Rationale and Comments

Older adults with limited life expectancy (life expectancy less than 24 months) continue to be consumers of health care resources, including preventive medications for chronic diseases that provide questionable benefit. At the end of life, consider shifting from curative to palliative goals of therapy with subsequent modifications in medication use concerning a patient’s goals of care. To identify older adults for whom medications are most likely to benefit (and most likely to harm), a framework that compares a patient’s life expectancy with the time to benefit has been proposed. Time to benefit may be defined as the point in time at which patients are expected to derive a benefit from treatment. Time to benefit is increasingly considered in addition to other measures of medication effectiveness to understand and contextualize the benefits and harms of a therapy for an individual patient. Reducing the use of unnecessary medications may reduce pill burden and adverse drug events and has the potential to improve quality of life. Some recent studies have highlighted medications to manage dementia (cholinesterase inhibitors and memantine) and possibly statins as medications of questionable benefit for older adults with advanced dementia.

Sponsoring Organizations

• American Society of Consultant Pharmacists

Sources

• Expert consensus

Disciplines

• Geriatric

References

• Holmes HM, Min LC, Yee M, et al. Rationalizing prescribing for older patients with multimorbidity: considering time to benefit. Drugs Aging. 2013;30(9):655-666.
• Lee SJ, Leipzig RM, Walter LC. Incorporating lag time to benefit into prevention decisions for older adults. JAMA. 2013;310(24):2609-2610.
• Lee SJ, Kim CM. Individualizing prevention for older adults. J Am Geriatr Soc. 2018;66(2):229-234.
• Matlow JN, Bronskill SE, Gruneir A, et al. Use of medications of questionable benefit at the end of life in nursing home residents with advanced dementia. J Am Geriatr Soc. 2017;65(7):1535-1542.
• Morin L, Vetrano DL, Grande G, et al. Use of medications of questionable benefit during the last year of life of older adults with dementia. J Am Med Dir Assoc. 2017;18(6):551.e1-551.e7.
• Lee SWH, Mak VSL, Tang YW. Pharmacist services in nursing homes: a systematic review and meta-analysis. Br J Clin Pharmacol. 2019;85(12):2668-2688.
• Zueger PM, Holmes HM, Calip GS, et al. Older Medicare beneficiaries frequently continue medications with limited benefit following hospice admission. J Gen Intern Med. 2019;34(10):2029-2037.
• Kutner JS, Blatchford PJ, Taylor DH Jr, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial [published corrections appear in JAMA Intern Med. 2015;175(5):869 and JAMA Intern Med. 20191;179(1):126-127]. JAMA Intern Med. 2015;175(5):691-700.