Deprescribing Helps Optimize Medication Use

With the population aging, concerns about polypharmacy are also growing. Polypharmacy is defined as the use of multiple medications to manage disease states and/or the prescribing of more medications than clinically appropriate. Studies have shown that older patients take an average of 2 to 9 medications per day, with the prevalence of inappropriate medication usage between 11.5% and 62.5%.¹

Deprescribing is one method to combat polypharmacy and its complications among older individuals. Deprescribing is a comprehensive, provider-driven process to identify inappropriate medications to either discontinue medications or reduce the dosage for effective and safe pharmacotherapy management.² Deprescribing should not be viewed as a process opposite of prescribing or one that withholds treatment from patients; instead, it is a system to promote safe prescribing. By providing frequent reassessments of medication regimens through the process of deprescribing, pharmacists can ensure proper medication usage.

Older patients have a disproportionate number of medications, especially those with highly sedating adverse effects (AEs), further contributing to the cumulative burden of polypharmacy. The common afflictions of older patients include diseases that cause cognitive impairment, which makes this population significantly susceptible to the AEs of sedating medications, whether they are indicated for sedation or have sedation as an adverse or compounding effect. Medications, such as antidepressants, antipsychotics, anxiolytics, and hypnotics, are heavily associated with sedation, as well as various other AEs that can be detrimental to older patients.³ A wide range of drug tools have been studied to assess the risk of sedating medications in older patients, including the Drug Burden Index and the Sedative Load model.^3,4

The Drug Burden Index is not specific to sedating medications alone but still serves as an appropriate tool to measure the burden of those drugs in vulnerable populations. This tool helps quantify the cumulative risks of anticholinergic and sedative medications because of overlapping AE profiles,then acts as a screening tool to predict the risk of iatrogenesis from these medications, focusing on blurred vision, confusion, constipation, delirium, drowsiness, and tachyarrhythmia, among others.^4,5

Anticholinergic medications are associated with a wide range of AEs that are particularly concerning in older patients. These include confusion, delirium, impaired cognition, and memory loss, as well as peripheral AEs, such as blurred vision and urinary retention.⁶ The significance of these AEs is related to the combination of the dosage, drug burden, duration of therapy, and inconsistent therapeutic monitoring. The use of anticholinergic medications among older patients requires standardized use of existing risk assessment tools to appropriately guide the escalation and, more importantly, the deescalation and eventual deprescribing of these medications to mitigate the harms of polypharmacy. The Anticholinergic Risk Scale is a tool with extensive literature and study reviews developed by a team of pharmacists and physicians that focuses on the risk of cognitive and physical impairment. The use of the Anticholinergic Risk Scale allows a categorized ranking of the risk that different anticholinergic medications pose, such as atropine products, benztropine, diphenhydramine, and fluphenazine, all at a score of 3; followed by medications, such as amantadine and baclofen, at a score of 2; and the lower-rated medications, such as mirtazapine and paroxetine, at a score of 1.6 The application of this tool has evidence for beneficial consultant-led medication reviews to effectively guide the deprescription of anticholinergic medications for older patients.

Challenges exist when deprescribing medications for older patients, including the lack of robust literature about the benefits, risks, and process of deprescribing. Although there have been studies with relatively small sample sizes that assessed the feasibility and tolerability of deprescribing, there have not been large trials that have studied longer-term clinical outcomes.⁷ The lack of known benefits and the possible harms of deprescribing are common reasons why some prescribers are not comfortable with deprescribing: They fear that the discontinuation of medications might cause deterioration in patients’ health, especially among older individuals who may be more susceptible to changes in medications. Health care providers may also erroneously attribute deterioration that presents after discontinuing a medication as a result of deprescribing, even if it is unrelated, and may use the symptom as a justification to continue to maintain the polypharmacy status quo.^7,8

Furthermore, there is a lack of guidance on how and when medications should be deprescribed, how the patient should be monitored while this occurs, and whether nonpharmacologic approaches could be used as an adequate substitute. Available literature to guide appropriate risk assessment and subsequent deprescription within this drug class and population lack validated standardization because of the need to account for many factors. For older patients, there are no explicit approaches to how anticholinergics or sedatives should be deprescribed, including whether they should be tapered, and there are no robust data showing that nonpharmacologic sleep-promoting methods are as effective as medications.⁹ Thus, there is a need for sufficiently powered randomized controlled trials with detailed patient monitoring information and a long follow-up period to accurately assess the true benefits and risks of deprescribing medications and how this should be done.⁷ This would allow more health care providers to be comfortable with discontinuing medications that do not have a favorable benefit-risk ratio.

