Epidemiological aspects of the elderly who require palliative care

Prolonging life has been and is a constant interest of the human species and seen in this way aging constitutes an achievement, however, aging not only means reaching a certain age, but this natural, progressive and irreversible process undermines physiological freshness with implications clinical, social and functional. Its confrontation constitutes a challenge for any society [15] and in turn a challenge for public health in particular [16].

It is published that around 80.0% of the elderly are diagnosed with more than one chronic disease [17]. Contel Segura et al [18] affirm that these diseases will be the greatest cause of disability and that by 2030 their prevalence will double. incidence in those older than 65 years. These authors report that 20.0% of patients with two or more chronic diseases (comorbidity) constitute 60.0% of the elderly who are admitted at least twice in a year.

In Cuba, most of the illnesses and deaths that occur in the group of 60 and over correspond to chronic diseases such as heart diseases, malignant tumors and cerebrovascular diseases [19]. Special mention deserves the dementia that has become in one of the most significant public health problems, as it constitutes the second cause of disability and the greatest contributor to care needs in the Cuban elderly [20].

The accumulation of multiple chronic diseases follows a long course of gradual decline with a high risk of functional deterioration, disability, dependency, institutionalization, hospitalization, poor quality of life and death [21].

Clinical indicators of gravity or severity of the disease have been proposed that relate more to the patient himself than to the underlying diseases, which are strongly associated with mortality, they are: malnutrition, functional impairment, cognitive impairment and symptoms that are difficult to control [22].

In the elderly at the end of life, the presence of symptoms is almost constant, which causes a great emotional impact on family members and the care team and has a negative impact on the quality of life and well-being of the patient. It is then necessary to design a strategy to control the symptoms, recognize them, evaluate them and treat them appropriately.

Palliative care

The relief of suffering in the final period of life, recognized in recent years as a universal human right, is one of the missions of medicine. It is palliative care that guarantees active and comprehensive care for patients whose disease does not respond to curative therapies and its foundation is the relief of pain and other accompanying symptoms that are intense, multifactorial, changing and lead to the suffering of the family and the patient. Patient [23].

It is very complex to face all the nuances when a human being is at the end of life; conflicts are established that involve family members, the patient and the doctor's decisions, which may vary with different patients and even at different evolutionary moments of the terminal phase of the same patient.

More frequently than desired, in clinical practice an irrational attempt is made to fight against death that is close and inevitable, this has been defined as cruelty, cruelty or therapeutic obstinacy. In this way, the principle of non-maleficence is violated since, many times, what is done when adopting these measures is to harm the patient unnecessarily, applying insubstantial treatments that cause inconveniences [24].

Palliative care translates a Good medical practice» at the end of life, this implies the application of proportionate therapeutic measures, avoiding therapeutic obstinacy, abandonment and unnecessary lengthening of life [25].

It is wrong to establish protocols for care at the end of life since this process is individual and different for each patient and is conditioned by a series of factors related to the diseases, the family environment and the characteristics of each patient.

Care for the elderly at the end of life still has important areas for improvement. One of the most striking is the inappropriate use of medications, well demonstrated in different countries and in different palliative care settings [26].

Therefore, clinical guidance is a priority to start, continue or suspend pharmacological treatments at the end of life in the elderly.

Potentially inappropriate prescriptions. detection instruments

The drug-therapeutic management of the elderly is convoluted and constitutes a critical point for any professional who pays attention to this age group, as they are high consumers of medications, particularly very susceptible and vulnerable to their undesirable effects.

Various factors support the above, age-related changes in pharmacokinetics and pharmacodynamics [27,28], as well as the increase in situations of clinical complexity that characterize the elderly with the consequent uncertainty and difficulty in making therapeutic decisión [29].

Since the last two decades, the scientific community has shown growing interest in finding mechanisms to define the adequacy of pharmacological treatments in the geriatric population. For this reason, different instruments are developed and applied for the detection of PPI.

A PPI is considered when the risk of adverse effects is greater than the clinical benefit and drugs are used with a dose or duration greater than that required according to the patient's comorbidity or condition [30,31].

The most used instruments include the Beers criteria, updated in 2019 [32] and the STOPP/START criteria (Screening Tool of Older Person's potentially inappropriate Prescriptions – Screening Tool to Alert drivers to the Right Treatment) validated in 2008 [33] and updated in 2015 [34].

The latter are applied to hospitalized Cuban elderly and a high number of PPIs are detected [35].

The purpose of these instruments is to improve the quality of medication use in the elderly, however, it is also imperative to adapt treatments in people who are nearing the end of life and thus avoid therapeutic blunders and the use of unsuccessful medications that cause harm rather than benefit.

In 2017, an article was published for the first time that validates the application of the STOPP criteria in frail adults with limited life expectancy [36], considered those elderly in the final and irreversible state of their disease, with a one-year survival prognosis, with severe functional and cognitive damage and where the priority of treatment is symptom control, rather than prevention of disease progression.

This novel instrument includes important aspects that are related to the principles of drug selection [37] by taking into account the convenience of the drug, the comfort of the administration schedule, the pharmaceutical form and the administration time.

