Editorials

How to move to a palliative approach to care for people with multimorbidity

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6324 (Published 21 September 2012) Cite this as: BMJ 2012;345:e6324

Re: How to move to a palliative approach to care for people with multimorbidity

We read with interest the editorial by Burge et al. on a palliative approach to care.[1]

As no studies investigated this topic by using an administrative database, we analyzed a cohort of elderly people (65-94 years old) recorded in the Prescription Administrative Database of the Lombardy Region (North of Italy) who died in 2010.[2,3] The aim was to evaluate the prevalence of drug utilization and the hospitalization rate occurred in the last year before the death, in order to highlight what treatment could be revised in the light of what has been explained by the authors.

In 2010, 70 145 elderly people died. The mean age was 81.5±7.3 years, 40% of the elderly were aged 85 years or more, and in the last year before the death 86% of them received at least one drug; 75% were exposed to polypharmacy (defined as exposure during the last year before the death to five or more different drugs) and 54% to chronic polypharmacy (defined as exposure during the last year before the death to five or more different chronic drugs, classified as the prescription of four packages with the same drug). Comparing with patients alive in 2010, the prevalence of polypharmacy and chronic polypharmacy rose from 53% to 75% and from 28 to 54%, respectively. Out of them, 73.8% received a prescription of drugs for the cardiovascular system, followed by 68.0% for the alimentary tract and metabolism and 64.4% for blood and blood-forming organs. Antithrombotic agents (56.8%) and drugs for peptic ulcer and gastro-oesophageal reflux disease (56.26%) were the most prescribed.

52 712 individuals (75% of elderly people included in the analyses) were hospitalized at least once in the last year of life, with 2.6 (±2.2) hospitalization per person. When the last hospitalization was considered, the most frequent reason was palliative care (4.2%). Grouping the diagnoses of the last hospital admission according to the main chapters of International Classification of Disease, Ninth Revision (ICD-9), patients hospitalized for illnesses of cardiovascular system were 22.8%, followed by those hospitalized for neoplasms (19.5%), and respiratory system diseases (15.4%).

Analysing the most frequently prescribed drugs in each group, patients with hospital admission for cardiovascular disease received above all antithrombotic agents (78.5%), drugs for peptic ulcer and gastro-oesophageal reflux disease (64.6%) and high-ceiling diuretics (54.6%). Patients with tumors showed an increased use of opioids (50.4%), corticosteroids for systemic use (47.1%), anti-inflammatory and anti-rheumatics products (39.7%), and antidepressants (21.1%), but antithrombotic agents and drugs for peptic ulcer and gastro-oesophageal reflux disease still remained most prescribed (75.2 and 59.9% respectively). Patients with a hospital admission for respiratory system illness were still more treated with antithrombotic agents (72.0%) and drugs for peptic ulcer and gastro-oesophageal reflux disease (69.2%), but quinolone antibacterials and inhalants for obstructive airway diseases and adrenergics rose to 50.2%, 36.1% and 34.0%.

As suggested by Burge et al,[1] at the end-of-life it should trigger a discussion with patients and caregivers about beginning a review of goals of care, with consequent revision of treatments and limitations in investigations. Avoiding or discontinuing drugs is usually common sense in end-life care, especially when the time needed to obtain the expected benefits from the drug is longer than the life expectancy.[4] A list of drugs that have been considered to be usually inappropriate in end-of-life care include lipid-lowering drugs, ACE inhibitors and ARBs, and anti-platelet drugs.4 Our results suggested an increased tendency in drug prescription in people at the end-of-life, also for prescribing drugs that are clearly not appropriate with this span of life.

References
1. Burge F, Lawson B, Mitchell G. How to move to a palliative approach to care for people with multimorbidity. BMJ 2012;345:e6324
2. Franchi C, Sequi M, Bonati M, Nobili A, Pasina L, Bortolotti A, Fortino I, Merlino L, Clavenna A. Differences in outpatient antibiotic prescription in Italy's Lombardy region. Infection. 2011;39:299-308.
3. Franchi C, Tettamanti M, Marengoni A, Bonometti F, Pasina L, Cortesi L, Fortino I, Bortolotti A, Merlino L, Lucca U, Riva E, Nobili A. Changes in trend of antipsychotics prescription in patients treated with cholinesterase inhibitors after warnings from Italian Medicines Agency. Results from the EPIFARM-Elderly Project. Eur Neuropsychopharmacol. 2012 Aug;22(8):569-77.
4. Cruz-Jentoft AJ, Boland B, Rexach L. Drug therapy optimization at the end of life. Drugs Aging. 2012 Jun 1;29(6):511-21. doi: 10.2165/11631740-000000000-00000. Review.

Competing interests: No competing interests

08 January 2013
Carlotta Franchi
pharmacist
Ida Fortino, Angela Bortolotti, Luca Merlino, Alessandro Nobili
Mario Negri Institute for Pharmacological Research
Via La Masa, 19 - 20159 Milan, Italy
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