A Swedish cohort study of over half a million older adults aged over 65 years who died in Sweden over a seven year period has concluded that “polypharmacy increases throughout the last year of life of older adults, fuelled not only by symptomatic medications but also by long-term preventive treatments of questionable benefit.”
In the study, polypharmacy was the primary outcome, defined as the monthly exposure to 10 or more prescription drugs. Prescription data was collected for the last 12 months before death.
Overall, just over half of individuals had five or more diagnosed chronic conditions at the time of death. The prevalence of polypharmacy increased from thirty percent to almost fifty percent throughout the last year of life, and the mean number of prescription drugs rose from 7.6 to 9.6. Those living in institutions were found to receive a greater number of medicines compared to those living in the community.
The likelihood of being exposed to polypharmacy varied significantly with illness at the time of death. For example, those who died from cancer were more likely to have been exposed to polypharmacy (odds ratio 3.34; 95% CI, 3.29-3.39) than those who died from neurodegenerative disorders (odds ratio 1.74; 95% CI, 1.71-1.77).
Antithrombotic agents, diuretics, analgesics, neuroleptics and beta-blockers were found to be the most common prescription drug classes. Agents acting on the renin-angiotensin systems, anaemia preparations, antidepressants and antacids were also highly prevalent.
polypharmacy increases throughout the last year of life of older adults, fuelled not only by symptomatic medications but also by long-term preventive treatments of questionable benefit
There was a marked increase in exposure to opioids (+120.7%), antimicrobials (+74.3%), anxiolytics (+59.5%), laxatives (+57.8%) and antipsychotics (+47.3%) during the last 12 months, with only a modest decrease in the use of preventative drugs such as beta-blockers, ACEI’s, vasodilators, lipid-lowering agents and calcium-channel blockers.
The authors suggest that the results of this study show that the significant increase in polypharmacy during the last year of life is not only fuelled by the increased use of medicines for symptom management but also by the continuation of long-term preventative treatments and disease-targeted drugs.
The authors classified the polypharmacy medicines into five categories:
- Symptom relievers such as analgesics, loop diuretics and anxiolytics
- Long-term prevention of chronic conditions that pose no immediate danger, such as statins
- Medicines to control the evolution of potentially life-threatening or disabling co-morbidities such as oral hypoglycaemics, antiplatelets, thyroid therapy, anti-dementia drugs and cardiac stimulants
- Drugs prescribed to cure or slow the progression of the main life-limiting illness such as chemotherapy or immunosuppressants
- Drugs that may be administered to counteract adverse effects of other medicines such as potassium supplements, proton-pump inhibitors and laxatives.
The authors suggest two key questions that clinicians should ask in the context of limited life-expectancy:
Is the patient’s life expectancy longer than the time needed for medication to achieve its benefit; and, are the objectives of the prescribed medication in keeping with the goals of care agreed between the clinician and the patient?
The authors conclude that safe and effective withdrawing or deprescribing of medicines requires timely patient-family-physician dialogue about the risk:benefit ratio of medications and close monitoring of symptoms over the following weeks. The goals of treatment should be reviewed as a patient’s condition worsens and that patients and families must receive clear information about their options in terms of palliative care.
Morin L et al. Choosing wisely? Measuring the burden of medications in older adults near the end of life: Nationwide, longitudinal cohort study. The American Journal of Medicine 2017;130(8): 927-936.