia and England).
S6.5.1 Reducing the harms of polypharmacy: are we targeting the right problem, at the right time, for the right people
Jonas W Wastesson
Karolinska Institutet, Stockholm, Sweden
Background: There is a lack of epidemiological evidence about the longitudinal course of polypharmacy. Is polypharmacy always a chronic state? What factors are associated with chronic polypharmacy? Methods: Using the Swedish Prescribed Drug Register linked to other administrative registers, we monitored drug use between 2010 to 2013 in the entire population of Sweden aged ?65 years. Drug use and polypharmacy (?5 drugs) were assessed monthly. Results: Among the 604,129 persons with polypharmacy at baseline, about 65% discontinued polypharmacy at least once during the 3-year study period. Having multimorbidity, multi-dose dispensing and using many drugs at baseline was associated with a more chronic exposure to polypharmacy. Conclusions: Polypharmacy is not an entirely steady state. Interventions to reduce polypharmacy could be successful. The identification of modifiable risk factors for chronic polypharmacy (e.g. multi-dose dispensing), could be potential targets for future interventions.
S6.5.2 User involvement to get the medication right
S6.5.3 Continuation of drugs of limited benefit near the end of life: a nationwide longitudinal study in Sweden
Karolinska Institutet, Stockholm, Sweden
Background: this study aimed to evaluate the prevalence and the determinants of prescribing drugs of questionable benefit during the last three months of life of older adults. Methods: register-based, longitudinal cohort study. All older adults (>75 years) who died in Sweden between 2013 and 2015 from diseases indicative of palliative care needs were included. Drugs of questionable benefit were identified a priori by a consensus panel of 40 European experts in palliative medicine, geriatrics, and clinical pharmacology. Results: A total of 175,979 deceased older adults were included. Mean age at time of death was 86.5 years (SD= 6.2). 56% of decedents were women, 49% died in nursing homes, and 50% had at least 6 diagnosed chronic diseases. During the last 3 months of life, 30.1% refilled at least one prescription of questionable benefit. Moreover, 11.8% initiated at least one drug treatment of questionable benefit during this period. Compared with older adults who died from cancer, those who died from organ failure (OR= 1.59, 95% CI 1.55–1.63) or dementia (OR= 1.98, 95% CI 1.92–2.03) were significantly more likely to continue drugs of questionable benefit. Conclusion: Our findings raise concern as significant proportion of older adults are exposed to drug treatments that provide little or no benefit, and can potentially be harmful. Optimization of drug prescribing and avoiding futile treatment near the end of life is an important challenge.
S6.5.4 Missed opportunities? Inappropriate prescribing of preventive medication in patients with advanced lung cancer
University of Newcastle, UK
Background: We aimed to examine the prescribing of preventative medication in a cohort of lung cancer patients pre- and post- hospital admission across different healthcare systems, and, to explore the factors that influence preventative medication prescribing at hospital discharge. Methods: retrospective cohort study, including patients who died of lung cancer in two tertiary care centers in the United Kingdom and the United States. Results: A total of 125 patients in the UK and 191 in the US were included. In the UK site, the mean number of preventative medications was 1.9 (SD ± 1.7) on admission, and 1.7 (SD ± 1.7) on discharge, whilst in the US site the mean number was 2.6 (SD ± 2.2) on admission and 1.9 (SD ± 2.2) on discharge. Anti-hypertensives were the most commonly prescribed preventative medications at time of discharge. Patient-related factors (age, cancer stage, cancer type, co-morbidity) and hospital factors (length of hospital admission, number of hospitalizations, number of days’ discharge before death) were not significantly associated with preventative medications on discharge. Conclusion: There may be scope to develop an intervention that embraces the principles of deprescribing at the point of hospital discharge to reduce inappropriate prescribing in lung cancer patients.
S6.5.5 Strategies to reverse the trend of increasing polypharmacy in Australian residential aged care services
Monash University, Australia
Background: Polypharmacy is one of five quality indicators collected on a quarterly-basis in 190 public-sector residential aged care services in Victoria. We assessed the implementation of three polypharmacy risk mitigation strategies. Methods: The strategies were the (1) development of medication-related quality indicators to provide feedback to clinicians; (2) development of sample dialogues to facilitate inter-professional and resident discussion about deprescribing; and (3) research into the role medication advisory committees (MACs). Results: Firstly, the reliability and validity of each new indicator was established and training videos to facilitate accurate collection were produced. Secondly, sample dialogues to facilitate deprescribing were developed through focus groups and interviews with residents, carers and clinicians. The sample dialogues were recorded in video format for dissemination through an online education portal. Finally, expert recommendations related to potential roles for local and regional MACs were informed by focus groups and interviews with 46 aged care clinicians and policy makers. Conclusions: Implementation of the strategies has been characterised by a high level of stakeholder support and engagement.