How Do We Help Them - Deprescribing at EOLHow Do We Help Them - Deprescribing at EOL Ruth Medak, MD,...
Transcript of How Do We Help Them - Deprescribing at EOLHow Do We Help Them - Deprescribing at EOL Ruth Medak, MD,...
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Oregon Hospice Association 2016 PPE “Creating a Cultural Mosaic”
September 27, 2016
How Do We Help Them - Deprescribing at EOL
Ruth Medak, MD, FACP Medical Director, Providence Hospice
Gregory Dyke, RPh President Clinical Consulting, OnePoint Patient Care
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© 2016 OnePoint Patient Care and Providence Health. Not to be reproduced, distributed, or transferred in any form except with prior written consent of OPPC and Providence Health.© 2016 OnePoint Patient Care and Providence Health. Not to be reproduced, distributed, or transferred in any form except with prior written consent of OPPC and Providence Health.
Bohemian Polypharmacy
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Bohemian Polypharmacy YouTube Video
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Objectives
• Define deprescribing and polypharmacy
• List at least 3 symptoms potentially aggravated at end of life (EOL) by frequently
prescribed medications
• List barriers to deprescribing medications
• Identify at least three classes of medications that are appropriate for
deprescribing
• Integrate strategies for discontinuing non-essential medications into the patient’s
plan of care
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“The task for the clinician is not to determine whether too many or
too few medications are being taken, but to determine if the patient is
taking the right medications”
Michael A. Steinman, MD
“Managing Medications in Clinically Complex Elders”
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Case Study
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Mary is a 78 year old female
− Conditions related to the terminal prognosis − Stage 4 NSCLC
− Comorbid conditions − DM Type 2, dementia (FAST 6d), hypertension, hypercholesterolemia, osteoporosis, anemia, insomnia
− Current history of symptoms− Cough, confusion, dyspnea, constipation, lightheadedness, incontinence, nausea
− Factors relevant to her current condition− Recent discharge from hospital secondary to a bout of pneumonia
− Recent problems swallowing, intermittent in nature
− Repeated falls in the past 3 months
− Vital Signs/Labs− BP 110/68 - FAST Level 6c
− Pulse 65/regular - Performance Status 40%
− Weight 110#
− HGB 10.8
− LDL-C 210
− BG 106
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Case Study – What would you do?
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MS ER 30mg q 12 hours
hydrocodone/APAP 5/325 q 4 hours prn
haloperidol 0.5mg q 4 hours prn
donepezil 10mg q HS
zolpidem 10mg q HS prn
ferrous sulfate 325mg TID
atorvastatin 40mg daily
MVI tablet daily
Glucovance 2.5/500 BID
lisinopril 10mg daily
omeprazole 20mg daily
Fosamax 70mg weekly
oxybutinin 5mg TID
Ca/Vitamin D daily
Preservision daily
Newly added at hospital discharge
Advair 250/50 BID
Spiriva Handihaler daily
levalbuterol inhaler q 4 hours prn
levofloxacin 750mg daily x 5 more days
promethazine/codeine 10ml q 4 hours prn
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Prescription drug use…prescribing inertia?(number of drugs taken concurrently: data 2007-2010)
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NOTE: Use is in the past 30 days. Except for age group estimates, percentages are age-adjusted.
SOURCE: CDC/NCHS, Health, United States, 2013, Figure 20. Data from the National Health and Nutrition Examination Survey.
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Over time, an aging population will drive drug use…
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US population > 65
years old
2013 - 44 million
2025 - 62 million
2035 - 77 million
2045 – 82 million
Baby Boomers
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Prescription drugs by therapeutic class(% of patients, by age group, taking at least one drug in the class - data 2007-2010)
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NOTE: Use is in the past 30 days. Cardiovascular agents include drug classes such as angiotensin-converting enzyme (ACE) inhibitors, beta blockers, calcium
channel blockers, and diuretics.
SOURCE: CDC/NCHS, Health, United States, 2013, Figure 21. Data from the National Health and Nutrition Examination Survey.
105 % increase
350 % increase
200 % increase
190 % increase
690 % increase
50% increase
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Models of healthcare delivery
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From Ray JPHAR:8341 Immunology, Rheumatology, Oncology & Transplant Therapeutics Source: Center to Advance Palliative Care
# of meds
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Why do we want to deprescribe?
