Polypharmacy and Deprescribing

from: https://www1.racgp.org.au/ajgp/2023/april/deprescribing-considerations-for-older-people-in-g

• Polypharmacy Definition:
  • Quality Indicator Program definition: Prescription of nine or more medicines.
  • Broader definition (Australian Commission on Safety and Quality in Health Care): Five or more medicines, consistent with international standards.
• Polypharmacy Prevalence:
  • Approximately 36% of older Australians are affected, with potentially higher rates in aged care settings
• Deprescribing Definition:
  • Deprescribing is a planned withdrawal of medications that are either causing harm or not providing benefit to the patient.
• Goal:
  • The aim is to provide evidence-based guidance to general practitioners (GPs) and nurse practitioners to deprescribe medications for older patients safely.

Importance of Deprescribing

• Dynamic Process of Prescribing: Medicine use and dosages require continuous reassessment to ensure they meet the therapeutic needs of the patient.
• Older Adults and Multimorbidity: The risk-benefit profile of medications changes frequently due to aging and the presence of multiple health conditions.

Inappropriate Polypharmacy

• Prevalence: In 2020–21, over 54% of medicines dispensed under the Pharmaceutical Benefits Scheme in Australia were for individuals aged 65 years and older.
• Definition: Polypharmacy typically refers to the concurrent use of five or more medications.
• Risks: Inappropriate polypharmacy can negatively impact cognition, health-related quality of life, and mortality. It also increases the risk of drug-drug interactions, medication errors, and healthcare costs.
• Patient Impact: Frail older adults are particularly vulnerable to polypharmacy’s negative consequences, leading to complex medication regimens, non-adherence, poor outcomes, and medicine wastage.

High-Risk Prescribing in Older Patients

• Potentially Inappropriate Medicines (PIMs): These are medications that may have an unfavorable benefit-harm ratio or lack a clear evidence-based indication for use in older patients. Anticholinergics and sedatives are common PIMs due to their association with serious adverse outcomes like increased frailty and impaired cognitive function.
• Prescribing Cascades: Occur when an adverse reaction to one medicine is misinterpreted as a new medical condition, leading to additional prescriptions. Example: Loop diuretics used for ankle edema caused by calcium channel blockers.

Deprescribing Strategy

• ‘Stop Slow, Go Low’ Approach: This method emphasizes gradual and careful medication withdrawal, ensuring minimal adverse drug withdrawal events.
• Partnership with Patients: Engaging patients in their deprescribing process enhances safety and acceptance.

Benefits of Deprescribing for Older People

• Reduced Pill Burden: Fewer medications lead to simpler regimens and improved adherence.
• Health Outcomes: Potentially reduces the risk of geriatric syndromes such as falls and cognitive impairment.
• Quality of Life: The overall goal of deprescribing is to improve patient well-being and minimize treatment burdens.

Patient Attitudes Toward Deprescribing

• Studies show 84-90% of patients are open to reducing or stopping medications when recommended by their GP.
• Patient engagement and a partnership approach are crucial to successful deprescribing, ensuring individual needs are met and care goals are tailored.

Barriers and Enablers to Deprescribing

• Clinician Barriers: Limited time/resources, competing priorities, communication issues between healthcare providers, potential lack of expertise.
• Patient Barriers: Limited knowledge about medication reviews, potential dependence on certain drugs, and personal beliefs.
• System Barriers: Issues with care transitions, insufficient health campaigns, suboptimal GP software, and limited non-pharmacological options.
• Collaboration: GPs, pharmacists, and nurses working together can address these barriers, with pharmacists aiding medication reviews and nurses supporting monitoring.

---

Available Tools for Deprescribing

• CEASE Algorithm: Current medicines, Elevated risk, Assess, Sort, Eliminate – helps identify and manage medications suitable for deprescribing.
• ERASE Approach: Evaluate, Resolved conditions, Ageing normally, Select targets, Eliminate – another systematic framework for deprescribing decisions.
• Beers and STOPP Criteria: Useful for identifying potentially inappropriate medicines (PIMs) that may pose risks in older patients.

