In October of 2010, Dr. Doron Garfinkel published study results from the application of the Good Palliative-Geriatric Practice algorithm in community-dwelling older adults, showing that reducing medication utilization by 47% led to 88% of participants reporting global improvement in health. Also remarkable from that study was that only 2% of discontinued medications needed to be restarted. There were no documented harms and 56 out of 70 participants reported improved cognition with three of them having MMSE changes from 14 to 24, 14 to 23 and 14 to 30, which is like saying someone with moderate dementia ended up having no or little evidence of dementia. The profound outcomes from this study have strong implications for the future of medication use in older adults.
In another study in long term care residents, Dr. Garfinkel was able to apply the same algorithm and discontinue 332 drugs in 119 disabled residents. What was observed was a lower one-year mortality rate than in the control group, 21% vs. 45%, and a lower rate of referrals to acute care facilities, 11.8% vs. 30% in the control group. This study also measured a substantial decrease in medication costs.
Reducing medication use in the old-old population makes perfect sense since many older adults will suffer from duplicate therapy and resultant toxicity; serious drug-drug interactions; lack of monitoring that leads to drug toxicity; cumulative anticholinergic drug burden with functional and cognitive decline; yet many of these drugs are used with lacking evidence of benefit in this population. It may be that we see a major shift, in a relatively short period of time, in how medications are used in long term care facilities, and the extended impact may be a significant reduction in hospitalizations thereby improving quality of life and helping save the Medicare system. You can find Dr. Garfinkel’s work referenced on his home page at: http://www.dr-g.co.il/.
It may prove fruitful for organizations involved in ACOs to strongly consider utilizing the assistance of those who understand the nuances of medication use in this population to take advantage of an opportunity that pays big dividends. A well thought out approach and launch of a formal program in LTC facilities can lead to a significant lowering of hospitalization rates.