This is the first in an ongoing series highlighting issues faced by geriatricians and their patients
by TS Dharmarajan MD, MACP, AGSF, FRCPE
Vice Chairman, Department of Medicine; Clinical Director, Geriatrics; Program Director, Geriatric Medicine Fellowship Program
Montefiore Medical Center (Wakefield Campus)
Professor of Medicine, Albert Einstein College of Medicine
Deprescription or Deprescribing is a relatively new term referring to the “appropriate and safe reduction in number or dosage of medications prescribed to an individual”; the process is intended to withdraw unwanted, ineffective medications.1 Deprescribing is not enforced, rather, is voluntary and carried out following discussions between provider and patient and/or caregiver, including acceptance by the latter. Following deprescribing the patient is followed for unexpected consequences that may warrant re-introduction of the medication.
An aging population with associated co-morbidity has resulted in the prescribing of numerous medications to older individuals. The redundant, excessive and inappropriate use of medications is termed “polypharmacy.” Definition of polypharmacy varies, ranging from three to five or more medications prescribed on a continued basis.2,3 Polypharmacy, in conjunction with over-the-counter medications and supplement use leads to adverse drug events (ADEs) and poor outcomes, including hospitalization. Examples of ADEs include falls, fractures, delirium, syncope, organ dysfunction and more. Sometimes, as exception, patients are appropriately on six or more essential medications, as with chronic kidney disease or heart failure. Seniors also visit multiple providers, each adding medications to the list; additionally, many elders also consume over-the-counter supplements.
Polypharmacy and associated ADEs result from drug-drug, drug-nutrient or drug-disease interactions. An ADE is “harm resulting from use of a drug, including all adverse drug reactions.”4 Failure to recognize an ADE leads to evaluation, additional prescribing and more poor outcomes. A new geriatric syndrome must be viewed as potentially drug related, prior to needless, expensive testing.
Who owns responsibility for addressing the burden of polypharmacy? In large part, it is the primary provider or geriatrician, whose onus it is to coordinate care for patients who visit multiple providers of care. Medication reconciliation and opportunity for deprescribing exist at every patient encounter. Periodically, a patient feels overburdened by the number of medications and initiates a request for deprescribing. Unfortunately, there is no incentive for providers to engage patients into long-drawn discussions to assess and withdraw medications which may contribute to the reluctance for providers to attempt deprescribing!
At times, reduction in the dose or drug withdrawal results in negative consequences, as with beta blockers, benzodiazepines and antidepressants. In such cases the drug must be promptly re-introduced. Options always exist. Is a non-drug (life style) approach available? Is the patient on another medication that suffices? Is there any benefit at all from the drug, considering co-morbidity and life expectancy? Has harm resulted from the drug, e.g. renal dysfunction, a fall or hyperkalemia? Several drug classes are always considerations for deprescribing: analgesics, anti-histamines, anti-psychotics, H2 blockers, proton pump inhibitors, vitamins, supplements and sedative hypnotics. In addition to improving outcomes, deprescribing reduces medication costs to patients and participating facilities.5
Ethical aspects may warrant consideration. One must factor comorbidity, life expectancy, quality of life and importantly, opinion of the patient with capacity (or that of caregiver should capacity be lacking). Properly utilized, safe deprescribing is a boon to older adults and results in better healthcare!