Sunday, June 22, 2008
Polypharmacy & the Meaning of Palliative Care
JAGS has a paper on polypharmacy/inappropriate medication use in patients with dementia receiving palliative care. More or less it's based on a consensus project involving geriatricians asking them what drugs are appropriate or not for patients with severe dementia receiving palliative care. That list was then applied to 30 some patients residing in long term care facilities and it was found that nearly a third of them were receiving at least one 'never use' drug. What is interesting to me is the actual list of drugs and what categories they were placed in via the consensus process.
First, statins and dementia meds (acetylcholinesterase inhibitors, etc.) were on the 'never use' list, along with chemotherapy. While I'm all for not using these agents in patients with severe dementia this very much implies an either/or model of palliative care being employed by these clinicians (as opposed to a concurrent care model; i.e. patients receiving palliative care means the patients are only receiving palliative care, so to speak).
Next, opioids ('narcotics') were on the 'always appropriate' list which is the first time I've seen such a listing for them on any sort of geriatric drug profile.
Last, and most interesting, were the drugs for which there was no consensus: the panel was too divided about their use. These included aspirin, muscle relaxants, 'sedatives and hypnotics,' and CNS stimulants. Clearly clinicians are divided over the use of these drug classes. Myself, looking over the list, found myself going "meh," or "no way" to a substantial number of the drug classifications (the above 4 for me would be rare, rare, sometimes, sometimes) . All of this I think bespeaks how idiosyncratic these decisions can be: the differences across clinicians as to what constitutes a worthless treatment, what is considered harmful or neutral (statin vs. aspirin - aspirin vs. clopidogrel [which was on the never use]), etc. Antiestrogens were on the never appropriate list (although they can have some analgesic/palliative benefit in breast cancer); they would have made my rarely appropriate list.
5 Responses to “Polypharmacy & the Meaning of Palliative Care”
June 22, 2008
I find the "Never" on acetylcholinesterase inhibitors fascinating, as there's published RCTs showing that even in late-stage AD, acetylcholinesterase inhibitors improve ability to participate in self-care activities and make patients more receptive to care from caregivers.
E
June 22, 2008
E, thanks for the comments. Nice blog, btw - particularly your clock post - very interesting.
I personally think acetylcholinesterase inhibitors are oversold for dementia; but that said I would have categorized them as 'rare' not 'never.' I think the discussion of them in this Fast Fact is quite good.
Like I said in the post what's most interesting to me is deducing what is meant by 'palliative care' and the plurality of meanings attached to it: it's an approach to care vis a vis the WHO definition, it's something all people with chronic illnesses should be getting, it's a team of specialists, it's comfort-oriented terminal care. I'm asked on a near monthly basis (by patients/families) where palliative care is given (i've never pursued this but have assumed they mean it's a place like a hospice facility or it's a spa like place with sweet palliatives and anodynes to be had).
June 23, 2008
Oh, I agree they're hideously oversold. They're not gonna improve grandma's bridge game nor are they going to turn back the clock, slow the rate of decline or restore normal cognitive functioning. I think they provide a modest degree of support to maintain ADLs and keep people in less-restrictive settings longer. Given that they do relieve some symptoms of the problem without a curative intent, though, to me, they seem like the ultimate in palliative agents.
I also take issue with the authors lumping multiple disorders with multiple etiologies as "dementia" - while the acetylcholine hypothesis has not been largely borne out in Alzheimer's, it's central to Dementia with Lewy Bodies / Parkinson's Disease Dementia, which may account for some 20% of dementias, and with vascular/multi-infarct dementia. I can't help but wonder if including neurologists among the participants in the Delphi process would have resulted in a different view of the utility of ChEIs in at least some dementia patients. In short, I think internal medicine specialists and neurologists differ greatly in their opinions of the value of ChEIs in this population.
One further difficulty with the ChEIs is that you can't just stop them as a trial and then resume the previous dosage when you decide they were doing some good. They all require re-titration to avoid the GI side effects. Thus, perhaps abandoning them should be viewed in light of modest usefulness vs. a major effort to reintroduce.
What I've not seen published research on is when, in absence of adverse events, one should initiate a withdrawal for futility or cost containment.
I am so in love with anodynes and sweet palliatives. What a terrific mental image.
E, Who Has Been A Woefully Neglectful Blogger Of Late, Dealing With Two People In His Life Receiving Palliative Care
June 23, 2008
Gotta agree with taking issue on the "never" for ChEIs. Probably wouldn't have questioned it before last weeks statewide palliative care meeting -- presentation by a gerontologist who works in the large dementia center at OHSU who discussed the role in helping with behavior issues. And seeing how that is one of the main reasons for family CG burnout (problem behaviors), institutionalization, or transfer to a higher care level (i.e. from an AL to a NH), I'm not so quick to pull them for someone who has intact swallowing and has done well on them.
June 24, 2008
howdy marachne, always love hearing from you. to your and eric's last comments, i think it still comes down to what the consensus panel meant by palliative care: i think they were operating under the comfort-only, terminal care model of palliative care (the 'old school hospice model' - that's probably going to annoy someone that i just said that; an important part of what we do for sure but it just adds to the confusion to label that 'palliative care') as opposed to what most of us are trying to define palliative care as: certainly that which encompasses comfort-focused terminal care (something which most of us find tremendously satisfying) but on a daily basis is more like a constant effort to clarify prognosis and what to expect; talk carefully through goals; match up medical care with those goals (which often involves providing counsel along the lines of just what should we do with the acetylcholinesterase inhibitors); plan and prepare for the future; all the while giving primary prominence to emotions & quality of life issues & symptom alleviation. this'package' is palliative care to me, and this is what the whole 'concurrent care'/palliative care early in disease course/palliative care for everyone movement is about and why i sometimes wonder if we need a new word for it. probably not, and it's probably easier to get people to use different language to describe terminal care.
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