Compelling Indications for Medication Discontinuation
• Changing goals of care
• Time to benefit
• Physiologic (organ system) changes
• Lack of efficacy
• Pill Burden
• Complexity of regimen
• Potential for a prescribing cascade
• Changed risk/benefit ratio
• Drug-drug interactions
• Drug-disease interactions
• Adverse effects
• Duplicate therapy
• Cost
• Regulations (CoP’s)
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Tools to assist deprescribing
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Prescribing Optimization
Method
Choosing Wisely Canada
Beers Criteria STOPP
START
ARMORGeriatric Palliative
Method
Anticholinergic Risk Scale
PLOS One Modified Delphi process for
Deprescribing
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Studies show…
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“The task for the clinician is not to
determine whether too many or too few
medications are being taken, but to
determine if the patient is
taking the right medications”
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Medication Appropriateness Index
Medication Appropriateness Index
1. Is there an indication for the drug?
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Example: PPI started in the hospital and
continued at discharge…forever
2. Will taking it increase comfort and quality of life for this person?
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The “low-hanging fruit”
• Medications that the patient…
– Does not want
– Cannot take
– Is not using
• Medications that cause unreasonable/
intolerable adverse effects
• Medications without clear benefit
– Drugs for primary or secondary prevention
– Some drugs for tertiary prevention
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What is the purpose of the medication?
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• No disease
• Avoids development of a disease
Primary Prevention
• Disease without symptoms
• Prevents progression of disease and emergence of symptoms
Secondary Prevention
• Disease with symptoms
• Reduces negative impact of already established disease
• Restores function, reduces disease-related complications
Tertiary Prevention
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Benefit of treatment
Is the patient truly more likely to be helped
or harmed by taking the drug?
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Harms
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Patients with prognosis of less than six months
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Virtually no benefit Benefit for selected patients
ALS and Huntington’s therapies in ES disease Allergy/cold medications
Androgens Anticoagulants
Appetite stimulants Antidepressants
Dementia drugs for ES disease Antiplatelet agents
Hormone replacement BPH medications
Hyperlipidemia medications Diabetes medications
Metered dose inhalers for ES COPD Gastric acid reducers
Multivitamins and supplements Gout medications
Osteoporosis drugs Homeopathic preparations
Incontinence medications
Thyroid hormone
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Medication Appropriateness Index
Medication Appropriateness Index
1. Is there an indication for the drug?
2. Will it increase comfort and quality of life for this patient?
3. What meaning does the drug have for the patient and family?
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Facts Feelings
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“My doctor told me I needed to take this
medicine for the rest of my life?”
“I don’t want my mother to die of a stroke”
“My medicines are working just fine”
“All I do is take pills”
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Barriers to discontinuing medications
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Barriers to Discontinuing Medications
at End-of-Life
Clinical Complexity
Rapidly progressing
disease trajectory
Ambiguous or changing goals
of care
Physiological or psychological attachment
Belief that medication
discontinuation = suboptimal
careFeelings of
abandonment or loss of hope
Lack of trust
Confrontation with mortality
Limited consultation time
Incomplete past medical history
Limited knowledge of harms
(continuing -discontinuing meds)
Multiple prescribers and fragmented care
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© 2016 OnePoint Patient Care and Providence Health. Not to be reproduced, distributed, or transferred in any form except with prior written consent of OPPC and Providence Health.© 2016 OnePoint Patient Care and Providence Health. Not to be reproduced, distributed, or transferred in any form except with prior written consent of OPPC and Providence Health.
Medication Appropriateness Index
Medication Appropriateness Index
1. Is there an indication for the drug?
2. Will it increase comfort and quality of life for this patient?
3. What meaning does the drug have for the patient and family?
4. Is there duplication or a better choice?
5. Are there clinically significant drug-drug interactions?
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Medication Appropriateness Index
Medication Appropriateness Index
1. Is there an indication for the drug?
2. Will it increase comfort and quality of life for this patient?
3. What meaning does the drug have for the patient and family?
4. Is there duplication or a better choice?
5. Are there clinically significant drug-drug interactions?
6. Could the dose be reduced without harm? with benefit? In anticipation
of loss of swallow?
7. Are the directions practical?
8. Is this drug the least expensive appropriate alternative?
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Continue Treatment Stop Treatment
- Family resistant to discontinuation
- Patient has demonstrated beneficial effect
of drug on behavior
- No proven efficacy for FAST 7C or beyond
- No proven efficacy for treatment continued
beyond than 12 months
- Reduced pill burden
- Reduced cost of care ($200-250/month)
- Reduced potential for drug-drug
interactions and side effects
Dementia: To treat or not to treat
“It’s my view that [patients with dementia] should stay on [donepezil]
until they reach the stage of needing 24-hour assistance. At that point, I
would say that the drug has no value.”
