Journal of Gerontological Nursing

Geropharmacology 

Combating Polypharmacy Through Deprescribing Potentially Inappropriate Medications

Joshua Chou, PharmD; Monica Tong, PharmD; Nicole J. Brandt, PharmD, MBA, BCGP, BCPP, FASCP

Abstract

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.]

Abstract

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.]

Click here to read a Letter to the Editor about this article.

In the United States, two thirds of adults ages 65 and older take at least five medications daily (Kim & Parish, 2017), and one quarter consume 10 or more medications (Muscedere et al., 2017). In recent years, the incidence of polypharmacy has almost doubled, increasing from 8.2% in 1999–2000 to 15% in 2011–2012 (Kantor, Rehm, Haas, Chan, & Giovannucci, 2015). In turn, polypharmacy increases the probability of side effects and drug–drug and drug–disease interactions. The occurrence of adverse drug events is common among older adults, with a rate of 50 per 1,000 person-years (Sato & Akazawa, 2013). The intent of the current article is to provide a framework of deprescribing with a discussion of tools aimed at reducing polypharmacy.

Defining Deprescribing, Potential Barriers, and its Impact

Deprescribing has been defined as a systematic process of identifying and discontinuing medications in instances in which existing or potential harms outweigh existing or potential benefits within the context of a patient's care goals, current level of functioning, life expectancy, values, and preferences (Scott et al., 2015). Deprescribing is a patient-centered and shared decision-making process among the patient, caregiver, and health care providers. Before beginning the deprescribing process, it is important to determine patient goals, assess the patient's willingness to deprescribe, provide education about the benefits and risks of deprescribing, and obtain the patient's consent.

A recent survey of Medicare beneficiaries in the United States showed that 92% of older adults were willing to stop one or more of their medications if their physicians told them it was possible (Reeve et al., 2018). Furthermore, 66% of older adults wanted to reduce the number of medications they were taking (Reeve et al., 2018). Although the survey shows that older adults are willing to discontinue medications, many barriers from patients, caregivers, and providers may arise in conversations about deprescribing. Patient and caregiver barriers include fears of withdrawal, return of symptoms, and current lack of adverse effects (Reeve et al., 2013). For providers, common barriers may include the need for a system to deprescribe or information supporting deprescribing and the process, fear of adverse withdrawal events, unwillingness to stop a medication started by another physician or specialist, cost- and time-effectiveness, and patient resistance (AlRasheed et al., 2018). Therefore, it is important to discuss and address these barriers before and during the deprescribing process.

To help address barriers, it is also important to educate patients, care-givers, and the health care team on the potential benefits of deprescribing medications. As deprescribing can be used to combat polypharmacy, potential benefits include reduction in harms associated with polypharmacy, reduction in potentially inappropriate medications (PIMs), decreased pill burden, increased adherence, and decreased cost to the patient and health care system. However, there is limited evidence of the clinical implications of deprescribing and large randomized trials are needed to evaluate the potential benefits or harms of deprescribing (Tjia, Velten, Parsons, Valluri, & Briesacher, 2013). The current evidence has focused on outcomes such as a reduction in PIMs, safety in terms of withdrawal side effects, and feasibility of deprescribing (Reeve, Thompson, & Farrell, 2017).

Deprescribing Framework

There are multiple suggested depre-scribing processes, which contain similarities in principles and steps. In a review of those different processes, a consolidated process with five steps—(a) conduct a comprehensive medication history and review, (b) identify PIMs, (c) determine if medication can be ceased and prioritize order of discontinuation, (d) plan and initiate withdrawal, and (e) provide monitoring support and documentation (Reeve, Shakib, Hendrix, Roberts, & Wiese, 2014)—is presented.

Step 1: Comprehensive Medication History and Review

To begin the deprescribing process, compilation of a comprehensive medication history from multiple sources is crucial and serves as the basis for the review. Patients, care-givers, pharmacy records, and medical records should be used as sources to gather all relevant information. A complete list of medications must be obtained, including prescription and over-the-counter (OTC) medications, supplements, and herbals, including the dose, frequency, formulation, route of administration, duration of use, and patient-reported indication (McGrath, Hajjar, Kumar, Hwang, & Salzman, 2017; Reeve et al., 2014; Scott et al., 2015).

