Discontinuation of Medications With Limited Benefit at End of Life in Community-Dwelling Older Veterans.

BACKGROUND

Discontinuation of medications with limited benefits (LBM) in patients nearing the end of life can reduce burden, adverse events, and costs, and enhance quality of life. However, most research on end-of-life prescribing has focused on nursing homes or hospice settings.

AIMS: To describe the prevalence of LBM use and discontinuation or deintensification over the last year of life in community-dwelling older veterans with advanced life-limiting conditions.

DESIGN

Retrospective, national cohort study of U.S. veteran decedents (≥ 65 years) with advanced life-limiting conditions who died between October 2016 and September 2017.

SETTING

Community-residing, non-hospice older veterans. LBM users were identified using consensus-based criteria and assessed for discontinuation over the last year of life. We estimated LBM discontinuation rate ratios using multivariable robust Poisson regression.

RESULTS

Among 37,193 decedents (mean age 78 years), 73% were on at least one LBM (e.g., statins, oral antidiabetics, antihypertensives, antithrombotics, anti-ulcer, or antidementia drugs) entering the last year (baseline). Of these baseline LBM users, 22.0% experienced at least one LBM discontinuation over their final year. Veterans residing in more rural counties had lower LBM discontinuation rates than those in large metropolitan counties. Discontinuation rates were also higher in the Midwest or South compared to the Northeast or West. Veterans with documented clinical indicators of limited life expectancy (e.g., pressure ulcers, malnutrition) or those receiving specialty palliative care, were more likely to have LBMs discontinued.

CONCLUSION

Among community-dwelling older veterans in their final year of life, 73% were receiving at least one LBM at the start of that year, and 78% of these individuals continued LBM use until death. These rates parallel those reported in long-term care populations and underscore the need for community-based healthcare providers to routinely screen for LBMs and support appropriate medication discontinuation in older patients with advanced illnesses and limited life expectancy.