Geriatric Medicine

OPTIMAL DRUG PRESCRIBING FOR OLDER PERSONS

Director	Contact
Paula Rochon	Baycrest Centre for Geriatric Care Kunin-Lunenfeld/Applied Research K Unit 3560 Bathurst St. Toronto, ON M6A 2E1

Brief Description

The appropriate use of drug therapy is probably the single most important medical intervention in the care of older adults and, in particular, has both clinical and policy relevance. Optimizing drug therapy for older adults means achieving the balance between under-prescribing of beneficial therapies and over-prescribing (i.e. excessive and unnecessary use of drug therapy).  For older adults with coexistent chronic diseases, this challenge is increasingly important, but quite complex, because these individuals often have multiple comorbid conditions, use multiple drug therapies, and are treated by a range of health care providers. Our health services research program targets these older adults with the intention of transforming the way drug therapies are prescribed to vulnerable populations and settings. Our overall goal is to develop a research team in the area of drug benefit and risk that fosters multidisciplinary collaboration and emphasizes research training for young investigators.

Principal Investigators

Recent Original Research Publications

Rochon PA, Gurwitz JH. Prescribing for seniors: too much or too little? JAMA 282:113-115, 1999.

Rochon PA, Anderson G, Tu J, Gurwitz JH, Clark JP, Shear NH, Lau P. Age and gender-related use of low dose drug therapy: the need to manufacture ‘seniors’ doses’ and to evaluate the minimum effective dosage. J Am Geriat Soc. 47:954-959, 1999.

Rochon PA, Tu JV, Anderson GM, Gurwitz JH, Clark JP, Lau P, Szalai JP, Sykora K, Naylor CD. Rate of heart failure and 1-year survival for older people receiving low-dose ß-blocker therapy after myocardial infarction. Lancet. 356:639-644, 2000.

Dhalla I, Anderson GM, Mamdani M, Bronskill S, Sykora K, Rochon PA. Inappropriate prescribing before and after nursing home admission. J Am Geriat Soc 50:995-1000, 2002.

Mamdani M, Rochon PA, Juurlink DN, Austin P, Kopp A, Anderson GM, Naglie G, Austin PC, Laupacis A. Observational study of upper gastrointestinal haemorrhage in elderly patients given selective cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs. Brit Med J 325:624, 2002.

Future Directions

This project will support a series of investigator-initiated clinical and methodology projects. While establishing a research team in the area of drug benefit and risk, the project will also develop the infrastructure for research training in the use of observational databases for young investigators and students. In addition, we will establish a series of annual workshops to explore the emerging science of observational data. These workshops will focus on the challenge of identification and characterization of chronic disease cohorts in addition to describing methodologic challenges commonly faced in observational studies. The project will also aim to develop interventions to disseminate our findings, in collaboration with policy makers and research transfer units.

QUALITY OF LIFE IN OLDER PERSONS

Brief Description

The purpose of this program is to evaluate the quality of life of older persons with chronic diseases.  Chronic diseases are extremely prevalent in seniors, with persons over 75 years of age generally having at least one chronic disease, and often several.  Most chronic diseases have a significant impact on quality of life, with some having a profound effect. Many older persons experiencing chronic diseases express the desire to add ‘life to years’ rather than ‘years to life’. This emphasizes the importance of characterizing the influence of chronic diseases on quality of life. Our program includes methodological expertise in quality of life measurement, outcomes evaluation, decision sciences and cost-effectiveness analysis.  Members of the research team have clinical experience in geriatric medicine, general internal medicine, rheumatology and psychology. Areas of research focus include evaluating the quality of life in older persons with prostate cancer, Alzheimer’s disease, Parkinson’s disease, cardiovascular disease, arthritis and acute leukemia. The Program evaluates existing measures of quality of life, and when these prove inadequate, develops new quality of life measures. For example, the team has developed a new disease-specific measure of quality of life for prostate cancer. 

Principal Investigators

Recent Original Research Publications

Krahn M, Ritvo P, Irvine J, Tomlinson G, Bezjak A, Trachtenberg J, Naglie G. Construction of the Patient-Oriented Prostate Utility Scale (PORPUS): a multi-attribute health state classification system for prostate cancer.  J Clin Epidem 53:920-930, 2000. 

Silberfeld M, Rueda S, Krahn M, Naglie G. Content validity for dementia of three generic preference based quality of life instruments.  Quality of Life Research 11:71-79, 2002. 

