(De)Prescribing in Hospitalized Sarcopenic Geriatric Patients

Rationale Acutely ill hospitalized geriatric patients have co-morbid disease and polypharmacy and 2/3 have low muscle strength and low muscle mass, called sarcopenic. Although all efforts are done by the multidisciplinary team to combat health problems and negative sequalae of sarcopenia, 80% of the (severely) sarcopenic patients will be deceased within 2 years. Optimalization medication is part of this multidisciplinary treatment strategy. The STOPP START criteria are applied to optimize the polypharmacy. However, it is not known whether this strategy actually results in a better or worse outcome for these patients. The question that arises is whether it is even better to minimize pharmacotherapy in these patients and only apply it if the aim is to combat symptoms and complaints and to stop (preventive) medication as much as possible. The latter is called a deprescribing pharmacotherapy approach (DPA) and seemed to be successful in a previous study concerning older frail patients.

Objective:

The effects of DPA compared to STOPP-START approach (SSA) prescribing on adverse drug reactions, medical complications, hospital readmission, quality of life in hospitalized geriatric patients with sarcopenia

Study design:

Prospective randomised intervention study. Patients will be randomised in two groups: intervention group (IG) with a DPA of 80 patients and an control group (CG) of 80 patients with a SSA.

Study population:

Acutely ill geriatric patients with sarcopenia and polypharmacy admitted to the acute care geriatric ward of Zuyderland Medical Centre.

Intervention:

Medication review in patients randomised to the IG group will be performed according to the principles of DPA and in the CG this will be performed following the SSA approach.

Main study parameters/endpoints:

Primary endpoint: the number and type of medication stopped and not restarted during medication review and number and type of medication restarted within 1, 3 and 6 months. Secondary endpoints: number and severity of Adverse Drug Reactions (ADR) and complications due to medication (e.g. delirium or falls), hospital readmission, quality of life (QoL) and mortality

Nature and extent of the burden and risks associated with participation, benefit and group relatedness:

In either of the two strategies of reviewing medication (SSA or DPA) there are risks for the sarcopenic patients with polypharmacy as part of the usual care. Applying the SSA, which is actually the usual care in the Dutch geriatric ward, there is serious risk of overtreatment with a risk of ADR and complications with holding off benefit because of a necessary time until benefit compared to the limited life expectancy. Although the risk for a ADR is low, a ADR with different kinds of impact can be expected however when starting e.g. preventive medication. But withholding preventative medication as part of DPA can cause a new health problem with minor to major impact if the life expectancy seems longer than predicted and exceeds the time until benefit. Overall, the aim of DPA is to optimize pharmacotherapy and reduce ADR, medication related complications and improve quality of life.

Inclusion criteria

• Aged 70 years and older
• Being frail according the Groningen Frailty Indicator (GFI score >3)
• Severely sarcopenic according the European Working Group On Sarcopenia-2 criteria (EWGSOP-2) based on handgrip strength (men < 27kg and women < 16kg), appendicular skeletal muscle mass (men < 7,0 kg/m2 and women < 5,5 kg/m2) and physical function below cut-off values (Short Physical Performance Battery <9)
• The use of 5 or more different medications before hospitalization

Exclusion criteria

• Being not instructible
• Having an implantable cardioverter defibrillator (ICD)
• No informed consent can be optained with the participant or a legal representative