Tools to aid deprescribing
Tool	Purpose	Example of applicability	Reference	Open access?
MATCH-D criteria (Medication Appropriateness Tool for Comorbid Health conditions during Dementia)	To optimise medicine use in people with dementia	For people with early stage dementia, consider stopping antiplatelet, anticoagulant and antithrombotic agents used for preventative measures	Page et al25	Yes, with the tool freely available at http://www.match-d.com.au/
Validated prescribing appropriateness criteria for older Australians	Australian prescribing indicators to help identify common medicine-related problems in older people	Patient taking a PPI is NOT taking a medication that may cause dyspepsia unless prescribed for gastroprotection	Basger et al26	Yes
Beers Criteria®	Explicit list of potentially inappropriate medicines in older people	Avoid using antipsychotics for behavioural problems of dementia	American Geriatrics Society Beers Criteria® Update Expert Panel27	No
STOPP (Screening Tool for Older Peoples Prescriptions)	Explicit rules for ceasing certain medicines	Cease calcium channel blockers with chronic constipation	O’Mahony et al28	Yes
Deprescribing algorithm modified from the Good Palliative – Geriatric Practice (GPGP) algorithm	Decision tree diagram for deprescribing	Inappropriate prescription Adverse effects or interaction Drug taken for symptom relief Drug intended to prevent serious future events	Page et al29	No
CEASE algorithm (Figure 2)	Guide the deprescribing process during a doctor–patient encounter	Current medicines, Elevated risk, Assess, Sort, Eliminate	Scott and Le Couteur30	Tool provided in this article
ERASE approach (Figure 3)	Review diagnoses and associated medicines	Evaluate diagnoses through the consideration of Resolved conditions, Ageing normally, Selecting appropriate targets to Eliminate unnecessary diagnoses and medicines	Page and Etherton-Beer6	Tool provided in this article
Prescribing and deprescribing in CKD	Optimising medicine use in people with CKD	List of commonly prescribed medications that may require dose reduction or cessation in people with CKD (eg diabetes medications)	Manski-Nankervis et al31	Yes
CCB, calcium channel blocker; CKD, chronic kidney disease; PPI, proton pump inhibitor.

---

Key Steps in Developing a Deprescribing Plan

1. Assess the Patient and Establish Goals of Care
   • Understand the patient’s health goals, preferences, and needs.
2. Comprehensive Medication History
   • Obtain a full medication history, including prescriptions, over-the-counter medications, supplements, and traditional medicines.
   • This history should be reviewed and reconciled with any additional medicine lists (e.g., Home Medicines Review (HMR), Residential Medication Management Review (RMMR), patient-provided lists, or discharge summaries).
   • Cross-check with digital health records like My Health Record.
   • Discuss and resolve any discrepancies with the patient, their carer, or healthcare facility staff.
3. Identify Potential Medicines for Cessation
   • Identify which medicines may be suitable to cease, focusing on potential harms, lack of indication, or inappropriate prescribing cascades.
4. Prioritise Medicines for Deprescribing
   • Prioritise which medicines should be ceased first based on:
     • Medicine-related risks and benefits.
     • Patient-specific factors (age, comorbidities, adherence history).
   • Take a stepwise approach, generally focusing on one medicine at a time, with changes made gradually over weeks or months.

Step-by-Step Deprescribing Process

Step 1: Review All Medicines

• Reconcile medications with other lists and check for consistency across sources such as HMR, RMMR, and digital health records.
• Engage with the patient, family, or carers to discuss discrepancies and update the list accordingly.

Step 2: Assess and Discuss

• Evaluate the benefits and risks of each medication for the patient.
• Discuss the patient’s preferences, comorbidities, functional status, and any previous or current adherence challenges.
• Educate the patient (and family) about the potential outcomes of continuing versus stopping medications, considering factors like age, cognitive ability, and other health conditions.

Step 3: Assess the Ongoing Need for Each Medicine

• Focus first on medications with the highest risk of harm and lowest anticipated benefit.
• Step 3A: Identify medicines providing no benefit due to:
  • Toxicity, no indication, or outdated diagnosis.
  • Contraindications or cascade prescribing.
• Step 3B: Consider if the harm outweighs benefits, such as a high anticholinergic load.
• Step 3C: Assess if disease-specific guidelines suggest medication withdrawal after a period of stability.
• Step 3D: Evaluate if preventive medicines may be unnecessary due to limited life expectancy.
• Step 3E: If a medicine is to be continued, ensure the dose is appropriate and monitoring is in place.

Step 4: Prioritise Medicines for Change

• Discuss and prioritize potential medication changes with the patient and their support system.
• Focus on one medication at a time, gradually reducing it over time as necessary.

Step 5: Implement and Monitor

• Implement the changes collaboratively with patient involvement.
• Highlight and monitor for potential withdrawal syndromes; taper doses as needed.
  • Gradual reduction is recommended, especially for CNS-active drugs, PPIs, beta-blockers, and NSAIDs, to avoid withdrawal symptoms.
• Create and communicate a medication management plan with all relevant parties (e.g., carers, pharmacists, community pharmacy).
• Continuously monitor for any changes or adverse effects and adjust as needed.

Deprescribing guidelines for specific medicines/drug classes
Medicine/drug class	Risk for use in older people	Relevant deprescribing guidelines
Allopurinol	Worsening renal dysfunction and serious skin toxicity	A
Anticholinergics	Cognitive impairment and urinary retention	B
Antihyperglycaemics	Hypoglycaemia and related morbidity	A, C
Antihypertensive agents	Falls	A
Antipsychotics	Parkinsonism or extrapyramidal symptoms, falls	A, B, C
Aspirin	GI bleeding	A
Benzodiazepines and/or Z-drugs	Sedation, falls, confusion, dependence	A, C
Bisphosphonates	Hypocalcaemia	A
Cholinesterase inhibitors and memantine	GI upset, urinary incontinence, bradycardia	A, C
Gabapentinoids	Sedation, ataxia, falls	D
Glaucoma eye drops	Mostly well tolerated but may no longer be indicated if life expectancy is limited	A
NSAIDs	GI bleeding, renal failure, exacerbation of cardiovascular diseases	A
Opioids	Sedation, falls, fractures, dependence	A, B, E
Proton pump inhibitors	Long-term use increases the risk of fractures, altered absorption of nutrients and some medicines	A, B, C, Turner et al32
Sedating antihistamines	Falls, fractures, confusion, drowsiness	B
SSRIs and SNRIs	Falls	B
Statins	Myopathy, rhabdomyolysis and fatigue	A
Tricyclic antidepressants	Falls, sedation, anticholinergic adverse effects	B
Vitamin D and calcium	Falls, hypercalcaemia	A
A, Primary Health Tasmania (https://www.primaryhealthtas.com.au/resources/deprescribing-resources/); B, New South Wales Therapeutic Advisory Group (http://www.nswtag.org.au/deprescribing-tools/); C, Bruyère Research Institute (https://deprescribing.org/resources/deprescribing-guidelines-algorithms/); D, Canadian Medication Appropriateness and Deprescribing Network (https://www.deprescribingnetwork.ca/patient-handouts); E, Victorian Department of Health (https://www.health.vic.gov.au/sites/default/files/migrated/files/collections/policies-and-guidelines/safe-opiod-use/recommendations-for-deprescribing-or-tapering-opioids—for-health-professionals.pdf). GI, gastrointestinal; NSAIDs, non-steroidal anti-inflammatory drugs; SNRIs, serotonin noradrenaline reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors; Z-drugs, zopiclone, eszopiclone, zaleplon and zolpidem.

Primary Prevention Medications That Can Be Stopped in Elderly Patients

1. Statins for Primary Prevention

• Indication: Used to lower cholesterol levels and prevent cardiovascular disease in patients without established cardiovascular disease.
• Consider Stopping When:
  • Limited life expectancy or significant frailty.
  • No established cardiovascular disease or no significant risk factors.
  • Potential for adverse effects (e.g., myopathy, liver dysfunction) outweighs benefits.
• Rationale: Evidence for statin benefit in primary prevention for individuals over 75 years without cardiovascular disease is limited.

2. Antihypertensives for Primary Prevention

• Indication: Used to prevent cardiovascular events in patients without established cardiovascular disease.
• Consider Stopping When:
  • Blood pressure is consistently below target, and the patient experiences side effects like dizziness, orthostatic hypotension, or falls.
  • Significant frailty, poor tolerance, or concerns about polypharmacy.
• Rationale: Aggressive blood pressure lowering may increase fall risk and hypotension in frail older adults without significant cardiovascular risk.

3. Aspirin for Primary Prevention

• Indication: Used to prevent cardiovascular events (e.g., heart attack, stroke) in patients without known cardiovascular disease.
• Consider Stopping When:
  • Limited life expectancy or increased bleeding risk.
  • Older age (>70 years), as risks of gastrointestinal bleeding and hemorrhagic stroke often outweigh benefits in primary prevention.
• Rationale: Recent evidence suggests that the risks of major bleeding often outweigh potential cardiovascular benefits in older adults without established cardiovascular disease.

4. Bisphosphonates for Osteoporosis Prevention

• Indication: Used to prevent bone loss and fractures in patients without prior fractures.
• Consider Stopping When:
  • Long-term use (>5 years) with no fractures or with evidence of low fracture risk.
  • Significant comorbidities that limit mobility or cause poor tolerance.
• Rationale: The benefit of ongoing bisphosphonate therapy beyond a few years may diminish, and there is a risk of rare adverse effects (e.g., osteonecrosis of the jaw, atypical femoral fractures).

5. Vitamins and Supplements

• Indication: Various vitamins and mineral supplements for general health.
• Consider Stopping When:
  • No clear deficiency or indication (e.g., routine vitamin D or calcium without osteoporosis).
  • Lack of benefit demonstrated in reducing primary disease risk.
• Rationale: Many vitamin and supplement regimens have not shown consistent benefit in primary prevention and may increase the pill burden unnecessarily.

6. Proton Pump Inhibitors (PPIs) for Primary Prevention of Gastric Ulcers

• Indication: Used prophylactically to prevent ulcers in patients at risk of gastrointestinal complications.
• Consider Stopping When:
  • No clear indication for ongoing use, such as NSAID discontinuation.
  • Concerns about long-term side effects (e.g., osteoporosis, kidney disease, infections).
• Rationale: Long-term use without a clear indication can lead to significant adverse effects.

7. Antiplatelet Agents for Primary Prevention in Non-High-Risk Patients

• Rationale: Use of antiplatelet agents like clopidogrel in primary prevention may pose more risk than benefit due to bleeding risk in elderly patients without cardiovascular disease.
• Indication: Used to reduce the risk of cardiovascular events in patients without established disease.
• Consider Stopping When:
• No history of cardiovascular disease, and the patient is at low risk.
• Increased bleeding risk (e.g., history of gastrointestinal bleeding or anticoagulation therapy).

Potential pitfalls of a deprescribing intervention
Potential consequences	Examples	Suggestions
Return of original disease symptoms	Symptoms of reflux on discontinuation of a proton pump inhibitor Rebound insomnia on discontinuation of temazepam	‘Stop slow, go low’ approach: – short-term pharmacological substitution or management taper the medicine – psychological support (if applicable) – periodic monitoring of the original disease
Adverse drug withdrawal events	Sleep disturbance, tremor, irritability, anxiety, and palpitation on discontinuation of a benzodiazepine	‘Stop slow, go low’ approach: – stop one medicine at a time – taper the medicine close monitoring
Unmasking drug interactions	For patients on warfarin, altered INR on discontinuation of amiodarone	Thorough medication review before deprescribing to identify any potential pharmacokinetic interactions
Damaging patient–doctor relationship	Patients may interpret deprescribing as ‘giving up’	Shared decision making and patient collaboration: – engage patients (and their caregivers) in every step of the intervention – clear explanation of expected risks and benefits – provide written patient information – psychological support where needed
Deprescribing-related complications	An occurrence of myocardial infarction being attributed to discontinuing a statin	Careful consideration of the benefit–harm ratio of a preventative medicine is key, taking into account an individual’s life expectancy – Consider other options for risk management (eg lifestyle changes)Document all reasonable grounds for stopping a medicine
INR, international normalised ratio.

