There are an increasing number of older adults (i.e., individuals 65 and older) who health care professionals and staff are caring for across all settings of care. Individuals 65 and older represented 14.1% of the U.S. population in 2013, and are expected to increase to 21.7% of the U.S. population by 2040 (Administration on Aging, 2015).
Along with the numbers of older adults, medical complexity is also increasing, with approximately 92% of older adults having at least one chronic condition and 77% having at least two chronic conditions (Centers for Disease Control and Prevention, 2015). Furthermore, some level of disability was reported by 36% of adults ages 65 and older, which has been noted to increase each decade of life, such as difficulty with hearing, vision, cognition, and ambulation (National Council on Aging, 2015). As this population continues to age, more individuals will be transitioning among various long-term care settings, such as assisted living facilities and skilled nursing units. It is estimated that approximately 23% of new admissions to skilled nursing facilities are due to medication nonadherence (Strandberg, 1984). Furthermore, it is estimated that 85% of residents within assisted living facilities need medication management administration and oversight (Strandberg, 1984).
With such a high percentage affected by multiple chronic medical conditions, the likelihood of increased medication use rises. According to a cross-sectional study on medication prevalence among older adults, 28% of men and 33% of women ages 65 to 74 used five or more prescription medications (Qato et al., 2008). The prevalence of polypharmacy was shown to increase with age; 36% of men ages 75 to 85 used five or more prescriptions, as well as 37% of women in this age category (Qato et al., 2008). In addition, older adults were found to be the largest consumers of over-the-counter medications and dietary supplements (Qato et al., 2008).
With a disproportionately higher use of medication among older adults in the United States, it is not surprising that there is a higher risk of medication-related problems. This problem spans beyond the well-being of older adults by significantly contributing to the national financial burden. According to a recent IMS Institute study (2012), the misuse of medications contributes to $500 billion in international health care spending. To address this preventable and expensive problem, the IMS Institute (2012) recommends investing in medical audits that focus on elderly patients. In the United States, more specifically, medication-related problems in the older adult population are associated with an annual expense of $8 billion (Burton, Hope, Murray, Hui, & Overhage, 2007). With the U.S. aged population growing at a faster rate than ever before, the need to ensure safe medication management for older adults presents an urgent need in the health care community. The current article highlights deprescribing as one clinical approach to improve medication use in older adults.
Art of Deprescribing
Deprescribing is “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” (Scott et al., 2015, p. 827). This assessment is based on the individual's characteristics (i.e., factors that are constantly changing so that although a medication may be necessary today for a particular patient that does not guarantee that in 5 years it will remain necessary). A common saying, first quoted by the Greek philosopher Heraclitus, “You never step into the same river twice,” is a useful way to understand this concept. Like a river, a patient is constantly changing. Medications that were beneficial when ordered may not have benefits that outweigh risks 1 year later. Changes are likely to have occurred in both the benefits and risks. For example, changes occur in organ function and the way in which drugs are distributed and eliminated due to age and disease; therefore, a medication prescribed at age 45 for work-related stress may lead to toxicity and adverse effects at age 70.
These changes are why it is imperative to obtain the patient's and family's goals of care (e.g., prolong life, prevent morbidity, slow disease progression, prevent decline, comfort care). These goals coupled with treatment targets, namely primary prevention, secondary prevention, chronic disease control, acute disease treatment, and symptom management, provide the foundation for deprescribing (Brandt & Stefanacci, 2011). One way to manage medications based on patient desires is to ask the patient about his/her treatment priorities. Listing a patient's problems along with the treatments for that problem and his/her values and goals (which may differ from medical treatment) and then ordering them in priority can improve medication management. In addition, the treatment objective can be identified as being one of either prevention or acute symptomatic control (Table 1). Identification of the treatment objective allows for easier discontinuation once the objective of primary prevention is no longer warranted because of competing priorities or a life expectancy that is shorter than the opportunity for prevention goals to be met or event to occur.
Levels of Disease Prevention
Applying these concepts is often seen in the context of cardiovascular disease and the use of statin therapy. Data from clinical trials guide the initiation of long-term medication therapy for primary or secondary prevention of cardiovascular disease but rarely define the timing, safety, or risks of discontinuing the agents. As a result, the number of medications often accumulates. In the last year of life, the number of medications increases by 50% (Currow, Stevenson, Abernethy, Plummer, & Shelby-James, 2007). In addition, the effects of advanced disease compounded with the aging process may further alter a patient's metabolism of medications and increase the risk of adverse effects (Holmes, Hayley, Alexander, & Sachs, 2006).