When recording the patient-reported indication, it is helpful to categorize the medications as either disease/symptom control medications or preventive medications to aid in the deprescribing decision-making process (Scott et al., 2015). During interviews with patients and/or care-givers, it is also important to ask if patients are taking the medication or why they are not taking it (in a nonjudgmental fashion), how they are taking the medication, and if they are noticing any benefits or harms from the medication to help assess patient values and thoughts about the medication (Reeve et al., 2014). Furthermore, any previous medication allergies, intolerances, and adverse drug reactions should be documented to collect information that may be relevant when providing education or addressing barriers. Step 1 goes beyond creating a simple list of medications by composing a comprehensive medication list and history.

Within Step 1, health care providers can also consider the second step of Scott et al.'s (2015) deprescribing process, which is to determine the overall risk of drug-induced harm to help determine the intensity of deprescribing. An increasing number of medication or patient risk factors indicate that a more aggressive depre-scribing approach should be used to prevent drug-induced harm in the patient. Medication risk factors include number of medications and use of high-risk medications, such as benzodiazepine drugs, psychotropic agents, nonsteroidal anti-inflammatory drugs, and anticholinergic agents (Scott et al., 2015). Patient risk factors include age >80 years, cognitive impairment, multiple comorbidities, substance use, multiple prescribers, and past or current nonadherence (Scott et al., 2015).

Step 2: Identify Potentially Inappropriate Medications

There are multiple reasons that a medication is potentially inappropriate and a candidate for discontinuation. Possible reasons to deprescribe a medication include adverse effects, potential harms that outweigh potential benefits, lack of therapeutic efficacy, lack of indication, medications that are unlikely to provide any additional benefit during a patient's lifespan, medications that may take a long time to benefit patients, and patient preference (McGrath et al., 2017; Reeve et al., 2014; Scott et al., 2015). Table 1 contains examples of common medications and reasons for deprescribing.

Reasons to Consider Deprescribing and Common Medication Examplesa

Table 1:

Reasons to Consider Deprescribing and Common Medication Examples

Within Step 2, health care providers need to identify PIMs or medications that can be potentially deprescribed. Multiple implicit and explicit tools and resources can be used to identify these medications. Implicit resources require providers to use their clinical judgment, whereas explicit resources list medications for providers to avoid.

Step 3: Determine if Medication can be Ceased and Prioritize Order of Discontinuation

When determining if a medication can be ceased and prioritizing the order of discontinuation, it is important to consider patient preferences, medications with the greatest harm and least benefit, and the easiest medication(s) to discontinue in terms of low likelihood for withdrawal or disease rebound (Scott et al., 2015). Within this process, the patient's choice needs to be respected within the discussion of discontinuing the medication and the order of discontinuation. A discussion with the physician and the team should also occur if applicable as it is a shared decision-making process.

Step 4: Plan and Initiate Withdrawal

To develop the deprescribing plan, general tapering strategies include halving the dose or reducing to the next available dosage form, then at the next appointment reviewing for withdrawal and benefits (Best Practice Advocacy Centre New Zealand, 2010). If it is safe to continue the taper, taper to quarter dose or next available dosage form and review at the next visit or stop the medication (Best Practice Advocacy Centre New Zealand, 2010). Titrating down a medication can also mirror the normal titration up on a medication; however, longer periods of time should occur to monitor for adverse withdrawal events or return of disease states. In older adults, it is important to decrease medications in small increments over longer periods of time due to the multiple pharmacodynamic and pharmacokinetic changes that occur with aging. Pharmacokinetic considerations within the deprescribing plan are medication half-life; mode of elimination of the medication (i.e., renal or hepatic), and if the patient is impaired in that system; and possible drug–drug interactions. There are also multiple evidence-based and medication-specific resources that may be used to aid in the creation of a deprescribing plan (Table 2).

Tools and Deprescribing Resourcesa

Table 2:

Tools and Deprescribing Resources

Once a consensus is reached, one medication should be stopped at a time to assess for potential benefits and harms. If multiple medications are stopped or decreased at the same time, it may be difficult to determine which potential benefits or harms are linked to stopping which medication. Potential harms of stopping medications include possible adverse withdrawal reactions or disease rebound symptoms. Multiple medications have adverse withdrawal events (e.g., opioids, benzodiazepine agents, diuretic agents, beta-blockers, proton pump inhibitors) (Liu & Campbell, 2016).

