{"id":7918,"date":"2025-01-07T07:47:37","date_gmt":"2025-01-07T12:47:37","guid":{"rendered":"https:\/\/www.silvercentury.org\/?p=7918"},"modified":"2025-01-07T07:47:37","modified_gmt":"2025-01-07T12:47:37","slug":"when-less-is-more-the-need-for-deprescribing","status":"publish","type":"post","link":"http:\/\/78.142.243.82\/~silvercentury\/2025\/01\/when-less-is-more-the-need-for-deprescribing\/","title":{"rendered":"When Less Is More: The Need for ‘Deprescribing’"},"content":{"rendered":"

Every time Jodie Pepin\u2019s mother saw another physician, it seemed like she was prescribed yet another medication. Each time Pepin wondered, \u201cWhy are they giving her that? She already has dementia.\u201d<\/span><\/p>\n

Pepin, clinical pharmacy program director at Harbor Health in Austin, TX, knew the medications could exacerbate dementia, cause drowsiness and affect gait. When her mother fell, multiple times, she blamed the drugs. <\/span><\/p>\n

\u201cThese medications just kept making it worse,\u201d said Pepin, PharmD, who is also a clinical assistant professor at the College of Pharmacy at the University of Texas at Austin. \u201cIt frustrated me to no end.\u201d <\/span><\/p>\n

Pepin lived in another state, so she reviewed her mother\u2019s medications and had many conversations with doctors over the phone. Each time, the doctor would stop one or two drugs. Then another health issue would arise for her mother, who would see another doctor, who would prescribe yet another medication. <\/span><\/p>\n

That kind of medical doom loop is not uncommon among older people, particularly those with multiple chronic conditions. Polypharmacy\u2014taking five or more medications\u2014is associated with increased hospital admissions, falls and premature mortality.  <\/span><\/p>\n

The problem has led to a growing movement among medical schools and hospital systems toward \u201cdeprescribing\u201d medications: discontinuing drugs that are either potentially harmful or no longer required, or reducing the dosage or frequency, always with medical supervision. <\/span><\/p>\n

Almost 90 percent of adults 65 and up take at least one prescription drug regularly; 54 percent of older adults report taking four or more prescription drugs. As the number of medicines goes up, medication management becomes more complex, and the risk of adverse reactions grows.  <\/span><\/p>\n

As people age, kidney and liver functioning decrease, along with lean body mass, affecting the way drugs are metabolized. Medications may stay in an older person\u2019s system longer, increasing the risk and severity of side effects. <\/span><\/p>\n

Troubles with the System<\/b><\/p>\n

The fragmented nature of the US health care system also contributes to the problem.  <\/span><\/p>\n

\u201cMany older people see multiple doctors in multiple specialties,\u201d said DeLon Canterbury, PharmD, founder of GeriatRx, a concierge telehealth service. “One is focused on the kidney, the other is focused on the heart, and so on. These providers are following their guidelines but not thinking about the whole picture.\u201d <\/span><\/p>\n

As a result, patients may end up with duplicate prescriptions for similar medications or medications that interact. <\/span><\/p>\n

Older patients are also at risk for what medical professionals call a \u201cprescribing cascade,\u201d according to Dominick Trombetta, PharmD, associate professor of pharmacy practice (geriatrics\/internal medicine) at Wilkes University School of Pharmacy in Wilkes-Barre, PA. <\/span><\/p>\n

A common scenario: a doctor prescribes amlodipine, a medication for high blood pressure. It\u2019s generally safe but can cause a patient\u2019s feet to swell. Instead of trying a different blood pressure medication or adjusting the dosage, the provider assumes the edema is yet another age-related condition and prescribes a diuretic. <\/span><\/p>\n

The diuretic, in turn, creates an electrolyte imbalance, which leads to a prescription for a potassium supplement, which causes heartburn, which leads to a prescription for antacids.<\/span><\/p>\n

Some whole categories of drugs carry special risks for older people.<\/b> <\/span><\/p><\/blockquote>\n

Some medications can be dangerous for older people or patients with certain health conditions. Canterbury saw this with his grandmother, Mildred, who had mild dementia. When she began declining rapidly, the family moved Mildred out of assisted living. But she didn\u2019t improve. <\/span><\/p>\n

\u201cShe was wandering around the house, hiding her dentures, hiding her glasses and not remembering us,\u201d Canterbury said. \u201cIt was heartbreaking.\u201d  <\/span><\/p>\n

