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Comment & Response
April 2014

Optimizing the Impact of Drugs on Symptom Burden in Older People With Multimorbidity at the End of Life

Author Affiliations
  • 1Faculty of Pharmacy and Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
  • 2Royal North Shore Hospital, Kolling Institute of Medical Research and Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
JAMA Intern Med. 2014;174(4):636-637. doi:10.1001/jamainternmed.2013.12875

To the Editor We commend Chaudhry et al1 on their excellent article that reported high prevalence of symptoms that negatively affect functioning and quality of life in a cohort of older community-dwelling people with multimorbidity and a life expectancy of less than 1 year.

In older people, mulitimorbidity often coexists with polypharmacy, commonly defined as the use of 5 or more drugs. In her Invited Commentary, Ritchie2 highlights that pharmacological treatment of 1 symptom may exacerbate another or a coexisting condition, which may in part explain the increase in symptoms in this population.

To minimize drug-related symptoms in older people at the end of life, pharmacological treatments should be prioritized and rationalized. Symptomatic relief should take preference over preventive treatments, and drug therapies deemed no longer necessary should be stopped to minimize cumulative drug-related adverse effects. For instance, among patients in their last year of life, with the exception of those experiencing sudden vascular death, continuing therapy with preventive drugs such as statins is unlikely to be of clinical benefit.3 In contrast, treatment with statins may lead to significant harms including cognitive impairment or muscle weakness.3 Our own research has demonstrated that more than 30% of patients with cancer were dispensed a statin in the month prior to death.4

Moreover, polypharmacy associated with multimorbidity is likely to result in cumulative adverse drug effects, which can be minimized by careful clinical review of the patient’s priorities and pharmacological profile of the patient’s drug therapies.5 For example, if the primary therapeutic aim is analgesia, and this requires opioids, then exposure to other drugs with sedating or constipating effects should be minimized. Tools like the Drug Burden Index, which measures cumulative exposure to anticholinergic and sedative drugs or other measures of anticholinergic burden,5 may help guide drug choices at the end of life.

Minimizing drug burden may reduce symptom burden in older people with multimorbidity and limited life expectancy. More research is required to provide evidence on the clinical impact on function and quality of life of continuing, stopping, and substituting pharmacological treatments in older patients with multimorbidity at the end of life.

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Article Information

Corresponding Author: Danijela Gnjidic, PhD, MPH, Faculty of Pharmacy, University of Sydney, Science Road, Bank Building A15, Sydney, NSW, Australia 2006 (danijela.gnjidic@sydney.edu.au).

Conflict of Interest Disclosures: None reported.

References
1.
Chaudhry  SI, Murphy  TE, Gahbauer  E, Sussman  LS, Allore  HG, Gill  TM.  Restricting symptoms in the last year of life: a prospective cohort study.  JAMA Intern Med. 2013;173(16):1534-1540.PubMedGoogle ScholarCrossref
2.
Ritchie  CS.  Symptom burden: in need of more attention and more evidence.  JAMA Intern Med. 2013;173(16):1541-1542.PubMedGoogle ScholarCrossref
3.
Hilmer  SN, Gnjidic  D.  Statins in older adults.  Aust Prescr. 2013;36:79-82.Google Scholar
4.
Stavrou  EP, Buckley  N, Olivier  J, Pearson  SA.  Discontinuation of statin therapy in older people: does a cancer diagnosis make a difference? an observational cohort study using data linkage.  BMJ Open. 2012;2(3):e000880.PubMedGoogle ScholarCrossref
5.
Hilmer  SN, Gnjidic  D, Abernethy  DR.  Pharmacoepidemiology in the postmarketing assessment of the safety and efficacy of drugs in older adults.  J Gerontol A Biol Sci Med Sci. 2012;67(2):181-188.PubMedGoogle ScholarCrossref
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