In a 2018 Cochrane review, Rankin et al surmised that no tool could evaluate all facets of polypharmacy and that it was not clear whether interventions provided to improve appropriate polypharmacy, such as pharmaceutical care, “resulted in clinically significant improvement.”14 The authors concluded that interventions directed at inappropriate pharmacology, such as medication reconciliation, resulted in improvement but the results were based on only 2 studies with bias limitations.14

How to Approach Deprescribing

The American Board of Internal Medicine began the Choosing Wisely Campaign to encourage communication between patients and their healthcare providers and enable patients to choose healthcare that is evidence based, does not include unnecessary testing, and does not endanger the patient.15 The AGS and American Society of Health-System Pharmacists both participated in the development of the Choosing Wisely Campaign, which addresses polypharmacy. When considering deprescribing, it is important to gather a full history, obtain an accurate list of all prescription and over-the-counter medications, and ascertain the indication for each medication (See Case Study).

Elderly Woman at Risk of Falling: Case Study
An 83-year-old woman comes to the clinic for a review of her medication regimens. She has a history of coronary artery disease, type 2 diabetes, hypertension, atrial fibrillation, chronic lymphocytic leukemia, breast cancer, hypothyroidism, osteoarthritis, fibromyalgia, and a stroke that left residual weakness in her right leg and hand. The patient lives at home with her 88-year-old husband, who is her primary caregiver. Since her stroke 2 years ago, the patient has an aide come into the home to help her with showering and dressing. She is ambulatory with a walker but recently has been having falls. Her surgical history includes stent placement to treat her coronary artery disease, hysterectomy, cholecystectomy, bilateral mastectomies to treat her breast cancer, colon resection for internal obstruction, hernia repair after the colon resection, right total knee replacement, left total hip replacement, and open reduction and internal fixation of a fractured left wrist. She was hospitalized with the flu approximately 3 months ago, at which time her dose of amiodarone was increased. Although her atrial fibrillation was well controlled before hospitalization and has since been well controlled, the amiodarone was never decreased. The patient’s vital signs include blood pressure 122/78 mm Hg, pulse rate 76 beats/min, and respiration rate 20 breaths/min. She is 63″ tall, weighs 66.7 kg, with a body mass index of 26 (overweight). Physical examination is unremarkable except for the presence of bilateral lower extremity edema. She reports that she is allergic to sulfa drugs; adverse events related to previous medications include a dry cough from lisinopril and muscle aches from statins. Her diabetes is well controlled with a glycated hemoglobin A1c of 7.0%; glomerular filtration rate is 74mL/min, and thyroid hormone level is within normal range (4.25 mU/L). The table highlights the multiple medications the patient was taking at the time of her clinic visit and the medication reconciliation process the provider undertook to deprescribe and optimize the patient’s medication regimen. The patient was seen again after 3 months. Her atrial fibrillation remained well controlled. Her blood pressure remained normal at 126/82 mm Hg and hemoglobin A1c remained stable (7.0%). She stated that she had not fallen since the last visit. Medication reconciliation was done again to determine whether further dosage adjustments were needed.

Providers must determine the medications that meet criteria for deprescribing. These include duplicate medications, medications with a potential for drug-drug interactions, and drugs causing ADEs. To ascertain the merit of continuing certain medications, providers should consider the complexity of the regimen, the pill burden, the life expectancy of the patient (with risk calculators), and whether the medications are cost effective.9,16 Lastly, providers should discuss the goals of treatment with the patient or caregiver and determine a treatment plan with patient input.9


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Many drugs may need to be tapered slowly to prevent withdrawal consequences; thus, patients need to be monitored closely after deprescribing. Duerden et al recommend discontinuation of 1 drug at a time to monitor for withdrawal symptoms, with tapering when possible.17 Providers must develop a clear follow-up plan and assure patients that they will be followed closely and monitored for any adverse effects from discontinuing the medication.18

