A substantial number of older adults die in residential aged care facilities, yet little is known about the characteristics of and how best to optimise medication use in the last year of life.
Aim:
The aim of this review was to map characteristics of medication use in aged care residents during the last year of life in order to examine key concepts related to medication safety and draw implications for further research and service provision.
Design:
A scoping review following Arskey and O’Malley’s framework was conducted using a targeted keyword search, followed by assessments of eligibility based on title and content of abstracts and full papers. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the scoping review protocol was prospectively registered to the Open Science Framework on 27 November 2018.
Data Sources:
We searched MEDLINE, EMBASE, AMED, CINAHL and Cochrane databases to identify peer-reviewed studies published between 1937 and 2018, written in English and looking at medication use in individuals living in aged care facilities within their last year of life.
Results:
A total of 30 papers were reviewed. Five key overarching themes were derived from the analysis process: (1) access to medicines at the end of life, (2) categorisation and classes: medicines and populations, (3) polypharmacy and total medication numbers, (4) use of symptomatic versus preventive medications and (5) ‘inappropriate’ medications.
Conclusion:
Number of prescriptions or blunt categorisations of medications to assess their appropriateness are unlikely to be sufficient to promote well-being and medication safety for older people in residential aged care in the final stages of life.
WolffJLStarfieldBAndersonG.Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med2002; 162(20): 2269–2276.
2.
HsuY-CWangJ-J.Physical, affective, and behavioral effects of group reminiscence on depressed institutionalized elders in Taiwan. Nurs Res2009; 58(4): 294–299.
3.
CharetteSL.Hospitalization of the nursing home patient. J Am Med Dir Assoc2003; 4(2): 90–94.
4.
BroadJBGottMKimH, et al. Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics. Int J Public Health2013; 58(2): 257–267.
5.
DaviesEHigginsonIJ and World Health Organization. Better palliative care for older people. Copenhagen: WHO Regional Office for Europe, 2004.
6.
GroverA.Thematic study on the realization of the right to health of older persons by the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Geneva: United Nations General Assembly, 2011.
StevensonJAbernethyAPMillerC, et al. Managing comorbidities in patients at the end of life. BMJ2004; 329(7471): 909–912.
9.
McNeilMJKamalAHKutnerJS, et al. The burden of polypharmacy in patients near the end of life. J Pain Symptom Manage2016; 51(2): 178–183.
10.
CurrowDCStevensonJPAbernethyAP, et al. Prescribing in palliative care as death approaches. J Am Geriatr Soc2007; 55(4): 590–595.
11.
RiechelmannRPZimmermannCChinSN, et al. Potential drug interactions in cancer patients receiving supportive care exclusively. J Pain Symptom Manage2008; 35(5): 535–543.
12.
StowDSpiersGMatthewsFE, et al. What is the evidence that people with frailty have needs for palliative care at the end of life. Palliat Med2019; 33(4): 399–414.
13.
FroggattKPayneSMorbeyH, et al. Palliative care development in European care homes and nursing homes: application of a typology of implementation. J Am Med Dir Assoc2017; 18(6): 550.e7–550.e14.
14.
EvansCJIsonLEllis-SmithC, et al. Service delivery models to maximize quality of life for older people at the end of life: a rapid review. Milbank Q2019; 97(1): 113–175.
15.
NarayanSWNishtalaPS.Discontinuation of preventive medicines in older people with limited life expectancy: a systematic review. Drugs Aging2017; 34(10): 767–776.
16.
TjiaJVeltenSJParsonsC, et al. Studies to reduce unnecessary medication use in frail older adults: a systematic review. Drugs Aging2013; 30(5): 285–307.
17.
PoudelAYatesPRowettD, et al. Use of preventive medication in patients with limited life expectancy: a systematic review. J Pain Symptom Manage2017; 53(6): 1097–1110.
18.
ToddAHusbandAAndrewI, et al. Inappropriate prescribing of preventative medication in patients with life-limiting illness: a systematic review. BMJ Support Palliat Care2017; 7(2): 113–121.
19.
