Clinicians who care for older adults understand the importance of considering the patient's values, preferences, and priorities in formulating a plan of treatment. In the frail elderly patient, outcomes related to quality of life and functional status may be more important than prolonging life to the maximum extent possible. This principle of considering patient preferences in decisions about treatment has been highlighted in several recent journal articles.

In a recent article in Journal of the American Medical Association, Krahn and Naglie noted the general lack of emphasis on patient preferences in the development of clinical practice guidelines.¹ The development of clinical practice guidelines involves a much greater diligence in search for evidence of effectiveness, for example, than in evidence about patient preference. The authors recommend that patient preferences should be considered at every stage of the guideline development and implementation process.

The two paradigms of modern medicine, evidence-based medicine and patient-centered medicine, need to be brought closer together. Both clinical evidence and patient preferences should be a part of clinical decision-making. The authors state: "Clinical practice guidelines are becoming more widely used as a method for standardizing clinical practice and building pay-for-performance programs. By not getting guidelines right for patients, perverse incentives may be introduced for clinicians to advocate treatments that are counter to what patients want and value."

Brown and colleagues explored the preferences of older adults with type 2 diabetes mellitus for intensity of treatment.² They note that the benefits of intensive glucose control may take seven or more years to accrue, whereas medications for diabetes may have adverse effects and decrease quality of life. They state: ". . . it has been increasingly recognized that the goals of care for diabetes mellitus must be carefully individualized to the clinical context, healthcare goals, and treatment preferences of the individual older patients."

The authors found that older patients' preferences for intensity of diabetes treatment varied widely and were not closely associated with vulnerability. It is, therefore, critical to involve older patients in decisions about treatment of diabetes mellitus, irrespective of clinical status. These authors also note the potential for conflict between recommendations of clinical practice guidelines and patient preferences. They state: "Pay-for-performance policies that reward providers for keeping a high proportion of their patients below nationally recommended risk-factor levels for conditions like diabetes mellitus are important for improving the overall health of the population, but these policies currently do not reward providers for the time-consuming process of individualizing chronic care management, which is particularly important for vulnerable, older patients with multiple chronic diseases."

One of the challenges in managing older adults with multiple conditions is that treatment of one condition may worsen another condition. Tinetti and colleagues explore this issue in a study assessing how older adults prioritize competing health outcome priorities from cardiovascular, fall injury, and medication-related symptoms.³ The incidences of nonfatal cardiovascular events in older persons with hypertension and of serious fall injury in older persons with fall risk are both approximately 16 percent. The study subjects were 123 community-dwelling persons age 70 or over with hypertension and fall risk. Discrete choice task was used to elicit the relative importance placed on reducing the risk of three outcomes: cardiovascular events, serious fall injuries, and medication symptoms.

The authors found a 50-50 split among the participants, with half placing greater importance on reducing the risk of cardiovascular events and half placing greater importance on reducing the risk of fall injuries and medication symptoms. This interindividual variability supports the importance of individualizing therapeutic decision-making and involving patients and their preferences as the decision is made.

The authors conclude: "If patients' priorities vary, then incorporating these priorities into decision-making is essential to patient-centered care. In the current case, at the very least, this means acknowledging that, as previously demonstrated, older adults consider medication-related symptoms to be health outcomes to be weighed against other outcomes."

Holmes and colleagues have previously published a proposed model for appropriate prescribing for patients late in life.⁴ This model recognizes that the benefit versus risk calculation for drug therapy may change as individuals age and as the end of life approaches. This model proposes consideration of four key criteria in evaluating appropriateness of medications near the end of life:

• The patient's remaining life expectancy
• The time required to obtain benefit from the medication
• The goals of care
• Treatment targets
  

The authors state: "Regardless of standards of care, practice guidelines, and other clinical pathways, shared decision-making among physicians, patients, and families about goals of care is important when deciding whether to stop, start, or continue therapy with a medicine for a patient late in life. As disease progresses and it is clearer that cure is not realistic, an individualized approach to a patient's treatment may become increasingly palliative."

Now, in a recent article in Journal of the American Geriatrics Society, Holmes and colleagues have turned their attention to identifying appropriate medication use in persons with advanced dementia.⁵ Prescription and over-the-counter medications taken by 34 patients in long-term care facilities with advanced dementia were recorded. Twelve geriatricians at the University of Chicago participated in a modified Delphi consensus panel to characterize the medications into one of four categories for use in palliative care of patients with advanced dementia: never appropriate, rarely appropriate, sometimes appropriate, or always appropriate. A list of the medications in each category is included in the article.

Patients with advanced dementia were defined as those having a Functional Assessment Stages (FAST)⁶ score of 6E, 7A, 7B, or 7C. These scores correspond to patients who need assistance with bathing, dressing, and toileting; have fecal or urinary incontinence (6E), and may have minimal verbal ability and inability to ambulate (7C).

The authors believe that "medications no longer appropriate for patients with advanced disease receiving palliative care should be identified to facilitate discontinuation of those that no longer conform with the goals of care. Discontinuing such medications at the end of life could improve quality of life and significantly reduce burdens on the patient."

The authors admit that this study is preliminary in nature, and a limitation of the study is that the consensus panel is rather homogenous. They support an expanded study with a more diverse and nationally representative panel to develop consensus criteria for rating of appropriateness of medication use in patients with advanced dementia.

Despite the limitations, this study is a step forward in exploring appropriateness of medication use in patients with advanced dementia, particularly in long-term care facilities.

1. Krahn M, Naglie G. The next step in guideline development: incorporating patient preferences. JAMA, July 23/30, 2008;300(4):436-8.
   http://jama.ama-assn.org/cgi/content/extract/300/4/436
   
   
2. Brown SES, Meltzer DO, Chin MH, et al. Perceptions of quality-of-life effects of treatments for diabetes mellitus in vulnerable and nonvulnerable older patients. J Am Geriatr Soc 2008;56:1183-90.
   http://www3.interscience.wiley.com/journal/120119640/abstract
   
   
3. Tinetti ME, McAvay GH, Fried TR, et al. Health outcome priorities among competing cardiovascular, fall injury, and medication-related symptom outcomes. J Am Geriatr Soc 2008.
   http://www3.interscience.wiley.com/journal/120847938/abstract
   
   
4. Holmes HM, Hayley DC, Alexander GC, et al. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166:6-609.
   http://archinte.ama-assn.org/cgi/content/extract/166/6/605
   
   
5. Holmes HM, Sachs GA, Shega JW, et al. Integrating palliative medicine into the care of persons with advanced dementia: identifying appropriate medication use. J Am Geriatr Soc 2008;56:1306-11.
   http://www3.interscience.wiley.com/journal/120119632/abstract
   
   
6. Functional Assessment Stages (FAST) instrument, available at http://geriatrics.uthscsa.edu/tools/FAST.pdf