Barriers to Deprescribing

Fragmented care is common in elderly patients, with many patients seeing multiple specialists. These patients are prone to polypharmacy because no single provider is tasked with overseeing medication safety.19,20 Patients also may be hesitant to discontinue medications, particularly those they have taken for a long time, fearing exacerbation of their disease or opposing the original prescribing provider.18 Clinicians also may be reluctant to discontinue a drug prescribed by another provider21 or to discontinue medications because of pressure from family and other caregivers.20

In addition, deprescribing is a complex process. Strict adherence to evidence-based guidelines for treatment may lead providers to focus on disease processes without assessing a patient’s comorbid conditions.22 Discontinuation of a drug may affect pharmacokinetics and pharmacodynamics of another drug or may induce withdrawal symptoms.18 Clinic schedules are extremely tight, and a provider may be seeing patients with multiple issues, leaving little time to discuss medication reconciliation and deprescribing.18,19

Using the available tools can assist providers with decision making and ease the time burden related to geriatric polypharmacy. Deprescribing is necessary in a healthcare environment in which patients are managed by multiple providers and take multiple medications. Primary care providers are in a perfect position to spearhead the deprescribing process.

Lynda Jarrell, DNP, APRN, FNP-BC, CNE, is a clinical assistant professor at the University of Texas at Arlington College of Nursing and Health Innovation.

References

  1. He W, Goodkind D, Kowal P. US Census Bureau. An Aging World: 2015: International Population Reports. US Government Publishing Office; Published March 2016. https://www.census.gov/content/dam/Census/library/publications/2016/demo/p95-16 1.pdf.
  2. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systemic review of definitions. BMC Geriatrics. 2017;17(1):230.
  3. Zarowitz BJ, Stebelsky LA, Muma BK, Romain TM, Peterson EL. Reduction of high-risk polypharmacy drug combinations in patients in a managed care setting. Pharmacotherapy. 2005;25(11):1636-1645.
  4. Bala SS, Chen TF, Nishtala, PS. Reducing potentially inappropriate medications in older adults: a way forward. Can J Aging. 2019;38(4):419-433.
  5. Hill-Taylor B, Sketris I, Hayden J, Byrne S, O’Sullivan D, Christie R. Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact. J Clin Pharm Ther. 2013;38(5):360-372.
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  8. Halli-Tierney AD, Scarbrough C, Carroll D. Polypharmacy: evaluating risks and deprescribing. Am Fam Physician. 2019;100(1):32-38.
  9. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-834.
  10. 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-694.
  11. O’Mahony D, O’Sullivan D, Bryne S, O’Connor MN, Ryan C, Gallager P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Aging. 2015;44(2):213-218.
  12. Curtin D, Gallagher PF, O’Mahony D. Explicit criteria as clinical tools to minimize inappropriate medication use and its consequences. Ther Adv Drug Saf. 2019;10:2042098619829431.
  13. Samsa GP, Hanlon JT, Schmader KE. A summated score for the Medication Appropriateness Index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol. 1994;47(8):891-896.
  14. Rankin A, Cadogan CA, Patterson SM, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2018;9(9):CD008165.
  15. American Board of Internal Medicine. Choosing Wisely. An initiative of the ABIM Foundation. https://www.choosingwisely.org/ Accessed September 29, 2020.
  16. Liu LM. Deprescribing: an approach to reduce polypharmacy in nursing home residents. J Nurse Pract. 2014;10(2):136-138.
  17. Duerden M, Payne R. Medicines management: the importance of when to stop. Prescriber. 2015;26(8):24-26.
  18. Endsley S. Deprescribing unnecessary medications: a four-part process. Fam Pract Manag. 2018;25(3):28-32.
  19. Reeve E, Hendrix I, Shakib S, Roberts M, Wiese M. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging. 2013;30(10):793-807.
  20. Anderson K, Stowasser D, Freeman C, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open. 2014;4(12):e006544.
  21. Corsonello A, Onder G, Abbatecola AM, Guffanti EE, Gareri P, Lattanzio F. Explicit criteria for potentially inappropriate medications to reduce the risk of adverse drug reactions in elderly people: from Beers to STOPP/START criteria. Drug Saf. 2012;35(suppl 1):21-28.
  22. Dowden A. Deprescribing: reducing inappropriate polypharmacy. Prescriber. 2017;28(2):45-49.