Drug consumption and futile medication prescribing in the last year of life: an observational study

Drug consumption and futile medication prescribing in the last year of life: an observational study Abstract Background the last year of life for many older people is associated with high symptom burden and frequent hospitalizations. Hospital physicians have an opportunity to prioritize essential medications and deprescribe potentially futile medications. Objective to measure medication consumption during hospitalization in the last year of life and the prevalence of potentially inappropriate medications (PIMs) at hospital discharge. Design retrospective chart review. Setting acute hospital. Subjects ≥65 years, hospitalized in the last year of life. Methods medication consumption was determined by examining hospital Medication Administration Records. PIMs were defined using STOPPFrail deprescribing criteria. Results the study included 410 patients. The mean age of participants was 80.8, 49.3% were female, and 63.7% were severely frail. The median number of days spent in hospital in the last year of life was 32 (interquartile range 15−59). During all hospitalizations, the mean number of individual medications consumed was 23.8 (standard deviation 10.1). One-in-six patients consumed 35 or more medications in their last year. Over 80% of patients were prescribed at least one PIM at discharge and 33% had ≥3 PIMs. Lipid-lowering medications, proton pump inhibitors, anti-psychotics and calcium supplements accounted for 59% of all PIMs. Full implementation of STOPPFrail recommendations would have resulted in one-in-four long-term medications being discontinued. Conclusion high levels of medication consumption in the last year of life not only reflect high symptom burden experienced by patients but also continued prescribing of futile medications. Physicians assisted by the STOPPFrail tool can reduce medication burden for older people approaching end of life. deprescribing, frailty, medications, elderly, STOPPFrail Background A hospital admission in an older person with end-stage chronic disease or progressive frailty is an appropriate time to review medications and goals of care [1–3]. Large observational studies have shown that hospitalizations are frequent in the last year of life due to high symptom and illness burden [4, 5]. Hospital physicians, therefore, have an opportunity to tailor medication regimens to the condition and prognosis of their patients and deprescribe potentially harmful or futile drugs. The STOPPFrail criteria (Table 1) are an explicit list of 27 indicators to assist physicians with deprescribing decisions in frail older individuals with poor 1-year survival prognosis [6]. The STOPPFrail criteria were developed by Delphi consensus of an expert panel comprising academic geriatricians, clinical pharmacologists, palliative care physicians, old age psychiatrists, general practitioners and clinical pharmacists. The tool is concise, has good inter-rater reliability [7], and is designed to be used by clinicians who commonly provide care for older people. The relevance and applicability of the STOPPFrail criteria to older people hospitalized in the last year of life has not yet been studied. Table 1. The STOPPFrail criteria STOPPFrail is a list of potentially inappropriate prescribing indicators designed to assist physicians with stopping such medications in older patients (≥65 years) who meet ALL of the criteria listed below: End-stage irreversible pathology Poor 1-year survival prognosis Severe functional or severe cognitive impairment or both Symptom control is the priority rather than prevention of disease progression The decision to prescribe/not prescribe medications to the patient, should also be influenced by the following issues: Drug adherence/compliance is difficult Administration of the medication is challenging Monitoring of the medication effect is challenging Drug adherence/ compliance is difficult Section A: general A1: Any drug that the patient persistently fails to take or tolerate despite adequate education and consideration of all appropriate formulations A2: Any drug without clear clinical indication Section B: cardiology system B1. Lipid lowering therapies (statins, ezetimibe, bile acid sequestrans, fibrates, nicotinic acid and acipimox) These medications need to be prescribed for a long duration to be of benefit. For short-term use, the risk of ADEs outweighs the potential benefits B2. Alpha-blockers for hypertension Stringent blood pressure control is not required in very frail older people. Alpha blockers in particular can cause marked vasodilatation, which can result in marked postural hypotension, falls and injuries Section C: coagulation system C1: Anti-platelets Avoid anti-platelet agents for primary (as distinct from secondary) cardiovascular prevention (no evidence of benefit) Section D: Central nervous system D1. Neuroleptic antipsychotics Aim to reduce dose and discontinue these drugs in patients taking them for longer than 12 weeks if there are no current clinical features of behavioural and psychiatric symptoms of dementia (BPSD) D2: Memantine Discontinue and monitor in patients with moderate to severe dementia, unless memantine has clearly improved BPSD (specifically in frail patients who meet the criteria above) Section E: gastrointestinal system E1. Proton pump inhibitors Proton pump inhibitors at full therapeutic dose ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E2: H2 receptor antagonist H2 receptor antagonist at full therapeutic dose for ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E3. Gastrointestinal antispasmodics Regular daily prescription of gastrointestinal antispasmodics agents unless the patient has frequent relapse of colic symptoms because of high risk of anti-cholinergic side effects Section F: respiratory system F1. Theophylline This drug has a narrow therapeutic index, requires monitoring of serum levels and interacts with other commonly prescribed drugs putting patients at an increased risk of ADEs F2. Leukotriene antagonists (Montelukast, Zafirlukast) These drugs have no proven role in COPD, they are indicated only in asthma (50) Section G: musculoskeletal system G1: Calcium supplementation Unlikely to be of any benefit in the short term G2: Anti-resorptive/bone anabolic drugsFOR OSTEOPOROSIS (bisphosphonates, strontium, teriparatide, denosumab) G3. Selective estrogen receptor modulators (SERMs) for osteoporosis Benefits unlikely to be achieved within 1 year, increased short-intermediate term risk of associated ADEs particularly venous thromboembolism and stroke G4. Long-term oral NSAIDs Increased risk of side effects (peptic ulcer disease, bleeding, worsening heart failure etc.) when taken regularly for ≥ 2 months G5. Long-term oral steroids Increased risk of side effects (peptic ulcer disease etc.) when taken regularly for ≥ 2 months. Consider careful dose reduction and discontinuation Section H: urogenital system H1. 5-alpha reductase inhibitors No benefit with long term urinary bladder catheterisation H2. Alpha blockers No benefit with long term urinary bladder catheterisation H3. Muscarinic antagonists No benefit with long-term urinary bladder catheterisation, unless clear history of painful detrusor hyperactivity Section I: endocrine system I1. Diabetic oral agents Aim for monotherapy. Target of HbA1c <8%/64mmol/mol. Stringent glycaemic control is unnecessary I2. ACE-inhibitors for diabetes Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I3. Angiotensin receptor blockers (ARBs) Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I4. Systemic oestrogens for menopausal symptoms Increases risk of stroke and VTE disease. Discontinue and only consider recommencing if recurrence of symptoms Section J: Miscellaneous J1. Multi-vitamin combination supplements Discontinue when prescribed for prophylaxis rather than treatment J2. Nutritional supplements (other than vitamins) Discontinue when prescribed for prophylaxis rather than treatment J3: Prophylactic antibiotics No firm evidence for prophylactic antibiotics to prevent recurrent cellulitis or UTIs Disclaimer (STOPPFrail) While every effort has been made to ensure that the potentially inappropriate prescribing criteria listed in STOPPFrail are accurate and evidence-based, it is emphasized that the final decision to avoid or initiate any drug referred to in these criteria rests entirely with the prescriber. It is also to be noted that the evidence base underlying certain criteria in STOPPFrail may change after the time of publication of these criteria. Therefore, it is advisable that prescribing decisions should take account of current published evidence in support of or against the use of drugs or drug classes described in STOPPFrail. STOPPFrail is a list of potentially inappropriate prescribing indicators designed to assist physicians with stopping such medications in older patients (≥65 years) who meet ALL of the criteria listed below: End-stage irreversible pathology Poor 1-year survival prognosis Severe functional or severe cognitive impairment or both Symptom control is the priority rather than prevention of disease progression The decision to prescribe/not prescribe medications to the patient, should also be influenced by the following issues: Drug adherence/compliance is difficult Administration of the medication is challenging Monitoring of the medication effect is challenging Drug adherence/ compliance is difficult Section A: general A1: Any drug that the patient persistently fails to take or tolerate despite adequate education and consideration of all appropriate formulations A2: Any drug without clear clinical indication Section B: cardiology system B1. Lipid lowering therapies (statins, ezetimibe, bile acid sequestrans, fibrates, nicotinic acid and acipimox) These medications need to be prescribed for a long duration to be of benefit. For short-term use, the risk of ADEs outweighs the potential benefits B2. Alpha-blockers for hypertension Stringent blood pressure control is not required in very frail older people. Alpha blockers in particular can cause marked vasodilatation, which can result in marked postural hypotension, falls and injuries Section C: coagulation system C1: Anti-platelets Avoid anti-platelet agents for primary (as distinct from secondary) cardiovascular prevention (no evidence of benefit) Section D: Central nervous system D1. Neuroleptic antipsychotics Aim to reduce dose and discontinue these drugs in patients taking them for longer than 12 weeks if there are no current clinical features of behavioural and psychiatric symptoms of dementia (BPSD) D2: Memantine Discontinue and monitor in patients with moderate to severe