Palliative care for older people - World Health Organization ...

Box 12.3. Fighting polypharmacyA team in Israel has developed novel procedures for improving drug therapy for frail older people. For eachperson, every medication is re-evaluated to decide whether to continue with the same dose, reduce it ordiscontinue it completely. Decisions are evidence-based wherever possible and otherwise based on clinicaljudgement. Using this procedure resulted in the discontinuation of an average of 2.8 drugs per person with nosignificant adverse effects. Mortality and referral rates to acute care facilities declined, and the cost of drugsdropped substantially.The same practice and algorithm for drug discontinuation was found to be safe and effective among olderpeople living in the community (average follow-up 19 months); 47% of all drugs were stopped (3.7 ± 2.5 drugsper participant), and successful discontinuation was eventually achieved among 81%. Drug discontinuationwas not associated with significant adverse effects. Eighty per cent of the people discontinuing drugs and theirfamilies reported improvements in health, functioning, mental well-being and cognitive performance.Sources: Garfinkel et al. (7) and Garfinkel (8).References1. Walsh D et al. Palliative medicine. New York, SaundersElsevier, 2008.2. Hanks G et al., eds. Oxford textbook of palliative medicine.4th ed. Oxford, Oxford University Press, 2009.3. Bruera E et al., eds. Textbook of palliative medicine. London,Hodder Arnold, 2006.4. Solano JP, Gomes B, Higginson IJ. A comparison of symptomprevalence in far advanced cancer, AIDS, heart disease,chronic obstructive pulmonary disease and renal disease.Journal of Pain and Symptom Management, 2006,31:58–69.5. Seale C, Cartwright A. The year before death. London,Avebury Press, 1994.6. American Geriatrics Society Panel on Persistent Pain in OlderPersons. The management of persistent pain in olderpersons. Journal of the American Geriatrics Society, 2002,50(Suppl.):S205–S224 (http://www.americangeriatrics.org/products/positionpapers/JGS5071.pdf, accessed 1 December2010).7. Garfinkel D, Zur-Gil S, Ben-Israel J. The war againstpolypharmacy: a new cost-effective geriatric-palliativeapproach for improving drug therapy in disabled elderlypeople. Israel Medical Association Journal, 2007, 9:430–434.8. Garfinkel D. Symposium title: the war against polypharmacyrethinking and re-evaluation needed for each and every drugin the elderly (results of the good-palliative-geriatric-practicein the first 70 case reports). 19th World Congress of theInternational Association of Geriatrics & Gerontology (IAGGWorld) Congress of Gerontology & Geriatrics, Paris, 5–9 July2009. Abstract book. Journal of Nutrition, Health & Aging,2009, 13(Suppl. 1): SB7 116–4.9. Lynch T et al. Barriers to the development of palliativecare in the countries of central and eastern Europe and theCommonwealth of Independent States. Journal of Pain andSymptom Management, 2009, 37:305–315.10. Kovach CR et al. Assessment and treatment of discomfortfor people with late-stage dementia. Journal of Pain andSymptom Management, 1999, 18:412–419.40