Response to Timo E. Strandberg
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To the Editor: We thank Professor Strandberg1 for his valuable comments and interest in our recently published letter to the editor.2 The aim of our study was to determine associations between statin use and incident dementia according to disease severity and multimorbidity, but since the publication of our letter, a new Cochrane review has shed additional light on the topic.3 This Cochrane review concludes that current evidence does not support the role of statins for prevention of dementia, which is in agreement with our study findings. Ensuring rational statin use in older adults is challenging because clinical trial data in older adults with multimorbidity and polypharmacy are limited. In addition, as people age, treatment goals may change from extending duration of life to maintaining function and quality of life.4 Therefore, more research is warranted to generate information about benefits and side effects of statins in real-world data from older adults. Research into deprescribing medications is an emerging area and requires robust evidence to inform clinical decisions.5 The need for evidence-based deprescribing guidelines for a range of medication classes including statins was highlighted in a recent Delphi process.6 We appreciate Professor Strindberg's comments, and we support more research efforts to inform rational drug prescribing for older adults worldwide. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed to this paper. Sponsor's Role: None.Keywords:
Deprescribing
Beers Criteria
The risks of polypharmacy are heightened in the elderly because of a number of factors including age-related physiologic changes and the presence of comorbid conditions. Polypharmacy is a strong predictor of potentially inappropriate medication (PIM) use in the elderly in which harm may outweigh potential benefits. Despite available lists and criteria of PIMs from expert panels regarding inappropriate use of medications for older adults, prescribing of PIMs continues to be reported. Empowering clinicians with evidence-based guidance to safely and effectively discontinue PIMs by "deprescribing" is the subject of current research. Pharmacists can play an important role as part of the circle of care for the elderly. The acronym "MINDFUL" serves as a reminder of steps commonly used by pharmacists to assess appropriateness of medications and optimize health outcomes for their senior patients.
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The increase in the number of medications used may result many negative consequences for patients and health system. Elderly patients are more likely to encounter these health problems associated with polypharmacy. Deprescribing, the process of tapering, withdrawing, discontinuing, or stopping medications, is important in reducing polypharmacy, adverse drug effects, inappropriate or ineffective medication use, and costs. Deprescribing in elderly patients in accordance with the evidence based guidelines has many positive outcomes in older people such as decrease in the risk of falls, improvement in cognition, and improvement in patients’ global health status. Therefore, each visit of an elderly patient should be considered as an opportunity to evaluate the unnecessary use or harms of the prescribed or nonprescribed medications. Clinicians should decide to deprescription process by individualized care goals in line with current guidelines. Beers Criteria, STOPP/START and The Medication Appropriateness Index-MAI can be used to assit clinicians to identify unnecessary or potentially inappropriate drugs and reduce the number of medications in older patients. But, a balance is required between over and under prescribing. In conclusion, prevention of polypharmacy and withdrawing unneccesary and inappropriate medications may be the best clinical decision for family physicians who follow the elderly in primary care.
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Polypharmacy is common among multimorbid adults and associated with increased morbidity and mortality. Excessive polypharmacy (ie, ≥10 medicine) is strongly associated with inappropriate medication use, but little is known about attitudes toward deprescribing in patients with excessive polypharmacy. We surveyed 100 Danish individuals aged 65 years and above with ≥10 prescribed medications, using the validated Patients' Attitudes Towards Deprescribing (PATD) instrument. Most participants (81, 81%) thought they took a large number of medications, and 79 (79%) believed that their medications were necessary. Even so, 85 (85%) reported that they would be willing to stop taking one or more of their regular medications if their doctor told them they could, and 11 (11%) felt that they took at least one regular medication that they no longer needed. When presented with visual presentation of various amounts of tablets and capsules, 62 (62%) of participants reported that they would be comfortable taking fewer medications than they did. Forty-two (42%) participants had experience with stopping a regular medication. Almost all participants (92%) wanted to receive follow-up by various means if a medication was discontinued. Forty-one (41%) participants were interested in a consultation at an outpatient clinic specializing in polypharmacy. Overall, the answers to the PATD questionnaire suggest that our cohort of Danish, multimorbid outpatients with extensive polypharmacy have a high confidence in their healthcare providers for medication-related decisions, even though some feel that they are taking more medications than they would like to and feel that some medications may be unnecessary. Our results underline the need for healthcare providers to offer medication reviews in patients with multimorbidity.