dementia, unless memantine has clearly improved BPSD (specifically in frail patients who meet the criteria above) Section E: gastrointestinal system E1. Proton pump inhibitors Proton pump inhibitors at full therapeutic dose ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E2: H2 receptor antagonist H2 receptor antagonist at full therapeutic dose for ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E3. Gastrointestinal antispasmodics Regular daily prescription of gastrointestinal antispasmodics agents unless the patient has frequent relapse of colic symptoms because of high risk of anti-cholinergic side effects Section F: respiratory system F1. Theophylline This drug has a narrow therapeutic index, requires monitoring of serum levels and interacts with other commonly prescribed drugs putting patients at an increased risk of ADEs F2. Leukotriene antagonists (Montelukast, Zafirlukast) These drugs have no proven role in COPD, they are indicated only in asthma (50) Section G: musculoskeletal system G1: Calcium supplementation Unlikely to be of any benefit in the short term G2: Anti-resorptive/bone anabolic drugsFOR OSTEOPOROSIS (bisphosphonates, strontium, teriparatide, denosumab) G3. Selective estrogen receptor modulators (SERMs) for osteoporosis Benefits unlikely to be achieved within 1 year, increased short-intermediate term risk of associated ADEs particularly venous thromboembolism and stroke G4. Long-term oral NSAIDs Increased risk of side effects (peptic ulcer disease, bleeding, worsening heart failure etc.) when taken regularly for ≥ 2 months G5. Long-term oral steroids Increased risk of side effects (peptic ulcer disease etc.) when taken regularly for ≥ 2 months. Consider careful dose reduction and discontinuation Section H: urogenital system H1. 5-alpha reductase inhibitors No benefit with long term urinary bladder catheterisation H2. Alpha blockers No benefit with long term urinary bladder catheterisation H3. Muscarinic antagonists No benefit with long-term urinary bladder catheterisation, unless clear history of painful detrusor hyperactivity Section I: endocrine system I1. Diabetic oral agents Aim for monotherapy. Target of HbA1c <8%/64mmol/mol. Stringent glycaemic control is unnecessary I2. ACE-inhibitors for diabetes Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I3. Angiotensin receptor blockers (ARBs) Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I4. Systemic oestrogens for menopausal symptoms Increases risk of stroke and VTE disease. Discontinue and only consider recommencing if recurrence of symptoms Section J: Miscellaneous J1. Multi-vitamin combination supplements Discontinue when prescribed for prophylaxis rather than treatment J2. Nutritional supplements (other than vitamins) Discontinue when prescribed for prophylaxis rather than treatment J3: Prophylactic antibiotics No firm evidence for prophylactic antibiotics to prevent recurrent cellulitis or UTIs Disclaimer (STOPPFrail) While every effort has been made to ensure that the potentially inappropriate prescribing criteria listed in STOPPFrail are accurate and evidence-based, it is emphasized that the final decision to avoid or initiate any drug referred to in these criteria rests entirely with the prescriber. It is also to be noted that the evidence base underlying certain criteria in STOPPFrail may change after the time of publication of these criteria. Therefore, it is advisable that prescribing decisions should take account of current published evidence in support of or against the use of drugs or drug classes described in STOPPFrail. Table 1. The STOPPFrail criteria STOPPFrail is a list of potentially inappropriate prescribing indicators designed to assist physicians with stopping such medications in older patients (≥65 years) who meet ALL of the criteria listed below: End-stage irreversible pathology Poor 1-year survival prognosis Severe functional or severe cognitive impairment or both Symptom control is the priority rather than prevention of disease progression The decision to prescribe/not prescribe medications to the patient, should also be influenced by the following issues: Drug adherence/compliance is difficult Administration of the medication is challenging Monitoring of the medication effect is challenging Drug adherence/ compliance is difficult Section A: general A1: Any drug that the patient persistently fails to take or tolerate despite adequate education and consideration of all appropriate formulations A2: Any drug without clear clinical indication Section B: cardiology system B1. Lipid lowering therapies (statins, ezetimibe, bile acid sequestrans, fibrates, nicotinic acid and acipimox) These medications need to be prescribed for a long duration to be of benefit. For short-term use, the risk of ADEs outweighs the potential benefits B2. Alpha-blockers for hypertension Stringent blood pressure control is not required in very frail older people. Alpha blockers in particular can cause marked vasodilatation, which can result in marked postural hypotension, falls and injuries Section C: coagulation system C1: Anti-platelets Avoid anti-platelet agents for primary (as distinct from secondary) cardiovascular prevention (no evidence of benefit) Section D: Central nervous system D1. Neuroleptic antipsychotics Aim to reduce dose and discontinue these drugs in patients taking them for longer than 12 weeks if there are no current clinical features of behavioural and psychiatric symptoms of dementia (BPSD) D2: Memantine Discontinue and monitor in patients with moderate to severe dementia, unless memantine has clearly improved BPSD (specifically in frail patients who meet the criteria above) Section E: gastrointestinal system E1. Proton pump inhibitors Proton pump inhibitors at full therapeutic dose ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E2: H2 receptor antagonist H2 receptor antagonist at full therapeutic dose for ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E3. Gastrointestinal antispasmodics Regular daily prescription of gastrointestinal antispasmodics agents unless the patient has frequent relapse of colic symptoms because of high risk of anti-cholinergic side effects Section F: respiratory system F1. Theophylline This drug has a narrow therapeutic index, requires monitoring of serum levels and interacts with other commonly prescribed drugs putting patients at an increased risk of ADEs F2. Leukotriene antagonists (Montelukast, Zafirlukast) These drugs have no proven role in COPD, they are indicated only in asthma (50) Section G: musculoskeletal system G1: Calcium supplementation Unlikely to be of any benefit in the short term G2: Anti-resorptive/bone anabolic drugsFOR OSTEOPOROSIS (bisphosphonates, strontium, teriparatide, denosumab) G3. Selective estrogen receptor modulators (SERMs) for osteoporosis Benefits unlikely to be achieved within 1 year, increased short-intermediate term risk of associated ADEs particularly venous thromboembolism and stroke G4. Long-term oral NSAIDs Increased risk of side effects (peptic ulcer disease, bleeding, worsening heart failure etc.) when taken regularly for ≥ 2 months G5. Long-term oral steroids Increased risk of side effects (peptic ulcer disease etc.) when taken regularly for ≥ 2 months. Consider careful dose reduction and discontinuation Section H: urogenital system H1. 5-alpha reductase inhibitors No benefit with long term urinary bladder catheterisation H2. Alpha blockers No benefit with long term urinary bladder catheterisation H3. Muscarinic antagonists No benefit with long-term urinary bladder catheterisation, unless clear history of painful detrusor hyperactivity Section I: endocrine system I1. Diabetic oral agents Aim for monotherapy. Target of HbA1c <8%/64mmol/mol. Stringent glycaemic control is unnecessary I2. ACE-inhibitors for diabetes Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I3. Angiotensin receptor blockers (ARBs) Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I4. Systemic oestrogens for menopausal symptoms Increases risk of stroke and VTE disease. Discontinue and only consider recommencing if recurrence of symptoms Section J: Miscellaneous J1. Multi-vitamin combination supplements Discontinue when prescribed for prophylaxis rather than treatment J2. Nutritional supplements (other than vitamins) Discontinue when prescribed for prophylaxis rather than treatment J3: Prophylactic antibiotics No firm evidence for prophylactic antibiotics to prevent recurrent cellulitis or UTIs Disclaimer (STOPPFrail) While every effort has been made to ensure that the potentially inappropriate prescribing criteria listed in STOPPFrail are accurate and evidence-based, it is emphasized that the final decision to avoid or initiate any drug referred to in these criteria rests entirely with the prescriber. It is also to be noted that the evidence base underlying certain criteria in STOPPFrail may change after the time of publication of these criteria. Therefore, it is advisable that prescribing decisions should take account of current published evidence in support of or against the use of drugs or drug classes described in STOPPFrail. STOPPFrail is a list of potentially inappropriate prescribing indicators designed to assist physicians with stopping such medications in older patients (≥65 years) who meet ALL of the criteria listed below: End-stage irreversible pathology Poor 1-year survival prognosis Severe functional or severe cognitive impairment or both Symptom control is the priority rather than prevention of disease progression The decision to prescribe/not prescribe medications to the patient, should also be influenced by the following issues: Drug adherence/compliance is difficult Administration of the medication is challenging Monitoring of the medication effect is challenging Drug adherence/ compliance is difficult Section A: general A1: Any drug that the patient persistently fails to take or tolerate despite adequate education and consideration of all appropriate formulations A2: Any drug without clear clinical indication Section B: cardiology system B1. Lipid lowering therapies (statins, ezetimibe, bile acid sequestrans, fibrates, nicotinic acid and acipimox) These medications need to be prescribed for a long duration to be of benefit. For short-term use, the risk of ADEs outweighs the potential benefits B2. Alpha-blockers for hypertension Stringent blood pressure control is not required in very frail older people. Alpha blockers in particular can cause marked vasodilatation, which can result in marked postural hypotension, falls and injuries Section C: coagulation system C1: Anti-platelets Avoid anti-platelet agents for primary (as distinct from secondary) cardiovascular prevention (no evidence of benefit) Section D: