It’s a Monday lunchtime and I’m doing a ward round at a local care home when they ask me to see a new resident. Maud is 93 years old and has advanced dementia. She doesn’t talk and is bedbound, surviving mainly on oral nutritional supplements and the occasional bowl of soup. Her family were doing a sterling job of caring for her at home, but it all got too much for them.
As well as dementia, Maud has diabetes, hypertension and high cholesterol, though she has never had a cardiovascular problem that we know of. She is on three oral hypoglycaemic medicines, four antihypertensives and a statin, as well as aspirin and a proton-pump inhibitor. The care home staff are already finding it difficult to give her these medications, as they upset her, and would like permission to administer them covertly.
This is an all too common situation. In the days of evidence-based medicine, we were supposed to follow guidelines as much as possible. But guidelines are generally written with a single condition in mind and can cope poorly with a frail multimorbid patient.
For many years, I have used my judgment to think about stopping some medicines for patients like Maud, remembering that the National Institute for Health and Care Excellence (Nice) writes “guidelines not tramlines”. I try to consider what I would want to happen if this was my relative, or indeed me in the years to come.
Deprescribing is not easy, because it forces clinicians, patients and their families to confront the limits of what medicine can achieve, and raises mortality issues. In previous years, we’ve got much better at applying the principles of palliative care, long-established in the management of cancer, to other conditions such as dementia, heart failure and chronic obstructive pulmonary disease (COPD). Deprescribing is a part of this.
Maud’s life-expectancy is unlikely to be long – she would likely be on the palliative care register at her GP practice. It also appears that harm is being done by the fact that she is distressed at taking medicines. So is it really appropriate for her to be using a statin for primary prevention? We know that with these drugs we would have to treat over 100 patients for over three years to prevent one death.
There seems to be no indication for her aspirin prescription either, and this isn’t an uncommon situation. Aspirin for primary prevention of cardiovascular disease has gone in and out of fashion so many times in the last couple of decades that there are a number of patients who were started on it when their hypertension was diagnosed and have never stopped. If we stop the aspirin, she probably won’t need the proton-pump inhibitor.
What is her average blood glucose level over the last few months? There seems to be little point in striving for tight diabetes control. Nice would back this up, with their focus on personalised targets. They say that we should consider relaxing the target for patients who are unlikely to benefit from tight control due to a reduced life expectancy.
When we look at the number of deaths due to hypertension, we would need to treat over 100 people for many years to prevent one death. Is this really appropriate for Maud?
Back at the surgery, I phone Maud’s daughter and we have a long conversation. It was a very difficult decision for them to move her into a care home, and they fully understand the palliative nature of her dementia.
They appreciate me taking the time to ring and we decide to start by stopping her aspirin, statin, proton-pump inhibitor and one of her antihypertensive drugs. I will review things at the next ward round and we will try to keep her comfortable, rather than striving for meaningless targets.
This feels like proper general practice – weighing up the risks and benefits for an individual patient rather than blindly following guidelines. It is an area where there is huge scope for pharmacist involvement. Hopefully in years to come we will see a more sensible approach to the management of frail multimorbid patients, and when we all get there ourselves there won’t be quite such a burden of pills for us to take.
Toni Hazell is a GP based in a practice in London