A patient-centered prescription model assessing the appropriateness of chronic drug therapy in older patients at the end of life

Abstract

IntroductionOlder patients with multimorbidity usually present with progressively worse impairment, resulting in a limited life prognosis. Consequently, drug therapy, which was previously appropriate can become inappropriate and be associated with negative health outcomes. The main objective is to identify inappropriate prescriptions in older patients and to optimize them according to patient directed care goals, established through the application of the patient-centered prescription model, which is based on a shared decision-making process including the patient, physicians and a clinical pharmacist. MethodsThis was a prospective observational study of patients admitted to an Acute Care Elderly Unit. Comprehensive Geriatric Assessment was applied to each patient in order to identify advanced frailty as an indicator of an end of life situation. In order to identify inappropriate prescriptions, each patient's pharmacotherapeutic plan was assessed by applying the Patient-Centered Prescription Model, a three-step process: (i) patient centered assessment, where care goals were established, setting the stage for the second and third steps; (ii) diagnosis-centered assessment; (iii) medication-centered assessment. ResultsThree hundred and nine patients (mean age 86.7 years) were included. Inappropriate prescribing occurred in 39.8% of patients, more frequently amongst end-of-life patients (47.2%) (P < 0.05). During admission, 93.4% of patients with inappropriate prescriptions received an optimized therapeutic plan. ConclusionsA high prevalence of inappropriate prescriptions among patients with multimorbidity was detected, especially in patients at end of life. The patient-centered prescription model helps to identify frail patients on potentially inappropriate prescriptions by means of a holistic review of each patient's situation, in a shared decision-making process.