David Knopman, MD, neurologist at the Mayo Clinic Alzheimer’s Disease Research Center
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Dementia treatment at EOL
• 2009 Survey of Hospice Medical Directors
– 75% reported that at least 20% of all patients were taking an AChE Inhibitor
– 33% reported that at least 20% of all patients were taking Namenda
– Majority said they did not believe either medication class was effective in persons
with end-stage dementia
• 80% recommended discontinuing these therapies
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Pulmonary medications – 3 “rights”
• Right drugs
• Right doses
• Right delivery method
For people with ES COPD consider routinely
switching to nebulized medications
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Dyspnea Cycle
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Diabetes treatment goals
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Life expectancy
Patient and family
concerns/beliefs
Risk and impact of hyper and
hypoglycemiaOral Intake
Medication and management
burden
Sweet
Spot
Find the Sweet Spot
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Diabetes treatment goals
Conventional
Early treatment goal
End-of-life
Hospice / palliative care goal
• Optimize length of healthy life
• Tight control of glucose, lipids, and
BP to reduce complications from
micro- and macrovascular disease
• Optimize quality of life
• Looser glucose control to minimize
symptoms of hypoglycemia as well
as hyperglycemia
• Reduce medications to minimize
pill burden, adverse effects and
burden of monitoring
• Allow patients to eat what they like
and want
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Deprescribing diabetes medications
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Patient
Categories
Enteral
Intake
Treatment Approach
Active Disease
but Relatively
Stable
Fair with
sporadic
improvements
or worsening
Prevent hypoglycemia
• Begin dialog about redefining control to prevent symptoms (140-
250 or even 350) and adjust medications accordingly
DM1: Continue insulin to prevent diabetic ketoacidosis (DKA)
DM2: Continue insulin if prone to symptomatic hyperglycemia
Impending
Death or Organ
or System
Failure
Declining
calorie intake
with anorexia
Prevent hypoglycemia
• Reduce or discontinue insulin and medication
Actively Dying None Patient comfort
• Reduce or discontinue insulin and medication
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Yvonne Morrissey, Michael Bedford, Jean Irving, Chris K. T. Farmer. Older people remain on blood pressure agents despite being hypotensive
resulting in increased mortality and hospital admission. Age and Ageing, 2016; DOI: 10.1093/ageing/afw120
What blood pressure target is right when prognosis is short?
• Medication side effects may decrease quality of life
• Both high and low blood pressure correlate with increased mortality in end stage
– heart failure
– liver disease
– CAD
– Chronic kidney disease
– Cerebrovascular disease
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Evidence of even
this value is poor.
Consider treating
at SBP> 160 or
emergence of
symptoms
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Adverse effects of anti-hypertensives
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Class Adverse Effects
ACE Inhibitors Hyperkalemia, dry cough
Angiotensin Receptor Blockers Dry cough, chest pain, diarrhea
Alpha1-Blockers Edema
Alpha2-Agonists Xerostomia, edema
Beta-Blockers Bradycardia, bronchospasm (non-selective agents)
DHP Calcium Channel Blockers Edema, nausea, flushing
Non-DHP Calcium Channel
Blockers
Edema, pain, bradycardia, constipation
Diuretics Electrolyte imbalance, dehydration
All antihypertensives have the potential to cause
hypotension, dizziness, weakness, and fatigue
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Anti-platelet agents – risk vs. benefit
• Is anti-platelet therapy a palliative intervention?
– 25% relative risk reduction
– Benefits survival over long-term
• 36 events prevented per 1,000 patients treated for 29 months (870 days)
– No evidence of decreased symptom burden
• Options: aspirin, Plavix (clopidogrel), Aggrenox (E.R. aspirin/dipyridamole)
• All approximately equally effective as monotherapy in most circumstances
• Combination aspirin + Plavix = increased bleeding risk
– Aggrenox – 40% get headaches after 1st dose
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Anti-platelet therapy is not typically a palliative intervention
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Plan ahead for loss of swallow
Drugs that should not be abruptly discontinued
• Gabapentin – 25% reduction per week
• Antidepressants – over 4 weeks, however tapering not necessary if life
expectancy is 1 week or less (symptoms begin to peak at 1 week (particularly
Paxil)
• Clonidine – over 2-4 days
• Antipsychotics – over 1-2 weeks
Alternative medications (to use)
• Methadone for neuropathic pain
• Fluoxetine for depression (long t1/2)
• Valproic acid, diazepam tablets, or phenobarbital for seizure prophylaxis
• Nitroglycerin paste for angina prophylaxis
• Haloperidol or valproic acid for behavioral disorders in dementia
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Deprescribing medications: a four step approach
1. Understand the reasons for discontinuing medications
– Diminished benefit
– Increased risk for adverse events
– Risk outweighs benefit
2. Identify/prioritize medications targeted for discontinuation
– Review of medical history, vital signs, clinical status/prognosis
– Communicate rationale with patient/family
3. Discontinue medication
– If time allows, taper medications with potential for withdrawal
4. Monitor patient for harmful or beneficial effects
– Physiological withdrawal
– Exacerbation of condition
– Onset of new symptoms
– Improvement of symptoms
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A prescribing model for end-of-life care
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Holmes, HM et al. Rational prescribing for patients with a reduced life
expectancy. Archives of Internal Medicine. 2006;166;605-9.