Another barrier to deprescribing is the lack of communication among providers. Older patients are more likely to have comorbidities and have specialists who prescribe different medications. These specialists may initiate medications and not communicate to other health care providers how and when the medication should be discontinued.⁸ For example, a patient who usually does not have trouble sleeping may be prescribed a sleep aid during a stressful period, as nonpharmacologic methods were not viable options at the time. This patient may be continued on the medication by a different provider if the original prescriber does not communicate that the medications are only temporary until the patient has time to use nonpharmacological sleep-promoting methods. This issue is commonly unresolved, as providers looking to deprescribe based on a Drug Burden Index assessment often leave the medications initiated by specialists alone, because they do not want to interfere with another provider’s care without confirmation from the specialist.⁸ Theconfirmation is seldomly received, as time restraints on the part of both providers prevent effective communication. These challenges to effective deprescribing could be resolved through effective communication ofanticipated end dates and the rationale behindmedication use.

Conclusion

Polypharmacy is a problem, particularly in older patients, as they are more likely to experience adverse reactions, especially if the medications have anticholinergic and/or sedative properties. Deprescribing using risk assessment tools can combat polypharmacy and its consequences. However, there are challenges, including a lack of protocols, interprovider communication, and randomized controlled trials. If these are addressed, more effective deprescribing occurs, and fewer patients face the consequences of polypharmacy.¹⁰

References

1. Dagli RJ, Sharma A. Polypharmacy: a global risk factor for elderly people. J Int Oral Health. 2014;6(6):i-ii.
2. Lee J, Singh N, Gray SL, Makris UE. Optimizing medication use in older adults with rheumatic musculoskeletal diseases: deprescribing as an approach when less may be more. ACR Open Rheumatol. 2022;10.1002/acr2.11503. doi:10.1002/acr2.11503
3. Parsons C, Haydock J, Mathie E, et al. Sedative load of medications prescribed for older people with dementia in care homes. BMC Geriatr. 2011;11:56. doi:10.1186/1471-2318-11-56
4. Shmuel S, Pate V, Pepin MJ, et al. Quantifying cumulative anticholinergic and sedative drug load among US Medicare Beneficiaries. Pharmacoepidemiology Drug Saf. 2020;30(2):144-156. doi:10.1002/pds.5144
5. Cardwell K, Kerse N, Ryan C, et al. The association between Drug Burden Index (DBI) and health-related outcomes: a longitudinal study of the ‘oldest old’ (LiLACS NZ). Drugs Aging. 2020;37(3):205-213. doi:10.1007/s40266-019-00735-z
6. Chatterjee S, Bali V, Carnahan RM, Chen H, Johnson ML, Aparasu RR. Anticholinergic burden and risk of cognitive impairment in elderly nursing home residents with depression. Res Soc Adm Pharm. 2020;16(3):329-335. doi:10.1016/j.sapharm.2019.05.020
7. Wu H, Kouladjian O’Donnell L, Fujita K, Masnoon N, Hilmer SN. Deprescribing in the older patient: a narrative review of challenges and solutions. Int J Gen Med. 2021;14:3793-3807. doi:10.2147/IJGM.S253177
8. Ailabouni NJ, Nishtala PS, Mangin D, Tordoff JM. Challenges and enablers of deprescribing: a general practitioner perspective. PLoS One. 2016;11(4):e0151066. doi:10.1371/journal.pone.0151066
9. MacLeod S, Musich S, Kraemer S, Wicker E. Practical non-pharmacological intervention approaches for sleep problems among older adults. Geriatr Nurs. 2018;39(5):506-512. doi:10.1016/j.gerinurse.2018.02.002
10. Reeve E, Wiese MD, Hendrix I, Roberts MS, Shakib S. People’s attitudes, beliefs, and experiences regarding polypharmacy and willingness to deprescribe. J Am Geriatr Soc. 2013;61(9):1508-1514. doi:10.1111/jgs.12418

About the Authors

Asad Ghani, Aditi Haribhakti, and Sabiyah Siddiqui are PharmD candidates at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway.

Deepali Dixit, PharmD, BCPS, BCCCP, FCCM, is a clinical associate professor of pharmacy practice and administration at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway.