Drug Therapy Optimization at the End of Life

Cruz-Jentoft, Alfonso J.; Boland, Benoît; Rexach, Lourdes

doi:10.2165/11631740-000000000-00000

Cited by 77 publications

(58 citation statements)

References 74 publications

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“…Furthermore, there were some medications, namely expectorants and tricyclic antidepressants, for which classifications of appropriateness varied widely. This variation may in part be explained by cross-national or cultural differences in prescribing in US and UK jurisdictions but may also reflect the complexity and variability in decision-making regarding medication use at the end of life for patients with advanced dementia and the lack of evidence-based guidance available to guide clinical practice [8,27,41].…”

Section: Discussionmentioning

confidence: 99%

Development and Application of Medication Appropriateness Indicators for Persons with Advanced Dementia: A Feasibility Study

et al. 2014

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USA) for their advice regarding study design. The authors would also like to thank the physicians who participated in the Delphi consensus panel survey, and the residents, their relatives and care home staff who participated in the feasibility study. AbstractBackground: No studies have been conducted in the United Kingdom (UK) context to date which categorise medications in terms of appropriateness for patients with advanced dementia, or which examine medication use in these vulnerable patients.Objectives: To categorise the appropriateness of a comprehensive list of medications and medication classes for use in patients with advanced dementia; to examine the feasibility of conducting a longitudinal prospective cohort study to collect clinical and medication use data;and to determine the appropriateness of prescribing for nursing home residents with advanced dementia in Northern Ireland (NI), using the categories developed.Methods: Three-round Delphi consensus panel survey of expert clinicians, to categorise the appropriateness of medications for patients with advanced dementia (defined as having Functional Assessment Staging [FAST] scores ranging from 6E to 7F). This was followed by a longitudinal prospective cohort feasibility study which was conducted in three nursing homes in NI. Clinical and medication use for participating residents with advanced dementia (FAST scores ranging from 6E to 7F) were collected and a short test of dementia severity administered.These data were collected at baseline and every three months for up to nine months or until death. For those residents who died during the study period, data were also collected within 14 days of death. The appropriateness ratings from the consensus panel survey were retrospectively applied to residents' medication data at each data collection timepoint to determine the appropriateness of medications prescribed for these residents.Results: Consensus was achieved for 87 (90%) of the 97 medications and medication classes included in the survey. Fifteen residents were recruited to participate in the longitudinal prospective cohort feasibility study, four of whom died during the data collection period. Mean numbers of medications prescribed per resident were 16.2 at baseline, 19.6 at three months, 17.4 at six months and 16.1 at nine months respectively. Fourteen residents at baseline were taking at least one medication considered by the consensus panel to be never appropriate, and approximately 25% of medications prescribed were considered to be never appropriate. Postdeath data collection indicated a decrease in the proportion of never appropriate medications and an increase in the proportion of always appropriate medications for those residents who died. Conclusions

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Section: Discussionmentioning

confidence: 99%

Development and Application of Medication Appropriateness Indicators for Persons with Advanced Dementia: A Feasibility Study

et al. 2014

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“…There are no data regarding the appropriate withdrawal of medications for patients with HF nearing the end of life; however, maintenance of volume status close to euvolemia and continuation of therapies that address the neurohormonal alterations of HF (such as ACEIs and β-blockers in HFrEF) palliate HF symptoms. 212,[220][221][222] All treatments ordered early in HF should be reevaluated in light of goals of care, particularly when patients or their surrogates have chosen to avoid hospitalization.…”

Section: End-of-life Carementioning

confidence: 99%

Heart Failure Management in Skilled Nursing Facilities

Jurgens¹,

Goodlin²,

Dolansky³

et al. 2015

Circ: Heart Failure

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655H eart failure (HF) is a complex syndrome in which structural or functional cardiac abnormalities impair the filling of ventricles or left ventricular ejection of blood. HF disproportionately occurs in those ≥65 years of age.1 Among the estimated 1.5 to 2 million residents in skilled nursing facilities (SNFs) in the United States, cardiovascular disease is the largest diagnostic category, and HF is common. 2,3Despite the high prevalence of HF in SNF residents, none of the large randomized clinical trials of HF therapy included SNF residents, and very few included patients >80 years of age with complex comorbidities.Several issues make it important to address HF care in SNFs. The healthcare environment and characteristics of SNF residents are distinct from those of community-dwelling adults. Comorbid illness unrelated to HF (eg, dementia, hip fracture) increases with age >75 years, and these conditions may complicate both the initial HF diagnosis and ongoing management. [4][5][6] Morbidity and mortality rates are significantly increased for hospitalized older adults with HF discharged to SNFs compared with those discharged to other sites. 7Transitions between hospitals and SNFs may be problematic. 8SNF 30-day rehospitalization rates for HF range from 27% to 43%, 7,9,10 and long-term care residents sent to the emergency department are at increased risk for hospital admission and death.11 The purpose of this scientific statement is to provide guidance for management of HF in SNFs to improve patientcentered outcomes and reduce hospitalizations. This statement addresses unique issues of SNF care and adapts HF guidelines and other recommendations to this setting. MethodsThis scientific statement on HF management in SNFs was developed by a writing group of experts representing nursing, medicine (cardiology, geriatrics, nursing home physicians, and palliative medicine), pharmacology, physical therapy, dietary clinical management, research, and quality of care. Sponsors (the American Heart Association [AHA] and the Heart Failure Society of America) identified specific members of the writing group, and others were selected on the basis of known expertise. A literature search was performed using the key The current document is solely the responsibility of the authors and does not represent the official views of the National Heart, Lung, and Blood Institute or the Department of Health and Human Services.The American Heart Association and the Heart Failure Society of America make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.This document was approved by the American Heart Association Science Advisory and Coordinating Committee on September 15, 2014, and by the...

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“…Although all medications were reviewed, special attention was paid to those previously identified in the literature as having a high potential for discontinuation at the end-of-life, such as those used for primary prevention. (Table 1) [15][16][17]. This allowed us to make prescribing decisions based on both the therapeutic objective of the medication and the previously established therapeutic goals of the patient.…”

Section: Diagnosis Centred Assessmentmentioning

confidence: 99%

“…Recently, published recommendations for end-of-life pharmacotherapy provide guidance on individualizing drug therapy regimens [15][16][17]. This requires re-thinking the prescription process, utilizing criteria specific to this patient population including:…”

Section: Introductionmentioning

confidence: 99%