Discontinuation of Preventive Medicines in Older People with Limited Life Expectancy: A Systematic Review.

BACKGROUND: In the presence of multimorbidity and limited life expectancy (LLE), the need for continued use of preventive medicines becomes uncertain as they may neither improve health nor confer continued health benefits.

OBJECTIVE: Our objective was to systematically review the literature to examine the discontinuation of preventive medicines in older people with LLE.

METHODS: A systematic literature search was conducted using the Ovid MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register databases. Studies investigating discontinuation of preventive medicines in older individuals (mean age ≥65 years) with LLE (≤12 months) published between 1 January 1997 and 28 February 2017 were included. The Cochrane risk-of-bias assessment criteria and the Newcastle-Ottawa Scale were used to assess the quality of the studies.

RESULTS: Ten studies-a randomized controlled trial (RCT), two case-control studies, and seven cohort studies-involving 26,854 participants with a mean age ranging from 66.0 to 85.0 years were included in this review. The studies were primarily conducted in palliative care (n = 3), residential facility (n = 2), and community (n = 1) settings, and the remainder were pharmacoepidemiological studies (n = 4). The most common life-limiting illnesses were cancer (n = 5), followed by other unspecified illnesses (n = 4) and advanced dementia (n = 1). The most common preventive medicine discontinued was statins, followed by warfarin and aspirin. LLE potentially prompted discontinuation; however, some individuals continued to receive preventive medicines until they died.

CONCLUSIONS: The review found that withdrawal of preventive medicines at the end of life is challenging. Decisions about the discontinuation of preventive medicines for individuals approaching the end of life are increasingly complicated by the lack of clear deprescribing guidelines for these medicines.