The potential for adverse effects is why many practitioners advocate for discontinuing unnecessary medicines in advanced life-limiting illness to reduce adverse effects, pill burden, and medication costs while potentially enhancing quality of life and possibly survival (Bain et al., 2008; Vollrath, Sinclair, & Hallenbeck, 2005). However, the choice of which medicines to discontinue, as well as timing and safety, is unclear (Case, O'Leary, Kim, Tinetti, & Fried, 2015; Holmes et al., 2013). The Figure provides an approach when faced with these tough decisions (Brandt & Stefanacci, 2011). This approach coupled with emerging evidence to support deprescribing is needed to help prescribers who commonly do not have this conversation with their patients. Case et al. (2015) reported that only one third of older adults said they had a specific conversation with their health care providers about priorities in health care decision making. Time to benefit should also be considered, as well as the relative benefit of treatment in specific clinical conditions (Holmes et al., 2013).
Statin therapy is commonly prescribed in older adults for primary and secondary prevention of cardiovascular disease. Although there is compelling evidence for prescribing statins for primary or secondary prevention for individuals who are expected to live for many years, no evidence exists to guide decisions to discontinue statin therapy in patients with limited prognosis. A recent randomized trial evaluated the safety and clinical impact of statin discontinuation in the palliative care setting (Kutner et al., 2015). The study showed in 381 patients with estimated life expectancy of <1 year who were on statin therapy for primary or secondary prevention for at least 3 months (69% for >5 years) that time until death after stopping statin therapy was 229 days with discontinuation versus 190 with continuation. By discontinuing statins alone, it is estimated to save $603 million in U.S. health care expenditures (Kutner et al., 2015). These same concepts have been shown in successfully deprescribing proton pump inhibitors (Reeve et al., 2015).
Clinical Tools to Assist with Deprescribing
To optimize prescribing through deprescribing, recent updates have been made to clinical tools and resources that may assist health care providers, namely the American Geriatrics Society (AGS) Beers Criteria, STOPP (Screening Tool of Older Persons' Potentially Inappropriate Prescriptions), and START (Screening Tool to Alert doctors to the Right Treatment).
American Geriatrics Society Beers Criteria
The initial Beers Criteria were published in 1991, targeting the use of potentially inappropriate medications in older adults residing in nursing homes. They were updated in 1997 to address older adults across all settings of care. These updated criteria were then adopted by the Health Care Finance Administration, now known as the Centers for Medicare and Medicaid Services (CMS), within the Interpretive Guidance for Nursing Homes used during the survey process. Further updates occurred in 2003, prior to the emergence of Medicare Part D, and some of the criteria were then adopted into various quality metrics. It was approximately one decade before the Beers Criteria were updated under the direction of the American Geriatrics Society in 2012 and most recently in 2015 (AGS 2015 Beers Criteria Update Expert Panel, 2015).
The criteria are intended for use in all ambulatory, acute, and institutionalized settings of care for populations aged 65 and older in the United States, with the exception of hospice and palliative care. The intentions of the criteria are to: (a) improve medication selection; (b) educate clinicians and patients; (c) reduce adverse drug events; and (d) serve as a tool for evaluating quality of care, cost, and patterns of drug use in older adults. The goal of the 2015 AGS Beers Criteria, as with previous versions, continues to be improving the care of older adults by reducing their exposure to potentially inappropriate medications.
STOPP and START Criteria
The STOPP/START criteria address inappropriate prescribing by discussing not only potentially inappropriate medications (STOPP), but also potential prescribing omissions (START) (O'Mahony et al., 2015). Since the first STOPP/START criteria in 2008, there have been noteworthy distinctions from other tools, namely:
- STOPP criteria medications are significantly associated with adverse drug events, unlike Beers Criteria 2003 medications (Hamilton, Gallagher, Ryan, Byrne, & O'Mahony, 2011).
- STOPP/START criteria as an intervention applied at a single time point during hospitalization for acute illness in older adults was shown to significantly improve medication appropriateness, which was maintained 6 months postintervention (Gallagher, O'Connor, & O'Mahony, 2011).
- STOPP/START criteria as an intervention applied within 72 hours of hospital admission significantly reduced adverse drug events and average length of stay by 3 days in older patients (Hamilton et al., 2011).
Despite some notable differences among these criteria, the process of reviewing an older adult's medications with the goal of minimizing potentially inappropriate medications has been shown to be effective at identifying a vulnerable patient population that benefits from ongoing medication review (Grace et al., 2014).
