Adequate, questionable, and inadequate drug prescribing for older adults at the end of life: a European expert consensus

BACKGROUND: Clinical guidance is needed to initiate, continue, and discontinue drug treatments near the end of life. AIM: To identify drugs and drug classes most often adequate, questionable, or inadequate for older people at the end of life. DESIGN: Delphi consensus survey. SETTING/PARTICIPANTS: Forty European experts in geriatrics, clinical pharmacology, and palliative medicine from 10 different countries. Panelists were asked to characterize drug classes as “often adequate,” “questionable,” or “often inadequate” for use in older adults aged 75 years or older with an estimated life expectancy of ≤ 3 months. We distinguished the continuation of a drug class that was previously prescribed from the initiation of a new drug. Consensus was considered achieved for a given drug or drug class if the level of agreement was ≥ 75%. RESULTS: The expert panel reached consensus on a set of 14 drug classes deemed as “often adequate,” 28 drug classes deemed “questionable,” and 10 drug classes deemed “often inadequate” for continuation during the last 3 months of life. Regarding the initiation of new drug treatments, the panel reached consensus on a set of 10 drug classes deemed “often adequate,” 23 drug classes deemed “questionable,” and 23 drug classes deemed “often inadequate”. Consensus remained unachieved for some very commonly prescribed drug treatments (e.g., proton-pump inhibitors, furosemide, haloperidol, olanzapine, zopiclone, and selective serotonin reuptake inhibitors). CONCLUSION: In the absence of high-quality evidence from randomized clinical trials, these consensus-based criteria provide guidance to rationalize drug prescribing for older adults near the end of life. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s00228-018-2507-4) contains supplementary material, which is available to authorized users.