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Elderly are mostly affected by polypharmacy induced adverse drug events as they are vulnerable due to numerous comorbidities. Deprescribing is a series of medicine ceasing process introduced to solve the problem arisen from polypharmacy. This study aimed to investigate the attitudes, beliefs and experiences towards polypharmacy among elderly with chronic diseases and their willingness to be deprescribed. A cross-sectional study was conducted among elderly patients in a tertiary hospital in Malaysia from August 2017 to October 2017 using a researcher assisted and validated questionnaire. A total number of 222 elderly patients were included in this study. 45.5% (n = 101) of the participants agreed that they were taking a large number of medicines (95% CI = 38.89%–52.10%). 56.3% (n = 125) of the participants had the desire to reduce their number of medications (95% CI = 49.73%–62.88%). Majority of them (n = 185, 83.33%) agreed to involve themselves in deprescribing process if permitted by their health care provider. 86.9% (n = 193) of the participants tended to not be afraid of deprescribing of their regular medications after a series of investigations by their health care provider (95% CI = 81%–89%). Majority of the elderly would like to participate in deprescribing process. Major factors that will affect patients' willingness to deprescribe were physicians' time and support as well as possible future benefits of their regular medications.
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Polypharmacy is a common and potentially preventable contributor to recurring emergency room visits, hospitalization, morbidity, and mortality. Its consequences are magnified in older adults due to the age-related decrease in functional and physiologic reserves, increased blood-brain barrier permeability, and altered drug metabolism, among others. In this article, we describe a case of polypharmacy in a septuagenarian to highlight the deprescribing approach implemented by the inpatient care team and to offer patient-centered insights to clinicians (primary care providers and hospitalists) when making deprescribing decisions. The overarching aim of this article is to build on existing literature regarding polypharmacy, prescribing cascades, and deprescribing in the context of what matters most and aligns with patient health priorities. This article highlights the importance of good geriatric medication reconciliation stewardship to avoid harm.
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Polypharmacy, which refers to using multiple medications by an individual, is becoming increasingly common in the aging population. Although it can be beneficial in treating complex medical conditions, it also carries inherent risks, such as adverse drug reactions, drug interactions, cognitive impairment, and increased healthcare costs. With increased medication use, it is essential to consider the risks and benefits of each prescribed medication. Evidence-based guidelines, such as the Beers Criteria and the Screening Tool of Older Persons’ Prescriptions criteria, can help healthcare providers reduce the risks of polypharmacy. Deprescribing, the process of reducing or stopping medication use that is no longer necessary or potentially harmful, is becoming increasingly important in managing polypharmacy. The 5Rs Framework and the Medication Appropriateness Index are two examples of clinical practice guidelines for deprescribing. Communication and collaboration between healthcare providers and patients, gradual tapering of medication, and involvement of patients and caregivers in decision-making are important considerations for deprescribing in primary care. This article provides an overview of the prevalence and negative consequences of polypharmacy, evidence-based guidelines for reducing polypharmacy, clinical practice guidelines for deprescribing, and considerations for deprescribing in primary care.
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Polypharmacy, defined as concurrent of five or more drugs, can occur in patients of all ages. Polypharmacy may be appropriate or inappropriate. Appropriate polypharmacy is defined as use of the correct drugs under appropriate conditions [in order] to treat the right diseases. A prescribed drug becomes inappropriate when its benefits no longer outweigh its risks. Inappropriate polypharmacy has been shown to increase the risks of hospitalization, adverse drug events, clinically relevant drug interactions, and all-cause mortality. Many tools are available to aid physicians in identifying inappropriate polypharmacy. Implicit tools, such as the Medication Appropriateness Index (MAI), provide guidance to be used alongside clinical judgement. Explicit tools, such as the American Geriatrics Society (AGS) Beers Criteria, provide lists of potentially inappropriate drugs and recommend alternatives. Collaboration with pharmacists is important in assessing drug appropriateness. It has been shown to reduce drug-related problems, emergency department visits, and hospitalizations and to improve overall patient health. A patient-centered, team-based approach is recommended in the process of deprescribing inappropriate drugs. Deprescribing should be approached in the same stepwise manner as prescribing of new drugs, and should include patient agreement to changes, evidence-based rationales, and of dosage tapering strategies.
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Polypharmacy, defined as the use of five or more medications, is becoming increasingly prevalent in older adults throughout the United States. Depre-scribing, along with the use of existing tools, such as the American Geriatrics Society Beers Criteria, can help guide health care providers in reducing the risks associated with polypharmacy such as side effects and drug interactions. The framework of deprescribing and the use of existing guidelines and resources are valuable in guiding health care providers in addressing polypharmacy. [Journal of Gerontological Nursing, 45(1), 9-15.].
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