Tackling polypharmacy by deprescribing

Contributed by: Dr. Douglas Faulder - View bio

Active multidisciplinary collaboration

Recommending and prescribing medication is a solemn responsibility that has a profound impact on people’s lives.

Case

You are an attending physician providing medical care at a long-term care facility in Alberta. You have heard that the average number of medications per resident at your facility is well above the Alberta average. You would like to know how you should go about addressing the issue.

Issue

How should a physician caring for the frail elderly in long-term care, and in the community, best go about tackling polypharmacy by deprescribing?

Background

Effective medical treatments are allowing seniors to live longer, but the accumulation of co-morbidities results in more medications. Adverse effects of medications can be interpreted as new problems and result in prescribing cascades.²

The daily routine of taking many medications is now the norm for many seniors.

As functional and cognitive decline progresses, many of these medications may then become unnecessary, potentially harmful or at odds with goals of treatment. The solution becomes the problem. The cure becomes the disease. The harm that prescribed medications can cause seniors is iatrogenic harm. Deprescribing is an under used approach that can reduce this harm.

Nowhere in Alberta is this truer than in long-term care. These principles are also broadly applicable to any frail elderly, especially those in Supportive Living or receiving Home Care services.

In the large urban zones in Alberta the average lifespan after admission to long-term care is about one year. Despite being in the last chapter of their lives, the average long-term care resident in Alberta is on 10 medications. Professional work in long-term care has evolved to be highly focused on medication management and administration, diverting this valuable resource away from caring conversations, companionship and health assessments.³ A Canadian study found that one to two minutes of professional time is needed for each medication dose.⁴

Prescribing in long-term care is complex for many reasons. The high prevalence of dementia and the need for surrogate decision makers being foremost. Polypharmacy and multimorbidity are the norm, not the exception. Physicians may perceive many other barriers to deprescribing. Long-term care is to a large extent an evidence-free area of health care. In reaction to these challenges the process of deprescribing has developed and taken hold in long-term care medicine globally.

Evidence

Deprescribing is the stopping or reduction of a medication. Minimizing polypharmacy with deprescribing is clearly beneficial and generally safe.⁵ Still, stopping or reducing a medication may be harmful. The process requires active involvement and supervision by a health professional. Even better, a team of health professionals.

The importance of shared decision making

In reality there are many barriers to deprescribing. Many patients have inaccurately heard that a medication will be “life-long” – a term that should be eradicated from our lexicon.

Patient’s beliefs about the importance of their medications correlate poorly with physician’s beliefs, proving the need for better dialog.⁶ Physicians should be aware of resources provided to patients by Alberta Health at Medicine check-ups for older adults.

There is insufficient evidence to support a single best way to achieve deprescribing, but research supports a patient- and family-centered approach.⁷ Having the patient/family and the health care team involved in shared decision making and discussion with a physician is a key enabler of deprescribing.^{8, 9, 10, 11} A good first step may be just starting by creating awareness with patients/families (and the health care team) that discontinuing some medications is possible and allowing them to contemplate that. A recommendation by a familiar physician is a strong influence for, or against, deprescribing.^{8, 12, 13, 14, 15} Deprescribing without effective patient/family involvement can seem arbitrary and even have negative consequences on the patient-doctor relationship.

Language is always important in communication with patients, long-term care residents and families. Research shows seniors to be the most receptive to statements about the risk of adverse effects, a harmful number of medications and working together. Wide variation in the most effective statements points out the need for a close patient-doctor relationship and an ability to customize the discussion.⁷

Part of a Palliative Approach to Care

To be successful in the long-term care context deprescribing must be a part of a wider and holistic care model. This is best characterized as a palliative approach to care. A palliative approach to care in persons with a life-limiting illness is not to be confused with palliative care at the end of life. A great resource for this is the Strengthening a Palliative Approach in LTC (SPA-LTC Project) developed by the Canadian Hospice Palliative Care Association. Key elements are advance care planning, symptom management and psychosocial support for residents, family and staff. Advance care planning is best done with a standardized and validated tool like the Serious illness conversation guide developed by Ariadne Labs and Dr. Atul Gawande. More Alberta specific information and education on Advance care Planning and Goals of care designations can be found at Advance Care Planning.

Multidisciplinary Collaboration

Multidisciplinary collaboration, and especially some delegation of decision making to pharmacists and nurses, is shown to be critical in successful deprescribing in Canada¹⁶ and elsewhere.^{5, 17, 18}

Empower the bedside staff down to the health care aides to watch for any change in condition and to provide an early warning of any medication effects. Likewise, communicate to the whole team what to watch for when starting or stopping a medication.

