Clinical practice guidelines for older people with multimorbidity and life-limiting illness: what are the implications for deprescribing?. (November 2018)

• Record Type: Journal Article
• Authors: Okeowo, Daniel; Patterson, Alastair; Boyd, Cynthia; Reeve, Emily; Gnjidic, Danijela; Todd, Adam
• Is Part Of: Therapeutic advances in drug safety. Volume 9:Number 11(2018)
• Page Start: 619
• Page End: 630
• Publication Date: 2018-11
• Subjects: clinical practice guidelines -- deprescribing -- medication utilization -- older people; Pharmacoepidemiology -- Periodicals; Drugs -- Side effects -- Periodicals; Drugs -- Toxicology -- Periodicals; Pharmaceutical Preparations -- adverse effects -- Periodicals; Toxicology -- Periodicals; 615.70405
• DOI: 10.1177/2042098618795770
• Languages: English
• ISSNs: 2042-0986

Abstract

Background: The aim of this study was (1) to apply the current United Kingdom (UK) National Institute for Health and Care Excellence (NICE) clinical practice guidelines to a hypothetical older patient with multimorbidity and life-limiting illness; (2) consider how treatment choices could be influenced by NICE guidance specifically related to multimorbidity; and, (3) ascertain if such clinical practice guidelines describe how and when medication should be reviewed, reduced and stopped. Methods: Based upon common long-term conditions in older people, a hypothetical older patient was constructed. Relevant NICE guidelines were applied to the hypothetical patient to determine what medication should be initiated in three treatment models: a new patient model, a treatment-resistant model, and a last-line model. Medication complexity for each model was assessed according to the medication regimen complexity index (MRCI). Results: The majority of the guidelines recommended the initiation of medication in the hypothetical patient; if the initial treatment approach was unsuccessful, each guideline advocated the use of more medication, with the regimen becoming increasingly complex. In the new patient model, 4 separate medications (9 dosage units) would be initiated per day; for the treatment-resistant model, 6 separate medications (15 dosage units); and, for the last-line model, 11 separate medications (20 dosage units). None of the guidelines used for the hypothetical patient discussed approaches to stopping medication. Conclusions: In a UK context, disease-specific clinical practice guidelines routinely advocate the initiation of medication to manage long-term conditions, with medication regimens becoming increasingly complex through the different steps of care. There is often a lack of information regarding specific treatment recommendations for older people with life-limiting illness and multimorbidity. While guidelines frequently explain how and when a medication should be initiated, there is often no information concerning when and how the medications should be reduced or stopped.