When initiating the deprescribing plan, patient and caregiver education should include the detailed deprescribing plan on how to taper the medication; the possible harms and timing of when those harms may appear; and plans to manage those harms, such as by contacting the provider, OTC or nonpharmaco-logical management, or going to the hospital.

Step 5: Monitoring Support and Documentation

Documentation of agreement on deprescribing, reasons for deprescribing, and education and plan provided are important for initial discussion. As the deprescribing plan is initiated, monitoring support and documentation should then be continued to assess for potential benefits and harms. Documentation can also be used to support the sustainability of depre-scribing and should be shared with all relevant parties.

Applications of Tools and Impact

The American Geriatrics Society (AGS) Beers Criteria, as well as other explicit tools, have been created to provide information and guidance on PIMs in older adults that can be deprescribed (AGS 2015 Beers Criteria Update Expert Panel, 2015). In addition, some of the explicit tools can be further used in Step 3 (prioritization), Step 4 (plan and initiate withdrawal), and Step 5 (monitoring). The following is a discussion of three different tools that have incorporated the Beers Criteria in identifying PIMs.

Ghent Older People's Prescriptions Community Pharmacy Screening Tool (GheOP3S)

The GheOP3S was developed in 2013 by a group of health care professionals based in Belgium. They sought to develop an explicit screening tool that identifies potentially inappropriate prescribing (PIP) in older adults, specifically in the community pharmacy setting (Tommelein et al., 2016). Using the Beers Criteria, along with other published lists of PIMs, such as the START/STOPP criteria, they built an 83-item screening tool.

From December 2013 to July 2014, a prospective cohort study was conducted in 204 community pharmacies in Belgium to validate the GheOP3S tool (Tommelein et al., 2017). In addition to validating the tool, the authors wanted to identify items or patient variables that may influence the occurrence of PIPs (Tommelein et al., 2017). The study found that 3,721 PIP items were detected in 987 patients (97%), which translates to a median of three PIPs per patient. In addition, it found that risk factors associated with higher number of PIPs include higher number of medications, female gender, worse functional status, and higher body mass index. The study also found that medications that were frequently associated with PIPs include central nervous system medications, such as antipsychotic and antidepressant agents. It should be noted that the investigators reported that one of the main concerns of this tool was the lack of incorporation into software, as well as its time-consuming nature. The mean duration of administering this tool, which also included estimating the clinical relevance of the detected items, was 38 minutes.

Seniors Medication Alert and Review Technology Intervention (SMART)

The SMART tool was designed by health care professionals based in Canada. These individuals sought to build clinician-acceptable medication management alerts that would be incorporated into an ambulatory care electronic medical record (EMR). This tool was designed to apply the 2012 Beers Criteria and implement the Cockcroft-Gault equation for estimates of glomerular filtration rates (Alagiakrishnan et al., 2016). Unlike the study that validated the GheOP3S tool, this study focused more on the qualitative impact of incorporating the SMART tool into the clinic's workflow. The investigators were largely successful in incorporating the SMART tool into an ambulatory care EMR. The tool was well-received by clinicians and did not significantly impact workflow.

Alagiakrishnan et al. (2016) found that the SMART clinical depression support generally confirmed physicians' clinical judgments. In other words, the tool exposed medication safety issues that physicians confirmed. Finally, they found that the SMART tool provided teaching opportunities for patients, residents, and other clinicians. Participants reported that they used prompts from the SMART tool for discussing patient safety when interacting with trainees or other colleagues. Similarly, participants referenced the alerts produced by the tool during patient education or to help discourage use of PIMs, such as benzodiazepine agents.

Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED)

EQUiPPED is a tool developed by investigators at the U.S. Department of Veterans Affairs (VA). Using the 2012 Beers Criteria as a basis for defining PIMs, EQUiPPED aims to improve medication safety by reducing PIMs prescribed to older adults seen in the emergency department (ED). It has been implemented in multiple VA medical center EDs throughout the United States. EQUiPPED is a multifaceted quality improvement initiative that combines education, EMR–based clinical decision support tools, and individual provider feedback. Provider education was delivered in the form of didactic lectures given to ED clinicians and residents by geriatricians and pharmacists. The lectures were accompanied by individual face-to-face feedback sessions and clinical decision support tools to help change prescribing practices (Stevens et al., 2017).

