Older adults often take numerous medications each day, contributing to polypharmacy and the continuous prescribing cascade. This may lead to adverse effects, poor outcomes, and decreased quality of life. Deprescribing may be one solution to this common scenario.
Deprescribing is defined as “the systematic process of identifying and discontinuing drugs in instances in which existing or potential harms outweigh existing or potential benefits within the context of an individual patient’s care goals, current level of functioning, life expectancy, values, and preferences” (JAMA Intern Med 2015;175:827–34). Deprescribing is part of the good prescribing continuum, which includes initiation, dosage changes, and discontinuation of medications, and it can occur across multiple care transitions, including the post-acute and long-term care setting.
Barriers and Reasons
Deprescribing may be considered for a variety of reasons but ultimately comes down to weighing the actual or potential risks versus the benefits of a medication’s use. One reason for deprescribing is prior lack of adherence to a medication if the disease is managed without it. Another reason is the lack of a clear indication (such as aspirin for “cardiovascular health” in a patient without cardiovascular disease). Duplicate therapies should be deprescribed when not providing any additional benefit (for instance, a patient taking a proton pump inhibitor plus an H2 blocker). Additionally, changing to an alternative medication may warrant the discontinuation of the previous medication.
Medications also may contribute to pill burden, financial burden, or treatment burden. For example, warfarin requires careful attention to an individual’s diet to maintain a consistent level of vitamin K, as well as close monitoring of international normalized ratio (INR) through fingersticks or venipuncture. Patients may feel the overall burden of this regimen outweighs the benefit. Also, patients may experience harm from a medication — an adverse side effect, drug interaction, or physical discomfort (as with subcutaneous injections). Clinicians should weigh these considerations against the potential benefits, and factor in the patient’s goals and values. This thought process can also be applied when weighing the potential harm versus potential benefit of a medication (such as an anticoagulant in a patient who has had recent gastrointestinal [GI] bleeding).
Medications may also be deprescribed if data are lacking to support a benefit (such as appetite stimulants in cachexia) or if the time to benefit is lacking, given the prognosis (such as bisphosphonates for a patient with a life expectancy of less than six months). Patients or caregivers also may express a preference to stop or continue a medication.
All these factors, along with provider buy-in, may become a barrier to successful deprescribing. When offering a recommendation of why a specific medication may not be indicated anymore, identifying the underlying concerns of patients or caregivers and providing medication education and counseling based on evidence-based guidelines or articles may be needed.
Medication Classes to Consider Deprescribing
Transitions of care between health care settings is a perfect time to reassess the need for each medication and its indication for use. The Centers for Medicare & Medicaid Services specifies that residents who reside in long-term care facilities should have treatment regimens free from unnecessary medications (State Operations Manual, F-757). The DE-PHARM Project, a deprescribing pilot initiative in long-term care facilities, recommends deprescribing for medications that are indicated for the prevention or management of disease states and excludes medications used for pain or other symptom management (Consult Pharm 2017;32:468–478).
Deprescribing starts with questioning the indication for the medication and weighing the risks versus benefits of use. Several common medication classes considered for deprescribing in the PALTC setting include antipsychotics, antidepressants, acetylcholinesterase inhibitors, antidiabetics, and proton pump inhibitors (PPIs).
Antipsychotics are associated with significant side effects, including somnolence, altered mental status, extrapyramidal symptoms, the metabolic syndrome, fall risk, and increased risk of mortality in patients with dementia. Their use may be appropriate to treat a diagnosed psychiatric condition, such as schizophrenia or bipolar disorder. Although nonpharmacologic interventions should be used to address behavioral symptoms of distress among individuals with dementia, there is some evidence that off-label use of antipsychotics may be helpful in treating physically aggressive behaviors and psychotic symptoms that place the patient with dementia or others at risk for harm. However, without these specific indications, antipsychotics should be considered for a gradual dose reduction to prevent risk of harm, especially in older adults. Similarly, use of antidepressants should be routinely reassessed due to the risk of side effects such as asthenia, somnolence, insomnia, GI upset, and prolonged QTc.
Dementia medications, including cholinesterase inhibitors and N-methyl-d-aspartate (NMDA) antagonists, are frequently prescribed to slow the cognitive and functional decline associated with dementia. However, once a resident has reached the point of advanced illness in the disease trajectory, where he or she requires a skilled nursing level of care, these medications are likely no longer providing significant benefit. They may only be contributing side effects such as nausea, diarrhea, and bradycardia. A recent study with nursing home residents showed deprescribing acetylcholinesterase inhibitors reduced the risk of serious falls and fractures and did not increase the risk for all-cause negative events including hospitalizations, emergency department visits, and mortality (Am Geriatr Soc 2020;68:699–707).
The American Diabetes Association provides recommendations for relaxed glycemic targets in the elderly (Diabetes Care 2020; 43:S152–S162). Diabetes goals should be individualized based on the patient’s age, comorbidities, prognosis, and risk of hypoglycemia. One alternative dosing strategy for insulin is to deprescribe short-acting insulin altogether and continue long-acting insulin with the intent of minimizing hypoglycemia and symptomatic hyperglycemia. Sliding-scale insulin should be discontinued to avoid unnecessary fingersticks and injections throughout the day that may be contributing to treatment burden, especially during the COVID-19 pandemic. More useful information can be found in the free guide “Optimizing Medication Management During the COVID-19 Pandemic: Implementation Guide for Post-Acute and Long-Term Care” (https://bit.ly/2Gnvm2u
) from the University of Maryland’s School of Pharmacy.
Finally, PPIs are often initiated during hospitalizations for stress ulcer prophylaxis. They may not be discontinued at hospital discharge, so it’s important to clarify whether there is a true indication for their use (such as gastroesophageal reflux disease or GI bleed). The side effects may include impaired vitamin B12 absorption and an increased risk of Clostridioides difficile infection and hip fractures. Deprescribing should be done thoughtfully, with a process in place for tapering the medication if necessary and monitoring for signs of efficacy and toxicity.
Several online tools and resources are available to assist clinicians in creating plans for deprescribing.
The US Deprescribing Research Network (https://deprescribingresearch.org
) offers guidelines and algorithms for deprescribing a variety of medication classes. The algorithms identify the appropriateness of deprescribing and offer specific tapering instructions and monitoring parameters.
Medstopper.com is a website that allows clinicians to enter the names medications and creates a plan, which includes stopping priority, a taper approach, and monitoring parameters, with symptoms of medication withdrawal, if applicable. It also pulls comments from the Beers and Screening Tool of Older Person’s Prescriptions (STOPP) criteria.
TaperMD.com is a web-based portal that creates a personalized deprescribing plan by incorporating drug interactions, warnings, and individual and cumulative drug risk to align medication regimens with patient goals.
Although these tools and resources assist the consultant pharmacist in gaining additional insight, one limitation is that they are not routinely integrated into the workflow. This can limit deprescribing efforts and potentially impact patient outcomes. As the tools continue to develop and become more widely recognized, health systems should consider integrating these deprescribing tools into the electronic health record with automatic screening tools to better enable clinicians to deprescribe unnecessary or high-risk medications.
Finally, it is crucial to gain clinician and resident/caregiver buy-in to the deprescribing process to allow adequate monitoring for rebound symptoms and overall disease-state control. It is often comforting for residents to hear from clinicians that deprescribing can be a trial, no medication changes are permanent. Also, collaboration is key: Allowing residents and families to be part of the deprescribing process gives them a sense of control and understanding that their treatment goals are being considered.
Dr. Cook is a palliative care clinical pharmacist who works with older adults.