First do no harm: a real need to deprescribe in older patients | MJA Online Sept 22nd (1)
The benefits and harms of deprescribing | MJA Online Sept 22nd (2)
Emperor Joseph II: My dear young man, don’t take it too hard. Your work is ingenious. It’s quality work. And there are simply too many notes, that’s all. Just cut a few and it will be perfect.
Mozart: Which few did you have in mind, Majesty?
Amadeus, 1984
(Image © Depositphotos.com/phpdopus)
Is your patient receiving a medication inappropriately? Almost certainly, if they are on 7 or more different pills.(1)
Adverse events from medications are a very significant cause of morbidity and cost, especially in older people.
Up to 30% of hospital admissions for patients over 75 years of age are medication related, and up to three-quarters are potentially preventable. Up to 40% of people living in either residential care or the community are prescribed potentially inappropriate medications. In both hospital and primary care settings, about one in five prescriptions issued for older adults are deemed inappropriate.
Polypharmacy in older people is associated with decreased physical and social functioning; increased risk of falls, delirium and other geriatric syndromes, hospital admissions, and death; and reduced adherence by patients to essential medicines. (1)
The solution to polypharmacy is to develop a culture of deprescibing, according to this article in the Medical Journal of Australia by Ian A Scott, Director of Internal Medicine and Clinical Epidemiology at Princess Alexandra Hospital, Brisbane et al.
The evidence suggests deprescribing will produce more benefits than harms, and can be done safely, according to another article in the MJA by Emily Reeve, Division of Health Sciences, University of South Australia.
The art of deprescribing is knowing which medications to stop, and when. As Mozart suggested to the Emperor, it’s tricky.
This is the ‘Practice improvement’ approach to deprescribing
De-prescribing is as important as Prescribing
1. Maintain accurate medication lists for each of your patients
Every time you prescribe, make sure you know which medications this patient is actually taking.
Medication lists are so frequently inaccurate that it often feels like any similarity between our medication list and what the patient is actually swallowing is just a co-incidence!
Even in the high-performing practices that participated in the eCollaboratives program, about 50% of the medications in each patient’s health summary were ‘out of date’.
Each time that we prescribe a new medication (or repeat a previously prescribed medication) is an appropriate time to check the accuracy of our medication lists.
2. Plan for de-prescribing at the time of prescribing.
A medication once prescribed gains an inertia that requires energy to stop, particularly in nursing home patients. It is often easier to just keep on rolling along.
When you do prescribe a new medication, also prescribe a review date to check that is doing its job.
How will we know that it is making a difference? How will we identify that it is causing problems?
Is the new medication replacing an old medication that should be de-prescribed?
3. Be systematic in reviewing your patients medications
Annual checks, care planning consultations and nursing home review visits are appropriate times to undertake a review of medications.
Which of the medications that are being taken by the patient are not doing anything useful?
Is the medication doing more harm than good?
Is the indication for which they were started now no longer relevant?
Have the symptoms for which they were started resolved? (has their dizziness resolved? do they still have reflux? did they ever really have angina? osteoporosis? significant hyperlipdaemia?)
Will the drug only be of benefit if they live to age 120?
Is it one of the ‘usual suspects‘?
Drugs that are high risk for adverse reactions in the elderly are in the Beers and STOPP lists?
A printable card version of the Beer criteria is here.
4. Which medications would the patient like to stop, and what is their priority?
Prescribing and de-prescribing should both be shared decisions.
5. Taper one medication at a time.
Start with one medication, and then gradually reduce it till ‘de-prescribed’.
Then repeat.
Adopting a proactive and systematic approach to deprescribing improves the quality and safety of our patient care.
Usual Suspects
These are the ‘usual suspects’ in my patients – drugs that often continue to be prescribed beyond their usefulness or without an ongoing indication, or drugs that may be doing more harm than good.
- Aspirin without indication
- Benzodiazepines
- Statins for primary prevention
- Any other cholesterol-lowering drug
- Nitrates where there is no angina
- Digoxin without AF
- Sulphonylureas or other glucose lowering agents where HbA1C is below the appropriate target for their age and co-morbidity
- Biphosphantes without fractures
- Anti-depressants where depression is long gone, or in the presence of dementia
- Long term Neuroleptics for behaviour in nursing homes
- Stemetil and Maxalon
- PPIs, especially at high dose
- Prednisone when noone can remember why it was started
- Muscle relaxants and antispasmodics for gut or urine when symptoms are no longer present
- Analgesics when pain has gone
- NSAIDS when pain has gone
- Lyrica when neuralgia has gone
- Frusemide
- ACE Inhibitor plus ARB
- Laxatives
- Vitamins, Glucosamine, Fish Oil
- Ventolin and other puffers without ongoing asthma
In your experience, what should be added to this list? Let us know in the comments.
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