Many older patients with blood cancers take too many medications and/or potentially inappropriate medications (PIMs) in addition to their prescribed cancer treatments, explains Tammy T. Hshieh, MD, MPH. “Evaluating the association of polypharmacy and PIMs with frailty is important since these medications may be contributing to frailty,” Dr. Hshieh says. “Multiple high-risk medications may, by themselves or together with cancer treatments, put an older patient with frailty at high risk for falls, toxicity, or other adverse events. Finding efficient and effective ways for hematologic oncologists to identify these medications is a need that motivated this research.”
Dr. Hshieh and colleagues set out to assess the definitions of polypharmacy and PIMs and determine their link with frailty and cognitive impairment in older patients with blood cancers. “Using data from the one of the largest groups of older patients (aged 75 and older) with leukemia, lymphoma, and multiple myeloma, in whom we have measured both frailty and cognition, we extracted all medications documented in the initial consult with their oncologist,” explains co-first author Clark DuMontier, MD, MPH.
Five or More Medications Most Common in This Population
“We quantified each patient’s total number of medications, with the average being five or more, and PIMs using the Anticholinergic Risk Scale (ARS),” he continues. “We also developed a new scale from the NCCN Older Adult Oncology Guidelines’ list of medications of concern in older adults with cancer, the GO-PIMs (Geriatric Oncology Potentially Inappropriate Medications) scale. Cross-sectional associations of PIMs were assessed with frailty in multivariable regression models adjusting for age, gender, and comorbidity.” The study team found that polypharmacy and PIMs are widespread in older adults with blood cancers and strongly linked with frailty, regardless of patient comorbidity. “Steroids, benzodiazepines, and antidepressants (selective serotonin reuptake inhibitors) were the most prevalent PIMs,” Dr. Hshieh says. “We found that the GO-PIM scale carried the strongest association with frailty, whereas the commonly used polypharmacy cutoff of five or greater total medications carried no significant association.”
Evaluating the Specific Types of Medication Is Key
These findings suggest that evaluating the specific types of medications an older patient is taking is more important than measuring the sheer number of medications, she points out. “The GOPIM scale can help hematologists identify these high-risk medications, and the NCCN Guidelines provide expert and evidenced-based recommendations on finding alternative options or deprescribing them,” Dr. Hshieh says.
A key takeaway from this study is that specific PIM scales are more strongly associated with frailty than polypharmacy scales. “For example, with each onepoint increase on the ARS, the odds of frailty increased by 19%,” Dr. Hshieh notes. “With each additional PIM on the GO-PIM scale, the odds of frailty increased by 65%. This was compared to each additional medication on a patient’s medication list increasing the odds for frailty by 8% (Table).”
Polypharmacy & PIMs Not Linked With Cognitive Impairment
Another key takeaway is that 14% to 19% of patients in the study had probable cognitive impairment. However, Dr. DuMontier points out, polypharmacy and PIMs were not significantly associated with cognitive impairment after adjusting for age, gender, and co-morbidity.
Given that certain medications can increase frailty risk in older patients, Drs. Hshieh, DuMontier, and colleagues highlight the importance of reviewing the medication lists for all older adults with blood cancers. “In addition, deprescribing high-risk medications in this population may be a high-yield intervention that improves patient health,” Dr. Hshieh says. “We understand that reviewing and adjusting medications can be challenging for busy hematologists and oncologists. They may also feel they lack expertise to do this effectively. We hope our GOPIMs scale will help clinicians collaborate with their patients to quickly identify and deprescribe medications that are most potentially inappropriate based the NCCN Guidelines.
‘Older Patients Are Increasingly Proactive About Their Care’
The study team suggests that future research in this area should be an intervention, perhaps using the GO-PIM scale, to deprescribe medications and improve the overall health and care of older adults with blood cancers. “Older patients are increasingly proactive about their care, so future research could examine ways patients can partner with their clinicians in managing their medications in a positive way,” Dr. Hshieh says.
She adds that the researchers were surprised that polypharmacy and PIMs were not associated with cognitive impairment. “Cognitive dysfunction among older patients with cancer is complex and multi-factorial,” she notes. “Thus, future research is needed to better understand the pathophysiology of cognitive dysfunction, and we need to use multidisciplinary approaches to tackle this problem.”