The Problem of Polypharmacy
Polypharmacy, commonly defined as the use of five or more medications, is a widespread issue among older adults due to the accumulation of chronic diseases over time. While some polypharmacy can be appropriate, a significant portion is not, leading to a cascade of potential health problems. Factors contributing to inappropriate polypharmacy include fragmented care from multiple providers, automatic prescription renewals, and the treatment of medication side effects with additional drugs.
For older individuals, the consequences of inappropriate polypharmacy can be severe. Adverse drug events (ADEs) are more likely to occur, and they are at an increased risk of falls, cognitive impairment, and hospitalizations. These negative outcomes not only diminish a person's quality of life but also place a significant burden on the healthcare system.
The Deprescribing Framework
Deprescribing offers a proactive and systematic solution to combat inappropriate polypharmacy. It is a multi-step process that ensures medication adjustments are made safely and with a patient-centered focus. This process is generally performed by a multidisciplinary healthcare team, including physicians, pharmacists, and nurses.
The Five-Step Deprescribing Process
- Gather a complete medication history: This includes all prescription drugs, over-the-counter medications, and supplements to get a full picture of the patient's regimen.
- Identify potentially inappropriate medications: Using evidence-based criteria, the healthcare team assesses which medications have a questionable risk-benefit profile given the patient's current health status and goals.
- Prioritize medications for reduction or discontinuation: The team, in consultation with the patient and family, decides which medications to target first based on the potential for harm, ease of withdrawal, and patient preferences.
- Implement a discontinuation plan: A strategy for tapering the medication is created. This may involve a gradual dosage reduction to minimize withdrawal effects.
- Monitor and support the patient: The patient is closely monitored for any adverse drug withdrawal events or the return of the condition, and adjustments are made as needed.
Potential Benefits and Risks of Deprescribing
Deprescribing is not without its considerations, and a careful balance of potential benefits and harms must be weighed in a shared decision-making process with the patient.
Benefits of Deprescribing
- Reduced adverse drug events: Fewer medications mean a lower risk of harmful side effects and drug interactions.
- Improved quality of life: Many older adults feel better, more alert, and more functional with a simpler medication regimen.
- Decreased fall risk: Deprescribing medications known to increase fall risk, like certain psychotropics, can lead to a significant reduction in falls.
- Lower healthcare costs: Reducing unnecessary medications saves patients and the healthcare system money.
- Enhanced medication adherence: Managing fewer pills simplifies the daily routine, making it easier for patients to stick to their regimen.
Risks and Considerations
- Adverse drug withdrawal events: Some medications require a slow taper to avoid side effects from stopping them abruptly.
- Symptom recurrence: The condition that the medication was treating could return, though careful monitoring can address this.
- Patient resistance: Patients may be reluctant to stop familiar medications, fearing a decline in their health.
Reactive vs. Proactive Deprescribing
Deprescribing can happen in different contexts, with a proactive approach being the most beneficial for long-term health.
| Aspect | Reactive Deprescribing | Proactive Deprescribing |
|---|---|---|
| Trigger | Triggered by an acute event like a fall, adverse drug reaction, or hospitalization. | Part of a routine, planned medication review in primary care or specialty clinics. |
| Initiator | Often initiated by a hospitalist, pharmacist, or specialist reacting to a specific event. | Initiated by the primary care physician or geriatric specialist in consultation with the patient and pharmacist. |
| Timing | Often occurs rapidly during or immediately after a crisis. | Occurs gradually over time, allowing for careful monitoring and tapering. |
| Focus | Addressing the immediate problem caused by a medication. | Optimizing the overall medication regimen to align with long-term health goals and patient preferences. |
| Outcome | Can solve the immediate issue but may not address broader polypharmacy problems. | Aims for sustained improvement in quality of life, reduced pill burden, and prevention of future harm. |
How Patients and Caregivers Can Start the Conversation
Initiating a discussion about deprescribing is a key step toward improving medication safety. The Canadian Deprescribing Network offers resources and questions to guide this conversation effectively. When speaking with a doctor or pharmacist, consider the following:
- Prepare in advance: Schedule a specific appointment to discuss medications, not as an afterthought during a routine visit.
- Bring a full list: Ensure your healthcare provider has a complete, up-to-date list of all prescriptions, supplements, and over-the-counter drugs.
- Ask questions: Inquire about the necessity and purpose of each medication, and whether there are safer alternatives.
- Discuss goals: Share your health priorities and goals to help frame the discussion around what is most important for your well-being.
Conclusion
For older adults with polypharmacy, deprescribing is a crucial, patient-centered strategy for optimizing medication use and reducing harm. By systematically evaluating the risk-benefit ratio of each medication, healthcare professionals can help patients reduce pill burden, minimize adverse effects, and ultimately improve their quality of life. This process requires collaboration between the patient and their healthcare team, moving away from reactive management to a proactive approach focused on achieving the best possible health outcomes as they age.
