Combating Polypharmacy Through Deprescribing Potentially Inappropriate Medications
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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.].Keywords:
Deprescribing
Beers Criteria
Gerontological nursing
Abstract Background/Objectives Successful deprescribing requires insight into patients' thoughts about deprescribing. We described attitudes towards deprescribing in a large sample of geriatric patients and nursing home residents. Design Interview‐based questionnaire study. Setting Denmark. Participants Geriatric inpatients ( n = 44), geriatric outpatients ( n = 94), and nursing home residents ( n = 162) with an Orientation‐Memory‐Concentration score of ≥8. Measurements Participants completed the validated Danish version of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire by interview. Attitudes were reported descriptively, and rPATD factor scores were compared between participant groups and across participant characteristics. Results Participants had a median age of 82 years (interquartile range [IQR] 76–89) and used a median of 8 medications (IQR 5–10). Thirty‐three percent of participants would like to try stopping one of their medications on their own, while 87% were willing to stop one on their physician's advice. Geriatric inpatients reported slightly greater perceived burden of taking medication compared to geriatric outpatients and nursing home residents (median "burden” score 50 vs 42, p = 0.11), while geriatric outpatients reported slightly more involvement in their medication use compared to nursing home residents (median “involvement” score 80 vs 75, p < 0.05) and geriatric inpatients (median “involvement” score 80 vs 70, p < 0.01). An increasing number of medications was associated with an increased “burden” score ( p trend = 0.001): Those using 1–4 medications daily had a median score of 25 (IQR 17–33) compared to 58 (IQR 42–75) among those using ≥10 medications daily. Similarly, an increasing number of medications was associated with a higher "concerns about stopping” score ( p trend = 0.001) and a lower "appropriateness” score ( p trend < 0.001), respectively. Conclusion Geriatric patients and nursing home residents are generally open towards deprescribing, particularly if proposed by their physician. Some differences exist between populations and across individual patient characteristics. Clinicians should increase awareness of deprescribing as a possibility in these populations and tailor their deprescribing approach to the individual patient.
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Few studies have evaluated the characteristics of elderly patients with polypharmacy refusing deprescribing. The aim of this study was to evaluate the prevalence of potentially inappropriate medication (PIM) use in elderly patients accepting and refusing a deprescribing intervention and to investigate factors associated with deprescribing refusal.We conducted a retrospective cross-sectional study by analyzing the electronic medical records from a single hospital. All consecutive patients aged 65 years or older who reported the use of five or more medications upon admission to the orthopedic ward from January 2015 to December 2016 and who were approached by a pharmacist for polypharmacy screening were included. Patients who had provided consent for the deprescribing intervention by the internal medicine physicians were defined as the acceptance group, and patients who did not were defined as the refusal group. The primary outcome was the use of any PIMs at admission, based on the 2015 American Geriatric Society Beers Criteria. Using multivariable logistic regression, predictive factors of refusing deprescribing were also evaluated.During the study period, 136 patients were eligible. Of those, 82 patients (60.3%) accepted the deprescribing intervention, and 54 patients (39.7%) declined the intervention. The mean age of all the patients was 81.1 years, and the mean number of medications at admission was 9.3. The overall proportion of patients taking any PIMs at admission was 77.2%. The proportion of patients taking any PIMs at admission was not different between the acceptance and refusal groups (78.0% and 75.9%, respectively; p = 0.84). None of the measured characteristics, including age, gender, residential status, comorbidity, alcohol use, smoking status, number of medications, or number of PIMs, were found to be associated with deprescribing refusal.The prevalence of any PIM use did not differ among elderly orthopedic patients with polypharmacy according to refusal or acceptance of the deprescribing intervention. Furthermore, none of the analyzed characteristics were found to be associated with deprescribing refusal. Given the high prevalence of PIM use, a strategy is needed for combating polypharmacy among elderly patients reluctant to undergo deprescribing.
