Drug conflicts. Ethical dilemmas in end-of-life-care. And empowering patients. Interview with professor in geriatric pharmacoepidemiology Kristina Johnell
If you take more than five different medications a day – which many elderly persons do – there is a risk of a drug conflict. A Swedish digital tool, the miniQ, empowers clinicians and patients to avoid drug conflicts.
This is one of the successes partly conducted by professor in medication and ageing, Kristina Johnell. Today she is the Head of the Department of Medical Epidemiology and Biostatistics at the Karolinska Institutet in Sweden with about 270 people in the department.
“People often want to talk about the use of medications among older people. Many can relate to it. If not themselves then their relatives use a lot of medications, and they worry about the side effects. I always try and give some advise and always tell them, that if they use miniQ, it should be together with their doctors,” says Kristina Johnell.
The miniQ innovation is a web-based clinical decision support system to help older patients and their doctors optimise prescriptions and to avoid potential complications caused by drug treatments.
Medications can be of more harm than benefit for older people. The growing proportion of older persons and their increasing drug utilisation call for more vigilance against drug conflicts, side-effects and other drug problems. This decision support system can prevent such problems. It was developed in Sweden and has been used since 2003, and is being exported to other European countries such as the UK and Spain.
Do you think we will see more patient empowering tools like the miniQ?
“There is a movement empowering the patients, which we also do with the patients module of the miniQ. You can find so much yourself about your health online today. Patient empowerment is great, but remember to talk to your doctor before tampering with your medications. There is a lot of confusing information out there, and with older people, relatives and caregivers are important” she says.
“The problem in the specific field of medications and ageing is that there is not enough evidence to rely on. And it is so complicated. Medications are typically tried out on younger healthier patients, not frail elderly, we need more research. So, I have work enough until my retirement.”
Johnell is part of the scientific advisory board at Challenge. She hopes the project will provide some of this very needed evidence.
“My hope for Challenge is getting more insight into combinations of medicines, seeing what is happening in the body, what are the mechanisms and reasons behind them, and what are the side effects. And how can we work better for personalised medicine: Who are most vulnerable. It is not so that one size fits all. With elderly patients we really need personalised medicine,” says Johnell.
What is your view on Challenge?
The most intriguing is the combining of the micro data (cells), meso data (tissues) and macro data (population data). This is really unique and as far as I know not done before in concert in this field. I am looking forward to the results and hope we can use them later on also in Sweden.”
Which ethical dilemmas do you encounter in your work?
“One example is drug treatment at end-of-life among older people. I had a PhD student who does a lot of research in end-of-life-care. We don’t have a lot of evidence-based medicine here either. How do we give these patients, who approach death, the best quality of life?”
One major question is when to stop preventive treatment, eg. medicine that may inhibit cardiovascular complications in the future.
“Some medications might not be of benefit to the older person approaching death, should this medication be de-prescribed and taken away from them?”
“It is very difficult to estimate the remaining life time of older patients. That would also be a help from Challenge, if we could do this better. It is such a delicate issue. You don’t want anybody to feel abandoned.”
Where are the limits of data use from your point of view?
“For the most frail patients, we should firsthand be guided by their best interests. Medications and ageing is unfortunately an under-researched area and also comes with many difficult dilemmas. E.g. if you are in the last phases of dementia and have difficulties with communicating, we cannot conduct focus groups to find out their research priorities.”
What do you do yourself to prepare for a better senior life?
“I have to admit that I am not really the best example because I live a quite stressful life. But I dance. I use the car very little and walk instead, and I try to sleep appropriate hours. And then I did something new and challenged myself, which I hear can be beneficial for good ageing: I took on this new intriguing job as head of department.”
Photo by Gunilla Sonnebring