Educational Needs for Workforce Training
During 2015, the U.S. Department of Health and Human Services, Human Resources and Service Administration awarded more than $37 million to centers throughout the country for the Geriatrics Workforce Enhancement Program (U.S. Department of Health and Human Services, 2015). This program supports the development of a health care work-force that improves health outcomes for older adults by integrating geriatrics with primary care, maximizing patient and family engagement, and transforming the health care system. It is well known that geriatrics training is needed throughout the interprofessional team—it is imperative that additional action be taken. Table 2 provides examples that may be useful in educating the interprofessional team with the focus on deprescribing.
Educational Resources for Deprescribing
Implications for Geriatric Nurses
Medication management is a complex task for patients as well as providers. Nursing involvement and understanding of all team members' roles is important to improving the process. Pharmacists are often underused members of the team who can help address polypharmacy. A recent study highlighted the importance of follow up after cessation of medications and a preference for face-to-face communication (Reeve, Wiese, Hendrix, Roberts, & Shakib, 2013). Although concerns exist with the potential for withdrawal effects and relapse of the previous condition, good communication and follow up may overcome this barrier (Reeve et al., 2013). Herein lies the opportunity for health professionals other than physicians (e.g., pharmacists and nurses) to initiate deprescribing. Both nurses and pharmacists are often in a good position to have discussions with older adults about their goals and concerns regarding continuing or discontinuing a medication.
As noted, there is an increased awareness regarding the concerns of medication management issues and the impact on use of resources and burden on patients and caregivers. Burden on caregivers and patients calls for concerted action, such as deprescribing initiatives, which will improve medication use. Future research is needed in the development of a deprescribing process, particularly in the areas of ability to stop medications determined to be inappropriate. In addition, deprescribing needs the collaborative planning of an interprofessional team to provide the support for the patient and caregiver.
- Administration on Aging. (2015). Aging statistics. Retrieved from http://www.aoa.acl.gov/Aging_Statistics/index.aspx
- American Geriatrics Society 2015 Beers Criteria Update Expert Panel. (2015). American Geriatrics Society 2015 Updated Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 63, 2227–2246. doi:10.1111/jgs.13702 [CrossRef]
- Bain, K.T., Holmes, H.M., Beers, M.H., Maio, V., Handler, S.M. & Pauker, S.G. (2008). Discontinuing medications: A novel approach for revising the prescribing stage of the medication-use process. Journal of the American Geriatrics Society, 56, 1946–1952. doi:10.1111/j.1532-5415.2008.01916.x [CrossRef]
- Brandt, N.J. & Stefanacci, R.G. (2011). Discontinuation of unnecessary medications in older adults. The Consultant Pharmacist, 26, 845–854. doi:10.4140/TCP.n.2011.845 [CrossRef]
- Burton, M.M., Hope, C., Murray, M.D., Hui, S. & Overhage, J.M. (2007). The cost of adverse drug events in ambulatory care. AMIA Annual Symposium Proceedings, 90–93.
- Case, S.M., O'Leary, J., Kim, N., Tinetti, M.E. & Fried, T.R. (2015). Older adults' recognition of trade-offs in healthcare decision-making. Journal of the American Geriatrics Society, 63, 1658–1662. doi:10.1111/jgs.13534 [CrossRef]
- Centers for Disease Control and Prevention. (2015). Healthy aging. Retrieved from http://www.cdc.gov/aging/index.html
- Currow, D.C., Stevenson, J.P., Abernethy, A.P., Plummer, J. & Shelby-James, T.M. (2007). Prescribing in palliative care as death approaches. Journal of the American Geriatrics Society, 55, 590–595. doi:10.1111/j.1532-5415.2007.01124.x [CrossRef]
- Gallagher, P.F., O'Connor, M.N. & O'Mahony, D. (2011). Prevention of potentially inappropriate prescribing for elderly patients: A randomized controlled trial using STOPP/START criteria. Clinical Pharmacology and Therapeutics, 89, 845–854. doi:10.1038/clpt.2011.44 [CrossRef]