DisalvoDLuckettTAgarM, et al. Systems to identify potentially inappropriate prescribing in people with advanced dementia: a systematic review. BMC Geriatr2016; 16: 114.
20.
PoudelAPeelNMMitchellC, et al. A systematic review of prescribing criteria to evaluate appropriateness of medications in frail older people. Rev Clin Gerontol2014; 24(4): 304–318.
21.
TangheMVan Den NoortgateNPivodicL, et al. Opioid, antipsychotic and hypnotic use in end of life in long-term care facilities in six European countries: results of PACE. Eur J Public Health2018; 29(1): 74–79.
22.
MaysNRobertsEPopayJ.Synthesizing research evidence. In: FulopNAllenPClarckeA, et al. (eds) Studying the organisation and delivery of health services: research methods. London: Routledge, 2001, pp. 188–219.
23.
ArkseyHO’MalleyL.Scoping studies: towards a methodological framework. Int J Soc Res Methodol2005; 8(1): 19–32.
24.
ShamseerLMoherDClarkeM, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ2015; 350: g7647.
25.
AitkenCCollierABoydM.Medication patterns and appropriateness in aged care residents towards the end of life. OSF, 27November2018, https://osf.io/8ad4b/ (accessed 29 January 2019).
26.
TriccoACLillieEZarinW, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med2018; 169(7): 467–473.
27.
McGowanJSampsonMSalzwedelDM, et al. PRESS peer review of electronic search strategies: 2015 guideline statement. J Clin Epidemiol2016; 75: 40–46.
SrivastavaPHopwoodN.A practical iterative framework for qualitative data analysis. Int J Qual Methods2009; 8(1): 76–84.
30.
AgarMLuckettTLuscombeG, et al. Effects of facilitated family case conferencing for advanced dementia: a cluster randomised clinical trial. PLoS ONE2017; 12(8): e0181020.
31.
AllenRSBurgioLDFisherSE, et al. Behavioral characteristics of agitated nursing home residents with dementia at the end of life. Gerontologist2005; 45(5): 661–666.
32.
BlassDMBlackBSPhillipsH, et al. Medication use in nursing home residents with advanced dementia. Int J Geriatr Psychiatry2008; 23(5): 490–496.
33.
ChenI-CLiuM-LTwuF-C, et al. Use of medication by nursing home residents nearing end of life: a preliminary report. J Nurs Res2010; 18(3): 199–205.
34.
D’AgataEMitchellSL.Patterns of antimicrobial use among nursing home residents with advanced dementia. Arch Intern Med2008; 168(4): 357–362.
35.
Di GiulioPToscaniFVillaniD, et al. Dying with advanced dementia in long-term care geriatric institutions: a retrospective study. J Palliat Med2008; 11(7): 1023–1028.
36.
EversMMPurohitDPerlD, et al. Palliative and aggressive end-of-life care for patients with dementia. Psychiatr Serv2002; 53(5): 609–613.
37.
GorlenTFGorlenTNeergaardMA.Death in nursing homes: a Danish qualitative study. Int J Palliat Nurs2013; 19(5): 236–242.
38.
HendriksSASmalbruggeMHertogh van der SteenJT.Dying with dementia: symptoms, treatment, and quality of life in the last week of life. J Pain Symptom Manage2014; 47(4): 710–720.
39.
HendriksSASmalbruggeMDeliensL, et al. End-of-life treatment decisions in nursing home residents dying with dementia in the Netherlands. Int J Geriatr Psychiatry2017; 32(12): e43–e49.
40.
HeppenstallCPBroadJBBoydM, et al. Medication use and potentially inappropriate medications in those with limited prognosis living in residential aged care. Australas J Ageing2016; 35(2): E18–E24.
41.
JansenKSchaufelMARuthsS.Drug treatment at the end of life: an epidemiologic study in nursing homes. Scand J Prim Health Care2014; 32(4): 187–192.
42.
KinleyJHockleyJ.A baseline review of medication provided to older people in nursing care homes in the last month of life. Int J Palliat Nurs2010; 16(5): 216–223.
43.