Process of Deprescribing

Many processes have been described, and a recent Canadian article is better than most.⁵ The steps outlined are:

• Comprehensive medication history
  • Not just as a special deprescribing process or initiative, but as an ongoing everyday process integrated into every encounter or transition of care.¹
• Individualized assessment
  • Patient/family specific assessment of risks vs. benefits, values, beliefs and goals of care.
• Identify potentially inappropriate medications
  • Use the Beers List or STOPP criteria and look for prescribing cascades.
• Decide on medications to be stopped or reduced by shared decision making.
  • Prioritize if more than one.
• Make a clear plan
  • It must be documented, validated by the patient/family and widely shared with the whole care team.
• Monitor and support
  • This must be active and ongoing. Non-pharmacological supports may have a role.¹⁸
• Documentation
  • Document all aspects of the deprescribing, successes and failures, and share widely.

Further comprehensive resources can be found at two excellent Canadian-based organizations – the Canadian Deprescribing Network and Deprescribing.org.

Summary

All physicians caring for frail seniors seek to provide the best care possible. Incorporating deprescribing into clinical practice is now recognized as essential. Physicians active in long-term care look after the frailest and most dependent seniors off all. They should champion deprescribing and actively seek the engagement and collaboration of the facility nurses and pharmacists. Shared decision making with long-term care residents and their families is critical and is an important principle in all aspects of long-term care clinical practice.

References

1. Levenson S. Addressing Medications Definitively By Avoiding “Medication Management”. Caring For the Ages 2021; 22(7):4-5
2. Sternberg MD, Shiri Guy-Alfandary PharmD, Paula A. Rochon MD. Prescribing cascades in older adults. CMAJ 2021;193:E215. doi: 10.1503/cmaj.201564
3. Sloane, Philip D. et al. Medications in Post-Acute and long-term care: Challenges and Controversies. JAMDA Journal of the American Medical Directors Association. 2021; 22(1):1 – 5
4. Thomson MS, Gruneir A, et al. Nursing time devoted to medication administration in long-term care: clinical, safety, and resource implications. J Am Geriatr Soc. 2009; 57(2):266-272. doi: 10.1111/j.1532-5415.2008.02101
5. Reeve E, Thompson W, Farrell B. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. European Journal of Internal Medicine 2017. March:3-11
6. Sidorkiewicz S, Tran V-T, Cousyn C, Perrodeau E, Ravaud P. Discordance between drug adherence as reported by patients and drug importance as assessed by physicians. Ann Fam Med 2016;14:415–21. http://dx.doi.org/10.1370/afm.1965.
7. Green AR, Aschmann H, Boyd CM, Schoenborn N. Assessment of Patient-Preferred Language to Achieve Goal-Aligned Deprescribing in Older Adults. JAMA Netw Open. 2021;4(4):e212633. doi:10.1001/jamanetworkopen.2021.2633
8. Luymes CH, van der Kleij RM, Poortvliet RK, de Ruijter W, Reis R, Numans ME. Deprescribing potentially inappropriate preventive cardiovascular medication: barriers and enablers for patients and general practitioners. Ann Pharmacother 2016. http://dx.doi.org/10.1177/1060028016637181.
9. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014;174(6):890-898. doi:10.1001/jamainternmed.2014.949
10. Veroff D, Marr A, Wennberg DE. Enhanced support for shared decision making reduced costs of care for patients with preference-sensitive conditions. Health Aff (Millwood). 2013;32(2):285-293. doi:10.1377/hlthaff. 2011.0941
11. Jansen J, Naganathan V, Carter S M, McLachlan A J, Nickel B, Irwig L et al. Too much medicine in older people? Deprescribing through shared decision making BMJ 2016; 353 :i2893. doi:10.1136/bmj.i2893
12. Bokhof B, Junius-Walker U. Reducing polypharmacy from the perspectives of general practitioners and older patients: a synthesis of qualitative studies. Drugs Aging 2016;33:249–66. http://dx.doi.org/10.1007/s40266-016-0354-5
13. Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging 2013;30:793–807. http:// dx.doi.org/10.1007/s40266-013-0106-8.
14. Reeve E, Low L-F, Hilmer SN. Beliefs and attitudes of older adults and carers about deprescribing of medications. Br J Gen Pract 2016;66:e552–60. http://dx.doi.org/ 10.3399/bjgp16X685669.
15. Linsky A, Simon SR, Bokhour B. Patient perceptions of proactive medication discontinuation. Patient Educ Couns 2015;98:220–5. http://dx.doi.org/10.1016/j.pec. 2014.11.010.
16. Garland TG, Guénette L, Kröger E, Carmichael P-H, Rouleau R, Sirois C. A New Care Model Reduces Polypharmacy and Potentially Inappropriate Medications in long-term care. JAMDA 2021;22:(1)141-147
17. Auvinen KJ, Räisänen J, Voutilainen A, Jyrkkä J, Mäntyselkä P, Lönnroos E. Interprofessional Medication Assessment has Effects on the Quality of Medication Among Home Care Patients: Randomized Controlled Intervention Study. JAMDA 2021;22:(1)74-81
18. Kua, Chong-Han et al. Association of Deprescribing With Reduction in Mortality and Hospitalization: A Pragmatic Stepped-Wedge Cluster-Randomized Controlled Trial. JAMDA 2021;22:(1) 82 - 89.e3
19. https://albertadoctors.org/news/publications/ops/when-medication-is-not-the-answer