Central nervous system D1. Neuroleptic antipsychotics Aim to reduce dose and discontinue these drugs in patients taking them for longer than 12 weeks if there are no current clinical features of behavioural and psychiatric symptoms of dementia (BPSD) D2: Memantine Discontinue and monitor in patients with moderate to severe dementia, unless memantine has clearly improved BPSD (specifically in frail patients who meet the criteria above) Section E: gastrointestinal system E1. Proton pump inhibitors Proton pump inhibitors at full therapeutic dose ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E2: H2 receptor antagonist H2 receptor antagonist at full therapeutic dose for ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E3. Gastrointestinal antispasmodics Regular daily prescription of gastrointestinal antispasmodics agents unless the patient has frequent relapse of colic symptoms because of high risk of anti-cholinergic side effects Section F: respiratory system F1. Theophylline This drug has a narrow therapeutic index, requires monitoring of serum levels and interacts with other commonly prescribed drugs putting patients at an increased risk of ADEs F2. Leukotriene antagonists (Montelukast, Zafirlukast) These drugs have no proven role in COPD, they are indicated only in asthma (50) Section G: musculoskeletal system G1: Calcium supplementation Unlikely to be of any benefit in the short term G2: Anti-resorptive/bone anabolic drugsFOR OSTEOPOROSIS (bisphosphonates, strontium, teriparatide, denosumab) G3. Selective estrogen receptor modulators (SERMs) for osteoporosis Benefits unlikely to be achieved within 1 year, increased short-intermediate term risk of associated ADEs particularly venous thromboembolism and stroke G4. Long-term oral NSAIDs Increased risk of side effects (peptic ulcer disease, bleeding, worsening heart failure etc.) when taken regularly for ≥ 2 months G5. Long-term oral steroids Increased risk of side effects (peptic ulcer disease etc.) when taken regularly for ≥ 2 months. Consider careful dose reduction and discontinuation Section H: urogenital system H1. 5-alpha reductase inhibitors No benefit with long term urinary bladder catheterisation H2. Alpha blockers No benefit with long term urinary bladder catheterisation H3. Muscarinic antagonists No benefit with long-term urinary bladder catheterisation, unless clear history of painful detrusor hyperactivity Section I: endocrine system I1. Diabetic oral agents Aim for monotherapy. Target of HbA1c <8%/64mmol/mol. Stringent glycaemic control is unnecessary I2. ACE-inhibitors for diabetes Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I3. Angiotensin receptor blockers (ARBs) Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I4. Systemic oestrogens for menopausal symptoms Increases risk of stroke and VTE disease. Discontinue and only consider recommencing if recurrence of symptoms Section J: Miscellaneous J1. Multi-vitamin combination supplements Discontinue when prescribed for prophylaxis rather than treatment J2. Nutritional supplements (other than vitamins) Discontinue when prescribed for prophylaxis rather than treatment J3: Prophylactic antibiotics No firm evidence for prophylactic antibiotics to prevent recurrent cellulitis or UTIs Disclaimer (STOPPFrail) While every effort has been made to ensure that the potentially inappropriate prescribing criteria listed in STOPPFrail are accurate and evidence-based, it is emphasized that the final decision to avoid or initiate any drug referred to in these criteria rests entirely with the prescriber. It is also to be noted that the evidence base underlying certain criteria in STOPPFrail may change after the time of publication of these criteria. Therefore, it is advisable that prescribing decisions should take account of current published evidence in support of or against the use of drugs or drug classes described in STOPPFrail. The aims of this study were: To determine the prevalence of potentially inappropriate medications (PIMs), as defined by the STOPPfrail tool, in the discharge prescription lists of older adults hospitalized in the last year of life. To measure medication consumption by older people while in hospital in the last year of life. Methods Study population We included people aged ≥65 years who were hospitalized for ≥2 days under general medical services in our institution in the year prior to death. The Hospital In-Patient Enquiry system (a national database of coded discharge summaries) was used to identify patients discharged between January 2013 to December 2014. When patients were admitted more than once during this period, a single hospitalization was randomly chosen as the index hospitalization. Patients who died during their index hospital admission and those discharged to a hospice, presumably in the final stages of a terminal illness, were excluded because the primary end point was to measure the prevalence of STOPPFrail-defined PIMs at the time of discharge. Deaths within 1 year of hospitalization were determined by accessing the Hospital Information System and an online death notification system (www.RIP.ie). In total, 603 patients were eligible for inclusion. We estimated that 50% of patients would be prescribed PIMs at discharge. Using a precision of 5% and a 95% level of confidence, we calculated that a minimum sample of 384 patients would be required for this study. To ensure an adequate final sample size, a random sample of 434 was generated using a randomization (RAND) function in Microsoft Excel©. The local Clinical Research Ethics Committee approved the study protocol. Data collection A retrospective chart review was conducted on all study patients by a Geriatric Medicine trained physician using a standardized data collection pro-forma. The prevalence of STOPPfrail-defined PIMs was measured by accessing the discharge prescriptions from the patients’ index hospitalization. Disease burden and performance status at the time of hospital discharge were determined using the Charlson Comorbidity Index (CCI) [8, 9] and the Clinical Frailty Scale (CFS) [10], respectively. The CFS is a 9-item scale and, in this study, we categorized patients into two groups: (i) those with scores of ≥7 (indicating severe frailty and/or terminal illness and therefore potentially eligible for the STOPPFrail tool) and (ii) those with scores <7 (indicating full independence, mild or moderate frailty). Medication consumption was determined by reviewing in-patient medication administration records from all hospitalizations in the last year of life. Medications that were prescribed but not consumed were not included, nor were nutritional products, blood products or intravenous fluids. A single ingredient constituted one medicine. For combination products, each ingredient was included as one drug as long as that ingredient was available as a medicine in the British National Formulary. Results Patient characteristics In total, 410 patients were included (24 patients were excluded because of missing data or because they were discharged to the care of community palliative services). The principal characteristics of the decedents are summarized in Table 2. The mean age of patients was 80.8 (standard deviation [SD] 7.9) and males and females were evenly represented. Polypharmacy was highly prevalent and the mean number of medications per patient at the time of hospital admission was 8.4 (SD 4.3). At the time of hospital discharge, 63.7% of patients were either severely frail or had an advanced terminal diagnosis (CFS ≥ 7). Table 2. Baseline characteristics and results Total (n = 410) Mean age (SD) at time of index hospitalization 80.8 (7.9) Female (%) 202 (49.3) Discharge health/functional status  Mean (SD) CCI score 6.2 (2.3)  CFS ≥7 261 (63.7%) Mean number (SD) of admission medications at index hospitalization 8.4 (4.3) Mean number (SD) of discharge medications at index hospitalization 8.7 (4.2) Median number (IQR) of days between index hospital discharge and death 124 (47–225.5) At index hospital discharge  Mean no. of PIMs per patient (SD) 1.9 (1.4)  ≥1 PIM 81.5%  ≥3 PIMs 34.0% In the last year of life  Median bed days (IQR) 32 (15–59)  Median hospital admissions (IQR) 2 (1.25–3)  Median emergency department episodes (IQR) 2 (1–3)  ≥30 Bed days 53.4%  ≥3 Hospital admissions 43.4%  ≥3 Emergency department episodes 34.0% Medications consumed during all hospitalizations in last year of life  Mean 23.8 (10.1)  ≥25 Medications 43.6%  ≥35 Medications 17.3% Medication-types consumed during all hospitalizations in last year of life  Disease/symptom control 87.3%  Long-term preventive 9.5%  Short-term preventive 3.2% Total (n = 410) Mean age (SD) at time of index hospitalization 80.8 (7.9) Female (%) 202 (49.3) Discharge health/functional status  Mean (SD) CCI score 6.2 (2.3)  CFS ≥7 261 (63.7%) Mean number (SD) of admission medications at index hospitalization 8.4 (4.3) Mean number (SD) of discharge medications at index hospitalization 8.7 (4.2) Median number (IQR) of days between index hospital discharge and death 124 (47–225.5) At index hospital discharge  Mean no. of PIMs per patient (SD) 1.9 (1.4)  ≥1 PIM 81.5%  ≥3 PIMs 34.0% In the last year of life  Median bed days (IQR) 32 (15–59)  Median hospital admissions (IQR) 2 (1.25–3)  Median emergency department episodes (IQR) 2 (1–3)  ≥30 Bed days 53.4%  ≥3 Hospital admissions 43.4%  ≥3 Emergency department episodes 34.0% Medications consumed during all hospitalizations in last year of life  Mean 23.8 (10.1)  ≥25 Medications 43.6%  ≥35 Medications 17.3% Medication-types consumed during all hospitalizations in last year of life  Disease/symptom control 87.3%  Long-term preventive 9.5%  Short-term preventive 3.2% Table 2. Baseline characteristics and results Total (n = 410) Mean age (SD) at time of index hospitalization 80.8 (7.9) Female (%) 202 (49.3) Discharge health/functional status  Mean (SD) CCI score 6.2 (2.3)  CFS ≥7 261 (63.7%) Mean number (SD) of admission medications at index hospitalization 8.4 (4.3) Mean number (SD) of discharge medications at index hospitalization 8.7 (4.2) Median number (IQR) of days between index hospital discharge and death 124 (47–225.5) At index hospital discharge  Mean no. of PIMs per patient (SD) 1.9 (1.4)  ≥1 PIM 81.5%  ≥3 PIMs 34.0% In the last year of life  Median bed days (IQR) 32 (15–59)  Median hospital admissions (IQR) 2 (1.25–3)  Median emergency department episodes (IQR) 2 (1–3)  ≥30 Bed days 53.4%  ≥3 Hospital admissions 43.4%  ≥3 Emergency department episodes 34.0% Medications consumed during all hospitalizations in last year of life  Mean 23.8 (10.1)  ≥25 Medications 43.6%  ≥35 Medications 17.3% Medication-types consumed during all hospitalizations in last year of life  