The number of Americans over the age of 65 years is increasing. According to the Census Bureau, people older than 65 years will outnumber those younger than 5 years sometime in 2020. By 2050, the number of people older than 65 years will be double the number younger than 5 years.1
With an aging population comes an increase in comorbidities and polypharmacy, defined as taking 5 or more medications.2,3 Polypharmacy can include appropriate pharmacology, in which medicine usage is evidence based, as well as use of potentially inappropriate medications (PIMs) that do not have an evidence-based indication, have the potential to interact with other medications the patient is taking, are continued beyond therapeutic benefit, or are given in place of less expensive options.4,5
Polypharmacy can result in many negative outcomes for patients and the healthcare system. For patients, these may include adverse drug events (ADEs), falls, and hospitalizations as well as decreased quality of life and increased nonadherence, cost, and mortality.6 Reducing pill burden can increase adherence and improve disease processes.7 The effects of polypharmacy on the healthcare system include decreases in healthcare provider productivity and quality of care and increases in medication errors.8
Scott et al define deprescribing as the systematic process of identifying and discontinuing drugs that pose more harm than good within the context of an individual patient’s care goals, current level of functioning, life expectancy, and preferences.9 As gatekeepers, primary care providers play a vital role in patient care and are positioned to implement the deprescribing process.
Tools available to assist in deprescribing include the Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults,10 STOPP (Screening Tool of Older Persons’ Prescriptions)/START (Screening Tool to Alert to Right Treatment),11 and the Medication Appropriateness Index (MAI).12 The Beers Criteria were developed by the American Geriatrics Society (AGS) and are updated every 3 years.10 The criteria consist of 5 categories:
- PIM in older adults independent of diagnosis
- PIM to avoid in older adults due to drug-drug or drug-disease interactions that may aggravate the disease process
- Medications to be used with substantial caution in older adults
- Medication combinations that may lead to adverse drug-drug interactions
- Medications that should be avoided or require dosing adjustments based on renal function4
Beers Criteria are useful in a variety of settings, are succinct, and use a powerful grading methodology. Drawbacks include a failure to identify all potentially inappropriate prescribing and to predict overprescribing and underprescribing.12 STOPP lists drugs according to physiologic systems and provides examples of situations in which drugs are inappropriately prescribed and should be discontinued. START, which is designed to be used in conjunction with STOPP, has 34 criteria and is organized according to physiologic systems. It also includes categories pertaining to analgesic agents, anticholinergic agents, and medications that induce falls. STOPP/ START is beneficial in the clinical setting.12
The MAI includes 10 questions about a drug related to indication, effectiveness, correct dosage, correct directions, practical directions, drug-drug interactions, drug-disease interactions, unnecessary duplication, correct duration, and whether the drug is the least expensive option. A calculator is used to measure risk. The MAI is more patient centered and works well in a clinic setting; however, it can be very time consuming, especially when a patient is taking multiple medications.13
These tools should not be substituted for clinical reasoning, available information, and individualized patient care. Changes to medications should be made using an interdisciplinary approach, including consultation with a pharmacist and with the patient. No single tool has been proven to be more effective than another.