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Conclusions
• Recognize that reduced remaining life expectancy presents an opportunity to re-
examine once appropriate therapies
• Many patients are willing to consider deprescribing if their physician thought it
appropriate
• Deprescribing is a patient-specific exercise
• Weigh risks vs. benefits of continued use of all medications at EOL in a manner
consistent with the patients goals of care
• Discontinue medications to:
– Improve quality of life
– Reduce adverse effects
– Resolve duplicate therapy
– Control costs
• Change the prescribing paradigm
From: Start low, go slow
To: Stop most, reduce dose
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Bohemian Polypharmacy
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Bohemian Polypharmacy YouTube Video
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Appendix
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Rationale to support deprescribing
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Drug Class Indications to Discontinue
AChE Inhibitors• FAST 7C or beyond; no proven efficacy for end-stage disease
• Cost of medication, adverse effects outweigh benefit
ALS Agents• Cost of medication/adverse effects such as nausea, vomiting, and fatigue outweigh
benefit
• Non-palliative medication
Antibiotics• Treatment with antibiotics is not to relieve symptoms of the infection
Anticoagulants• Injections, required monitoring are too much of a burden for the patient
• Risk of falls and/or bleeding outweigh the benefit of prophylaxis
Antihypertensives• Weight loss; hypotension
• Aggressive treatment of hypertension may not benefit patients >75 years old
Antiparkinsons Agents • Adverse effects outweigh benefit of continued use
Antiplatelets• The risk of bleeding outweighs the potential benefit
• Non-palliative medication
Asthma/COPD inhalers• Failure to meet minimum inspiratory flow requirements; patient lacks
coordination/cognitive ability to use properly
• No relief of symptoms despite use
Bisphosphonates
• Dysphagia; delayed esophageal emptying; patient cannot sit upright for 30 minutes after
dose; CrCl <35 ml/min
• Consider prognosis: stopping the drug not associated with increased risk of vertebral/hip
fracture
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Rationale to support deprescribing (cont.)
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Drug Class Indications to Discontinue
Chemotherapy• The medication has been given an adequate trial and found to be ineffective, non-
palliative
• Cost of medication, adverse effects outweigh potential benefits
Hematopoietic Agents• Epoetin/darbepoetin: inadequate iron stores; Hgb >10 g/dL; uncontrolled hypertension
• Cost of medication, adverse effects outweigh potential benefits
HMG CoA Reductase
Inhibitors
• Inconsistent evidence for effect of overall and cardiovascular mortality in patients 70-82
years old
• Non-palliative medication; cost of medication, adverse effects outweigh potential benefit
IV Fluids
• Patient experiencing peripheral edema, difficulty breathing, increased blood pressure
• Terminally dehydrated patients may be less aware of pain than medically hydrated
patients
NMDA Receptor
Antagonist
• FAST 7C or beyond; no proven efficacy for end-stage disease
• No significant benefits in mod-severe Alzheimer’s Disease when in combo with donepezil
Opioids• Fentanyl: Limited prognosis; fluctuating pain level; unpredictable absorption in patients
who are cachectic, morbidly obese, edematous, febrile.
Proton Pump Inhibitors• No clear indication for therapy (GERD, active ulcer, concomitant NSAID/steroid, etc.)
• Risk of adverse effects with continued use (drug-drug interactions, fracture, c. diff, etc.)
Vitamins• Not offering any improvement In quality of life
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References
1. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults.
Journal of the American Geriatrics Society. 2012;60(4):616-631.
2. Angelo M, Ruchalski C, Sproge BJ. An approach to diabetes mellitus in hospice and palliative medicine. Journal of Palliative Medicine. 2011;14(1):83-87.
3. Arima, H., et al. PROGRESS: Prevention of Recurrent Stroke. The Journal of Clinical Hypertension, Vol. 13, No. 9, Sept. 2011.
4. Bain KT, Holmes HM, Beers MH, et al. Discontinuing medications: a novel approach for revising the prescribing stage of the medications-use process. Journal of the American Geriatrics
Society. 2008;56(10):1946-1952.