Disease/symptom control 87.3%  Long-term preventive 9.5%  Short-term preventive 3.2% Total (n = 410) Mean age (SD) at time of index hospitalization 80.8 (7.9) Female (%) 202 (49.3) Discharge health/functional status  Mean (SD) CCI score 6.2 (2.3)  CFS ≥7 261 (63.7%) Mean number (SD) of admission medications at index hospitalization 8.4 (4.3) Mean number (SD) of discharge medications at index hospitalization 8.7 (4.2) Median number (IQR) of days between index hospital discharge and death 124 (47–225.5) At index hospital discharge  Mean no. of PIMs per patient (SD) 1.9 (1.4)  ≥1 PIM 81.5%  ≥3 PIMs 34.0% In the last year of life  Median bed days (IQR) 32 (15–59)  Median hospital admissions (IQR) 2 (1.25–3)  Median emergency department episodes (IQR) 2 (1–3)  ≥30 Bed days 53.4%  ≥3 Hospital admissions 43.4%  ≥3 Emergency department episodes 34.0% Medications consumed during all hospitalizations in last year of life  Mean 23.8 (10.1)  ≥25 Medications 43.6%  ≥35 Medications 17.3% Medication-types consumed during all hospitalizations in last year of life  Disease/symptom control 87.3%  Long-term preventive 9.5%  Short-term preventive 3.2% Prevalence of STOPPfrail PIMs at hospital discharge The mean number of medications prescribed per patient did not change significantly from index hospital admission to discharge (8.4 [SD 4.3] versus 8.7 [SD 4.2], P = 0.275). More than 80% of patients were prescribed at least one STOPPfrail-defined PIM in their discharge prescription and 34% had ≥3 PIMs prescribed (Table 2). The mean number of PIMs did not differ significantly between patients’ potentially eligible for STOPPFrail-guided deprescribing (CFS ≥ 7) and those with less advanced stages of frailty (2.0 [SD 1.5] versus 1.8 [SD 1.4], P = 0.053). Full implementation of the STOPPFrail recommendations for those with polypharmacy (defined here as ≥5 long-term medications) would have resulted in, on average, a 23% reduction in total medication burden. Lipid-lowering medications, proton pump inhibitors, anti-psychotics and calcium supplements accounted for 59% of all STOPPfrail-defined PIMs (Supplementary Appendix 1). Medication consumption while in hospital in the last year of life In the year prior to death, the median number of days in hospital was 32 (interquartile range [IQR] 15–58). One-third of people had three or more emergency department presentations. During all hospital stays in the last year of life, the mean number of individual medications consumed per patient was 23.8 (SD 10.1). One-in-six patients consumed ≥35 different medications (Table 2). Long-term preventive medications accounted for 9.5% of all medications consumed during hospitalization but 24.9% of medications prescribed at the time of hospital discharge. Discussion This is the first study of its kind using recently validated explicit deprescribing criteria designed for application in the frailest older people. Our data show that older people in their last year of life receive high levels of polypharmacy, a quarter of which includes long-term preventive therapies which are likely futile. Hospital physicians need to (i) be able to recognize frailer older patients in their last year of life, and (ii) be prepared to deprescribe thoughtfully where appropriate, particularly long-term preventive drugs where benefit is unlikely to be realized. Symptoms at end of life are often complex. A large nationally representative longitudinal survey of adults in the USA reported that symptoms such as depression, confusion, dyspnea, incontinence, fatigue, anorexia and vomiting were all common in the last year of life [11]. While improvements can usually be made regarding prescribing quality, high levels of medication consumption may be inevitable. This is important because the number of medications prescribed is the most important predictor of iatrogenic harm [12]. The challenge for the prescribing physician is to strike a balance between controlling multiple symptoms and minimizing the inherent risks of polypharmacy. Full implementation of STOPFrail recommendations for hospitalized patients would have resulted in almost one-in-four long-term medications being discontinued. The process of deprescribing, of course, must be individualized and patients’ preferences, clinical contextual factors and the potential for adverse drug withdrawal events given due consideration. Other deprescribing tools (e.g. CEASE [13], Good Palliative-Geriatric Practice [14]) are ‘implicit’ and demand that the prescriber balance risk and benefit of each medication. The real-world applicability of these methods to all but expert prescribers is doubtful. The value of STOPPFrail is that it is explicit, concise, easy-to-use, and, as we have shown, highly relevant to the practice of hospital physicians. Recognizing when people are in the final phase of life is key to operationalizing deprescribing. A 2012 systematic review by Yourman et al. [15] concluded that there was insufficient evidence to recommend application of any of the available prognostic models for older adults. Some degree of uncertainty when predicting prognosis seems inevitable. In this study, the majority of patients were severely frail and functional status has been shown to be a strong predictor of mortality in older people [1, 15]. In addition, functional decline following hospitalization is associated with a poor survival prognosis [16]. Perhaps then, it is patients who are severely frail at the time of hospital admission, and those who decline to a new frailer baseline despite adequate rehabilitation, that should be considered appropriate candidates for deprescribing. Our study has some limitations. Firstly, the experience described does not apply to the 18–29% of older people who are not hospitalized in the last year of life [1, 4]. However, symptom, disease and medication burden are presumably less marked in this cohort. Secondly, we may have underestimated medication exposure and acute hospital care utilization because information about hospitalizations outside of our institution was not captured. In summary, hospitalizations are common and drug burden is high in the last year of life and people are frequently discharged home with prescriptions for potentially futile medications. The STOPPFrail criteria are highly relevant and may assist physicians with deprescribing decisions. Key points The last year of life is associated with frequent and prolonged hospital admissions. Medication consumption is high in the last year of life and many patients consume medications that are potentially futile. Hospital physicians can reduce medication burden for older people approaching end of life using the STOPPFrail tool. Supplementary data Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. Funding D.C. and D.O.M. are supported by the FP7 EC-funded SENATOR project (grant number 305930). Conflicts of interest D.OM. and P.G. were involved in the development of the STOPPFrail Criteria which were used to define ‘futile medications’. References 1 Gill TM , Gahbauer EA , Han L , Allore HG . The role of intervening hospital admissions on trajectories of disability in the last year of life: prospective cohort study of older people . BMJ 2015 ; 350 : h2361 . Google Scholar CrossRef Search ADS PubMed 2 Jansen J , Naganathan V , Carter SM et al. . Too much medicine in older people? Deprescribing through shared decision making . BMJ 2016 ; 353 : I2893 . Google Scholar CrossRef Search ADS PubMed 3 Scott IA , Hilmer SN , Reeve E et al. . Reducing inappropriate polypharmacy: the process of deprescribing . JAMA Intern Med 2015 ; 175 : 827 – 34 . Google Scholar CrossRef Search ADS PubMed 4 Goldsbury DE , O’Connell DL , Girgis A et al. . Acute hospital-based services used by adults during the last year of life in New South Wales. In: BMC Health Serv Res ; 15 . Australia : a population-based retrospective cohort study , 2015 ; p. 537 . 5 Bekelman JE , Halpern SD , Blankart CR et al. . Comparison of site of death, health care utilization, and hospital expenditures for patients dying with cancer in 7 developed countries . JAMA 2016 ; 315 : 272 – 83 . Google Scholar CrossRef Search ADS PubMed 6 Lavan AH , Gallagher P , Parsons C , O’Mahony D . STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation . Age Ageing 2017 ; 46 : 600 – 607 . Google Scholar CrossRef Search ADS PubMed 7 Lavan AH , Gallagher P , O’Mahony D . Inter-rater reliability of STOPPFrail [Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy] criteria amongst 12 physicians . Eur J Clin Pharmacol 2017 . doi:10.1007/s00228-017-2376-2 ; [Epub ahead of print]. 8 Charlson ME , Pompei P , Ales KL , MacKenzie CR . A new method of classifying prognostic comorbidity in longitudinal studies: development and validation . J Chronic Dis 1987 ; 40 : 373 – 83 . Google Scholar CrossRef Search ADS PubMed 9 Quan H , Li B , Couris CM et al. . Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries . Am J Epidemiol 2011 ; 173 : 678 – 82 . Google Scholar CrossRef Search ADS 10 Rockwood K , Song X , MacKnight C et al. . A global clinical measure of fitness and frailty in elderly people . CMAJ 2005 ; 2005 : 489 – 95 . Google Scholar CrossRef Search ADS 11 Singer AE , Meeker D , Teno JM , Lynn J , Lunney JR , Lorenz KA . Symptom trends in the last year of life, 1998–2010: a cohort study . Ann Intern Med 2015 ; 162 : 175 – 83 . Google Scholar CrossRef Search ADS PubMed 12 Steinman MA , Miao Y , Boscardin WJ , Komaiko KD , Schwartz JB . Prescribing quality in older veterans: a multifocal approach . J Gen Intern Med 2014 ; 29 : 1379 – 86 . Google Scholar CrossRef Search ADS PubMed 13 Scott IA , Le Couteur D . Physicians need to take the lead in deprescribing . Intern Med J 2015 ; 45 : 352 – 6 . Google Scholar CrossRef Search ADS PubMed 14 Garfinkel D , Zur-Gil S , Ben-Israel J . The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elldery people . Is Med Assoc J 2007 ; 9 : 430 – 4 . 15 Yourman LC , Lee SJ , Schonberg MA , Widera EW , Smith AK . Prognostic indices for older adults: a systematic review . JAMA 2012 ; 307 : 182 – 92 . Google Scholar CrossRef Search ADS PubMed 16 Boyd CM , Landefeld SC , Counsell SR , Palmer RM , Fortinsky RH , Kresevic D . Recovery in activities of daily living among older adults following hospitalization for acute medical illness . J Am Geriatr Soc 2008 ; 56 : 2171 – 9 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Age and Ageing Oxford University Press

Drug consumption and futile medication prescribing in the last year of life: an observational study

Loading next page...
 
/lp/ou_press/drug-consumption-and-futile-medication-prescribing-in-the-last-year-of-VB1637q4u8
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com
ISSN
0002-0729
eISSN
1468-2834
D.O.I.
