Newer, better, safer drugs are
the holy grail of medical research, and before they
hit the market, lots of work is put into figuring out
exactly how they should be used and who should take
them. But almost no one ever asks when it's time to
stop a medication. Now, a group of University of Chicago
geriatricians has shed some light on when to call it
quits with a new framework for taking elderly patients
off their meds.
As the years pile on, so do the
prescriptions, until seniors are taking a fearsome cocktail
of drugs that have often never been adequately tested
in their age group. The risk of adverse events and dangerous
drug interactions, "can grow to the point where the
burden greatly outweighs the benefit," says lead author
Dr Holly Holmes (see "Improper
prescribing puts seniors in peril", NRM February
15, 2006, Vol 3, No 3, Page 8). So she and her team
have proposed a way to help you decide when it's time
to toss one. Their model includes four components: the
patient's remaining life expectancy, the expected time
until benefit of the drug in question, the patient's
goals of care and the treatment target that a physician
might consider attainable with the drug. The study was
published in the Archives of Internal Medicine
on March 26.
LOOK
TO THE NEAR FUTURE
The researchers present their model as a pyramid, where
the wide base represents all the drugs that might be
considered appropriate for a 65-year-old patient, and
the four walls are the four components of the decision
process. As options narrow over time, so the pyramid
narrows towards the top, and an ever-diminishing list
of drugs remains appropriate.
"In this model, the drugs most
likely to fall by the wayside over time are those with
a long-term preventive effect, such as statins," says
co-author Dr Deon Cox-Hayley, Medical Director of Windermere
Senior Health Center in Chicago. Those most likely to
remain on the list are short acting drugs for symptom
control.
You'd expect patients to panic
when they realize your focus is shifting to palliative
care, but Dr Cox-Hayley says just the opposite is true
— many actually find it quite liberating. While
the young old still expect therapies aimed at prevention,
or if necessary, cure, the authors found the very old
come to expect symptomatic control. "Most of our patients
know, frankly, that the end is near, and they've learned
to accept that," she says. "There's less resistance
than you might think." In fact, many jump at the chance
to drop some of their medications, at least in part
because it will save them a lot of money.
Whether the same enthusiasm would
exist in Canada, where many seniors don't pay drug costs
out of pocket, is a debatable point. "We may find out
soon enough, with the introduction of the new prescription
drug plan [in the US]. The cost argument may not be
on our side anymore in the future," says Dr Holmes.
But she's quick to point out that there are plenty of
good reasons besides money. "It's well established for
many drugs that adverse events grow more serious and
common in older patients."
TRIALS
AND ERRORS
Dr Holmes says the increased risk of adverse events
in the elderly is compounded by the fact that most drugs
are hardly tested in this population. And often, the
trials that do include seniors don't last long enough
to get a good sense of time to benefit. "This makes
it harder to measure the trade-off between benefit and
burden, so we can't possibly devise a chart or table
that will reliably tell us when to drop medications,"
she says. "It has to be case-by-case, and a question
of clinical judgement."
The question of getting older patients
into clinical trials is often raised, but most studies
eliminate candidates with comorbid conditions. Some
older patients are excluded because of other treatments
they're receiving, or because their primary chronic
condition is too advanced. Often, to avoid hassle, researchers
just set a maximum age.
Only one study has set out to measure
adverse events from discontinuing medications in elderly
patients. It too, was published in the Archives of
Internal Medicine, back in 1997 and revealed very
few problems. The Chicago group are now planning their
own prospective study, focusing on patients with moderate
dementia.
In the meantime, Dr Holmes advises
asking elderly patients what they think of their drug
regimen before suggesting withdrawal of medicines. "I
rarely sit a patient down and say 'let's stop controlling
your hypertension'. Instead of telling a patient straight
out, I find it helps to elicit their opinion first."
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