• Laroche et al [38] in 2018 list a set of medications that they classify as: often adequate, questionable or often inappropriate both for the continuity of treatment and to start their prescription in elderly people 75 years of age or older who are at the end of life. life with estimated survival equal to or less than three months.
• Very recently, in 2020, the development and validation of another instrument was revealed: STOPPFrail in its second versión [39], with the aim of re-evaluating and updating the STOPPFrail criterio [36] and attempting greater patient-centered efficiency. In this case, the elderly candidates to apply this deprescription guide would be those with functional dependency for basic activities of daily living and/or severe chronic illness and/or terminal illness; high risk of acute medical complications and clinical deterioration, with estimated survival of one year.
• In general, these instruments use the Delphi method to obtain expert consensus based on up-to-date scientific evidence. These instruments are permeated by deprescription criteria, aimed at improving decision-making in the elderly at the end of life, to reduce morbidity and suffering due to inappropriate use of medications. These criteria illustrate the complexity of pharmacotherapy in the elderly due to the high number and type of medications to which they refer.

Considerations on PPI referred to in different instruments

The underuse of beneficial drugs in treatments is also considered inappropriate, hence the relevance of the START [33] criteria, which means starting a prescription, as it is considered appropriate. These criteria collect the most common errors in treatment when detecting the omission of medications necessary for the elderly.

When performing their analysis, of 33 START criteria, almost all of them constitute PPI for the elderly at the end of life, excluding in section B (respiratory system) what refers to home oxygen therapy and in section H (analgesics) the prescription of potent opioids in moderate or severe pain when acetaminophen, nonsteroidal anti-inflammatory drugs, or low-potency opioids are not appropriate for the severity of the pain.

This reveals the singularity that gravitates in the stage at the end of life, where

The objective of the therapeutic plan is not to improve or lengthen the prognosis of the disease, but to minimize the impact of the disease on the patient and their environment, guaranteeing comfort and well-being.

As for the PPIs referred to in the deprescribing instruments in the elderly at the end of life [36,38,39], statins, calcium and vitamin D supplements, antihypertensives, antiresorptives and medications for dementia treatment.

Statins play their main role in the treatment of hyperlipidemia and in the prevention of arteriosclerotic disease due to their beneficial effects on endothelial function. Some of its undesirable effects include hepatotoxicity, myopathies, muscle weakness, rhabdomyolysis. They interact with calcium inhibitors, warfarin, digoxin, among other drugs [40,41]. Their prescription is completely inappropriate in these patients.

With the progressive increase in age, it is common to find autonomic imbalance that contributes to orthostatic hypotension, which increases the risk of falls, syncope and cardiovascular events [42]. The decrease in blood pressure is a predictor of death in the elderly at end of life, therefore, the prescription of antihypertensives could be unwise.

Calcium, vitamin D and antiresorptive supplements are prescribed for preventive purposes and are unlikely to produce short-term benefits, apart from their undesirable effects [43]. Before prescribing a drug for preventive purposes, it is necessary to consider life expectancy of the sick

Anticholinesterase drugs and memantine, whose purpose is to delay cognitive deterioration in dementia, do not seem to have a place in the phase at the end of life, in addition, the advanced nature of the disease or other terminal comorbidities make it difficult to assess the possible changes or benefits that these drugs they report. The use of antipsychotics is meritorious only if there are psychiatric and behavioral symptoms of dementia, they should not be prescribed permanently.

The STOPPFrail [36] and STOPPFrail criteria in their second versión [39] agree that platelet antiaggregants, oral antidiabetics, proton pump inhibitors and theophylline are PPIs, while other authors [38] declare them as frequently questionable prescriptions .

The author considers that the prescription of these drugs is based on the control and prevention of diseases that do not immediately threaten life.

The prescription of oral antidiabetics is inappropriate, the elderly with significant functional impairment and comorbidities that limit life expectancy, a glycosylated hemoglobin goal of up to 8.0% can be considered, therefore strict glycemic control is not appropriate [44] Lo more important is to counteract the symptoms of possible hyperglycemia [39].

Proton pump inhibitors are often prescribed to counteract the undesirable effects of other treatments. Its prescription could be successful to relieve dyspeptic symptoms but not at full doses.

Decision making for the management of dyspnea in the elderly at the end of life is equally complex, palliative treatment is aimed at symptomatic relief.

Theophylline has a narrow therapeutic margin, requires monitoring of serum levels and interacts with other commonly prescribed drugs, putting the patient at risk of adverse reactions [45]. Its prescription is incorrect and other options are more reasonable.

The instruments available with the intention of improving the quality of medication prescription in the elderly use two types of criteria: the implicit ones, based on clinical judgment, and the explicit ones, based on criteria of consensus and expert opinions that focus more on the drug and the disease than on the particularities of each patient [46].

When comparing the explicit criteria published for the detection of PPI in the elderly with the latest explicit criteria to be applied in the elderly at the end of life, the author estimates that the latter achieve a better approximation to the needs and characteristics of the patient, are more adherent to medical thought by taking into account aspects such as life expectancy, monitoring, follow-up and convenience of the medication, assessing in a particular way in each specific case the risk/benefit ratio of said prescription.

These instruments constitute an indicator of prescription safety and quality.

These lists of possible deprescriptions do not discriminate against the elderly who are at the end of their life, depriving them of therapeutic opportunities or promoting a deliberate shortening of it, but rather exempt the elderly from excessive, unsafe, ineffective and unnecessary medications that inevitably affect their well-being and the right to die with dignity.