10.1093/ageing/afy054
Publisher site
See Article on Publisher Site

Abstract

Abstract Background the last year of life for many older people is associated with high symptom burden and frequent hospitalizations. Hospital physicians have an opportunity to prioritize essential medications and deprescribe potentially futile medications. Objective to measure medication consumption during hospitalization in the last year of life and the prevalence of potentially inappropriate medications (PIMs) at hospital discharge. Design retrospective chart review. Setting acute hospital. Subjects ≥65 years, hospitalized in the last year of life. Methods medication consumption was determined by examining hospital Medication Administration Records. PIMs were defined using STOPPFrail deprescribing criteria. Results the study included 410 patients. The mean age of participants was 80.8, 49.3% were female, and 63.7% were severely frail. The median number of days spent in hospital in the last year of life was 32 (interquartile range 15−59). During all hospitalizations, the mean number of individual medications consumed was 23.8 (standard deviation 10.1). One-in-six patients consumed 35 or more medications in their last year. Over 80% of patients were prescribed at least one PIM at discharge and 33% had ≥3 PIMs. Lipid-lowering medications, proton pump inhibitors, anti-psychotics and calcium supplements accounted for 59% of all PIMs. Full implementation of STOPPFrail recommendations would have resulted in one-in-four long-term medications being discontinued. Conclusion high levels of medication consumption in the last year of life not only reflect high symptom burden experienced by patients but also continued prescribing of futile medications. Physicians assisted by the STOPPFrail tool can reduce medication burden for older people approaching end of life. deprescribing, frailty, medications, elderly, STOPPFrail Background A hospital admission in an older person with end-stage chronic disease or progressive frailty is an appropriate time to review medications and goals of care [1–3]. Large observational studies have shown that hospitalizations are frequent in the last year of life due to high symptom and illness burden [4, 5]. Hospital physicians, therefore, have an opportunity to tailor medication regimens to the condition and prognosis of their patients and deprescribe potentially harmful or futile drugs. The STOPPFrail criteria (Table 1) are an explicit list of 27 indicators to assist physicians with deprescribing decisions in frail older individuals with poor 1-year survival prognosis [6]. The STOPPFrail criteria were developed by Delphi consensus of an expert panel comprising academic geriatricians, clinical pharmacologists, palliative care physicians, old age psychiatrists, general practitioners and clinical pharmacists. The tool is concise, has good inter-rater reliability [7], and is designed to be used by clinicians who commonly provide care for older people. The relevance and applicability of the STOPPFrail criteria to older people hospitalized in the last year of life has not yet been studied. Table 1. The STOPPFrail criteria STOPPFrail is a list of potentially inappropriate prescribing indicators designed to assist physicians with stopping such medications in older patients (≥65 years) who meet ALL of the criteria listed below: End-stage irreversible pathology Poor 1-year survival prognosis Severe functional or severe cognitive impairment or both Symptom control is the priority rather than prevention of disease progression The decision to prescribe/not prescribe medications to the patient, should also be influenced by the following issues: Drug adherence/compliance is difficult Administration of the medication is challenging Monitoring of the medication effect is challenging Drug adherence/ compliance is difficult Section A: general A1: Any drug that the patient persistently fails to take or tolerate despite adequate education and consideration of all appropriate formulations A2: Any drug without clear clinical indication Section B: cardiology system B1. Lipid lowering therapies (statins, ezetimibe, bile acid sequestrans, fibrates, nicotinic acid and acipimox) These medications need to be prescribed for a long duration to be of benefit. For short-term use, the risk of ADEs outweighs the potential benefits B2. Alpha-blockers for hypertension Stringent blood pressure control is not required in very frail older people. Alpha blockers in particular can cause marked vasodilatation, which can result in marked postural hypotension, falls and injuries Section C: coagulation system C1: Anti-platelets Avoid anti-platelet agents for primary (as distinct from secondary) cardiovascular prevention (no evidence of benefit) Section D: Central nervous system D1. Neuroleptic antipsychotics Aim to reduce dose and discontinue these drugs in patients taking them for longer than 12 weeks if there are no current clinical features of behavioural and psychiatric symptoms of dementia (BPSD) D2: Memantine Discontinue and monitor in patients with moderate to severe dementia, unless memantine has clearly improved BPSD (specifically in frail patients who meet the criteria above) Section E: gastrointestinal system E1. Proton pump inhibitors Proton pump inhibitors at full therapeutic dose ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E2: H2 receptor antagonist H2 receptor antagonist at full therapeutic dose for ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E3. Gastrointestinal antispasmodics Regular daily prescription of gastrointestinal antispasmodics agents unless the patient has frequent relapse of colic symptoms because of high risk of anti-cholinergic side effects Section F: respiratory system F1. Theophylline This drug has a narrow therapeutic index, requires monitoring of serum levels and interacts with other commonly prescribed drugs putting patients at an increased risk of ADEs F2. Leukotriene antagonists (Montelukast, Zafirlukast) These drugs have no proven role in COPD, they are indicated only in asthma (50) Section G: musculoskeletal system G1: Calcium supplementation Unlikely to be of any benefit in the short term G2: Anti-resorptive/bone anabolic drugsFOR OSTEOPOROSIS (bisphosphonates, strontium, teriparatide, denosumab) G3. Selective estrogen receptor modulators (SERMs) for osteoporosis Benefits unlikely to be achieved within 1 year, increased short-intermediate term risk of associated ADEs particularly venous thromboembolism and stroke G4. Long-term oral NSAIDs Increased risk of side effects (peptic ulcer disease, bleeding, worsening heart failure etc.) when taken regularly for ≥ 2 months G5. Long-term oral steroids Increased risk of side effects (peptic ulcer disease etc.) when taken regularly for ≥ 2 months. Consider careful dose reduction and discontinuation Section H: urogenital system H1. 5-alpha reductase inhibitors No benefit with long term urinary bladder catheterisation H2. Alpha blockers No benefit with long term urinary bladder catheterisation H3. Muscarinic antagonists No benefit with long-term urinary bladder catheterisation, unless clear history of painful detrusor hyperactivity Section I: endocrine system I1. Diabetic oral agents Aim for monotherapy. Target of HbA1c <8%/64mmol/mol. Stringent glycaemic control is unnecessary I2. ACE-inhibitors for diabetes Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I3. Angiotensin receptor blockers (ARBs) Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I4. Systemic oestrogens for menopausal symptoms Increases risk of stroke and VTE disease. Discontinue and only consider recommencing if recurrence of symptoms Section J: Miscellaneous J1. Multi-vitamin combination supplements Discontinue when prescribed for prophylaxis rather than treatment J2. Nutritional supplements (other than vitamins) Discontinue when prescribed for prophylaxis rather than treatment J3: Prophylactic antibiotics No firm evidence for prophylactic antibiotics to prevent recurrent cellulitis or UTIs Disclaimer (STOPPFrail) While every effort has been made to ensure that the potentially inappropriate prescribing criteria listed in STOPPFrail are accurate and evidence-based, it is emphasized that the final decision to avoid or initiate any drug referred to in these criteria rests entirely with the prescriber. It is also to be noted that the evidence base underlying certain criteria in STOPPFrail may change after the time of publication of these criteria. Therefore, it is advisable that prescribing decisions should take account of current published evidence in support of or against the use of drugs or drug classes described in STOPPFrail. STOPPFrail is a list of potentially inappropriate prescribing indicators designed to assist physicians with stopping such medications in older patients (≥65 years) who meet ALL of the criteria listed below: End-stage irreversible pathology Poor 1-year survival prognosis Severe functional or severe cognitive impairment or both Symptom control is the priority rather than prevention of disease progression The decision to prescribe/not prescribe medications to the patient, should also be influenced by the following issues: Drug adherence/compliance is difficult Administration of the medication is challenging Monitoring of the medication effect is challenging Drug adherence/ compliance is difficult Section A: general A1: Any drug that the patient persistently fails to take or tolerate despite adequate education and consideration of all appropriate formulations A2: Any drug without clear clinical indication Section B: cardiology system B1. Lipid lowering therapies (statins, ezetimibe, bile acid sequestrans, fibrates, nicotinic acid and acipimox) These medications need to be prescribed for a long duration to be of benefit. For short-term use, the risk of ADEs outweighs the potential benefits B2. Alpha-blockers for hypertension Stringent blood pressure control is not required in very frail older people. Alpha blockers in particular can cause marked vasodilatation, which can result in marked postural hypotension, falls and injuries Section C: coagulation system C1: Anti-platelets Avoid anti-platelet agents for primary (as distinct from secondary) cardiovascular prevention (no evidence of benefit) Section D: Central nervous system D1. Neuroleptic antipsychotics Aim to reduce dose and discontinue these drugs in patients taking them for longer than 12 weeks if there are no current clinical features of behavioural and psychiatric symptoms of dementia (BPSD) D2: Memantine Discontinue and monitor in patients with moderate to severe dementia, unless memantine has clearly improved BPSD (specifically in