Maetzel A, Krahn M, Naglie G. The cost-effectiveness of rofecoxib and celecoxib in patients with osteoarthritis or rheumatoid arthritis.  Arth Care Res  (in press). 

Krahn M, Ritvo P, Irvine J, Tomlinson G, Bezjak A, Trachetenberg J, Naglie G. Patient and community preferences for outcomes in prostate cancer: implications for clinical policy. Med Care (in press).

Marras C, Lang A, Krahn M, Tomlinson G, Naglie G, and the Parkinson Study Group. Quality of life impact of motor complications of dopaminergic therapy in early Parkinson’s disease.  (under review). 

Future Directions

The research team is currently embarking on a national study of quality of life in Alzheimer’s disease (AD). The objectives of the study are to assess the quality of life of AD patients and their caregivers across the spectrum of disease severity, and to evaluate the longitudinal changes in quality of life over time.  

There is emerging evidence that androgen deprivation therapy for prostate cancer can significantly reduce muscle mass and energy in seniors, resulting in decreased mobility and function. We will study the impact of androgen deprivation therapy on quality of life, functional status and physical performance in seniors with prostate cancer.

Acute myelogenous leukemia (AML) is a common form of leukemia in seniors with extremely poor long-term survival. Little is known about how well older persons tolerate chemotherapeutic treatments for AML. The team will begin to evaluate the quality of life of seniors with AML who are managed with intensive or palliative approaches.

PROSTATE CANCER IN OLDER MEN

Brief Description

The purpose of this program is to study the diagnosis and treatment of prostate cancer in older men. Prostate cancer is the most common malignancy in men and the second most common cause of cancer death. Decision-making is hampered by the lack of high quality clinical trial evidence of treatment efficacy and of potentially serious long-term treatment-associated complications. Potentially important interactions between coexisting chronic medical illnesses (common in older adults) and prostate cancer may also impact upon treatment. Our program includes methodological expertise in outcomes evaluation, quality of life measurement, decision sciences, and cost-effectiveness analysis. Members of the research team have clinical experience in geriatric medicine, general internal medicine, oncology, urology, and statistics.  Areas of research focus include examining the optimal treatment of localized prostate cancer, examining age biases in the treatment of localized prostate cancer, examining factors associated with suboptimal treatment of localized prostate cancer, estimating the costs associated with prostate cancer and its treatment, and examining quality of life, physical function, and cognitive function in older men initiating androgen deprivation therapy for non-metastatic prostate cancer.

Principal Investigators

Recent Original Research Publications

Alibhai SMH, Naglie G, Nam R, Trachtenberg J, Krahn MD. Influence of age and comorbidity on optimal treatment of localized prostate cancer – a decision-analytic view. J Clin Oncol 2003 (in press)

Schwartz K, Alibhai SMH, Tomlinson G, Naglie G, Krahn MD. The continued under-treatment of older men with localized prostate cancer. Urology 2003 (in press)

Krahn MD, Bremner K, Asaria J, Alibhai SMH, Nam R, Tomlinson G, Warde P, Jewett MA, Naglie G.  The ten-year rule revisited: accuracy of clinicians’ estimates of life expectancy in patients with localized prostate cancer.  Urology 60:258-63, 2002

Future Directions

Radical prostatectomy is used to treat localized prostate cancer and is associated with the highest cure rates and best long-term survival. However, many otherwise healthy older men currently do not receive radical prostatectomy. One potential explanation is that complication rates associated with radical prostatectomy increase in older age groups, particularly due to co-existing chronic illnesses. Using large administrative databases, our group is examining short-term peri-operative morbidity and mortality as a function of age and co-existing illnesses in order to derive more accurate post-operative complication rates.

There is emerging evidence that androgen deprivation therapy for prostate cancer can significantly reduce muscle mass and energy in seniors, resulting in decreased mobility, physical function, and cognitive performance. However androgen deprivation therapy is commonly used to treat a variety of men with prostate cancer. We will study the impact of androgen deprivation therapy on quality of life, physical function, and cognitive function in seniors with non-metastatic prostate cancer.

Prostate cancer is both common and often associated with a relatively long survival after diagnosis. Over time, the disease and its treatment result in significant costs to patients and health care plans. Our group will examine the costs associated with prostate cancer diagnosis and treatment over the course of the disease in three secular cohorts of men.