Polypharmacy During Final Months of Life Can Be Futile

A new study published in The American Journal of Medicine finds that older adults often receive numerous medications of questionable benefit in their final months of life. Previous estimates have shown that between 25 and 40 percent of people aged 65 or older receive a minimum of five different medications during the last year of their lives. The issue, the study says, is whether the benefits, which may not even occur before death, outweigh the potential negative effects.

Known as polypharmacy, this practice is potentially dangerous because of possible drug interactions and serious side effects. Polypharmacy is also an ethical issue because the use of multiple drugs is often futile at the end of life. The authors also distinguish between polypharmacy (four or five medications) and “excessive polypharmacy,” which is the use of at least nine or 10 medications at once. The authors chose to use instances of excessive polypharmacy for their study.

“People with life-limiting illness often receive medications whose benefit is unlikely to be achieved within their remaining lifespan,” notes lead author Lucas Morin, of the Aging Research Center at Karolinska Institutet in Stockholm, Sweden. “Future research and clinical guidelines need to be informed by findings that are generalizable beyond a specific illness or care setting.”

The researchers identified over 500,000 adults older than 65 who died in Sweden between 2007 and 2013. They used the Swedish Prescribed Drug Register to reconstruct each person’s drug prescription history for each month of their final year of life.

Main Findings

The authors of the study came to two main conclusions. First, they found that the number of older patients prescribed 10 or more drugs increases over the last year of life. They discovered that the proportion of individuals exposed to 10 or more prescription drugs rose from 30.3 percent to 47.2 percent between the twelfth and final month of their life.

Their second finding is that “polypharmacy is fueled not only by an increased use of medications directed toward symptom management but also by the frequent continuation of long-term preventive treatments and disease-targeted drugs.” That means that polypharmacy is due not only to drugs such as painkillers but also those that treat or prevent progression of chronic disease.

For example, between 15 and 45 percent of older adults take medicines to prevent heart attacks and strokes. These include platelet anti-aggregants, beta-blockers, ACE inhibitors, vasodilators and statins. Yet few of these medications will benefit a person who is in the final months of their life.

Credit: a seniorschoiceonline.com

Questionable Benefits

“The clinical benefit of drugs aiming at preventing cardiovascular diseases during the final month of life is at the very least questionable,” the authors note. They call for more research aimed at reducing the “burden of medications of questionable benefit” in older adults. Further, they posit that physicians should consider discontinuing drugs when it’s likely they will do more harm than good or when they are unlikely to have any benefit before death occurs. They also believe researchers should develop a set of clinical guidelines that will support doctors in their efforts to avoid over-prescribing medications during the last years of patients’ lives.

The idea that doctors would prescribe drugs without considering the potential for drug interactions and serious side effects is disheartening. If someone is close to death, it would seem fitting that symptom management should be the primary goal. Clearly, there are no easy answers. But this study shows that discussions about the role of prescription drugs are an important aspect of end-of-life care.