frail patients who meet the criteria above) Section E: gastrointestinal system E1. Proton pump inhibitors Proton pump inhibitors at full therapeutic dose ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E2: H2 receptor antagonist H2 receptor antagonist at full therapeutic dose for ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E3. Gastrointestinal antispasmodics Regular daily prescription of gastrointestinal antispasmodics agents unless the patient has frequent relapse of colic symptoms because of high risk of anti-cholinergic side effects Section F: respiratory system F1. Theophylline This drug has a narrow therapeutic index, requires monitoring of serum levels and interacts with other commonly prescribed drugs putting patients at an increased risk of ADEs F2. Leukotriene antagonists (Montelukast, Zafirlukast) These drugs have no proven role in COPD, they are indicated only in asthma (50) Section G: musculoskeletal system G1: Calcium supplementation Unlikely to be of any benefit in the short term G2: Anti-resorptive/bone anabolic drugsFOR OSTEOPOROSIS (bisphosphonates, strontium, teriparatide, denosumab) G3. Selective estrogen receptor modulators (SERMs) for osteoporosis Benefits unlikely to be achieved within 1 year, increased short-intermediate term risk of associated ADEs particularly venous thromboembolism and stroke G4. Long-term oral NSAIDs Increased risk of side effects (peptic ulcer disease, bleeding, worsening heart failure etc.) when taken regularly for ≥ 2 months G5. Long-term oral steroids Increased risk of side effects (peptic ulcer disease etc.) when taken regularly for ≥ 2 months. Consider careful dose reduction and discontinuation Section H: urogenital system H1. 5-alpha reductase inhibitors No benefit with long term urinary bladder catheterisation H2. Alpha blockers No benefit with long term urinary bladder catheterisation H3. Muscarinic antagonists No benefit with long-term urinary bladder catheterisation, unless clear history of painful detrusor hyperactivity Section I: endocrine system I1. Diabetic oral agents Aim for monotherapy. Target of HbA1c <8%/64mmol/mol. Stringent glycaemic control is unnecessary I2. ACE-inhibitors for diabetes Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I3. Angiotensin receptor blockers (ARBs) Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I4. Systemic oestrogens for menopausal symptoms Increases risk of stroke and VTE disease. Discontinue and only consider recommencing if recurrence of symptoms Section J: Miscellaneous J1. Multi-vitamin combination supplements Discontinue when prescribed for prophylaxis rather than treatment J2. Nutritional supplements (other than vitamins) Discontinue when prescribed for prophylaxis rather than treatment J3: Prophylactic antibiotics No firm evidence for prophylactic antibiotics to prevent recurrent cellulitis or UTIs Disclaimer (STOPPFrail) While every effort has been made to ensure that the potentially inappropriate prescribing criteria listed in STOPPFrail are accurate and evidence-based, it is emphasized that the final decision to avoid or initiate any drug referred to in these criteria rests entirely with the prescriber. It is also to be noted that the evidence base underlying certain criteria in STOPPFrail may change after the time of publication of these criteria. Therefore, it is advisable that prescribing decisions should take account of current published evidence in support of or against the use of drugs or drug classes described in STOPPFrail. Table 1. The STOPPFrail criteria STOPPFrail is a list of potentially inappropriate prescribing indicators designed to assist physicians with stopping such medications in older patients (≥65 years) who meet ALL of the criteria listed below: End-stage irreversible pathology Poor 1-year survival prognosis Severe functional or severe cognitive impairment or both Symptom control is the priority rather than prevention of disease progression The decision to prescribe/not prescribe medications to the patient, should also be influenced by the following issues: Drug adherence/compliance is difficult Administration of the medication is challenging Monitoring of the medication effect is challenging Drug adherence/ compliance is difficult Section A: general A1: Any drug that the patient persistently fails to take or tolerate despite adequate education and consideration of all appropriate formulations A2: Any drug without clear clinical indication Section B: cardiology system B1. Lipid lowering therapies (statins, ezetimibe, bile acid sequestrans, fibrates, nicotinic acid and acipimox) These medications need to be prescribed for a long duration to be of benefit. For short-term use, the risk of ADEs outweighs the potential benefits B2. Alpha-blockers for hypertension Stringent blood pressure control is not required in very frail older people. Alpha blockers in particular can cause marked vasodilatation, which can result in marked postural hypotension, falls and injuries Section C: coagulation system C1: Anti-platelets Avoid anti-platelet agents for primary (as distinct from secondary) cardiovascular prevention (no evidence of benefit) Section D: Central nervous system D1. Neuroleptic antipsychotics Aim to reduce dose and discontinue these drugs in patients taking them for longer than 12 weeks if there are no current clinical features of behavioural and psychiatric symptoms of dementia (BPSD) D2: Memantine Discontinue and monitor in patients with moderate to severe dementia, unless memantine has clearly improved BPSD (specifically in frail patients who meet the criteria above) Section E: gastrointestinal system E1. Proton pump inhibitors Proton pump inhibitors at full therapeutic dose ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E2: H2 receptor antagonist H2 receptor antagonist at full therapeutic dose for ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E3. Gastrointestinal antispasmodics Regular daily prescription of gastrointestinal antispasmodics agents unless the patient has frequent relapse of colic symptoms because of high risk of anti-cholinergic side effects Section F: respiratory system F1. Theophylline This drug has a narrow therapeutic index, requires monitoring of serum levels and interacts with other commonly prescribed drugs putting patients at an increased risk of ADEs F2. Leukotriene antagonists (Montelukast, Zafirlukast) These drugs have no proven role in COPD, they are indicated only in asthma (50) Section G: musculoskeletal system G1: Calcium supplementation Unlikely to be of any benefit in the short term G2: Anti-resorptive/bone anabolic drugsFOR OSTEOPOROSIS (bisphosphonates, strontium, teriparatide, denosumab) G3. Selective estrogen receptor modulators (SERMs) for osteoporosis Benefits unlikely to be achieved within 1 year, increased short-intermediate term risk of associated ADEs particularly venous thromboembolism and stroke G4. Long-term oral NSAIDs Increased risk of side effects (peptic ulcer disease, bleeding, worsening heart failure etc.) when taken regularly for ≥ 2 months G5. Long-term oral steroids Increased risk of side effects (peptic ulcer disease etc.) when taken regularly for ≥ 2 months. Consider careful dose reduction and discontinuation Section H: urogenital system H1. 5-alpha reductase inhibitors No benefit with long term urinary bladder catheterisation H2. Alpha blockers No benefit with long term urinary bladder catheterisation H3. Muscarinic antagonists No benefit with long-term urinary bladder catheterisation, unless clear history of painful detrusor hyperactivity Section I: endocrine system I1. Diabetic oral agents Aim for monotherapy. Target of HbA1c <8%/64mmol/mol. Stringent glycaemic control is unnecessary I2. ACE-inhibitors for diabetes Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I3. Angiotensin receptor blockers (ARBs) Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I4. Systemic oestrogens for menopausal symptoms Increases risk of stroke and VTE disease. Discontinue and only consider recommencing if recurrence of symptoms Section J: Miscellaneous J1. Multi-vitamin combination supplements Discontinue when prescribed for prophylaxis rather than treatment J2. Nutritional supplements (other than vitamins) Discontinue when prescribed for prophylaxis rather than treatment J3: Prophylactic antibiotics No firm evidence for prophylactic antibiotics to prevent recurrent cellulitis or UTIs Disclaimer (STOPPFrail) While every effort has been made to ensure that the potentially inappropriate prescribing criteria listed in STOPPFrail are accurate and evidence-based, it is emphasized that the final decision to avoid or initiate any drug referred to in these criteria rests entirely with the prescriber. It is also to be noted that the evidence base underlying certain criteria in STOPPFrail may change after the time of publication of these criteria. Therefore, it is advisable that prescribing decisions should take account of current published evidence in support of or against the use of drugs or drug classes described in STOPPFrail. STOPPFrail is a list of potentially inappropriate prescribing indicators designed to assist physicians with stopping such medications in older patients (≥65 years) who meet ALL of the criteria listed below: End-stage irreversible pathology Poor 1-year survival prognosis Severe functional or severe cognitive impairment or both Symptom control is the priority rather than prevention of disease progression The decision to prescribe/not prescribe medications to the patient, should also be influenced by the following issues: Drug adherence/compliance is difficult Administration of the medication is challenging Monitoring of the medication effect is challenging Drug adherence/ compliance is difficult Section A: general A1: Any drug that the patient persistently fails to take or tolerate despite adequate education and consideration of all appropriate formulations A2: Any drug without clear clinical indication Section B: cardiology system B1. Lipid lowering therapies (statins, ezetimibe, bile acid sequestrans, fibrates, nicotinic acid and acipimox) These medications need to be prescribed for a long duration to be of benefit. For short-term use, the risk of ADEs outweighs the potential benefits B2. Alpha-blockers for hypertension Stringent blood pressure control is not required in very frail older people. Alpha blockers in particular can cause marked vasodilatation, which can result in marked postural hypotension, falls and injuries Section C: coagulation system C1: Anti-platelets Avoid anti-platelet agents for primary (as distinct from secondary) cardiovascular prevention (no evidence of benefit) Section D: Central