5. Brandt NJ, Stefanacci RG. Discontinuation of unnecessary medications in older adults. The Consultant Pharmacist. 2011;26(11): 845-854.
6. Collier KS, Kimbrel JM, Protus BM. Medication appropriateness at end of life: a new tool for balancing medicine and communication for optimal outcomes – the BUILD model. Home
Healthcare Nurse. 2013;31(9):518-524.
7. Cucchiara, et al. Antiplatelet therapy for secondary prevention of stroke; UpToDate; current through Dec 2013; accessed online Jan 2015.
8. Currow DC, Stevenson JP, Abernathy AP, et al. Prescribing in palliative care as death approaches. Journal of the American Geriatrics Society. 2007;55(4):590-595.
9. Gage, B. et al., CHADS2 score. JAMA 2001; 285:2864.
10. Gallagher P, Ryan C, Byrne S, et al. STOPP (screening tool of older person’s prescriptions) and START (screening tool to alert doctors to right treatment). Consensus validation.
International Journal of Clinical Pharmacology and Therapeutics. 2008;46(2):72-83.
11. Garfinkel D., et al. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: Addressing polypharmacy. Archives of Internal Medicine 2010;
170:1648.
12. Hilmer, S., et al. A Drug Burden Index to Define the Functional Burden of Medications in Older People. Archives of Internal Medicine, 2007; 167:781-787.
13. Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Archives of Internal Medicine. 2006;166:605-609.
14. Hyman DJ, Taffet GE. Blood pressure control in the elderly: can you have too much of a good thing? Current Hypertension Reports. 2009;11:337-342.
15. James PA, Oparil S, Carter BL, et al. 2015 Evidence-based guidelines for the management of high blood pressure in adults: report from the panel members appointed to the eighth joint
national committee (JNC8). Journal of the American Medical Association. 2015;311(5):507-520.
16. JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertension Research. 2008; 31:2115-
2127.
17. Jeffreys E, Rosielle D. Diabetes management at the end of life. Fast Facts and Concepts. October 2012; 258. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_258.htm.
18. Kaplan, N., et al. Antihypertensive therapy to prevent recurrent stroke or transient ischemic attack. UpToDate; Literature review current through July 2015.
19. Lip, G. Implications of the CHA2DS2-VASc and HAS-BLED Scores for thromboprophylaxis in atrial fibrillation. Am J Med, 2011; 124:111.
20. Maggini, Marina et al, Cholinesterase Inhibitors: Drugs Looking for a Disease? PLoS Medicine, Vol. 3 Issue 4, April 2006.
21. Manning, W. et al., Antithrombotic therapy to prevent embolization in atrial fibrillation; UpToDate; current through December 2013.
22. Medicare program; FY 2015 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements and Process and Appeals for Part D Payment for Drugs for
Beneficiaries Enrolled in Hospice, Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS), HHS. Available online at:
http://federalregister.gov/a/2015-10505.
23. Parsons C, Hughes CM, Passmore AP, et al. Withholding, discontinuing and withdrawing medications in dementia patients at the end of life: a neglected problem in the disadvantaged
dying? Drugs & Aging. 2010;27(6):435-449.
24. Poulson J. The management of diabetes in patients with advanced cancer. Journal of Pain and Symptom Management. 1997;13(6):339-346.
25. PROGRESS collaborative group. Randomised trial of a perindopril based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischemic attack.
Lancet. 2001; 358:1033-1041.
26. Shega JW, Ellner L, Lau DT, et al. Cholinesterase inhibitor and n-methyl-d-aspartic acid receptor antagonist use in older adults with end-stage dementia: a survey of hospice medical
directors. Journal of Palliative Medicine. 2009;12(9):779-783.
27. Spiess, J., et al. Can I Stop the Warfarin? A Review of the Risks and Benefits of Discontinuing Anticoagulation. Journal of Palliative Medicine 2009 Vol.12, No. 1.
28. Steinman MA, Hanlon JT. Managing medications in clinically complex elders: “there’s got to be a happy medium”. Journal of the American Medical Association. 2010;304(14):1592-1601.
29. Stevenson J, Abernethy A, Miller C, et al. Managing comorbidities in patients at the end of life. BMJ. 2004;329:909-912.
30. Weschules DJ, Maxwell TL, Shega JW. Acetylcholinesterase inhibitor and n-methyl-d-aspartic acid receptor antagonist use among hospice enrollees with a primary diagnosis of dementia.
Journal of Palliative Medicine. 2008;11(5):738-745.
31. US Department of Commerce, Department of Statistics, US Census Bureau
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