What are the primary palliative care considerations for an older patient?

From the Guidelines

The primary palliative care considerations for an older patient should focus on overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity, as strict glucose and blood pressure control are not necessary in this setting. When palliative care is needed, providers should initiate conversations regarding the goals and intensity of care, and simplification of regimens can be considered 1. The management of older adults at the end of life receiving palliative medicine or hospice care is a unique situation, where palliative medicine promotes comfort, symptom control, and preservation of dignity and quality of life in patients with limited life expectancy.

Key Considerations

• Overall comfort and quality of life should be the primary goals for diabetes management at the end of life, rather than strict glucose and blood pressure control 1.
• Providers should initiate conversations regarding the goals and intensity of care, and consider simplification of regimens, including relaxation of lipid management and withdrawal of lipid-lowering therapy if necessary 1.
• Avoidance of severe hypertension and hyperglycemia aligns with the goals of palliative care, and glucose targets should aim to prevent hypoglycemia and hyperglycemia 1.
• Treatment interventions should be mindful of quality of life, and careful monitoring of oral intake is warranted, with a focus on preventing dehydration and managing symptoms such as pain, nausea, and constipation.

Patient Categories

• Different patient categories have been proposed for diabetes management in those with advanced disease, including stable patients, patients with organ failure, and dying patients 1.
• For stable patients, the focus should be on preventing hypoglycemia and managing hyperglycemia using blood glucose testing, while for patients with organ failure, preventing hypoglycemia is of greatest significance, and dehydration must be prevented and treated.
• For dying patients, the discontinuation of all medications may be a reasonable approach, although for patients with type 1 diabetes, a small amount of basal insulin may be necessary to maintain glucose levels and prevent acute hyperglycemic complications 1.

Care Plan

• The care plan should be tailored to the patient's functional status and comorbidities, with a focus on maintaining comfort and quality of life rather than aggressive symptom control that may cause more harm than benefit 1.
• Regular reassessment and adjustment of the care plan is essential to meet the changing needs of older patients in palliative care, and consideration should be given to referral to specialist palliative care for complex symptom management or psychosocial issues.

From the FDA Drug Label

The total number of patients treated with gabapentin in controlled clinical trials in patients with postherpetic neuralgia was 336, of which 102 (30%) were 65 to 74 years of age, and 168 (50%) were 75 years of age and older. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and dose should be adjusted based on creatinine clearance values in these patients [see Dosage and Administration (2. 4), Adverse Reactions (6), and Clinical Pharmacology (12.3)].

The primary palliative care considerations for an older patient taking gabapentin include:

• Dose selection: should be cautious, usually starting at the low end of the dosing range
• Renal function: decreased renal function is more common in elderly patients, and dose should be adjusted based on creatinine clearance values
• Adverse reactions: elderly patients may be more susceptible to adverse reactions such as peripheral edema and ataxia
• Concomitant disease or other drug therapy: should be taken into account when selecting a dose for an elderly patient 2

From the Research

Primary Palliative Care Considerations

The primary palliative care considerations for an older patient include:

• Symptom management, such as pain, fatigue, and anxiety/depression 3, 4, 5, 6
• Advanced care planning (ACP) to develop goals of care that are congruent with the individual's priorities 6
• Comprehensive geriatric assessment to help the palliative care team successfully treat individuals 6
• Integration of palliative care with primary and community care for older people with chronic conditions 3
• Addressing geriatric-specific issues, such as polypharmacy and inappropriate prescribing 7

Multidisciplinary Team Approach

A multidisciplinary team approach is critical for optimum care, including:

• Specialist palliative care teams working with general practitioners and community nurses 3
• Geriatricians participating in the administration of palliative care 6
• Collaboration between palliative care teams and primary care geriatrics to provide more access to care 6

Effective Interventions

Effective interventions for older patients with chronic noncancer conditions and frailty include:

• Short-term integrated palliative and supportive care to reduce symptom distress and promote quality of life 3
• Personalized cancer treatment, including choosing treatment options that best fit the needs of each individual patient 5
• Prevention of common complications, such as neutropenia and mucositis, to allow for the administration of treatment in full and effective doses 5