The validating study used this tool in four large, urban, academically affiliated VA medical centers with 24-hour ED coverage. The study was designed as a pre/post quality improvement study. The use of PIMs was tracked 6 months before EQUiPPED interventions were started, throughout the implementation phase, and for at least 12 months after all EQUiPPED components were completed. The primary outcome reported was the monthly proportion of PIMs prescribed to patients age 65 or older who were discharged from the ED. As seen from the results, all four sites demonstrated a significantly decreased number of PIMs after the tool was implemented. At baseline, the monthly PIMs prescribing rate ranged from 7.4% to 11.9%. However, once the tool was implemented, the rate decreased to 4.5% to 6.1%.

Conclusion

Medication use and safety in older adults continue to be paramount concerns. The entire health care team plays an important role in promoting deprescribing and engaging patients and their families in the process. In particular, RNs and nurse practitioners (NPs) are often front-line staff who play an integral role throughout the deprescribing process. For instance, they can start the conversation of deprescribing by providing patient-friendly educational materials and decisions aids created by Deprescribing.org and Choosing Wisely®. Furthermore, they are often involved in administering or prescribing medications; therefore, tools such as the AGS Beers or STOPP criteria assist with identifying PIMS for older adults. In turn, in identifying PIMS, RNs and NPs play a critical role in monitoring for any potential adverse effects from these medications and constructing a safe and effective medication regimen for older adults. Finally, they play a valuable role in providing support throughout the deprescribing process and can use resources within Deprescribing.org and Medstopper.com for monitoring considerations and strategies to address any adverse drug withdrawal events. Systematic and scalable tactics are needed to sustain change and improve health care delivery.

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Reasons to Consider Deprescribing and Common Medication Examplesa

Reasons to Consider Deprescribing Common Examples
Causing an adverse effect <list-item>

Any medication

</list-item>
Potential harms outweigh potential benefits <list-item>

Medications that meet criteria for potentially inappropriate medications for older adults (e.g., American Geriatrics Society Beer's Criteria, Choosing Wisely, Screening Tool for Older People's Prescriptions)

</list-item><list-item>

Antipsychotic, anticholinergic, benzodiazepine, and nonsteroidal anti-inflammatory drugs

</list-item>
Lack of therapeutic efficacy (i.e., no longer treating the condition for which it was originally prescribed or no improvement in symptoms) <list-item>

Cholinesterase inhibitors and memantine in patients with severe Alzheimer's disease

</list-item><list-item>

Docusate for treatment of constipation

</list-item>
Lack of indication (i.e., no indication present for any medication or medication is part of a prescribing cascade) <list-item>

Proton pump inhibitor initiated for stress ulcer prophylaxis continued after intensive care unit stay

</list-item><list-item>

Inhalers started for shortness of breath for an emergency department visit for chronic heart failure and continued on

</list-item>
Used beyond recommended duration of use <list-item>

Proton pump inhibitors and gastroesophageal disease

</list-item>
Unlikely to provide additional benefit during a patient's life span (estimated life expectancy <5 years) <list-item>

Statin started for primary prevention

</list-item><list-item>

Bisphosphonates in a low-risk patient

</list-item>
Patient preference <list-item>

Medications with adverse effects

</list-item><list-item>

Medications with a complex dosing regimen

</list-item><list-item>

High-cost medications

</list-item>

Tools and Deprescribing Resourcesa

Tool Description
Medication Appropriateness Index (Hanlon & Schmader, 2013) <list-item>

Measures elements of appropriate prescribing through 10 questions

</list-item><list-item>

Can be used in inpatient and outpatient settings

</list-item>
Fit for the Aged Criteria (Wehling, 2016) <list-item>

Grades medications based on criteria to assess for appropriateness

</list-item><list-item>

Validated in hospitalized patients

</list-item>
Prescribing Optimization Method (Drenth-van Maanen, van Marum, Knol, van der Linden, & Jansen, 2009) <list-item>