A medication review by the family\u2019s pharmacist revealed that Mildred was taking an antipsychotic with a \u201cBlack Box Warning\u201d (the Food and Drug Administration\u2019s highest safety-related warning). The drug was associated with \u201cincreased mortality in elderly patients with dementia-related psychosis.\u201d <\/span><\/p>\n

Mildred returned to her baseline level of functioning after she stopped the meds.<\/span><\/p>\n

Trombetta notes that some drug categories tend to be inappropriately prescribed for older patients. Proton pump inhibitors, such as omeprazole, omeprazole or pantoprazole, are often prescribed in hospitals to prevent gastrointestinal bleeding. That\u2019s appropriate while the patient is in the hospital, but the patient may no longer need it after discharge, and continued use increases the risk for fractures, severe diarrhea, pneumonia or B12 deficiency. <\/span><\/p>\n

Diabetes medications are also frequently prescribed inappropriately. For younger or middle-aged patients, doctors prescribe for tight control of blood sugar levels, because high blood sugar can harm the heart and pose other long-term risks. For older people, it often makes sense to relax the control of blood sugar levels and reduce or change medications accordingly. The goal is to minimize the risk of hypoglycemia (dangerously low blood sugar), which can lead to falls or even death.    <\/span><\/p>\n

Taking Precautions<\/b><\/p>\n

To help avoid polypharmacy issues, the American Geriatrics Society publishes the Beers List, a database that flags medicines that health care providers should either avoid or prescribe with caution for older patients. The list is updated every three years, most recently in 2023.<\/span><\/p>\n

The Beer\u2019s List includes seemingly innocuous, over-the-counter medications like diphenhydramine (Benadryl), which may lead to confusion or falls for older patients, and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, which should be avoided by older people with kidney disease. Other cautions on the list include antibiotics like Cipro, which may interact with blood thinners, and benzodiazepines like Valium, which can impair cognitive function and cause an unsteady gait. Doctors may still choose to prescribe these medications, but the list helps them proceed with caution. <\/span><\/p>\n

Some hospitals are implementing programs to avoid over-prescribing medications or to encourage physicians to consider deprescribing. <\/span><\/p>\n

Pepin was involved in one such effort at a trauma unit. Working with trauma surgeons, she designed an admission order for older patients. Previously, doctors were prescribing the same doses of sleep or pain meds regardless of patients\u2019 ages. Following the Beers criteria, the orders were customized for older patients, which led to a decrease in oversedation or respiratory depression.<\/span><\/p>\n

Safety Is an Utmost Concern<\/b><\/p>\n

More than 80 percent of adults aged 50 to 80 would be open to stopping one or more of their prescription drugs, according to the University of Michigan National Poll on Healthy Aging. <\/span><\/p>\n

Some patients are taking matters into their own hands. More than a third of those polled said they stopped taking a medication without consulting a medical professional\u2014in some cases, due to concerns about cost. <\/span><\/p>\n

But self-deprescribing is risky, said Sarah Vordenberg, PharmD, a clinical associate professor at the University of Michigan College of Pharmacy, who worked on the poll.<\/span><\/p>\n

\u201cIn our research, we found that the types of medications that older adults are interested in stopping are not always the types that health care professionals think are best to stop,\u201d she said. A patient who discontinues a cholesterol medication, for example, may not notice any changes, but their risk of heart attacks or stroke may be increased.\u201d<\/span><\/p>\n

Bottom line: deprescribing should always be done in consultation with a physician or other primary care provider. <\/span><\/p>\n

Taking Charge<\/b><\/p>\n

Patients and their caregivers can take a proactive role in managing their medications. Start by always keeping an updated list of all medications, including over-the-counter drugs, supplements and vitamins\u2014even non-oral medications like eye drops\u2014with the actual doses being taken, even if not as prescribed. If the cost of a medication is an issue, tell the provider that too. <\/span><\/p>\n

Bring that list to every doctor visit. Don\u2019t assume the provider has a correct list.  <\/span><\/p>\n

Patients may request a comprehensive medication review by a pharmacist or other provider. Most retail pharmacists can provide this service, which is covered by Medicare and other insurance, but an appointment is usually required. If possible, patients should get all their prescriptions filled at the same pharmacy. Those who use more than one pharmacy, or take nonprescription drugs or supplements, should be sure the reviewing pharmacist has that information. <\/span><\/p>\n

Medications should also be reviewed at every annual checkup, with an eye toward deprescribing. If a physician does recommend cutting some medications, be sure to get detailed instructions on how. Some medications need to be tapered rather than stopped cold turkey. And always ask how long new medications should be taken. <\/span><\/p>\n

In addition to the annual checkup, experts advise having all medications reviewed at every medical transition, including: <\/span><\/p>\n