Outcomes and Evidence

• Systematic reviews indicate deprescribing does not significantly alter mortality in randomized trials but may reduce mortality in non-randomized settings.
• While benefits to overall health outcomes are variable, deprescribing remains feasible and safe, focusing on improving quality of life through patient-centered care.

---

Case study

The case study of Tom, an 80-year-old man, illustrates a practical application of deprescribing in an older patient with multiple chronic conditions and medications. Here’s a detailed explanation:

Background on Tom’s Condition and Medications

• Medical Conditions: Tom has hypercholesterolaemia, hypertension, gout, chronic constipation, and insomnia.
• Current Medications:
  • Rosuvastatin (10 mg): For hypercholesterolaemia.
  • Ramipril (5 mg): For hypertension.
  • Hydrochlorothiazide (25 mg): A diuretic for blood pressure management.
  • Allopurinol (150 mg): For gout prevention.
  • Amitriptyline (10 mg): Likely for insomnia, pain, or mood disorders.
  • Docusate sodium/senna (50 mg/8 mg): For chronic constipation.

Identifying the Problem

• Patient’s Concerns: Tom mentions side effects, adherence difficulties, and increased treatment burden from his medications. This opens the door to discuss deprescribing.
• Patient Engagement: Tom is willing to reduce or stop medications, emphasizing the importance of shared decision-making.

Use of CEASE Algorithm and Deprescribing Tools

• Step 1: Medicine Reconciliation: This includes reviewing all of Tom’s medications and considering a Home Medicines Review with a pharmacist.
• Step 2: Identifying High-Risk Medications:
  • Amitriptyline: Highlighted as potentially inappropriate due to high anticholinergic and sedative properties, which can lead to issues such as orthostatic hypotension, worsening constipation, and may be contributing to a prescribing cascade with docusate/senna.
  • Hydrochlorothiazide: Recognized as potentially exacerbating Tom’s gout, creating a possible prescribing cascade with allopurinol.

Benefit-Harm Assessment and Deprescribing Targets

• Benefit-Harm Assessment: Factors considered include Tom’s age, overall health, medication burden, and preferences.
• Potential Deprescribing Targets:
  • Rosuvastatin: Considered for deprescribing if its primary prevention benefits are less significant at Tom’s age.
  • Ramipril: May be adjusted based on age-related blood pressure targets.
  • Docusate Sodium/Senna: Evidence suggests it may be ineffective.
  • Allopurinol: May be considered for discontinuation if gout has been asymptomatic, and diuretics or lifestyle changes have been made.

Prioritization and Deprescribing Strategy

• Priority Selection: Amitriptyline was prioritized for cessation due to its higher risk profile and potential harm.
• Deprescribing Plan:
  • Gradual tapering of amitriptyline, following evidence-based deprescribing guidelines, to minimize withdrawal symptoms.
  • Tom was informed about possible effects, expected outcomes, and was given support materials, such as lifestyle modifications for insomnia.

Follow-Up and Next Steps

• Monitoring: Tom’s progress would be closely monitored for changes in symptoms or new adverse effects.
• Future Deprescribing: If successful with amitriptyline withdrawal, other medications (e.g., docusate, hydrochlorothiazide) could then be considered for deprescribing based on updated assessments.

Key Takeaways

• Patient-Centered Approach: Involves engaging with Tom, respecting his preferences, and personalizing care.
• Multidisciplinary Collaboration: Pharmacists and nurses may be involved in reviews, patient education, and monitoring.
• Safety and Individualization: Tapering high-risk medications and closely monitoring outcomes ensures safety.