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JAMA Internal Medicine commentary: 'Improving Prescribing for Patients Late in Life'


INDIANAPOLIS — Older adults are typically prescribed a large number of medications, often including drugs that should not be taken by individuals late in life. In a commentary published online by JAMA Internal Medicine on September 8, Regenstrief Institute investigator Greg Sachs, M.D., calls for physicians to carefully review older patients’ medication lists.

According to Dr. Sachs, current prescribing guidelines fail to adequately address instances in which specific drugs are not beneficial or may even be harmful to older adults. Current guidelines also fail to identify age-adjusted standards for dosages and fail to address use, drug interactions and metabolism concerns. Dr. Sachs, professor of medicine and director of the Division of General Internal Medicine and Geriatrics at Indiana University School of Medicine, and colleagues have proposed a model for prescribing medications that additionally incorporates a patient’s anticipated life expectancy, the treatment target, the time needed for medication to produce its intended benefit and the patient’s goals of care.

“Caring for older patients with their multiple health problems is problematic,” said Dr. Sachs, a geriatrician. “Doctors, who only have limited time with each person they see, tend to reach for prescription pads or e-prescribing tools. Patients expect prescriptions and if they don’t receive one will wonder what their doctor has done for them. As a result, the elderly receive too many prescriptions.

“Physicians often have trouble talking with patients and their families about where the patient is in their lifespan. But goals of care conversations about what does and what doesn’t make sense given the patient’s medical conditions and mental status should inform or influence goals of care and the treatment to be given in support of these goals. These conversations shouldn’t be put off until the patient is in the ICU; they should occur during routine office visits and be updated as the patient ages.”

The commentary, “Improving Prescribing Practices Late in Life,” accompanies “Medications of Questionable Benefit Used in Advanced Dementia,” a research study of nursing home residents from across the United States. The University of Massachusetts Medical School and Harvard Medical School authors of the study reported that a majority of nursing home residents with advanced dementia received at least one medication with questionable benefits, possible harms and substantial associated costs.

Dr. Sachs’s commentary concludes, “Perhaps before I retire, I will get to hear more presentations [oral reports from medical students, residents, fellows or fellows to attending physicians] that sound like the following: Mrs. Jones is a 74-year-old, ambulatory woman who lives at home with her daughter. She was recently hospitalized briefly after a fall. Because of her limited remaining life expectancy and prior preferences, our discussions of her goals of care centered on maximizing comfort, maintaining function and mobility to the extent possible, and minimizing trips to the emergency department and hospital, and less stringent targets for her chronic diseases. We cancelled the screening mammogram that had been scheduled in the hospital; took her off one of her anti-hypertensives; stopped her statin altogether; recommended daily supervised walks; and completed a Physician Orders for Life-Sustaining Treatment form.”