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Potentially inappropriate medications ( PIM s) continue to be prescribed and used as first‐line treatment for the most vulnerable of older adults, despite evidence of poor outcomes from the use of PIM s in older adults. PIM s now form an integral part of policy and practice and are incorporated into several quality measures. The specific aim of this project was to update the previous B eers C riteria using a comprehensive, systematic review and grading of the evidence on drug‐related problems and adverse drug events ( ADE s) in older adults. This was accomplished through the support of The A merican G eriatrics S ociety ( AGS ) and the work of an interdisciplinary panel of 11 experts in geriatric care and pharmacotherapy who applied a modified D elphi method to the systematic review and grading to reach consensus on the updated 2012 AGS B eers C riteria. Fifty‐three medications or medication classes encompass the final updated C riteria, which are divided into three categories: potentially inappropriate medications and classes to avoid in older adults, potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate, and finally medications to be used with caution in older adults. This update has much strength, including the use of an evidence‐based approach using the I nstitute of M edicine standards and the development of a partnership to regularly update the C riteria. Thoughtful application of the C riteria will allow for (a) closer monitoring of drug use, (b) application of real‐time e‐prescribing and interventions to decrease ADE s in older adults, and (c) better patient outcomes.
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With increasing age, there is chance of developing different chronic conditions which are often accompanied by use of multiple medicines that can lead to polypharmacy which can be defined as use of five or more medicine which include the one that has been prescribed, over the counter (OTC) as well as complementary medicine. Geriatric people particularly those with multiple co-morbid health conditions, may develop polypharmacy with high risk of Adverse Drug Events (ADE) and Drug Interaction (DI). Presence of multiple co-morbidities makes them the highest consumer of pharmaceutical drugs, so a high degree of caution is required while prescribing drug to the elderly population. Concept of Deprescribing and several tools like Medication Appropriateness Index, ARMOR (Assess, Review, Minimize, Optimize, and Reassess), and START/STOPP (Screening tool for older persons potentially inappropriate prescription/ Screening tool to alert doctors to right treatment) etc have emerged as practical guides to solve problems related to polypharmacy and these tools should be considered by the prescriber while prescribing the drug to the elderly population.
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Abstract Medication management for older persons can be complex. With over 50% of all hospital admissions being for people aged over 65 years, understanding age‐related functional, cognitive and social factor changes and their impact on medication use is critical for pharmacists working in most adult medicine areas. This paper provides an overview of critical elements of medication management for older persons for pharmacists. Key elements include age‐related changes impacting medication effectiveness and safety, frailty, geriatric syndromes, polypharmacy and deprescribing, minimising medication‐related harm at transitions of care, dose administration aids and other strategies to support individuals in medication management and multidisciplinary comprehensive geriatric assessment.
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This article is free to read on the publishers website Introduction: Residential aged care facilities (RACFs) in Australia have attracted considerable attention in recent times as institutions where prescribing of certain classes of high-risk drugs such as antipsychotics, potent analgesics, and sedatives is excessive and potentially inappropriate. To ensure appropriateness of therapy in RACFs, well-organized approaches are needed. We examined the patterns of prescribing, and subsequent changes made by geriatricians, in the context of comprehensive geriatric assessment consultations provided to residents of RACFs delivered by video-conference. Methods: Design: Prospective observational study. Setting: Three residential aged care facilities in Queensland, Australia. Participants: 75 residents referred by General Practitioners (GPs) for comprehensive geriatric assessment delivered by video-consultation. Results: Patients had multiple co-morbidities (mean 6), high levels of dependency and were prescribed a mean of 8.6 regular medications. Polypharmacy (≥5 medications) prevalence was over 90% with 10% (n = 70) of medications identified as potentially inappropriate according to the 2012 Beers criteria. High-risk medications (based on the list of high risk medications in older people) accounted for 26.5% (n= 183). Geriatrician intervention recommended withdrawal of 12% (n = 83) and dose alteration in 7% (n = 48) of all medications prescribed. New medication were initiated in 56% (n= 42) patients. Of those medications identified as potentially inappropriate and high-risk, only 11% (n = 28) were stopped and dose altered in 9% (n = 23). Conclusion: There was a high prevalence of potentially inappropriate and high-risk medications. However, in spite of this awareness, geriatricians made relatively few changes, suggesting either that, on balance, prescription of these medications was appropriate or, because of other factors, there was a reluctance to adjust medications. Further research, including a broader survey, is required to understand these dynamics.
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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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