nervous system D1. Neuroleptic antipsychotics Aim to reduce dose and discontinue these drugs in patients taking them for longer than 12 weeks if there are no current clinical features of behavioural and psychiatric symptoms of dementia (BPSD) D2: Memantine Discontinue and monitor in patients with moderate to severe dementia, unless memantine has clearly improved BPSD (specifically in frail patients who meet the criteria above) Section E: gastrointestinal system E1. Proton pump inhibitors Proton pump inhibitors at full therapeutic dose ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E2: H2 receptor antagonist H2 receptor antagonist at full therapeutic dose for ≥ 8/52, unless persistent dyspeptic symptoms at lower maintenance dose E3. Gastrointestinal antispasmodics Regular daily prescription of gastrointestinal antispasmodics agents unless the patient has frequent relapse of colic symptoms because of high risk of anti-cholinergic side effects Section F: respiratory system F1. Theophylline This drug has a narrow therapeutic index, requires monitoring of serum levels and interacts with other commonly prescribed drugs putting patients at an increased risk of ADEs F2. Leukotriene antagonists (Montelukast, Zafirlukast) These drugs have no proven role in COPD, they are indicated only in asthma (50) Section G: musculoskeletal system G1: Calcium supplementation Unlikely to be of any benefit in the short term G2: Anti-resorptive/bone anabolic drugsFOR OSTEOPOROSIS (bisphosphonates, strontium, teriparatide, denosumab) G3. Selective estrogen receptor modulators (SERMs) for osteoporosis Benefits unlikely to be achieved within 1 year, increased short-intermediate term risk of associated ADEs particularly venous thromboembolism and stroke G4. Long-term oral NSAIDs Increased risk of side effects (peptic ulcer disease, bleeding, worsening heart failure etc.) when taken regularly for ≥ 2 months G5. Long-term oral steroids Increased risk of side effects (peptic ulcer disease etc.) when taken regularly for ≥ 2 months. Consider careful dose reduction and discontinuation Section H: urogenital system H1. 5-alpha reductase inhibitors No benefit with long term urinary bladder catheterisation H2. Alpha blockers No benefit with long term urinary bladder catheterisation H3. Muscarinic antagonists No benefit with long-term urinary bladder catheterisation, unless clear history of painful detrusor hyperactivity Section I: endocrine system I1. Diabetic oral agents Aim for monotherapy. Target of HbA1c <8%/64mmol/mol. Stringent glycaemic control is unnecessary I2. ACE-inhibitors for diabetes Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I3. Angiotensin receptor blockers (ARBs) Stop where prescribed only for prevention and treatment of diabetic nephropathy. There is no clear benefit in older people with advanced frailty with poor survival prognosis I4. Systemic oestrogens for menopausal symptoms Increases risk of stroke and VTE disease. Discontinue and only consider recommencing if recurrence of symptoms Section J: Miscellaneous J1. Multi-vitamin combination supplements Discontinue when prescribed for prophylaxis rather than treatment J2. Nutritional supplements (other than vitamins) Discontinue when prescribed for prophylaxis rather than treatment J3: Prophylactic antibiotics No firm evidence for prophylactic antibiotics to prevent recurrent cellulitis or UTIs Disclaimer (STOPPFrail) While every effort has been made to ensure that the potentially inappropriate prescribing criteria listed in STOPPFrail are accurate and evidence-based, it is emphasized that the final decision to avoid or initiate any drug referred to in these criteria rests entirely with the prescriber. It is also to be noted that the evidence base underlying certain criteria in STOPPFrail may change after the time of publication of these criteria. Therefore, it is advisable that prescribing decisions should take account of current published evidence in support of or against the use of drugs or drug classes described in STOPPFrail. The aims of this study were: To determine the prevalence of potentially inappropriate medications (PIMs), as defined by the STOPPfrail tool, in the discharge prescription lists of older adults hospitalized in the last year of life. To measure medication consumption by older people while in hospital in the last year of life. Methods Study population We included people aged ≥65 years who were hospitalized for ≥2 days under general medical services in our institution in the year prior to death. The Hospital In-Patient Enquiry system (a national database of coded discharge summaries) was used to identify patients discharged between January 2013 to December 2014. When patients were admitted more than once during this period, a single hospitalization was randomly chosen as the index hospitalization. Patients who died during their index hospital admission and those discharged to a hospice, presumably in the final stages of a terminal illness, were excluded because the primary end point was to measure the prevalence of STOPPFrail-defined PIMs at the time of discharge. Deaths within 1 year of hospitalization were determined by accessing the Hospital Information System and an online death notification system (www.RIP.ie). In total, 603 patients were eligible for inclusion. We estimated that 50% of patients would be prescribed PIMs at discharge. Using a precision of 5% and a 95% level of confidence, we calculated that a minimum sample of 384 patients would be required for this study. To ensure an adequate final sample size, a random sample of 434 was generated using a randomization (RAND) function in Microsoft Excel©. The local Clinical Research Ethics Committee approved the study protocol. Data collection A retrospective chart review was conducted on all study patients by a Geriatric Medicine trained physician using a standardized data collection pro-forma. The prevalence of STOPPfrail-defined PIMs was measured by accessing the discharge prescriptions from the patients’ index hospitalization. Disease burden and performance status at the time of hospital discharge were determined using the Charlson Comorbidity Index (CCI) [8, 9] and the Clinical Frailty Scale (CFS) [10], respectively. The CFS is a 9-item scale and, in this study, we categorized patients into two groups: (i) those with scores of ≥7 (indicating severe frailty and/or terminal illness and therefore potentially eligible for the STOPPFrail tool) and (ii) those with scores <7 (indicating full independence, mild or moderate frailty). Medication consumption was determined by reviewing in-patient medication administration records from all hospitalizations in the last year of life. Medications that were prescribed but not consumed were not included, nor were nutritional products, blood products or intravenous fluids. A single ingredient constituted one medicine. For combination products, each ingredient was included as one drug as long as that ingredient was available as a medicine in the British National Formulary. Results Patient characteristics In total, 410 patients were included (24 patients were excluded because of missing data or because they were discharged to the care of community palliative services). The principal characteristics of the decedents are summarized in Table 2. The mean age of patients was 80.8 (standard deviation [SD] 7.9) and males and females were evenly represented. Polypharmacy was highly prevalent and the mean number of medications per patient at the time of hospital admission was 8.4 (SD 4.3). At the time of hospital discharge, 63.7% of patients were either severely frail or had an advanced terminal diagnosis (CFS ≥ 7). Table 2. Baseline characteristics and results Total (n = 410) Mean age (SD) at time of index hospitalization 80.8 (7.9) Female (%) 202 (49.3) Discharge health/functional status  Mean (SD) CCI score 6.2 (2.3)  CFS ≥7 261 (63.7%) Mean number (SD) of admission medications at index hospitalization 8.4 (4.3) Mean number (SD) of discharge medications at index hospitalization 8.7 (4.2) Median number (IQR) of days between index hospital discharge and death 124 (47–225.5) At index hospital discharge  Mean no. of PIMs per patient (SD) 1.9 (1.4)  ≥1 PIM 81.5%  ≥3 PIMs 34.0% In the last year of life  Median bed days (IQR) 32 (15–59)  Median hospital admissions (IQR) 2 (1.25–3)  Median emergency department episodes (IQR) 2 (1–3)  ≥30 Bed days 53.4%  ≥3 Hospital admissions 43.4%  ≥3 Emergency department episodes 34.0% Medications consumed during all hospitalizations in last year of life  Mean 23.8 (10.1)  ≥25 Medications 43.6%  ≥35 Medications 17.3% Medication-types consumed during all hospitalizations in last year of life  Disease/symptom control 87.3%  Long-term preventive 9.5%  Short-term preventive 3.2% Total (n = 410) Mean age (SD) at time of index hospitalization 80.8 (7.9) Female (%) 202 (49.3) Discharge health/functional status  Mean (SD) CCI score 6.2 (2.3)  CFS ≥7 261 (63.7%) Mean number (SD) of admission medications at index hospitalization 8.4 (4.3) Mean number (SD) of discharge medications at index hospitalization 8.7 (4.2) Median number (IQR) of days between index hospital discharge and death 124 (47–225.5) At index hospital discharge  Mean no. of PIMs per patient (SD) 1.9 (1.4)  ≥1 PIM 81.5%  ≥3 PIMs 34.0% In the last year of life  Median bed days (IQR) 32 (15–59)  Median hospital admissions (IQR) 2 (1.25–3)  Median emergency department episodes (IQR) 2 (1–3)  ≥30 Bed days 53.4%  ≥3 Hospital admissions 43.4%  ≥3 Emergency department episodes 34.0% Medications consumed during all hospitalizations in last year of life  Mean 23.8 (10.1)  ≥25 Medications 43.6%  ≥35 Medications 17.3% Medication-types consumed during all hospitalizations in last year of life  Disease/symptom control 87.3%  Long-term preventive 9.5%  Short-term preventive 3.2% Table 2. Baseline characteristics and results Total (n = 410) Mean age (SD) at time of index hospitalization 80.8 (7.9) Female (%) 202 (49.3) Discharge health/functional status  Mean (SD) CCI score 6.2 (2.3)  CFS ≥7 261 (63.7%) Mean number (SD) of admission medications at index hospitalization 8.4 (4.3) Mean number (SD) of discharge medications at index hospitalization 8.7 (4.2) Median number (IQR) of days between index hospital discharge and death 124 (47–225.5) At index hospital discharge  Mean no. of PIMs per patient (SD) 1.9 (1.4)  ≥1 PIM 81.5%  ≥3 PIMs 34.0% In the last year of life  Median bed days (IQR) 32 (15–59)  Median hospital admissions (IQR) 2 (1.25–3)  Median emergency department episodes (IQR) 2 (1–3)  ≥30 Bed days 53.4%  ≥3 Hospital admissions 43.4%  ≥3 Emergency department episodes 34.0% Medications consumed during all