KlapwijkMSCaljouwMAAvan Soest-PoortvlietMC, et al. Symptoms and treatment when death is expected in dementia patients in long-term care facilities. BMC Geriatr2014; 14: 99.
44.
LauDTMasin-PetersJBerdesC, et al. Perceived barriers that impede provider relations and medication delivery: hospice providers’ experiences in nursing homes and private homes. J Palliat Med2010; 13(3): 305–310.
45.
MansourDWongRKuskowskiM, et al. Discontinuation of acetylcholinesterase inhibitor treatment in the nursing home. Am J Geriatr Pharmacother2011; 9(5): 345–350.
46.
MatlowJNBronskillSEGruneirA, et al. Use of medications of questionable benefit at the end of life in nursing home residents with advanced dementia. J Am Geriatr Soc2017; 65(7): 1535–1542.
47.
MillerSCMorVWuN, et al. Does receipt of hospice care in nursing homes improve the management of pain at the end of life. J Am Geriatr Soc2002; 50(3): 507–515.
48.
MillerSCLimaJCMitchellSL.Influence of hospice on nursing home residents with advanced dementia who received Medicare-skilled nursing facility care near the end of life. J Am Geriatr Soc2012; 60(11): 2035–2041.
49.
MitchellSLKielyDKHamelMB.Dying with advanced dementia in the nursing home. Arch Intern Med2004; 164(3): 321–326.
50.
MitchellSLMorrisJNParkPS, et al. Terminal care for persons with advanced dementia in the nursing home and home care settings. J Palliat Med2004; 7(6): 808–816.
51.
MonroeTBCarterMAFeldtKS, et al. Pain and hospice care in nursing home residents with dementia and terminal cancer. Geriatr Gerontol Int2013; 13(4): 1018–1025.
52.
MorinLVetranoDLGrandeG, et al. Use of medications of questionable benefit during the last year of life of older adults with dementia. J Am Med Dir Assoc2017; 18(6): 551.e1–551.e7.
53.
MorinLVetranoDLRizzutoD, et al. Choosing wisely? Measuring the burden of medications in older adults near the end of life: nationwide, longitudinal cohort study. Am J Med2017; 130(8): 927–936.
54.
MunnJCHansonLCZimmermanS, et al. Is hospice associated with improved end-of-life care in nursing homes and assisted living facilities. J Am Geriatr Soc2006; 54(3): 490–495.
55.
SourdetSRochetteCde Souto BarretoP, et al. Drug prescriptions in nursing home residents during their last 6 months of life: data from the IQUARE study. J Nutr Health Aging2018; 22(8): 904–910.
56.
SuhrieEMHanlonJTJaffeEJ, et al. Impact of a geriatric nursing home palliative care service on unnecessary medication prescribing. Am J Geriatr Pharmacother2009; 7(1): 20–25.
57.
TjiaJRothmanMRKielyDK, et al. Daily medication use in nursing home residents with advanced dementia. J Am Geriatr Soc2010; 58(5): 880–888.
58.
Van der MeerHGTaxisKPontLG.Changes in prescribing symptomatic and preventive medications in the last year of life in older nursing home residents. Front Pharmacol2017; 8: 990.
59.
FernerREAronsonJK.Communicating information about drug safety. BMJ2006; 333(7559): 143–145.
60.
American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc2012; 60(4): 616–631.
61.
GallagherPRyanCByrneS, et al. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther2008; 46(2): 72–83.
62.
HolmesHMSachsGAShegaJW, et al. Integrating palliative medicine into the care of persons with advanced dementia: identifying appropriate medication use. J Am Geriatr Soc2008; 56(7): 1306–1311.
63.
LarocheM-LCharmesJ-PMerleL.Potentially inappropriate medications in the elderly: a French consensus panel list. Eur J Clin Pharmacol2007; 63(8): 725–731.
64.
HanlonJTSchmaderKESamsaGP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol1992; 45(10): 1045–1051.
65.
Australian Institute of Health and Welfare. Residential aged care in Australia 2010–11: a statistical overview. Canberra, ACT, Australia: Australian Institute of Health and Welfare, 2012.
66.
