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Discontinuation of Preventive Medicines in Older People with Limited Life Expectancy: A Systematic Review

Abstract

Background

In the presence of multimorbidity and limited life expectancy (LLE), the need for continued use of preventive medicines becomes uncertain as they may neither improve health nor confer continued health benefits.

Objective

Our objective was to systematically review the literature to examine the discontinuation of preventive medicines in older people with LLE.

Methods

A systematic literature search was conducted using the Ovid MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register databases. Studies investigating discontinuation of preventive medicines in older individuals (mean age ≥65 years) with LLE (≤12 months) published between 1 January 1997 and 28 February 2017 were included. The Cochrane risk-of-bias assessment criteria and the Newcastle–Ottawa Scale were used to assess the quality of the studies.

Results

Ten studies—a randomized controlled trial (RCT), two case–control studies, and seven cohort studies—involving 26,854 participants with a mean age ranging from 66.0 to 85.0 years were included in this review. The studies were primarily conducted in palliative care (n = 3), residential facility (n = 2), and community (n = 1) settings, and the remainder were pharmacoepidemiological studies (n = 4). The most common life-limiting illnesses were cancer (n = 5), followed by other unspecified illnesses (n = 4) and advanced dementia (n = 1). The most common preventive medicine discontinued was statins, followed by warfarin and aspirin. LLE potentially prompted discontinuation; however, some individuals continued to receive preventive medicines until they died.

Conclusions

The review found that withdrawal of preventive medicines at the end of life is challenging. Decisions about the discontinuation of preventive medicines for individuals approaching the end of life are increasingly complicated by the lack of clear deprescribing guidelines for these medicines.

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References

  1. Narayan SW, Tordoff JM, Nishtala PS. Temporal trends in the utilisation of preventive medicines by older people: a 9-year population-based study. Arch Gerontol Geriatr. 2016;62:103–11.

    Article  PubMed  Google Scholar 

  2. McNeil MJ, Kamal AH, Kutner JS, Ritchie CS, Abernethy AP. The Burden of polypharmacy in patients near the end of life. J Pain Symptom Manage. 2016;51(2):178–83.e2.

  3. Nishtala PS, Narayan SW, Wang T, Hilmer SN. Associations of drug burden index with falls, general practitioner visits, and mortality in older people. Pharmacoepidemiol Drug Saf. 2014;23(7):753–8.

    Article  PubMed  Google Scholar 

  4. Narayan SW, Nishtala PS. Associations of potentially inappropriate medicine use with fall-related hospitalisations and primary care visits in older New Zealanders: a population-level study using the updated 2012 Beers Criteria. Drugs Real World Outcomes. 2015;2(2):137–41.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Todd A, Husband A, Andrew I, et al. Inappropriate prescribing of preventative medication in patients with life-limiting illness: a systematic review. BMJ Support Palliat Care. 2017;7(2):113–21.

    Article  PubMed  Google Scholar 

  6. Narayan SW, Nishtala PS. Decade-long temporal trends in the utilization of preventive medicines by centenarians. J Clin Pharm Ther. 2017;42(2):165–9. doi:10.1111/jcpt.12487 (Epub 2016 Dec 10).

    CAS  Article  PubMed  Google Scholar 

  7. Kakar P. Preventive medicine in the older patient: a United Kingdom perspective. Int J Prev Med. 2012;3(6):379–85.

    PubMed  PubMed Central  Google Scholar 

  8. Currow DC, Abernethy AP. Frameworks for approaching prescribing at the end of life. Arch Intern Med. 2006;166(21):2404.

    PubMed  Google Scholar 

  9. Bain KT, Holmes HM, Beers MH, et al. Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process. J Am Geriatr Soc. 2008;56(10):1946–52.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Parsons C, Hughes CM, Passmore AP, Lapane KL. Withholding, discontinuing and withdrawing medications in dementia patients at the end of life: a neglected problem in the disadvantaged dying? Drugs Aging. 2010;27(6):435–49.

    Article  PubMed  Google Scholar 

  11. Kutner JS, Blatchford PJ, Taylor DH Jr, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med. 2015;175(5):691–700.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Bayliss EA, Bronsert MR, Reifler LM, et al. Statin prescribing patterns in a cohort of cancer patients with poor prognosis. J Palliat Med. 2013;16(4):412–8.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Riechelmann RP, Krzyzanowska MK, Zimmermann C. Futile medication use in terminally ill cancer patients. Support Care Cancer. 2009;17(6):745–8.

    Article  PubMed  Google Scholar 

  14. Ailabouni NJ, Nishtala PS, Mangin D, Tordoff JM. General practitioners’ insight into deprescribing for the multimorbid older individual: a qualitative study. Int J Clin Pract. 2016;70(3):261–76.

    CAS  Article  PubMed  Google Scholar 

  15. Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166(6):605–9.

