Many older adults take too many prescription drugs or take them at too-high doses. Prescriptions started long ago to treat temporary medical conditions somehow never get stopped. Other preventive drugs may offer little to no benefit after a certain age and bring unacceptable side effects for older users.
A movement is underway to eliminate excess medications that are more likely to harm than help older patients. Known as deprescribing, it comes down to thoughtfully evaluating and rightsizing individual drug regimens that build up for patients in the course of their lives.
Polypharmacy, or overmedication, is defined in a variety of ways. One commonly used threshold is a medication routine involving five or more different drugs. Patients may accumulate much higher drug totals, according to Cynthia Blevins, a certified registered nurse practitioner at Penn State Health General Internal Medicine of Lancaster. Blevins, a strong proponent of deprescribing, is also an adjunct professor with the nurse practitioner program at Millersville University in Pennsylvania.
It’s not just a matter of counting pills. The larger issue is people taking medication they don’t need.
Blevins describes a patient who came in for admission to a nursing home where she practiced. Earlier in life, he was obese and had high blood pressure. But circumstances changed and he lost a significant amount of weight – yet he still was taking four antihypertensive drugs. As a result, his blood pressure was dangerously low. “Nobody was following up on or carefully tracking him,” she says. Once these medications were cut, his blood pressure became stable.
More than one-third of U.S. adults in their early 60s and beyond take at least five prescription medications, according to a review article in the July 2017 issue of the Journal of Family Practice. The study, led by Dr. Kathryn McGrath, a geriatrician and an assistant professor affiliated with Thomas Jefferson University Hospitals in Philadelphia, gives health care providers a roadmap for deprescribing.
An unintended but vicious cycle can lead to overmedication. “Polypharmacy often occurs when an adverse drug effect is misinterpreted as a new medical problem – leading to the prescribing of more medication to treat the initial drug-induced symptom,” the authors explain.
Drug interactions can worsen fluid retention for people with heart failure, increase stroke risk in people with dementia, further damage kidney function in people with kidney disease or worsen urinary problems such as retention or incontinence.
Research on the health benefits of deprescribing is ongoing, but findings so far are promising. After deprescribing, patients have been shown to have fewer falls, improved cognition and greater satisfaction.
Talk to your health care providers and pharmacist about trimming your medication list down to size. Here’s how deprescribing works.
Identify your medication “quarterback.” Your primary care physician or nurse practitioner – your regular health care provider – is likely the best choice for re-evaluating your medication collection. After you’ve been discharged from the hospital or have seen a specialist, your regular provider can sort out new drug orders.
“Often, the cardiologist has not paid attention to what the rheumatologist has prescribed,” says James McCormack, a professor in the faculty of pharmaceutical sciences with the University of British Columbia in Vancouver, Canada. “The rheumatologist has not paid attention to what the psychiatrist has prescribed. That’s where everything goes to hell in a handbasket.”
Talk to your pharmacist. Your community pharmacist can alert you to medication hazards and identify drugs that could be safely tapered and eliminated. Maximizing quality of life for older adults is a primary goal of deprescribing, says Tasha Woodall, the associate director of pharmacotherapy in geriatrics with the Mountain Area Health Education Center in Asheville, North Carolina.
Bring in all your medications for review. A massive collection of medications in their respective containers makes a powerful case for deprescribing. To do so, clinicians use specific deprescribing guidelines and algorithms to evaluate and prioritize your medications.
Re-evaluate dosages. Your body’s ability to break down and eliminate drugs decreases by about half from age 30 to 70, McCormack says. “Probably three-quarters to 80 percent of all side effects are due to doses: giving too much,” he says. Reducing doses as people get older is a major component of proper prescribing and deprescribing.
Consider lifestyle alternatives. Instead of taking a statin, you could realize as much or more benefit by exercising and eating in a healthier way to lower your risk of a heart attack or stroke. Similarly, doing these lifestyle changes will likely reduce borderline high blood pressure without the side effects of antihypertensive drugs.
Ask whether benefits are meaningful. Among people who’ve never had a heart attack or stroke, only about one to three of 100 will benefit over five to 10 years from taking a statin or blood-pressure drug, McCormack says. Whether that preventive boost is worth it depends on the individual, he says: “There’s only one person who can decide that – and that’s you.”
Take a hard look at risks. Older adults with an irregular heartbeat called atrial fibrillation are often prescribed blood-thinning, or anticoagulant, drugs to reduce their risk for stroke. However, warfarin and other anti-clotting pills carry bleeding risks. Doctors and patients should weigh these risks together.
Be cautious with sedatives. Cutting back on insomnia or anxiety drugs like Xanax and Ativan is a good starting point for deprescribing, Woodall says. Any medication that affects the central nervous system – including sedatives, antipsychotics and antidepressants – should be carefully reconsidered.
“A lot of those medications continue to be appropriate for somebody’s entire life,” Woodall says. “But the cumulative effect of having someone on three, four or five of these psychotropic medications that impact their brain can spell out a recipe for disaster in terms of falling and cognitive decline.”
Pay attention to antacids. Antacid drugs known as “proton pump inhibitors,” such as Nexium, Prilosec or generic omeprazole provide short-term relief for gastrointestinal issues like acid reflux or heartburn. However, long-term use tends to accelerate bone loss, Woodall says.
Long-term use of PPI drugs also puts older adults at risk for infection with Clostridium difficile bacteria, Blevins notes, which can cause severe gastric problems. Pneumonia is another potential C. difficile side effect.
Don’t overlook OTC drugs. It’s also important to sift through any over-the-counter drugs and products. For instance, using Benadryl as a sleep aid, which many seniors do, is discouraged. Vitamins, dietary supplements, herbal remedies and even topical creams and gels should be scrutinized, too.
Think about cost. Reducing costs is another benefit of eliminating unneeded medication. For drugs that do help, switching to generic versions is another way to cut costs.
Eliminate medications with care. By discontinuing only one medication at a time, you and your health care team can keep a close eye on how that affects you. In many cases, gradually reducing the dose on a tapering schedule is safer than abruptly discontinuing the medication.
Deprescribing isn’t a one-time measure, but a process, Woodall says: “We continue circling back with the patient. Sometimes we have to add things back that we tried to get rid of. Other times it’s very successful and we keep going and peeling things away the best that we can.”
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