- Grace, A.R., Briggs, R., Kieran, R.E., Corcoran, R.M., Romero-Ortuno, R., Coughlan, T.L. & Kennelly, S.P. (2014). A comparison of Beers and STOPP criteria in assessing potentially inappropriate medications in nursing home residents attending the emergency department. Journal of the American Medical Directors Association, 15, 830–834. doi:10.1016/j.jamda.2014.08.008 [CrossRef]
- Hamilton, H., Gallagher, P., Ryan, C., Byrne, S. & O'Mahony, D. (2011). Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Archives of Internal Medicine, 171, 1013–1019. doi:10.1001/archinternmed.2011.215 [CrossRef]
- Holmes, H.M., Hayley, D.C., Alexander, G.C. & Sachs, G.A. (2006). Reconsidering medication appropriateness for patients late in life. Archives of Internal Medicine, 166, 605–609. doi:10.1001/archinte.166.6.605 [CrossRef]
- Holmes, H.M., Min, L.C., Yee, M., Varadhan, R., Basran, J., Dale, W. & Boyd, C.M. (2013). Rationalizing prescribing for older patients with multimorbidity: Considering time to benefit. Drugs & Aging, 30, 655–666. doi:10.1007/s40266-013-0095-7 [CrossRef]
- IMS Institute. (2012, October). IMS Institute study: $500B in global health spending can be avoided annually through more responsible use of medicines. Retrieved from http://www.imshealth.com/vi_VN/thought-leadership/ims-institute/reports/responsible-use-of-medicines-report#ims-form
- Kutner, J.S., Blatchford, P.J., Taylor, D.H. Jr.. , Ritchie, C.S., Bull, J.H., Fairclough, D.L. & Abernethy, A.P. (2015). Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: A randomized clinical trial. JAMA Internal Medicine, 175, 691–700. doi:10.1001/jamainternmed.2015.0289 [CrossRef]
- National Council on Aging. (2015). Statistics on function. Retrieved from https://www.ncoa.org
- O'Mahony, D., O'Sullivan, D., Byrne, S., O'Connor, M.N., Ryan, C. & Gallagher, P. (2015). STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age and Ageing, 44, 213–218. doi:10.1093/ageing/afu145 [CrossRef]
- Qato, D.M., Alexander, G.C., Conti, R.M., Johnson, M., Schumm, P. & Lindau, S.T. (2008). Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. Journal of the American Medical Association, 300, 2867–2878. doi:10.1001/jama.2008.892 [CrossRef]
- Reeve, E., Andrews, J.M., Weise, M.D., Hendrix, I., Roberts, M.S. & Shakib, S. (2015). Feasibility of a patient-centered deprescribing process to reduce inappropriate use of proton pump inhibitors. Annals of Pharmacotherapy, 49, 29–38. doi:10.1177/1060028014558290 [CrossRef]
- Reeve, E., Wiese, M.D., Hendrix, I., Roberts, M.S. & Shakib, S. (2013). People's attitudes, beliefs, and experiences regarding polypharmacy and willingness to deprescribe. Journal of the American Geriatrics Society, 61, 1508–1514. doi:10.1111/jgs.12418 [CrossRef]
- Scott, I.A., Hilmer, S.N., Reeve, E., Potter, K., Le Couteur, D., Rigby, D. & Martin, J.H. (2015). Reducing inappropriate polypharmacy: The process of deprescribing. JAMA Internal Medicine, 175, 827–834. doi:10.1001/jamainternmed.2015.0324 [CrossRef]
- Strandberg, L.R. (1984). Drugs as a reason for nursing home admissions. Journal of the American Health Care Association, 10, 20–23.
- U.S. Department of Health and Human Services. (2015). Geriatrics workforce enhancement program. Retrieved from http://bhpr.hrsa.gov/grants/geriatricsalliedhealth/gwep.html
- Vollrath, A.M., Sinclair, C. & Hallenbeck, J. (2005). Discontinuing cardiovascular medications at the end of life: Lipid-lowering agents. Journal of Palliative Medicine, 8, 876–881. doi:10.1089/jpm.2005.8.876 [CrossRef]
Levels of Disease Prevention
|Primary prevention||Avoids the development of a disease. Most population-based health promotion activities are primary preventive measures.|
|Secondary prevention||Activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and emergence of symptoms.|
|Tertiary prevention||Reduces the negative impact of an already established disease by restoring function and reducing disease-related complications.|
Educational Resources for Deprescribing
|OPEN: Ontario Pharmacy Research Collaboration||Developed deprescribing protocols focusing on proton pump inhibitors, benzodiazepine drugs, and antipsychotic drugs||http://www.open-pharmacy-research.ca/research-projects/emerging-services/deprescribing-guidelines?|
|American Geriatrics Society (AGS)||Developed tools such as the 2015 AGS Beers Criteria and Managing Multimorbidity||http://www.americangeriatrics.org|
|Bohemian Polypharmacy||Video illustrating the importance of addressing polypharmacy||https://www.youtube.com/watch?v=Lp3pFjKoZl8?|