SpinewineASchmaderKEBarberN, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised?Lancet2007; 370(9582): 173–184.
67.
BeersMH.Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med1997; 157(14): 1531–1536.
68.
LeeSJLeipzigRMWalterLC.Incorporating lag time to benefit into prevention decisions for older adults. JAMA2013; 310(24): 2609–2610.
69.
GoldbergRMMabeeJChanL, et al. Drug-drug and drug-disease interactions in the ED: analysis of a high-risk population. Am J Emerg Med1996; 14(5): 447–450.
70.
WengMCTsaiCFSheuKL, et al. The impact of number of drugs prescribed on the risk of potentially inappropriate medication among outpatient older adults with chronic diseases. QJM2013; 106(11): 1009–1015.
71.
RoutledgePAO’MahonyMSWoodhouseKW.Adverse drug reactions in elderly patients. Br J Clin Pharmacol2004; 57(2): 121–126.
72.
American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American geriatrics society 2015 updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc2015; 63(11): 2227–2246.
73.
PoudelAHubbardRENissenL, et al. Frailty: a key indicator to minimize inappropriate medication in older people. QJM2013; 106(10): 969–975.
74.
HagemannVBauseweinCRemiC.Drug use beyond the licence in palliative care: a systematic review and narrative synthesis. Palliat Med2019; 33(6): 650–662.
75.
BeerCLohP-KPengYG, et al. A pilot randomized controlled trial of deprescribing. Ther Adv Drug Saf2011; 2(2): 37–43.
76.
GarfinkelDZur-GilSBen-IsraelJ.The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people. Isr Med Assoc J2007; 9(6): 430–434.
77.
KutnerJSBlatchfordPJTaylorDHJr, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med2015; 175(5): 691–700.
78.
BertozzoGZoppellaroGGranzieraS, et al. Reasons for and consequences of vitamin K antagonist discontinuation in very elderly patients with non-valvular atrial fibrillation. J Thromb Haemost2016; 14(11): 2124–2131.
79.
SwagertyD.Integrating palliative care in the nursing home: an interprofessional opportunity. J Am Med Dir Assoc2014; 15(12): 863–865.
80.
WeathersEO’CaoimhRCornallyN, et al. Advance care planning: a systematic review of randomised controlled trials conducted with older adults. Maturitas2016; 91: 101–109.
81.
OliverDPPorockDZweigS.End-of-life care in U.S. nursing homes: a review of the evidence. J Am Med Dir Assoc2005; 6(3 Suppl.): S21–S30.
82.
MorinLLarocheM-LVetranoDL, et al. Adequate, questionable, and inadequate drug prescribing for older adults at the end of life: a European expert consensus. Eur J Clin Pharmacol2018; 74(10): 1333–1342.
83.
SteinmanMALandefeldCSRosenthalGE, et al. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc2006; 54(10): 1516–1523.
84.
GriffioenCWillemsEGHuseboBS, et al. Prevalence of the use of opioids for treatment of pain in persons with a cognitive impairment compared with cognitively intact persons: a systematic review. Curr Alzheimer Res2017; 14(5): 512–522.
85.
GoodmanCEvansCWilcockJ, et al. End of life care for community dwelling older people with dementia: an integrated review. Int J Geriatr Psychiatry2010; 25(4): 329–337.
86.
PivodicLPardonKVan den BlockL, et al. Palliative care service use in four European countries: a cross-national retrospective study via representative networks of general practitioners. PLoS ONE2013; 8(12): e84440.
87.
SampsonELGouldVLeeD, et al. Differences in care received by patients with and without dementia who died during acute hospital admission: a retrospective case note study. Age Ageing2006; 35(2): 187–189.
88.
ToscaniFDi GiulioPVillaniD, et al. Treatments and prescriptions in advanced dementia patients residing in long-term care institutions and at home. J Palliat Med2013; 16(1): 31–37.
89.
SpitzAMooreAAPapaleontiouM, et al. Primary care providers’ perspective on prescribing opioids to older adults with chronic non-cancer pain: a qualitative study. BMC Geriatr2011; 11: 35.