Six questions focused on undertreatment, adherence, drugs that can be discontinued or are inappropriate, adverse drug events, interactions, and dosing

</list-item><list-item>

Validated in the outpatient setting

</list-item>
Good Palliative-Geriatric Practice Algorithm (Garfinkel, Zur-Gil, & Ben-Israel, 2007) <list-item>

Flowchart designed to reduce polypharmacy by considering drug indication, dose, benefits, and potential adverse effects

</list-item><list-item>

Validated in nursing homes

</list-item>
American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults (AGS 2015 Beers Criteria Update Expert Panel, 2015) <list-item>

Tables of potentially PIMs, selected drug interactions (disease and drugs), and selected renal dosing

</list-item><list-item>

Validated by a systematic literature review, expert panel, and GRADE rating process

</list-item>
Screening Tool for Older People's Prescriptions (Europe) (O'Mahony et al., 2015) <list-item>

Concise list of PIMs identified by organ systems

</list-item><list-item>

Validated by a systematic literature review and approved by a Delphi panel

</list-item>
Choosing Wisely®<ext-link ext-link-type="uri" xlink:href="http://www.choosingwisely.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">http://www.choosingwisely.org</ext-link> <list-item>

Recommendations to identify unnecessary medical tests, treatments, and procedures for all settings, diseases, and ages

</list-item><list-item>

Patient materials

</list-item><list-item>

Based on evidence-based recommendations from national organizations

</list-item>
Deprescribing.org (Canada) <ext-link ext-link-type="uri" xlink:href="https://deprescribing.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://deprescribing.org</ext-link> <list-item>

Guidelines and algorithms on certain medication classes to consider deprescribing

</list-item><list-item>

Patient decision aids

</list-item><list-item>

Validated by systematic literature review and GRADE rating process

</list-item>
Medstopper.com (Canada) <ext-link ext-link-type="uri" xlink:href="http://medstopper.com" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">http://medstopper.com</ext-link> <list-item>

Stopping priority for each medication based on color

</list-item><list-item>

Tapering strategy included

</list-item><list-item>

Developed based on evidence and expert panel ranking

</list-item>
PrescQIPP (England) <ext-link ext-link-type="uri" xlink:href="https://www.prescqipp.info/our-resources/webkits/polypharmacy-and-deprescribing" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.prescqipp.info/our-resources/webkits/polypharmacy-and-deprescribing</ext-link> <list-item>

Web kit on deprescribing (educational tools, screening tools, and algorithms)

</list-item><list-item>

Provider training on deprescribing

</list-item><list-item>

Evidence-based and quality assurance process in place

</list-item>
Primary Health Tasmania (Australia) <ext-link ext-link-type="uri" xlink:href="https://www.primaryhealthtas.com.au/resources/deprescribing-guides" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.primaryhealthtas.com.au/resources/deprescribing-guides</ext-link> <list-item>

Concise handouts on evidence and algorithms for deprescribing multiple medications

</list-item><list-item>

Reviews the potential benefits and harms

</list-item><list-item>

Evidence-based

</list-item>
A Practical Guide to Stopping Medication in the Elderly (New Zealand) <ext-link ext-link-type="uri" xlink:href="https://bpac.org.nz/BPJ/2010/April/stopguide.aspx" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://bpac.org.nz/BPJ/2010/April/stopguide.aspx</ext-link> <list-item>

Reasoning behind deprescribing and algorithms for multiple medications

</list-item><list-item>

Evidence-based

</list-item>
Authors

Dr. Chou is Geriatric Pharmacotherapy Fellow, Dr. Tong is PGY2 Geriatric Pharmacy Resident, and Dr. Brandt is Professor, Geriatric Pharmacotherapy, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy; Dr. Brandt is also Executive Director, Peter Lamy Center on Drug Therapy and Aging, Baltimore, Maryland.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Nicole J. Brandt, PharmD, MBA, BCGP, BCPP, FASCP, Professor, Geriatric Pharmacotherapy, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, and Executive Director, Peter Lamy Center on Drug Therapy and Aging, 20 North Pine Street, Baltimore, MD 21201; e-mail: nbrandt@rx.umaryland.edu.

10.3928/00989134-20190102-01

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