End of Life Care in Frailty: Medicines management

Harm from medicines is the fifth frailty syndrome, and so the influence of medicines on any adverse health outcome in frail older adults should not be overlooked. Regular medicines review and identification of potential medicines-related harm (MRH) should be standard practice, with an increased focus on high-risk situations, and patient and carer involvement.

Medicines review

Current medicines review strategies in older adults, such as potentially inappropriate medicines criteria and deprescribing, are predicated on age-related alterations in drug handling and polypharmacy. While important, when used in isolation they have limited impact on quality of life, clinical and economic outcomes. In frail older adults even ‘appropriate’ medicines can present as a situational challenge, and be harmful due to reduced physiological and psychosocial mechanisms to deal with even minor side-effects. Existing systems fail to recognise this vulnerability, and the instability of individuals living with frailty or approaching the end of life. 

Formal structured medicines review must therefore form part of a multi-agency assessment to determine patient-focused goals of care that are documented in an agreed individual care plan and reviewed regularly. Deprescribing (the withdrawal of medicines) should not be the sole aim - indeed optimal symptom control may require the initiation of medicines, but stopping long-term preventative medicines will be one of the main aspects of medicines optimisation in this patient group. Patient, carer and healthcare professional’s fear of stopping medicines must be acknowledged, and can be managed through a structured medicine review as outlined below.

Who should do a medicines review?

A structured medicines review should be led by a healthcare professional who has the appropriate clinical and therapeutic knowledge, access to the necessary resources, and skills - including the ability to communicate effectively with patients, carers, and health and social care professionals. This could be a GP, geriatrician, specialist pharmacist or specialist nurse.

Triggers for medicines review

Current policy recommends primary care medicines reviews should be conducted at least every 12 months, however recognising the high level of vulnerability in this population, we recommend that reviews are conducted routinely and in response to certain triggers, including:

• Transitions of care.
• Acute illness, especially involving a hospital admission.
• Disease progression.
• Change of medicines (including starting, stopping and dose or formulation change).
• Change in package of care.
• Bereavement.
• Patient, carer or allied health professional reporting potential medicines-related problem.

Patient and carer role

The patient should be at the heart of the review process, in person or via an appropriate representative. Resources to support patients and carers get the most from a medicines review are available (refer to the bottom of this page for some helpful links). Useful questions include:

• Do I really need this test, treatment or procedure?
• What are the risks or downsides?
• What are the possible side effects?
• Are there simpler, safer options?
• What will happen if I do nothing?

Patients and carers are key players in the prevention and early identification of medicine-related problems, and should be supported to recognise and report sub-optimal medicines outcomes.

Care plans should outline the action to take, for example, when the patient has reduced oral intake and is prescribed anti-diabetic medicines. Utilisation of accessible healthcare professionals, such as community pharmacists, should be highlighted to facilitate early engagement in the end of life care process.

Make every contact count

Other examples of opportunities to help in the early identification of medicines-related problems include: physiotherapists identifying postural hypotension limiting rehabilitation potential and requesting a review of medicines; occupational therapists reporting difficulties with opening food packets and enquiring how the patient manages to open medicines packets; or carers noticing unused medicines and checking if the patient still needs them.

Tools to support structured medicines reviews

General approaches to medicines review are provided by the NHS Scotland’s 7 steps to appropriate polypharmacy and BGS’s CGA in Primary Care Settings, which include:

• Establish goals.
• Complete medicines reconciliation.
• Review how a patient uses their medicines.
• Check interactions and side effects (particularly, in frail or end of life patients, when prescribing drugs with active metabolites which are renally or hepatically excreted, such as codeine).
• Confirm medical history to determine appropriateness and understanding.
• Review each medicine for appropriateness.
• List and prioritise medicines-related problems.

Data on numbers needed to treat, numbers needed to harm and time to benefit are summarised here and may be useful when weighing up the risk and benefit, when long-term risk reduction may be less relevant in limited life span and not reflective of current patient priorities.

Some key topics to consider in frail older adults are available here, covering:

• Blood pressure control
• Blood sugar control
• Treatments to preserve renal function
• Blood thinners
• Heart rate control

Additionally, the unique aspects of pain control at the end of life in frail older adults should be considered, including:

• If frail, or <50kg, the maximum dose of paracetamol should be reduced to 2g per day.
• Opioid dosing should start low and increase more slowly, monitoring for increased side effects, especially when using drugs with active metabolites.

Recognition of life-limiting diseases, such as dementia, may help with the identification of treatment priorities. The MATCH-D criteria¹ provides thoughtful guidance on the management of dementia and its associated symptoms, in addition to the management of comorbidities in patients at different stages of dementia. Emphasis is placed on the importance of individualising treatment and reviewing treatments as the dementia progress. Both points are pertinent to frail older adults approaching the end of life with, or without dementia.

STOPPFrail,² a modified version of the STOPP criteria applicable to those with life-limiting disease and predicted survival of less than one year, may also be a useful tool.

When starting medicines, the BEGIN algorithm,³ designed to guide appropriate pharmacological interventions in the treatment of hypertension in older adults, is potentially applicable to the initiation of medicines in any condition.

References

1. Page AT, Potter K, Clifford R, McLachlan AJ, Etherton‐Beer C. Medication appropriateness tool for co-morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel. Intern Med J 2016;46(10):1189–97.
2. STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation. Age and Ageing, Oxford Academic [Internet]. Available at: https://academic.oup.com/ageing/article/46/4/600/2948308
3. Parekh N, Page A, Ali K, Davies K, Rajkumar C. A practical approach to the pharmacological management of hypertension in older people. Ther Adv Drug Saf. 2017;8(4):117–32.

Resources

• NHS Scotland: Polypharmacy Guidance – Medicines Review
• Choosing Wisely UK: I am a Patient/Carer