    Article  PubMed  Google Scholar 

  16. Stevenson J, Abernethy AP, Miller C, Currow DC. Managing comorbidities in patients at the end of life. BMJ. 2004;329(7471):909–12.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Schuling J, Gebben H, Veehof LJ, Haaijer-Ruskamp FM. Deprescribing medication in very elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study. BMC Fam Pract. 2012;13:56.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Todd A, Nazar H, Pearson S, et al. Inappropriate prescribing in patients accessing specialist palliative day care services. Int J Clin Pharm. 2014;36(3):535–43.

    CAS  Article  PubMed  Google Scholar 

  19. The New Zealand Formulary. http://nzformulary.org/. Accessed 22 July 2016.

  20. The Cochrane Collaboration’s tool for assessing risk of bias. London: Cochrane Collaboration. http://handbook.cochrane.org/chapter_8/8_5_the_cochrane_collaborations_tool_for_assessing_risk_of_bias.htm. Accessed 24 Mar 2017.

  21. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 24 Mar 2017.

  22. STROBE Statement. https://www.strobe-statement.org/index.php?id=strobe-home. Accessed 24 Mar 2017.

  23. Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687.

    Article  PubMed  Google Scholar 

  24. Tjia J, Cutrona SL, Peterson D, et al. Statin discontinuation in nursing home residents with advanced dementia. J Am Geriatr Soc. 2014;62(11):2095–101.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Bertozzo G, Zoppellaro G, Granziera S, et al. Reasons for and consequences of vitamin K antagonist discontinuation in very elderly patients with non-valvular atrial fibrillation. J Thromb Haemost. 2016;14(11):2124–31.

    CAS  Article  PubMed  Google Scholar 

  26. Stavrou EP, Buckley N, Olivier J, Pearson SA. Discontinuation of statin therapy in older people: does a cancer diagnosis make a difference? An observational cohort study using data linkage. BMJ Open. 2012;2(3):1–6.

    Article  Google Scholar 

  27. Tanvetyanon T, Choudhury AM. Physician practice in the discontinuation of statins among patients with advanced lung cancer. J Palliat Care. 2006;22(4):281–5.

    PubMed  Google Scholar 

  28. Nishtala PS, Gnjidic D, Chyou T, Hilmer SN. Discontinuation of statins in a population of older New Zealanders with limited life expectancy. Intern Med J. 2016;46(4):493–6.

    CAS  Article  PubMed  Google Scholar 

  29. Silveira MJ, Kazanis AS, Shevrin MP. Statins in the last six months of life: a recognizable, life-limiting condition does not decrease their use. J Palliat Med. 2008;11(5):685–93.

    Article  PubMed  Google Scholar 

  30. Currow DC, Stevenson JP, Abernethy AP, Plummer J, Shelby-James TM. Prescribing in palliative care as death approaches. J Am Geriatr Soc. 2007;55(4):590–5.

    Article  PubMed  Google Scholar 

  31. Holmes HM, Min LC, Yee M, et al. Rationalizing prescribing for older patients with multimorbidity: considering time to benefit. Drugs Aging. 2013;30(9):655–66.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Holmes HM, Todd A. Evidence-based deprescribing of statins in patients with advanced illness. JAMA Intern Med. 2015;175(5):701–2.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Poudel A, Yates P, Rowett D, Nissen LM. Use of preventive medication in patients with limited life expectancy: a systematic review. J Pain Symptom Manage. 2017;53(6):1097–1110.e1. doi: 10.1016/j.jpainsymman.2016.12.350 (Epub 2017 Feb 9).

  34. Todd A, Husband A, Andrew I, et al. Inappropriate prescribing of preventative medication in patients with life-limiting illness: a systematic review. BMJ Support Palliat Care. 2017;7(2):113–21. doi:10.1136/bmjspcare-2015-000941 (Epub 2016 Jan 5).

    Article  PubMed  Google Scholar 

  35. Lee SJ, Leipzig RM, Walter LC. Incorporating lag time to benefit into prevention decisions for older adults. JAMA. 2013;310(24):2609–10.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  36. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–31.

    Article  Google Scholar 

  37. Shrank WH, Polinski JM, Avorn J. Quality indicators for medication use in vulnerable elders. J Am Geriatr Soc. 2007;55(Suppl 2):S373–82.

    Article  PubMed  Google Scholar 

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Correspondence to Sujita W. Narayan.

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Funding

The authors thank the RiPE (Research in Pharmacoepidemiology) group, School of Pharmacy, University of Otago, New Zealand, for providing support. Sujita Narayan is supported by a doctoral scholarship from the School of Pharmacy, University of Otago, Dunedin, New Zealand. The funding institution did not play a role in the study concept, data analysis, or interpretation.

Conflicts of interest

Sujita Narayan and Prasad Nishtala have no conflicts of interest relevant to the content of this review.

Ethical considerations

All patient data evaluated in this review were de-identified.

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Narayan, S.W., Nishtala, P.S. Discontinuation of Preventive Medicines in Older People with Limited Life Expectancy: A Systematic Review. Drugs Aging 34, 767–776 (2017). https://doi.org/10.1007/s40266-017-0487-1

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  • DOI: https://doi.org/10.1007/s40266-017-0487-1