Preventive drugs in the last year of life of older adults with cancer: Is there room for deprescribing?

BACKGROUND: The continuation of preventive drugs among older patients with advanced cancer has come under scrutiny because these drugs are unlikely to achieve their clinical benefit during the patients' remaining lifespan. METHODS: A nationwide cohort study of older adults (those aged ≥65 years) with solid tumors who died between 2007 and 2013 was performed in Sweden, using routinely collected data with record linkage. The authors calculated the monthly use and cost of preventive drugs throughout the last year before the patients' death. RESULTS: Among 151,201 older persons who died with cancer (mean age, 81.3 years [standard deviation, 8.1 years]), the average number of drugs increased from 6.9 to 10.1 over the course of the last year before death. Preventive drugs frequently were continued until the final month of life, including antihypertensives, platelet aggregation inhibitors, anticoagulants, statins, and oral antidiabetics. Median drug costs amounted to $1482 (interquartile range [IQR],$700-$2896]) per person, including$213 (IQR, $77-$490) for preventive therapies. Compared with older adults who died with lung cancer (median drug cost, $205; IQR,$61-$523), costs for preventive drugs were higher among older adults who died with pancreatic cancer (adjusted median difference,$13; 95% confidence interval, $5-$22) or gynecological cancers (adjusted median difference, $27; 95$18-$36). There was no decrease noted with regard to the cost of preventive drugs throughout the last year of life. CONCLUSIONS: Preventive drugs commonly are prescribed during the last year of life among older adults with cancer, and often are continued until the final weeks before death. Adequate deprescribing strategies are warranted to reduce the burden of drugs with limited clinical benefit near the end of life

Appraising the intention of other people: Ecological validity and procedures for investigating effects of lighting for pedestrians

One of the aims of outdoor lighting public spaces such as pathways and subsidiary roads is to help pedestrians to evaluate the intentions of other people. This paper discusses how a pedestrians’ appraisal of another persons’ intentions in artificially lit outdoor environments can be studied. We review the visual cues that might be used, and the experimental design with which effects of changes in lighting could be investigated to best resemble the pedestrian experience in artificially lit urban environments. Proposals are made to establish appropriate operationalisation of the identified visual cues, choice of methods and measurements representing critical situations. It is concluded that the intentions of other people should be evaluated using facial emotion recognition; eye tracking data suggest a tendency to make these observations at an interpersonal distance of 15 m and for a duration of 500 ms. Photographs are considered suitable for evaluating the effect of changes in light level and spectral power distribution. To support investigation of changes in spatial distribution further investigation is needed with 3D targets. Further data are also required to examine the influence of glare

Understanding deprescribing of preventive cardiovascular medication: a Q-methodology study in patients

Clare H Luymes,1 Nelleke J Boelhouwer,1 Rosalinde KE Poortvliet,1 Wouter de Ruijter,1 Ria Reis,1–3 Mattijs E Numans1 1Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, 2Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, the Netherlands; 3The Children’s Institute, University of Cape Town, Cape Town, South Africa Background: Patients with low cardiovascular disease (CVD) risk potentially use preventive cardiovascular medication unnecessarily. Our aim was to identify various viewpoints and beliefs concerning the preventive CVD management of patients with low CVD risk using preventive cardiovascular medication. Furthermore, we investigated whether certain viewpoints were related to a preference for deprescription or the continuation of preventive cardiovascular medication.Methods: In 2015, we purposively sampled patients from the intervention arm of the Evaluating Cessation of STatins and Antihypertensive Treatment In primary Care (ECSTATIC) trial in the Netherlands for this study. Participants made Q-sorts by ranking 43 statements concerning preventive CVD management from “totally disagree” to “totally agree”. These Q-sorts were analyzed using PQMethod 2.35 software. A varimax procedure presented the distinguishing viewpoints that were favored by our participants. We used group discussion quotations to underline our findings. For validation purposes, we asked participants how well each viewpoint fitted them.Results: Of 291 invited patients, 33 participated. Thirty-one Q-sorts were analyzed. The following three viewpoints were found: 1) a controlling viewpoint, in which patients held the belief that monitoring blood pressure and cholesterol levels is important (n=13, of which seven had their medication deprescribed and six continued their medication); 2) an autonomous viewpoint, in which patients showed a dislike of medication (n=8, of which seven had their medication deprescribed and one had it continued); and 3) an afraid viewpoint, in which patients were fearful of developing CVD (n=8, of which two had their medication deprescribed and six had it continued). Seventy-four percent of the participants believed that the viewpoint to which they were assigned was a good fit.Conclusion: Three well-discriminating viewpoints about preventive CVD management were determined. Knowing and recognizing these viewpoints is effective for general practitioners when discussing the deprescribing of preventive cardiovascular medications with patients and may be used to promote implementation of deprescription. Keywords: general practice, preventive medicine, cardiovascular diseases, antihypertensive agents, anticholesteremic agents, inappropriate prescribin