Deprescribing long-term medications in frail older people approaching end-of-life

Abstract

One of the great successes of modern medicine is that it has transformed relatively acute causes of death (i.e. cardiovascular disease, organ failure and some cancers) into chronic diseases. In the developed world, most people will now grow old and, over decades, accumulate various chronic diseases before eventually succumbing to a final illness. Older people in their final years are commonly prescribed multiple medications to manage their chronic diseases. These medications may ameliorate symptoms, prevent future adverse health events and extend life. However, the use of multiple medications is also associated with higher risks of side-effects, adverse drug-interactions, and adherence problems. Furthermore, as older people become increasingly frail, the use of multiple medications may be considered burdensome for them or even futile. For frail older patients taking multiple medications, when does the scale shift from net benefit to net harm? If declining health and death are unavoidable, it follows logically that there must come a point when patients no longer benefit from certain chronic disease therapies.

This thesis primarily attempts to address two important questions. Firstly, how can we recognize when older people are approaching end-of-life? For such people, a personalized approach that prioritizes comfort and symptom relief is likely to be more appropriate than the pursuit of strict chronic disease targets. Secondly, when attempting to address a frailer older person’s complex and burdensome medication regimen, how do we separate essential medications from those that are dispensable?