hospitalizations in last year of life  Mean 23.8 (10.1)  ≥25 Medications 43.6%  ≥35 Medications 17.3% Medication-types consumed during all hospitalizations in last year of life  Disease/symptom control 87.3%  Long-term preventive 9.5%  Short-term preventive 3.2% Total (n = 410) Mean age (SD) at time of index hospitalization 80.8 (7.9) Female (%) 202 (49.3) Discharge health/functional status  Mean (SD) CCI score 6.2 (2.3)  CFS ≥7 261 (63.7%) Mean number (SD) of admission medications at index hospitalization 8.4 (4.3) Mean number (SD) of discharge medications at index hospitalization 8.7 (4.2) Median number (IQR) of days between index hospital discharge and death 124 (47–225.5) At index hospital discharge  Mean no. of PIMs per patient (SD) 1.9 (1.4)  ≥1 PIM 81.5%  ≥3 PIMs 34.0% In the last year of life  Median bed days (IQR) 32 (15–59)  Median hospital admissions (IQR) 2 (1.25–3)  Median emergency department episodes (IQR) 2 (1–3)  ≥30 Bed days 53.4%  ≥3 Hospital admissions 43.4%  ≥3 Emergency department episodes 34.0% Medications consumed during all hospitalizations in last year of life  Mean 23.8 (10.1)  ≥25 Medications 43.6%  ≥35 Medications 17.3% Medication-types consumed during all hospitalizations in last year of life  Disease/symptom control 87.3%  Long-term preventive 9.5%  Short-term preventive 3.2% Prevalence of STOPPfrail PIMs at hospital discharge The mean number of medications prescribed per patient did not change significantly from index hospital admission to discharge (8.4 [SD 4.3] versus 8.7 [SD 4.2], P = 0.275). More than 80% of patients were prescribed at least one STOPPfrail-defined PIM in their discharge prescription and 34% had ≥3 PIMs prescribed (Table 2). The mean number of PIMs did not differ significantly between patients’ potentially eligible for STOPPFrail-guided deprescribing (CFS ≥ 7) and those with less advanced stages of frailty (2.0 [SD 1.5] versus 1.8 [SD 1.4], P = 0.053). Full implementation of the STOPPFrail recommendations for those with polypharmacy (defined here as ≥5 long-term medications) would have resulted in, on average, a 23% reduction in total medication burden. Lipid-lowering medications, proton pump inhibitors, anti-psychotics and calcium supplements accounted for 59% of all STOPPfrail-defined PIMs (Supplementary Appendix 1). Medication consumption while in hospital in the last year of life In the year prior to death, the median number of days in hospital was 32 (interquartile range [IQR] 15–58). One-third of people had three or more emergency department presentations. During all hospital stays in the last year of life, the mean number of individual medications consumed per patient was 23.8 (SD 10.1). One-in-six patients consumed ≥35 different medications (Table 2). Long-term preventive medications accounted for 9.5% of all medications consumed during hospitalization but 24.9% of medications prescribed at the time of hospital discharge. Discussion This is the first study of its kind using recently validated explicit deprescribing criteria designed for application in the frailest older people. Our data show that older people in their last year of life receive high levels of polypharmacy, a quarter of which includes long-term preventive therapies which are likely futile. Hospital physicians need to (i) be able to recognize frailer older patients in their last year of life, and (ii) be prepared to deprescribe thoughtfully where appropriate, particularly long-term preventive drugs where benefit is unlikely to be realized. Symptoms at end of life are often complex. A large nationally representative longitudinal survey of adults in the USA reported that symptoms such as depression, confusion, dyspnea, incontinence, fatigue, anorexia and vomiting were all common in the last year of life [11]. While improvements can usually be made regarding prescribing quality, high levels of medication consumption may be inevitable. This is important because the number of medications prescribed is the most important predictor of iatrogenic harm [12]. The challenge for the prescribing physician is to strike a balance between controlling multiple symptoms and minimizing the inherent risks of polypharmacy. Full implementation of STOPFrail recommendations for hospitalized patients would have resulted in almost one-in-four long-term medications being discontinued. The process of deprescribing, of course, must be individualized and patients’ preferences, clinical contextual factors and the potential for adverse drug withdrawal events given due consideration. Other deprescribing tools (e.g. CEASE [13], Good Palliative-Geriatric Practice [14]) are ‘implicit’ and demand that the prescriber balance risk and benefit of each medication. The real-world applicability of these methods to all but expert prescribers is doubtful. The value of STOPPFrail is that it is explicit, concise, easy-to-use, and, as we have shown, highly relevant to the practice of hospital physicians. Recognizing when people are in the final phase of life is key to operationalizing deprescribing. A 2012 systematic review by Yourman et al. [15] concluded that there was insufficient evidence to recommend application of any of the available prognostic models for older adults. Some degree of uncertainty when predicting prognosis seems inevitable. In this study, the majority of patients were severely frail and functional status has been shown to be a strong predictor of mortality in older people [1, 15]. In addition, functional decline following hospitalization is associated with a poor survival prognosis [16]. Perhaps then, it is patients who are severely frail at the time of hospital admission, and those who decline to a new frailer baseline despite adequate rehabilitation, that should be considered appropriate candidates for deprescribing. Our study has some limitations. Firstly, the experience described does not apply to the 18–29% of older people who are not hospitalized in the last year of life [1, 4]. However, symptom, disease and medication burden are presumably less marked in this cohort. Secondly, we may have underestimated medication exposure and acute hospital care utilization because information about hospitalizations outside of our institution was not captured. In summary, hospitalizations are common and drug burden is high in the last year of life and people are frequently discharged home with prescriptions for potentially futile medications. The STOPPFrail criteria are highly relevant and may assist physicians with deprescribing decisions. Key points The last year of life is associated with frequent and prolonged hospital admissions. Medication consumption is high in the last year of life and many patients consume medications that are potentially futile. Hospital physicians can reduce medication burden for older people approaching end of life using the STOPPFrail tool. Supplementary data Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. Funding D.C. and D.O.M. are supported by the FP7 EC-funded SENATOR project (grant number 305930). Conflicts of interest D.OM. and P.G. were involved in the development of the STOPPFrail Criteria which were used to define ‘futile medications’. References 1 Gill TM , Gahbauer EA , Han L , Allore HG . The role of intervening hospital admissions on trajectories of disability in the last year of life: prospective cohort study of older people . BMJ 2015 ; 350 : h2361 . Google Scholar CrossRef Search ADS PubMed 2 Jansen J , Naganathan V , Carter SM et al. . Too much medicine in older people? Deprescribing through shared decision making . BMJ 2016 ; 353 : I2893 . Google Scholar CrossRef Search ADS PubMed 3 Scott IA , Hilmer SN , Reeve E et al. . Reducing inappropriate polypharmacy: the process of deprescribing . JAMA Intern Med 2015 ; 175 : 827 – 34 . Google Scholar CrossRef Search ADS PubMed 4 Goldsbury DE , O’Connell DL , Girgis A et al. . Acute hospital-based services used by adults during the last year of life in New South Wales. In: BMC Health Serv Res ; 15 . Australia : a population-based retrospective cohort study , 2015 ; p. 537 . 5 Bekelman JE , Halpern SD , Blankart CR et al. . Comparison of site of death, health care utilization, and hospital expenditures for patients dying with cancer in 7 developed countries . JAMA 2016 ; 315 : 272 – 83 . Google Scholar CrossRef Search ADS PubMed 6 Lavan AH , Gallagher P , Parsons C , O’Mahony D . STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation . Age Ageing 2017 ; 46 : 600 – 607 . Google Scholar CrossRef Search ADS PubMed 7 Lavan AH , Gallagher P , O’Mahony D . Inter-rater reliability of STOPPFrail [Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy] criteria amongst 12 physicians . Eur J Clin Pharmacol 2017 . doi:10.1007/s00228-017-2376-2 ; [Epub ahead of print]. 8 Charlson ME , Pompei P , Ales KL , MacKenzie CR . A new method of classifying prognostic comorbidity in longitudinal studies: development and validation . J Chronic Dis 1987 ; 40 : 373 – 83 . Google Scholar CrossRef Search ADS PubMed 9 Quan H , Li B , Couris CM et al. . Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries . Am J Epidemiol 2011 ; 173 : 678 – 82 . Google Scholar CrossRef Search ADS 10 Rockwood K , Song X , MacKnight C et al. . A global clinical measure of fitness and frailty in elderly people . CMAJ 2005 ; 2005 : 489 – 95 . Google Scholar CrossRef Search ADS 11 Singer AE , Meeker D , Teno JM , Lynn J , Lunney JR , Lorenz KA . Symptom trends in the last year of life, 1998–2010: a cohort study . Ann Intern Med 2015 ; 162 : 175 – 83 . Google Scholar CrossRef Search ADS PubMed 12 Steinman MA , Miao Y , Boscardin WJ , Komaiko KD , Schwartz JB . Prescribing quality in older veterans: a multifocal approach . J Gen Intern Med 2014 ; 29 : 1379 – 86 . Google Scholar CrossRef Search ADS PubMed 13 Scott IA , Le Couteur D . Physicians need to take the lead in deprescribing . Intern Med J 2015 ; 45 : 352 – 6 . Google Scholar CrossRef Search ADS PubMed 14 Garfinkel D , Zur-Gil S , Ben-Israel J . The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elldery people . Is Med Assoc J 2007 ; 9 : 430 – 4 . 15 Yourman LC , Lee SJ , Schonberg MA , Widera EW , Smith AK . Prognostic indices for older adults: a systematic review . JAMA 2012 ; 307 : 182 – 92 . Google Scholar CrossRef Search ADS PubMed 16 Boyd CM , Landefeld SC , Counsell SR , Palmer RM , Fortinsky RH , Kresevic D . Recovery in activities of daily living among older adults following hospitalization for acute medical illness . J Am Geriatr Soc 2008 ; 56 : 2171 – 9 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Age and AgeingOxford University Press

Published: Apr 23, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off