Providing guideline-adherent care for many medical conditions increasingly means the addition of more medications to reach disease-specific targets.1 When might it be best to withhold or discontinue medications that are otherwise appropriate on the basis of guidelines? Receiving facsimiles from the pharmacy serving a local nursing home encouraging us to prescribe statins for residents there symbolizes the issues. Most of these patients had a limited life expectancy, were older than 90 years, or had advanced dementia. Similar situations occur in patients with functional impairments, frailty, or diseases like emphysema, congestive heart failure, or coronary artery disease in their advanced stages, for whom starting or continuing many recommended drugs does not seem the best way to optimize care.
The Medication Appropriateness Index.3 Reprinted with permission from Elsevier.
Upper, middle, and lower quartiles for life expectancies for women (A) and men (B) on the basis of the US life tables. The 3 numbers provided for each 5-year age cohort reflect remaining life expectancy for the top 25th, middle 50th, and lowest 25th percentile. For example, 75%, 50%, and 25% of 75-year-old women will live fewer than 17, 11.9, and 6.8 years, respectively. Although the median life expectancy for 75-year-old women is 11.9 years, women with advanced comorbidities and functional impairments may live fewer than 6.8 years. Reprinted with permission from JAMA.7
The model shows that the 4 steps in medication decision making form a pyramid, visually representing the appropriate medications at any level. At the top are represented patients for whom remaining life expectancy is limited, drugs should have the shortest time until benefit, goals of care are palliative, and treatment targets are focused on symptom management. Moving toward the bottom, the base of appropriate medications expands as the patient's life expectancy is longer, time until benefit may be longer, goals of care are more aggressive, and treatment targets are aimed more at preventive strategies. The bottom of the pyramid therefore contains all medications that are otherwise appropriate according to existing criteria for patients 65 years and older.
Use of the model in 3 distinct cases illustrates how it is used depending on the 4 components.
An example of a distorted model shows that all 4 components may not readily agree. Sometimes the time until benefit of a particular medicine will be considerably longer than a patient's estimated remaining life expectancy. Aggressive goals of care despite advanced disease may result in consideration of unrealistic treatment targets. When all 4 components are not consistent with each other, the resulting figure is a visually distorted, nonplanar slice of the model.
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